Can Oral Dextrose Gel Keep Infants Out of the ICU?
After an institution installed a protocol for hypoglycemia using oral dextrose gel for repletion, rates of hypoglycemia requiring NICU transfer significantly decreased—all while saving the institution $77,000 per year in medical expenses.
Journal: Journal of Perinatology (IF 2.4)
Article Year: 2024
Researchers conducted a retrospective study assessing acute asymptomatic hypoglycemia outcomes before and after implementation of a new hypoglycemia protocol at a newborn nursery. Data from healthy newborns of gestational age ≥ 34 weeks whose birth weight >2000 g and who either met high risk criteria for transitional hypoglycemia per the AAP guidelines or demonstrated clinical concerns such as excessive weight loss and/or breastfeeding insufficiency were included in the study. 655 infants met criteria prior to protocol implementation (also called the “baseline period”) alongside 3,775 infants after protocol implementation (AKA the “intervention period”). The study ran from April 2016 through March 2023. (Not terribly important but a caveat nonetheless: the study does not include results from between February 2017 and December 2017 as the institution was switching to Cerner over this period.)
Let’s dive into the study’s criteria for hypoglycemia. During both the baseline and intervention periods, serial heel sticks screened for blood glucose levels and, if <50 mg/dL, were subsequently confirmed using the glucose oxidase method. For baseline babies, infants with BG <40mg/dL were deemed hypoglycemic and thus fed either BM or formula. Simple enough, but for intervention infants, if BG <30mg/dL and aged <4 hours of life OR if BG <40mg/dL and aged 4-24 hours of life, clinicians gave 0.5 ml/kg of 40% sublingual dextrose gel then fed them bovine milk-derived newborn formula.
Comparing NICU criteria, for baseline infants, if BG dropped below 35mg/dL during the first 24h of life OR if they demonstrated three consecutive borderline BG levels between 35–39 mg/dL, they were shipped off to the NICU. For intervention infants, two BG levels <30 mg/dL within the first 4 h of life, any BG level <35 mg/dL from 4 to 24 h of life, three consecutive doses of ODG, or more than six cumulative doses of ODG warranted escalation of care. (I agree, the pathway is a bit convoluted, but fear not for the original article contains helpful flowcharts that visually depict the same info.)
The results? Regarding the primary outcome, rate of NICU admission for at-risk infants demonstrated a statistically significant decrease from 4% in baseline babies to 2% upon intervention and for those with low BG levels from 16% to 7%. Further, for intervention infants <4h of life, implementing the AAP guidelines (i.e., tolerating lower BG levels for 4-hour-olds) led to a significant drop in NICU transfers from 11% to 0% (p < 0.001) in this group, even when adjusted for risk factors and feeding modality. Intervention infants also saw no episodes of recurrent hypoglycemia throughout the study, and only three infants went on to experience single-episode self-resolving hyperglycemia (up from one infant experiencing hyperglycemia in the baseline group, albeit in the setting of a much smaller population than that of the intervention group). Cost-analysis was performed and demonstrated a dramatic $77,216 per year in medical expenses saved via prevention of NICU escalation.
The Spin: There is no shortage of research regarding OGD’s efficacy for infantile hypoglycemia, but the literature demonstrates significant variability of findings due to variability in research protocols (e.g., OGD dose, feeding frequency and type, BG screening timing). For example, other studies that demonstrated more dramatic efficacy of OGD preventing NICU admission employed infants exclusively breastfed which is independently known to improve prevention of hypoglycemia. In this study, the different BG thresholds for NICU escalation between the two groups may also confound interpretation of this study—it is unclear the extent of OGD’s ability to independently keep kids out of the NICU. Alternatives to ODG include single-dose IM glucagon which has been proven to reduce NICU escalation incidence but may cause clinically significant hyperglycemia without necessarily preventing hypoglycemic episodes down the road. In any case, this study demonstrates that both ODG and the new AAP tolerance for transitional hyperglycemia are together appropriate strategies for managing episodes of hypoglycemia in the newborn nursery, though future studies may assess the independent strength of OGD.
To read more: Batra, M., Ikeri, K., Blake, M., Mantell, G., Bhat, R., & Zayek, M. (2024). Oral dextrose gel for hypoglycemia in a well-baby nursery: a baby-friendly initiative. Journal of perinatology: official journal of the California Perinatal Association, 10.1038/s41372-024-02114-y. https://doi.org/10.1038/s41372-024-02114-y