Northern California Neonatal Consortium Updates...Management of Apnea of Prematurity Management of...

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Tanya Hatfield, RNC-NIC, MSNUCSF Benioff Children’s Hospital

Northern California Neonatal Consortium:Guidelines & Updates

▪ Identify why the Northern California Neonatal Consortium (NCNC) exists

▪ Discuss recommendations, guidelines, and supporting evidence NCNC uses to create consensus statements

▪ Demonstrate ways to implement the NCNC guidelines in the community setting

Course Objectives

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▪ Formed in 2013

▪ Intent: To increase collaboration between BCH & community hospitals

▪ Goal: Standardize care and eliminate unwanted variations in clinical practice within and across institutions

Northern California Neonatal Consortium (NCNC)

▪ Meets quarterly

▪ Participating hospitals

○ UCSF Benioff San Francisco

○ San Francisco General Hospital

○ Marin General Hospital

○ Washington Hospital

○ Santa Rosa Memorial Hospital

○ Natividad Medical Center

○ Community Hospital of the Monterey Peninsula

How NCNC Works

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▪ Sources

○ Medical literature review

○ National practice standards

○ Local topical experts

▪ Outcomes

○ Specific process & outcome metrics at participating sites

▪ Consensus guidelines are reviewed periodically to remain consistent with current literature

NCNC Content & Evaluation

▪ Management of Apnea of Prematurity

▪ Management of Neonatal Abstinence Syndrome and Drug Exposed Newborns

▪ Early Onset Sepsis Screening and Management in Infants > 34 weeks

▪ Late Preterm Infant Feeding Guidelines

▪ Hyperbilirubinemia in Neonates > 35 weeks

▪ Screening and Management of Hypoglycemia in Late Preterm and Term Infants < 34 weeks

▪ Partial Exchange Transfusion for Polycythemia in Newborns

▪ Consensus Statement for Infant Car Seat Challenge Testing

▪ COMING SOON - Care for the Growing Preemie

NCNC Clinical Guidelines

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▪ https://www.ucsfbenioffchildrens.org/neonatal_consortium/

▪ https://bchsfoutreach.ucsf.edu/

▪ Google “Northern California Neonatal Consortium”

▪ ***Pediatric guidelines also available on website

Where To Access NCNC

▪ Definition

○ 20 seconds respiratory pause OR <20 sec with brady/desat/change in color

○ “significant” events

▪ Objectives

○ Standardization

○ Minimize non-evidence based treatment

○ Provide guidance for safe discharge

Management of Apnea of Prematurity

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▪ What is the solution for AoP?

Management of Apnea of Prematurity

https://sites.psu.edu/siowfa13/2013/09/15/caffeine-your-baby/https://kohanacoffee.com/blogs/news/the-magic-of-caffeine

▪ < 30 week GA

▪ Tall, Grande or Venti?

○ Loading dose: 20 mg/kg IV caffeine citrate

○ Maintenance: 5 mg/kg q24 hours IV or PO

Who will receive caffeine?

http://onwardpro.co/how-much-caffeine-in-starbucks-coffee/

For a 66 kg (145 lb) person that’s the equivalent of Starbucks Grande!!(for maintenance dosing)

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▪ “Event free observation” starts 120 hours (5 days) after last dose of caffeine

○ Infants born <30 weeks GA: 7 days

○ Infants born >30 weeks GA: 5 days

Start the Countdown (discharge)

▪ Infants born <26 weeks: d/c at 36 weeks CGA*

▪ Infants born >26 weeks: d/c at 33-34 weeks CGA

○ (both require being apnea free x3 days)

When to Stop

Management of Neonatal Abstinence Syndrome and Drug Exposed Newborns

Photo credit: https://woay.tv/west-virginia-dhhr-releases-neonatal-abstinence-syndrome-data-for-2017/

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▪ Known opiate using mothers

