Standard-Dose Oral Dextrose Gel for Neonatal Hypoglycemia

Abstract

Source: Purnahamsi P, Verma S, Bhargava S, et al. Implementation and outcomes of a standard dose dextrose gel protocol for management of transient neonatal hypoglycemia [published online ahead of print January 3, 2022]. J Perinatol. doi: 10.1038/s41372-021-01284-3.Investigators from multiple institutions conducted a retrospective study to assess the effectiveness of oral dextrose gel in the management of at-risk newborns with hypoglycemia. Study participants were neonates born at New York University Langone Health Center, New York, NY, between July 1, 2015 and July 1, 2018 who were born ≥35 weeks’ gestation and >2,000 grams and developed hypoglycemia (glucose <40 mg/dL) in the first 24 hours of life. The medical records of study participants were reviewed and information on demographics, birth history, and hospital course abstracted. Throughout the study period, a standardized protocol was used for screening at-risk newborns for hypoglycemia. Treatment for hypoglycemia was enteral feeds between 2015 and November 2016 (pre-gel epoch), weight-based dextrose gel (WD, 0.5 mL/kg [200 mg/kg]) from December 2015 to March 2017, and standard dose dextrose gel (SD, 2 mL) from March 2017 to July 2018. The primary study outcome was intravenous (IV) glucose administration, and secondary outcomes included NICU admission and rates of exclusive breastfeeding at hospital discharge. Chi square tests were used to compare outcomes among neonates born during the pre-gel and post-gel epochs; bivariate comparisons between newborns treated with WD and SD also were conducted. Multivariate regression was used to compare outcomes to assess the independent association between treatment epochs (pre-gel vs post-gel and WD vs SD) and risk of IV glucose administration, after adjusting for hypoglycemia risk factors.During the study period, 1,329 newborns developed hypoglycemia. The rate of hypoglycemia was higher in the post-gel than pre-gel epoch (8.9% vs 7.1%; P <0.001). The rate of IV glucose administration was significantly lower among newborns in the post-gel epoch than pre-gel period (6.5% vs 10.9%; P = 0.004). Rates of NICU admission (16.1% vs 27.9%; P <0.001) were significantly lower, and rates of exclusive breastfeeding were significantly higher (43.5% vs 33.8%; P = 0.001) in hypoglycemic infants treated with dextrose gel than in those born in the pre-gel epoch. There were no significant differences for any of these outcomes in newborns treated with WD or SD. In the multivariate models, newborns with hypoglycemia born during the post-gel epoch were at significantly lower risk of receiving IV glucose than those born during the pre-gel epoch (adjusted odds ratio [aOR], 0.55; 95% confidence interval [CI], 0.37, 0.83); there was no significant difference between those treated with SD compared to WD (aOR, 0.70; 95% CI, 0.34, 1.45).The authors conclude that oral dextrose gel was associated with lower rates of IV glucose administration and NICU admission and higher breastfeeding rates, compared to enteral treatment, for neonatal hypoglycemia.Dr Von Kohorn has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The goal of screening for and treating neonatal hypoglycemia (NH) is to prevent brain injury. A satisfactory, uncontroversial definition of NH remains elusive, with ongoing controversy about the range of normal blood glucose values and what level and duration of NH leads to brain injury.1 (See AAP Grand Rounds. 2020;43[5]:58.) Optimal treatment of NH also is unknown. (See AAP Grand Rounds. 2017;38[5]:53.) Current US guidelines offer differing opinions about when clinicians should intervene to treat NH, with higher “lower limit” thresholds resulting in more, possibly unnecessary, intervention.2 Regardless of threshold, dextrose gel as a first-line treatment for NH has been shown to increase blood sugar levels, support lactation, and decrease IV glucose and NICU admission compared to enteral feedings alone.1The current investigators describe a quality improvement initiative that achieved these same results with introduction of dextrose gel to a NH protocol. In addition to the main outcomes, the current authors observed an increased length of stay for infants ultimately admitted to the NICU, suggesting that the improvement initiative better delineated the population of infants with more severe disease. Importantly, the current authors found that SD dextrose gel improved protocol adherence compared to WD while maintaining improved outcomes. The authors do not explain an important nuance in their study. In bivariate analysis, infants receiving SD compared to WD dextrose gel were more likely to receive enteral supplementation with formula or donor breast milk. In multivariate analysis, the authors included the variable exclusive breastfeeding at discharge, which can be inclusive of donor breast milk. Although it is a human product, donor breast milk is a supplement that can impede lactogene-sis.3 Future implementation protocols of SD dextrose gel should carefully evaluate all supplemental feedings.Standard dose oral dextrose gel as a first-line treatment for NH can improve protocol adherence without compromising decreased rates of IV glucose use and NICU admission. Support for a mother’s own milk feedings remains a priority in implementation of NH protocols.