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Decreasing early hypoglycemia frequency in at-risk newborns after implementing a new hypoglycemia screening algorithm

Abstract

Background

Neonatal hypoglycemia may affect long-term neurodevelopment.

Methods

Quality improvement (QI) initiative for Mother-Baby-Unit (MBU) admissions (birthweight ≥ 2100 g; ≥35 weeks’ gestation) over two epochs from 2016–2019 to reduce the frequency of early (≤3 h) neonatal hypoglycemia in small and large newborns.

Intervention

New algorithm using Olsen’s growth curves, hypoglycemia thresholds of <2.22 mmol/L [40 mg/dL] (0–3 h) and <2.61 mmol/L [47 mg/dL] (>3 to 24 h), feeding optimization and 24-hour glucose checks for small for gestational age and preterm newborns.

Results

Among 39,460 newborns, using subsets with identical screening criteria, early hypoglycemia decreased significantly after QI implementation among large for gestational age newborns with birthweight >3850 g (66%) and small for gestational age newborns with birthweight <2500 g (70%). Among all MBU admissions, the adjusted odds of any hypoglycemia in 24 h decreased (P < 0.001).

Conclusions

Feeding optimization may decrease early hypoglycemia frequency in large and small newborns.

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Fig. 1: Flow diagram of newborn groups.
Fig. 2: Percent neonates with any hypoglycemia during the first 3 h postnatal, p control charts.

References

  1. 1.

    Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics. 2008;122:65–74.

    Article  Google Scholar 

  2. 2.

    Lucas A, Morley R, Cole TJ. Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. BMJ. 1988;297:1304–8.

    CAS  Article  Google Scholar 

  3. 3.

    Kaiser JR, Bai S, Gibson N, Holland G, Lin TM, Swearingen CJ, et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: a population-based study. JAMA Pediatr. 2015;169:913–21.

    Article  Google Scholar 

  4. 4.

    McKinlay CJD, Alsweiler JM, Anstice NS, Burakevych N, Chakraborty A, Chase JG.CHYLD study group et al. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr. 2017;171:972–83.

    Article  Google Scholar 

  5. 5.

    McKinlay CJ, Alsweiler JM, Ansell JM, Anstice NS, Chase JG, Gamble GD, et al. Neonatal glycemia and neurodevelopmental outcomes at 2 years. N. Engl J Med. 2015;373:1507–18.

    CAS  Article  Google Scholar 

  6. 6.

    Shah R, Harding J, Brown J, McKinlay C. Neonatal glycaemia and neurodevelopmental outcomes: a systematic review and meta-analysis. Neonatology. 2019;115:116–26.

    CAS  Article  Google Scholar 

  7. 7.

    Harris DL, Weston PJ, Harding JE. Incidence of neonatal hypoglycemia in babies identified as at risk. J Pediatr. 2012;161:787–91.

    CAS  Article  Google Scholar 

  8. 8.

    Gyurkovits Z, Kálló K, Bakki J, Katona M, Bitó T, Pál A, et al. Neonatal outcome of macrosomic infants: an analysis of a two-year period. Eur J Obstet Gynecol Reprod Biol. 2011;159:289–92.

    Article  Google Scholar 

  9. 9.

    Adamkin DH. Neonatal hypoglycemia. Semin Fetal Neonatal Med. 2017;22:36–41.

    Article  Google Scholar 

  10. 10.

    Srinvasan G, Pildes RS, Cattamanchi G. Plasma glucose values in normal neonates: a new look. J Pediatr. 1986;109:114–7.

    Article  Google Scholar 

  11. 11.

    Committee on Fetus and Newborn, Adamkin DH. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127:575–9.

    Article  Google Scholar 

  12. 12.

    Thornton PS, Stanley CA, De Leon DD, Harris D, Haymond MW, Hussain K, et al. Recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children. J Pediatr. 2015;167:238–45.

    Article  Google Scholar 

  13. 13.

