In the ongoing story of how and when to treat lower than average blood sugars in at-risk newborn infants, some clarity for some points is emerging.
We know the following:
1. some babies have lower blood sugars than others (!)
2. some babies with prolonged very low blood sugars have poor long term outcomes
3. more minor “hypoglycemia” has statistical associations with poorer outcomes, but we have no idea if this is causative.
4. Being in an at-risk group increases risk of poor long term outcomes, even if you are never documented to be hypoglycemic.
4. we have no idea if aggressive blood sugar monitoring and intervention for lower than average blood sugars improves outcomes. The best data we have (from Harding’s group in New Zealand) suggest the opposite, they found no detectable benefit of being ‘aggressive’) See this blog post for a longer discussion
5. Babies with low blood sugars might have multiple interventions, be separated from their mothers, have their breast-feeding interrupted, have multiple painful heelstick procedures, and end up in the NICU with an iv infusion, and with parents who think their babies are abnormal.
5. We should as a result minimize potential harms from our monitoring, while ensuring safe blood sugar concentrations.
The glucose gel approach first studied in the Sugarbabies trial from New Zealand at least decreases the harms of treatment, and it is now clear that that benefit can be achieved in other centers.
Makker K, et al. Glucose Gel in Infants at Risk for Transitional Neonatal Hypoglycemia. American journal of perinatology. 2018. This US study showed a reduction in glucose infusion rates, which in their hospital also required an NICU admission, and greatly increased hospital charges. The article includes a figure showing their protocol (the figure is a bit confusing as it shows both the before and after protocols, but with a bit of persistence you could create your own protocol from it).
Rawat M, et al. Oral Dextrose Gel Reduces the Need for Intravenous Dextrose Therapy in Neonatal Hypoglycemia. Biomed Hub. 2016;1(3). This is a report from Buffalo NY, which is freely available on-line and which showed a reduction in dextrose infusions and which also includes their protocol.
Ter M, et al. Implementation of dextrose gel in the management of neonatal hypoglycaemia. Journal of Paediatrics and Child Health. 2016. This study from Melbourne also showed a reduction in dextrose infusions, and describes their protocol, but doesn’t have a pretty coloured figure like the one from Buffalo.
Coors SM, et al. Prophylactic Dextrose Gel Does Not Prevent Neonatal Hypoglycemia: A Quasi-Experimental Pilot Study. The Journal of pediatrics. 2018. In this study the authors tried to prevent hypoglycemia, they selected some at-risk infants and gave them oral glucose gel after the first feed, but the incidence of hypoglycemia and NICU admission was the same between groups.
These oral gels are easily available as they are used by diabetics for hypoglycemic episodes, unfortunately they all have colorants, artificial flavours and other additives that our babies could do without, but a single use, or occasionally 2 or 3 uses, will probably not cause any harm to a full term baby. A preparation designed in a single dose sachet without additives for full term babies could probably have a big market. If anybody reads this and decides to create such a product, I expect a cut of the profits!
Neonatal Research 
I think a company called Sandbox medical makes the single dose applicator
Damn, there goes my last chance to make a fortune.
The Sandbox Medical product, SugarUp, comes in a 15 ml cup and is, indeed preservative-free. It’s much thinner than the Glutose that we’ve been using and easy to draw into a syringe. Their new 2.25 ml prefilled syringe (what I’ve been waiting for) does have preservatives :(. They also advertise the product as xanthum gum-free (the ingredient in Simply Thick implicated in causing NEC).
Discontinued unfortunately
Indeed. Dr. Barrington can go after that fortune after all. In the meantime, back to preservatives, which are hopefully insignificant in the doses prescribed.
Keith…great review…as always! We will incorporate your commentary as the Perinatal Quality Collaborative of North Carolina (PQCNC) continues in its development phase of our Newborn Hypoglycemia Prevention and Care (NHPC) initiative. We will be including glucose gel for treatment of hypoglycemia as a potentially best practice for hospitals to consider. This is an initiative now being considered by our Expert Team, which will meet next on May 15th via Web Ex. We are inviting hospitals and state perinatal quality collaboratives nationally (US) and internationally to participate. PQCNC supports facilitation of the Expert Team and the execution of the project. The Expert Team currently includes 60 members…parents, providers of all types from newborn and NICU care areas, payers, purchasers, pharmacists, lactation consultants, public health officials as we create our NHPC action plan and key driver diagram. Interested parties are welcome to offer their input to the Expert Team. Sign up at https://www.pqcnc.org/node/13901!
We believe hypoglycemia offers tremendous challenges, but also opportunity…to standardize care, within and across hospitals, to promote mom-baby bonding, to support breastfeeding, to reduce escalation of care and need for transfers to special care nurseries and NICUs.
Thank you Keith for your commitment to plain presentations regarding the evidence, and lack thereof, in the care we provide newborns.
Thanks for the comment Marty, although as I said I don’t think, for the majority of babies who will receive a single dose of gel, or sometimes 2, that the excipients in the gel are a huge problem. The quantities of food colourings, flavours, preservatives and even a tiny bit of phthalates are probably tolerable. But it turns out there are alternatives! This one for example http://www.sandboxmedical.com/sugarbabies_product.html and there is a European product in development called Dexproneo that should be available soon.
For preterm babies I would be happier to have a reduced excipient, or excipient-free, product, so these alternatives could extend the protocols to smaller babies.
By the way, I have no conflict of interest in making this comment!
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