▪ High-risk mothers

○ h/o substance use, no/limited prenatal, characteristics associated with substance use

▪ Identify high-risk infants

○ maternal +verbal or tox screen, high-risk mother without tox screen, symptoms of NAS

○ While consent is not required, discuss with family prior to testing

■ Obtain tox screen as soon as possible after birth

Screening for Substance Use Disorders

▪ Discuss pain management for before and after delivery

▪ Give handouts to parents explaining ESC approach/ expectations for involvement

▪ Screen all mothers through interviewing

○ 4 P’s

▪ Urine tox for high-risk mothers

▪ Suggest discussion between peds/neo, MSW, parents for what to expect after delivery

▪ Consider involving psychiatry

Collaborating with Obstetricians

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▪ Methods of scoring & evaluation

▪ Non-Pharmacologic

▪ Pharmacologic

▪ Treatment of opioid withdrawal seizure

Management of NAS

▪ The “old” way

○ Finnegan scoring

○ 21 items

○ Only validated tool, but difficult to use

▪ The “new” way

○ ESC - Eat, Sleep, Console

▪ Patient should be monitored 3-5 days without symptoms, before discharge home

Methods of Scoring & Evaluation

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▪ Grossman, et al (2017) developed a new way to manage NAS infants, based on the newborn’s ability to function (eat, sleep, be consoled)

○ Eat - can the infant eat ~30 mL per feed? Can the baby have quality breastfeeding?

○ Sleep - Can the newborn sleep for at least 1 hour without waking?

○ Console - Can the patient be consoled within 10 minutes

Eat, Sleep, Console - The ESC approach

Grossman MR, Berkwitt AK, Osborn RR, et al An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360

▪ Inability to eat, sleep, console/ unresponsive to non-pharmacologic interventions may require PRN dosing of meds

○ 4 doses PRN methadone may be given before initiating scheduled methadone

▪ Why methadone?

○ Still debated

○ Longer half-life

○ Morphine is another option


Grossman MR, Berkwitt AK, Osborn RR, et al An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6):e20163360

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NO

Level Daily dose

1 0.2 mg/kg/day

2 0.4 mg/kg/day

3 0.6 mg/kg/day

4 0.8 mg/kg/day

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Minimum Observation Period

▪ Small frequent feeds with high calorie formula or breastfeeding*

▪ Rooming-in

▪ Swaddling, gentle handling

▪ Limiting external stimulation (decreased noise, minimizing overhead lights)

▪ Positioning on back or side

▪ Non-nutritive sucking

▪ Rubbing instead of patting the infant when burping

▪ Skin to skin

Nonpharmacologic Interventions

Weiss , J., & Gehringer , K. (2015, August 21). Managing NAS Scores with Non-Pharmacological Measures. Retrieved November 1, 2019, from https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1528&context=patient-care-services-nursing.

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▪ Methadone (compounded w/o alcohol) first-line drug

○ Standard 1 mg/1 mL solution

▪ Dosing frequency

○ q8 hours, or q8 hours PRN

▪ Initiation dose 0.07 mg/kg PO

○ Consider PRN start after team huddle

○ Can give 4 PRNs before scheduled dosing

■ Team huddle before EACH PRN

▪ Methadone can be increased once per day

Pharmacologic Interventions

▪ Adjunctive medication

○ Clonidine

■ May affect BP

▪ Treatment for opioid-withdrawal seizure

○ Morphine 0.1-0.2 mg/kg IV or IM

▪ Narcan is not recommended in delivery room or for any NAS baby

Pharmacologic Interventions

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▪ Management of other substance exposures

○ Suboxone, benzodiazepines, methamphetamines, cocaine, SSRIs, Marijuana, poly-substance

▪ Breastfeeding policies

▪ Adjunctive care

○ Social services

Other Topics NAS Guideline Covers...