    Kaiser JR, Bai S, Rozance PJ. Newborn plasma glucose concentration nadirs by gestational-age group. Neonatology. 2018;113:353–9. [published correction appears in Neonatology. 2018; 114: 165; 2018; 114: 166].

    CAS  Article  Google Scholar 

  14. 14.

    Murray YL, Paul IM, Miller JR, Thrash SZ, Kaiser JR. Variability in the use of growth curves between preterm and term infants in NICUs and newborn nurseries. Pediatr Res. 2021;89:711–3.

    Article  Google Scholar 

  15. 15.

    Pickerel KK, Waldrop J, Freeman E, Haushalter J, D’Auria J. Improving the accuracy of newborn weight classification. J Pediatr Nurs. 2020;50:54–8.

    Article  Google Scholar 

  16. 16.

    Lubchenco LO, Hansman C, Boyd E. Intrauterine growth in length and head circumference as estimated from live births at GAs from 26 to 42 weeks. Pediatrics. 1966;37:403–8.

    CAS  Article  Google Scholar 

  17. 17.

    Dietzen DJ, Wilhite TR, Rasmussen M, Sheffield M. Point-of-care glucose analysis in neonates using modified quinoprotein glucose dehydrogenase. Diabetes Technol Ther. 2013;15:923–8.

    CAS  Article  Google Scholar 

  18. 18.

    Wight N, Marinelli KA. Academy of Breastfeeding Medicine. ABM clinical protocol #1: guidelines for blood glucose monitoring and treatment of hypoglycemia in term and late-preterm neonates, revised 2014. Breastfeed Med. 2014;9:173–9.

    Article  Google Scholar 

  19. 19.

    Wickström R, Skiöld B, Petersson G, Stephansson O, Altman M. Moderate neonatal hypoglycemia and adverse neurological development at 2–6 years of age. Eur J Epidemiol. 2018;33:1011–20.

    Article  Google Scholar 

  20. 20.

    Qiao LX, Wang J, Yan JH, Xu SX, Wang H, Zhu WY, et al. Follow-up study of neurodevelopment in 2-year-old infants who had suffered from neonatal hypoglycemia. BMC Pediatr. 2019;19:133.

    Article  Google Scholar 

  21. 21.

    Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel BS. New intrauterine growth curves based on United States data. Pediatrics. 2010;125:e214–24.

    Article  Google Scholar 

  22. 22.

    Gupta M, Kaplan HC. Measurement for quality improvement: using data to drive change. J Perinatol. 2020;40:962–71.

    Article  Google Scholar 

  23. 23.

    Gupta M, Kaplan HC. Using statistical process control to drive improvement in neonatal care: A practical introduction to control charts. Clin Perinatol. 2017;44:627–44.

    Article  Google Scholar 

  24. 24.

    Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373–9.

    CAS  Article  Google Scholar 

  25. 25.

    Schreiber-Gregory D. Multicollinearity: what is it, why should we care, and how can it be controlled? Paper 1404-2017. http://support.sas.com/resources/papers/proceedings17/1404-2017.pdf, accessed 2/20/21.

  26. 26.

    Cordero L, Ramesh S, Hillier K, Giannone PJ, Nankervis CA. Early feeding and neonatal hypoglycemia in infants of diabetic mothers. SAGE Open Med. 2013;19:2050312113516613.

    Google Scholar 

  27. 27.

    Zhou Y, Bai S, Bornhorst JA, Elhassan NO, Kaiser JR. The effect of early feeding on initial glucose concentrations in term newborns. J Pediatr. 2017;181:112–5.

    CAS  Article  Google Scholar 

  28. 28.

    Bragg JJ, Green R, Holzman IR. Does early enteral feeding prevent hypoglycemia in small for GA neonates? J Neonatal Perinat Med. 2013;6:131–5.

    CAS  Article  Google Scholar 

  29. 29.

