P0141 - Oral glucose gel for asymptomatic neonatal hypoglycemia: Is it a sweet deal?

Background:
Asymptomatic hypoglycemia is common in certain newborn infants and can require treatment with dextrose-containing intravenous fluids, resulting in transfer from newborn nurseries to neonatal intensive care units (NICUs), and maternal-infant separation. 40% oral glucose gel (GG) has been reported to be an effective, non-invasive treatment for asymptomatic hypoglycemia in neonates, often reducing the number of transfers to a higher level of care.

Objective:
To implement the use of GG to reduce NICU admissions by 20% in infants > 36 week gestation detected to have asymptomatic hypoglycemia (blood glucose < 45 mg/dL) by December 2019.
Methodology:
A multidisciplinary team across two newborn nursery units at Duke University Hospital (DUH) and Duke Regional Hospital (DRH), established baseline data on glucose values and NICU admissions for persistent hypoglycemia. A key driver diagram was created with drivers that addressed education, compliance, and data collection. Plan-do-study-act (PDSA) cycles were followed to revise the previous hypoglycemia protocol and implement a new protocol to include GG. A maximum of 3 doses of GG were allowed in the first 24 hours of life. The primary outcome measure was the percentage of infants in the newborn nurseries with asymptomatic hypoglycemia that required admission to the NICU. Control charts were created and analyzed for NICU admissions. A generalized regression model was used to assess the interaction of factors influencing admissions to the NICU for infants receiving GG.

Discussion:
Among 2,886 hypoglycemic infants, 885 were treated with GG in the months following the new protocol. Pre-GG data revealed that the rate of hypoglycemic infants transferred to the NICU was approximately 30% at DRH (Figure 1A), and 15% at DUH (Figure 1B). Implementation of GG in both the nurseries did not result in a reduction in NICU admissions due to hypoglycemia. Factors increasing the likelihood of patients who received GG that were later admitted to a higher level of care included birth weight, sex, and lowest measured glucose (Figure 2).

Conclusion:
Implementation of GG was ineffective in reducing admissions to our NICUs for asymptomatic hypoglycemia, contrary to previous reports. Our next PDSA cycle will modify the algorithm to ensure that supplemental feeds are provided with the second and third administration of GG. Further analysis is needed in identifying factors contributing to our current results.