▪ Updated May 2019

▪ Kaiser Newborn Sepsis Calculator

○ Desktop

■ https://neonatalsepsiscalculator.kaiserpermanente.org/

○ Mobile

■ http://newbornsepsiscalculator.org/

○ Or google “Kaiser sepsis calculator”

Early Onset Sepsis Screening and Management in Infants > 34 weeks

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▪ Interactive online validated prediction tool

▪ How it works

○ Specific maternal risk factors

○ Infants clinical status

○ Provides basic clinical recommendation for management based on calculated risk

■ RED, YELLOW, GREEN

Kaiser Newborn Sepsis Calculator

▪ Anyone with EOS risk factors

○ GA <37wks, ROM >18hrs, Maternal fever, chorio, GBS+, need for resuscitation/illness at birth, VS/clinical abnormalities in the first 12 hrs of life

Who gets screened?

▪ 1st HOL in infant with EOS risk factors

▪ When abnormal VS/clinical symptoms are detected

When do we screen?

Who does the screen?

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▪ Well-Appearing

▪ Equivocal

▪ Clinical Illness

○ Additional s/s to consider

■ Lethargy, apnea, metabolic acidosis, or worsening blood gases

The Clinical Exam

Equivocal Signs

▪ In the first 12 hours of life, the baby experiences either:

• Two (2) of the following abnormalities that persist for 2 hours, OR

• One (1) abnormality that persists for 4 hours

▪ Heart rate ≥ 160

▪ Respiratory rate ≥ 60

▪ Temperature ≥ 100.4F or < 97.5F

▪ Respiratory distress (grunting, flaring or retracting)

(Escobar, et al. 2014)

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Clinical Illness

▪ Persistent need for NCPAP / HFNC / mechanical ventilation (outside of the delivery room)

▪ Hemodynamic instability requiring vasoactive drugs

▪ Neonatal encephalopathy /Perinatal depression

▪ Seizure

▪ Apgar Score @ 5 minutes < 5

▪ Need for supplemental O2 > 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)

“The Calculator” – Let’s try it!

https://neonatalsepsiscalculator.kaiserpermanente.org/

▪ CASE: 39 1/7 week G3P1 presents with c/o labor. Contractions every 3 - 5 minutes. Cervical exam at 1.5 cm. BOW intact. Labors to complete in 1.5 hours. Ruptures 20 min prior to delivery. GBS negative, no antibiotics administered. Last temperature prior to delivery 98.9 degrees F.

▪ Based on the calculator, what is the baseline risk of EOS?

▪ What if the gestational is 35 1/7 weeks?

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▪ Blood culture

○ Follow Sepsis Calculator “clinical recommendation”

▪ CBC

○ Reliability and predictive value improves with increased time from birth

■ Draw CBC with culture if starting Abx

○ Low WBC concerning for sepsis

Lab Studies

Photo credit: https://www.paediatricfoam.com/blood-test/

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▪ CRP

○ Consider if infant receiving empiric abx

○ NOT useful in determining to start abx

○ Obtain at 12 and 36hrs of age**

○ Two low/decreasing CRPs and asymptomatic/improving infant d/c abx

○ Elevating/increasing CRPs - use other lab and clinical factors whether to continue or stop abx

Lab Studies, continued

▪ Lumbar Puncture

○ Infants in CLINICAL ILLNESS zone with neurologic symptoms (change in LOC, seizures, apnea in term infant)

○ Infant with positive blood culture

○ Consider LP in infants with negative BC, but are receiving abx course for sepsis

■ ONLY perform LP for infants that can tolerate the procedure

○ Abnormal results may increase abx time

Lab Studies, continued

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▪ Rule-out sepsis (timing based on blood cx)

○ Stop abx at 24 hours if asymptomatic, neg blood culture and/or normal/low CRP

■ Infant should not be d/c’d before 36-48 hours after birth

○ Stop abx at 48 hours if negative blood cultures, persistent respiratory symptoms with no apparent infection (pneumonia) and/or normal/low CRP x 2