    Pickerel KK, Waldrop J, Freeman E, Haushalter J, D’Auria J. Improving the accuracy of newborn weight classification. J Pediatr Nurs. 2020;50:54–8.

    Article  Google Scholar 

  30. 30.

    ElHassan NO, Schaefer EW, Gonzalez B, Nienaber T, Brion LP, Kaiser JR. Early transient hypoglycemia and test performance in at-risk newborns. Am J Perinatol. 2021. https://doi.org/10.1055/s-0041-1732380. Epub ahead of print.

  31. 31.

    Le HT, Harris NS, Estilong AJ, Olson A, Rice MJ. Blood glucose measurement in the intensive care unit: what is the best method? J Diabetes Sci Technol. 2013;7:489–99.

    Article  Google Scholar 

  32. 32.

    Ballou J, Wiseman C, Jackson L, Godfrey R, Cagle D. Lactation Skills Workshop: a collaboration of the city of Dallas WIC and local Hospitals. J Nutr Educ Behav. 2017;49:S202–6.e1.

    Article  Google Scholar 

  33. 33.

    Parkland recognized as a Designated Baby-Friendly birth facility. Posted 8/19/2019. https://www.parklandhospital.com/news-and-updates/parkland-recognized-as-a-designated-babyfriendly-b-1619, accessed 09/04/2021.

  34. 34.

    van Kempen AAMW, Eskes PF, Nuytemans DHGM, van der Lee JH, Dijksman LM, van Veenendaal NR, et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N. Engl J Med.2020;382:534–44.

    Article  Google Scholar 

  35. 35.

    Harris DL, Weston PJ, Gamble GD, Harding JE. Glucose profiles in healthy term infants in the first 5 Days: The Glucose in Well Babies (GLOW) Study. J Pediatr. 2020;223:34–41.

    CAS  Article  Google Scholar 

  36. 36.

    Makker K, Alissa R, Dudek C, Travers L, Smotherman C, Hudak ML. Glucose gel in infants at risk for transitional neonatal hypoglycemia. Am J Perinatol. 2018;35:1050–6.

    Article  Google Scholar 

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Acknowledgements

We acknowledge the hard work of our MBU staff. We thank Kakkilaya V for help with initial poster control charts and Muraleedharan P for help constructing figures and tables. We thank Jaleel M for his contribution in deciding glucose cutoffs and for manuscript review. We thank Savani RC for reviewing the final manuscript. We thank Gilbert J and Stehel EK for data on breastfeeding in the MBU. Preliminary results were presented as a poster: MS, JS, KJ: “Implementing an Improved Neonatal Hypoglycemia Algorithm” at the Pediatric Academic Societies Meeting, April 2019. An abstract by the current authors was presented as a platform presentation by MS: “Decreasing Early Hypoglycemia Frequency in At-Risk Newborns by Implementing a New Hypoglycemia Screening Algorithm” at the Pediatric Academic Societies Meeting, May 2021.

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Authors

Contributions

All authors reviewed, edited and approved the manuscript as written. MS conceptualized the project, interpreted data and wrote the first draft of the manuscript. MS and KAJ took part in project planning, literature and manuscript review, meetings, logistics, analysis and implementation. KAJ developed the consensus algorithm, provided staff education and supervised implementation. JHS participated in planning, data analysis and interpretation. LSB gave statistical input. PJB compiled NICU data. DBN contributed maternal data. JRK, LPB, SB and NOE participated in the analysis of glucose cutoffs from the Arkansas cohort. LPB participated in building the algorithm and selection of growth curves; he conducted statistical analyses and built the statistical process control charts.

Corresponding author

Correspondence to Muraleedharan Sivarajan.

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Sivarajan, M., Schneider, J.H., Johnson, K.A. et al. Decreasing early hypoglycemia frequency in at-risk newborns after implementing a new hypoglycemia screening algorithm. J Perinatol 41, 2840–2846 (2021). https://doi.org/10.1038/s41372-021-01263-8

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