EOS Treatment Duration

▪ Empiric treatment course (culture negative, but significant clinical illness)

○ Generally 7 days (but no strong evidence)

○ Longer course for infants with concern for/ confirmed CNS involvement

▪ Culture positive treatment course

○ Recommend pediatric infectious disease consult

EOS Treatment Duration

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▪ Empiric treatment course

○ Ampicillin & Gentamicin

▪ Culture positive identified organism

○ Modify antibiotic coverage

○ Consult pediatric infectious disease

Antibiotic Choice

Photo credit: http://whatdoctorsknow.com/antibiotics-linked-higher-food-allergies-children/


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▪ Updated in 2018

▪ Goal:

○ Encourage human milk feeding/exclusive BF

○ Avoid co-morbidities associated with inadequate feeding

○ Provide adequate intake of calories, protein, micronutrients for optimal growth

Late Preterm Infant Feeding Guidelines

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▪ Skin-to-skin

▪ Lactation Consultant

○ Offered to ALL LPI mothers

▪ Milk Expression

○ Hand expression or pump 8x/24hrs, 10-20 min

▪ Assessment of Breast Milk Transfer

○ Latch scoring, weights

▪ Assessment of Hydration Status

▪ Duration of Supplementation

Support for Breastfeeding!

photo credit: https://www.medela.com/breastfeeding-professionals/education/lactation-period/breastfeeding-positions

▪ Estimated Needs

○ 34-36 weeks

○ 37-38 weeks

○ < 3kg

○ > 3kg

▪ Expected Weight Gain

○ >2kg or 34-38 weeks

○ 0-3 months CGA

○ 3-6 months CGA

▪ For catch-up growth increase goals by 10-20%

LPI Nutritional Needs / Goals

Photo credit: https://neonataltherapists.com/the-late-preterm-infant-brain-critical-points-to-ponder/

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LPI Vitamins and Nutritional Supplements

Exclusive Breastfeeding & >36 weeks OR

Supplemented Breastfeeding / Fortified MBM

● Infant multivitamin 1ml Qday*● Fe Sulfate 2 mg/kg elemental iron

Qday if Hct <40

Full Formula Feeding

● Discharge weight <3500 grams: Infant multivitamin 1ml Qday*

● Discharge weight >3500 grams: Vitamin D 400 IU Qday (D-vi-sol)

Note: 1 ml Poly-vi-sol with iron contains 10 mg iron and no vitamin B12; it is not recommended for an infant of a vegan breastfeeding mother. In addition, it has too much iron for an infant weighing less than 5kg.

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▪ Updated 2018

▪ Objectives:

○ Standardize approach to screening and management to reduce incidence of severe hyperbilirubinemia and kernicterus while minimizing risks of unintended harm

○ Improve quality and safety of care

■ Improve recognition and efficient management of infants at high risk for complications

■ Decrease unnecessary testing

■ Deliver safe, effective, appropriate phototherapy

■ Decrease unnecessary hospital stays

○ Update hyperbilirubinemia guidelines with latest research

Hyperbilirubinemia in Neonates > 35 weeks

▪ Based on limited evidence

▪ No population-based studies

▪ No studies to allow number needed to treat (NNT)

▪ Research since 2004 suggests guideline leads to overtreatment

▪ Potential associations between phototherapy and childhood cancer and epilepsy

Concerns Regarding 2004 Guidelines

Photo credit: https://www.ucsf.edu/news/2016/05/403001/slight-increase-pediatric-cancer-risk-seen-infant-phototherapy

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▪ Blood typing

○ All newborn cord blood should be sent to blood bank, with testing in the following circumstances:

■ Rh neg mother→Rh type + direct antiglobulin test (DAT)

■ O pos mother→DAT only

● NOTE: ABO group unnecessary, does not change management (e.g. neonate is low risk if DAT negative, regardless of ABO group)

● OPTION: send cord blood to blood bank to hold on infants born to O pos mothers; order DAT (and other studies) only IF clinical jaundice is noted

■ Maternal antibody screen positive DAT

● Consider: cord blood bilirubin level

■ Maternal blood type and antibody screen unknown→DAT

Jaundice and Bilirubin Screening

▪ Transcutaneous Bilirubin (TcB) Screening

○ 24-48hrs of life in all neonates and/or prior to discharge

○ Anytime jaundice is detected

○ Earlier + more frequent screening if DAT positive

○ Frequent re-assessment if TcB close to phototherapy threshold or rapidly rising

▪ Total Serum Bilirubin (TSB) Testing

○ TcB within 3 mg/dL of phototherapy threshold

○ Consider if TcB >12-13 (TcB less accurate above this range)

○ Follow TSB if TcB >13 or if TSB has been >15 until declining

Jaundice and Bilirubin Screening

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▪ General recommendations

○ Lactation support, oral hydration

○ AGGRESSIVE MEDICAL THERAPY: for babies within 2 mg/dL of NCNC exchange transfusion threshold, or rapidly rising (>7 mg/dL in 24hrs or > 0.3mg/dL per hour)

■ Aggressive IV + PO hydration

■ Intensive phototherapy

■ Monitor TSB every 2-4 hours depending on rate of rise

■ Consult with neonatologist re: additional therapies

Treatment

▪ Basic recommendations:

○ Identify neurotoxicity risk factors:

■ Isoimmune hemolytic disease, G6PD deficiency, or other hemolytic disease

■ Sepsis or suspected sepsis (sufficient to be currently on antibiotics)

■ Acidosis (BE ≤ −8 meq/L or pCO2 >50 mmHg within the last 24 hr)

■ Albumin <3.0 mg/dL

■ Any clinical instability

Phototherapy Thresholds

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○ TSB within 1-2 mg/dL below NCNC phototherapy threshold = CONSIDER PHOTOTHERAPY

■ Optimize feeding (breastfeeding support, supplement, formula, etc)

■ Repeat TSB @ 4-24hrs (prior to discharge if during birth admission)

■ Consider phototherapy (including home phototherapy if available)

■ NOTE: NCNC threshold to initiate phototherapy is lower for younger gestational ages, rapid rate of rise, or neurotoxicity risk factors (i.e. “medium risk” or “higher risk” infants)



○ TSB ≥ NCNC threshold = PERFORM PHOTOTHERAPY

■ Start phototherapy

■ Optimize feeding

○ If there is suspicion for hemolysis or other underlying causes of hyperbilirubinemia (G6PD, sepsis, etc), it is appropriate to start phototherapy at the threshold for newborns with neurotoxicity risk factors and proceed with an appropriate work up for those causes.

○ CONSIDER: Higher threshold for readmission for phototherapy if infant at home (≥ 2-3 days of life) versus newborn at birth admission

▪ See website for calculator: www.phototherapyguidelines.com


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▪ Consultation with neonatologist when infants have bilirubin within 2 mg/dL of NCNC exchange transfusion threshold or rapidly rising (>7 mg/dL in 24 hours or >0.3mg/dL/hr), particularly in first 48 hours of life

▪ INITIAL bilirubin (e.g. no prior bilirubin measurement or intervention)

○ > 2 mg/dL above NCNC Exchange Transfusion threshold = PREPARE FOR IMMEDIATE EXCHANGE TRANSFUSION

■ Perform aggressive medical therapy as above while preparing for exchange transfusion OR initiating transfer to institution capable of performing exchange transfusion

○ 0-2 mg/dL above NCNC threshold = CONSIDER EXCHANGE TRANSFUSION

■ Aggressive medical therapy as above

■ Strongly consider transfer to institution capable of performing exchange transfusion

○ 0-2 mg/dL below NCNC Threshold

■ Aggressive medical therapy as above

Exchange Transfusion Thresholds

▪ Prior to initiation of phototherapy:

○ NOTE: For infants readmitted for phototherapy, if last TSB was >4-6 hours prior, repeat TSB

▪ During phototherapy:

○ For all infants, check TSB within 12 hours of initiation of phototherapy

■ TSB ~ q12 hours:

● No hemolytic disease or rapid rate of rise

■ TSB within 6-8 hours:

● Evidence or suspicion of hemolytic disease

● Rapid rate of rise (>7 mg/dL/24 hours or >0.3mg/dL/hr)

● Other neurotoxicity risk factors (i.e. sepis or acidosis)

■ TSB q2-4 hours:

● Bilirubin within 1-2 mg/dL of NCNC threshold for exchange transfusion

NOTE: all bilirubin monitoring during phototherapy should be done via serum bilirubin levels; transcutaneous bilirubin is not accurate

Bilirubin Monitoring

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▪ Discontinue phototherapy when TSB is at least 2-3 mg/dL below the phototherapy initiation threshold

○ Indications for longer course of phototherapy:

■ Ongoing feeding difficulty, <37 weeks GA, slow rate of decrease on phototherapy, hemolytic jaundice

Discontinuation

▪ Support breastfeeding

▪ Consider enteral supplementation with expressed breast milk, formula, etc

▪ Consider IV fluids only if close to exchange transfusion or if other indications for IV fluids

Hydration and Nutrition Considerations

▪ Indications for ordering rebound TSB:

○ Hemolytic jaundice

○ Prematurity (<37 weeks GA)

○ If phototherapy is discontinued sooner than 2-3 mg/dL below the phototherapy initiation threshold

○ If phototherapy was started prior to 48 hours of life

▪ Timing: 6-24 hours

▪ TcB may be inaccurate following phototherapy. Use TSB in this setting.

Always turn off your bili lights when drawing labs!

Rebound Bilirubin Measurement

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▪ Goals:

○ Improve recognition of infants showing symptoms of polycythemia

○ Decrease unnecessary screening

○ Provide recommendations on how to perform partial exchange transfusion safely and effectively

○ Decrease morbidity associated with unnecessary partial exchange transfusions

Partial Exchange Transfusion (PET) for Polycythemia in Newborns

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▪ Asymptomatic patients should not be routinely screened regardless of risk factors

▪ Only screen symptomatic patients for polycythemia

Who SHOULD receive PET?

▪ Do NOT perform PET in asymptomatic infant with Hct <=75%

▪ Consider PET in infants with Hct >65% who are demonstrating signs/symptoms of polycythemia

▪ Consider PET in asymptomatic infants with Hct >75%, but note there is minimal data for benefit of PET in asymptomatic infants.

Polycythemia - Who to Screen

▪ Cardiovascular symptoms (cyanosis/tachycardia)

▪ Respiratory symptoms (tachypnea, PPHN)

▪ GI symptoms (vomiting, poor feeding, distension, blood in stool)

▪ Metabolic - Hypoglycemia

▪ Hematologic - Hyperbilirubinemia, thrombocytopenia, DIC

▪ Genetic – Trisomy 21

▪ Renal – hematuria, oliguria/anuria, renal vein thrombosis

▪ CNS – lethargy, tremors, hypotonia, irritability, abnormal cry, seizures, apnea

▪ Skin – plethora, prolong capillary refill

Polycythemia Signs

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▪ Persistent hypoglycemia requiring high GIR, rapid escalation, or central line

▪ Persistent or severe respiratory distress unresponsive to routine therapies

▪ Stroke or other evidence of venous thrombosis

How to screen:

▪ Site of sampling

○ HCT varies with source of blood

■ Capillary Hct (heel stick) is 5-15% >venous.

■ Arterial Hct averages 6% <venous.

● Capillary Hct is a reasonable screening test.

Signs for which a HCT should be obtained

▪ If performing PET, please consult with you Tertiary Care center and neonatologist and consider transfer

▪ PET should be done as soon as possible in symptomatic infants

▪ Guideline also includes:

○ How to perform PET

■ Volume

■ Calculations

■ Technique

■ Monitoring

■ When to transfer

Partial Exchange Transfusion

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▪ Updated in 2018

Screening and Management of Hypoglycemia in Late Preterm and Term Infants < 34 weeks

▪ Inadequate glycogen stores

○ Small for gestational age (SGA), Intrauterine growth restriction (IUGR), Prematurity (<37 weeks gestational age), Post-term gestation (≥42 weeks gestational age)

▪ Increased glucose utilization

○ Large for gestational age (LGA), Infant of a diabetic mother (IDM), Conditions which increase metabolic demand

▪ Hyperinsulinemia

○ LGA, IUGR, IDM, Certain genetic/metabolic conditions (e.g. Beckwith-Weidemann Syndrome)

Risk Factors for Hypoglycemia

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▪ “Plasma glucose concentration below which normal brain function cannot occur”

Definition of Hypoglycemia

Committee on Fetus and Newborn. Postnatal Glucose Homeostasis in Late-Preterm and Term InfantsPediatrics 2011; 127(3); 575-9

▪ Blood glucose concentrations as low as 30 mg/dL are common in healthy neonates by 1-2 hrs after birth

▪ Low concentrations are usually transient, asymptomatic and considered to be part of normal adaptation to postnatal life

▪ Recurrent episodes of hypoglycemia are more predictive of long-term sequelae

▪ Target/goal neonatal blood glucose:

○ >/= 45 prior to routine feeds @ 0-24 hours after birth

○ >/= 50 prior to routine feeds @ >24 hours after birth

▪ NOTE: values based primarily on 2011 AAP clinical report

NCNC consensus thresholds for hypoglycemia

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▪ Who gets screened:

○ IDM

○ Growth Restricted or Macrosomic

■ Growth Restricted (<5th%)

■ Macrosomic (>97.5th%)

○ Late preterm, Post term

○ Additional considerations (polycythemia, sepsis)

Screening of ASYMPTOMATIC, at risk infants

37-37+6/7

weeks38-38+6/7

weeks39-39+6/7

weeks40-40+6/7

weeks>41 weeks

Growth restricted (<5th%) 2280 g 2470 g 2650 g 2820 g 3000 g

Macrosomic (>97.5th%) 3950 g 4180 g 4400 g 4630 g 4880 g

▪ Glucometer

○ Accuracy in low ranges depend on make/model

○ Samples should be drawn from warm heel

▪ Confirm low values with iSTAT or STAT blood sample

○ Do NOT delay treatment, consider starting treatment before labs return

Methods of Screening

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▪ General principles

○ Initial screen after first (breast)feeding (by ~1 hour after birth)

○ More frequent screening in first 2-4 hours of life, then pre-prandial screening that is roughly linked to feeding schedule

○ Stop screening at 12 hours for macrosomic, IDM infants

○ Continue screening until 24 hours for growth restricted, late preterm infants

○ Consider 36 hour screening for growth restricted, late preterm infants if glucoses consistently <45 in first 24 hours after birth

▪ Time points for Glucose Screening: ~1, 2, 4, 6, 9, 12, 24 hours unless intervention is required

Timing of Screening

▪ Consider discontinuing glucose screening prior to completion of all time points in asymptomatic infants with “stable”, “normal” glucoses in the first 24 hours after birth:

○ Glucoses >45 on 3 occasions

○ Repeat one pre-prandial glucose measurement at 24 hours after birth for growth restricted, late preterm infants

▪ NOTE: these recommendations are consensus-based; no specific evidence is currently available to support these recommendations

“Early Exit”

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▪ Breastfeeding• Expressed Maternal breast milk

‒ Consider formula after 2x breastfeeds▪ Bottle-feeding

• Donor Breast Milk• Formula

‒ Use protein hydrolysate formula (i.e. Alimentum, Nutramigen, Pregestimil) preferentially if available to reduce exposure to cow milk protein▪ 1-4 hours 10-20 mL ▪ 4-24 hours 15-30 mL

▪ If glucose low after 2 feeds, consider IV treatment

“Feed”

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▪ Inexpensive, non-invasive and easy to administer ▪ Applied to buccal mucosa for rapid correction ▪ Absorption rate is similar to IV administration ▪ Dosing is weight based (0.2g/kg = 0.5mL/kg) ▪ Promotes continued breastfeeding and maternal

bonding ▪ Decreases ICN admissions

Glucose Gel!!

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▪ Wipe inside of infant’s cheek to dry area with a 2x2

▪ Apply 0.5 ml of gel to (gloved) finger and massage into infant’s cheek for ~5 seconds

▪ Repeat procedure in other cheek; alternating in 0.5mL increments until entire dose is administered

▪ NOTE: Max 3 doses glucose gel in 24 hour period

▪ Consider IV treatment before 3rd dose if not having sequential rises in response to oral therapy

How to Administer?

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▪ Indications:

○ Glucoses not responding appropriately to oral glucose and feeding therapy

○ Persistent hypoglycemia after 3 doses of oral glucose gel

○ Any glucose <35 after 5 HOL

IV Therapy

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▪ D10W 2-3 ml/kg IV bolus, followed by:

▪ D10W @ 80 ml/kg/day (3.5 ml/kg/hr)

○ Glucose infusion rate (GIR) 5.5 mg/kg/min

○ Increase D10W in increments of 20 ml/kg/day (0.8 ml/kg/hr) if needed for persistent hypoglycemia

○ NOTE: If total fluid administration exceeds 150 ml/kg/day (6.25 ml/kg/hr), consider increasing dextrose concentration to D12.5 rather than IV rate to avoid fluid overload

▪ Continue IV treatment until glucose levels are stable >50, then wean IV gradually

NOTE: For any infant with persistent hypoglycemia, consider further evaluation for underlying etiology in parallel with treatment

IV Therapy

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UCSF NC2 Asymptomatic Infants-at risk

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85

UCSF NC2 Asymptomatic Infants-at risk

▪ Symptoms of hypoglycemia may include:

○ General symptoms:

■ Abnormal cry, poor feeding, hypothermia, diaphoresis

○ Neurologic symptoms:

■ Tremors, jitteriness, hypotonia, irritability, high-pitched cry, lethargy, seizures

○ Cardiorespiratory disturbances:

■ Cyanosis, pallor, tachypnea, apnea, cardiac arrest

Management of SYMPTOMATIC infants

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▪ “CONCERNING”

○ seizure, lethargy/poorly responsive, hypotonia, apnea, cyanosis

▪ “POSSIBLE”

○ jitteriness, tremors, irritability, exaggerated Moro reflex, high-pitched cry, poor feeding, excessive sleepiness/drowsiness

“Concerning” vs “Possible” symptoms hypoglycemia

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▪ Treatment thresholds and treatment methods are different for infants in these higher level care settings; consult neonatology for recommendations

NICU and Special Care / Transitional Care Nursery

▪ Why the change in current practice?

▪ What does the literature say?

NCNC recommends

NO routine ICSC testing

Consensus Statement for Infant Car Seat Challenge Testing

Photo credit: https://community.today.com/parentingteam/post/car-seats-and-premature-babies-coming-home

11/8/2019

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▪ The NCNC guidelines are created for use at community hospitals to provide guidance and standardization

▪ Statements are continually updated with the latest evidence

▪ Are available 24/7 at:

○ https://www.ucsfbenioffchildrens.org/neonatal_consortium/

○ https://bchsfoutreach.ucsf.edu/

In Summary...

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Northern California Neonatal Consortium Updates...Management of Apnea of Prematurity Management of...

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