First of all, we would like to thank Almighty God for His safeguard from evil things and keeps healthy during our day to day activities. Next, our sincere and deepest gratitude goes to Amare H. (Bsc, Msc) who gave us the opportunity to do this assignment which is very important to our future practice in making a good clinical audit which brings a change in the healthcare delivery. We really appreciate your commitment and assistance; we sincerely thank you. Finally, we would also like to acknowledge all group members who actively participate in this assignment.
Table of contents
Table of contents. ii
List of abbreviations. iii
Table: 1. iv
1. Background. 1
2. Justification. 2
3. Aim and objectives. 3
4. Standard: management of neonatal hypoglycemia. 4
5. Audit methodology. 6
5.1. Audit population. 6
5.2. Audit sample size and sampling technique. 6
5.3. Data collection. 6
6. Operational definitions. 7
7. References. 8
List of abbreviations
ABM Academy of Breastfeeding Medicine
D10W Dextrose 10% in water
GG Glucometer Glucose
GUH Gondar University Hospital
IDM Infant of Diabetic Mother
LGA Large for Gestational Age
NICU Neonatal Intensive care Unit
SGA Small for Gestational Age
Table: 1 clinical audit planning on the management of neonatal hypoglycemia in University of Gondar Hospital NICU, January 2, 2018.
Clinical audit planning and summary
University of Gondar Hospital
Management of neonatal hypoglycemia
Audit ref. No.
1. Enyew Getaneh
2. Mekdess Wesenyeleh
3. Gamechu Atomsa
The term “hypoglycemia” refers to a low blood glucose concentration. Clinically significant neonatal hypoglycemia reflects an imbalance between the supply and utilization of glucose and alternative fuels and may result from several disturbed regulatory mechanisms. (1)
It is one of the most common metabolic problems in neonatal medicine. Negative effects of prolonged hypoglycemia on long-term outcomes of preterm and term children include both transient and permanent structural abnormalities on brain imaging and adverse neurodevelopment outcomes. (2)
Neonatal hypoglycemia is one of the most frequently encountered problems in the first 48 h of life, and low glucose concentrations are perhaps the most common biochemical abnormality seen by providers caring for newborns. (3)
Hypoglycemia is the leading causes of term admission to neonatal units: anonymised patient-level data from neonatal admissions in England between 2011-2013 showed that hypoglycemia accounted for around 10% of term admissions, and yet the first recorded blood glucose concentration was >2.0mmol/l in 52% of cases and >2.6mmol/l in 28% of cases. One-third of cases were admitted within four hours of birth. (4)
It is also a common problem in Ethiopian newborns. A cross-sectional study conducted on newborns admitted and born in Tikur Anbassa Teaching Hospital showed that the prevalence of hypoglycemia was found to be 14.89%. (5)
According to ABM Clinical Protocol: the revised 2014 Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, breastfeeding should be initiated for Healthy, appropriate weight for gestational age, term infants within 30–60 minutes of life and continue breastfeeding on cue, with the recognition that that crying is a very late sign of hunger. Initiation and establishment of breastfeeding and reduction of hypoglycemia risk are facilitated by skin-to-skin contact between the mother and her infant immediately after birth for at least the first hour of life and continuing as much as possible. (1)
This audit is intended to provide properly, timely and regularly identification, monitoring and management protocol of neonatal hypoglycemia in the hospital to prevent the complications of severe or persistent hypoglycemia including brain injury resulting in developmental delay and learning disabilities, heart failure or seizures.
3. Aim and objectives
To improve the management of neonatal hypoglycemia in Gondar University Hospital (GUH).
To assess the current management protocol of neonatal hypoglycemia in GUH.
To compare the management protocol of neonatal hypoglycemia in GUH with the standards.
To inform the findings of the audit to relevant clinicians.
4. Standard: management of neonatal hypoglycemia
Adopted from: Neonatal clinical practice guideline in Winnipeg Regional Health Authority: Hypoglycemia in newborns
Assess and identify those at risk of hypoglycemia immediately at birth and on an ongoing basis.
Neonatal clinical practice guideline
If any of the symptoms are present, glucometer glucose (GG) is checked immediately.
Immediate GG checkup may not be necessary.
For infants with ?35 weeks gestation at birth, skin to skin care with mother and feeding by breast or 5-10 mL/kg of formula or expressed breast milk is facilitated
Indicated only for those on at risk.
Check GG at approximately 2 hours after birth, after the first feed
Check GG every 3-6 hours prior to feeds continue until 2 consecutive measurements are ? 2.6 mmol/L
If infant SGA or 35-36 weeks gestation, check GG every 3-4 hours prior to feeds for the first 36 hours
Strict follow up is required for preterm and SGA infants.
Give glucose gel 0.5 mL/kg and repeat GG 30 minutes after glucose gel
Start IV D10W at 80 mL/kg/24 hours if infant does not have an IV already
Give IV bolus D10W 2 mL/kg and repeat glucometer glucose 30 minutes after glucose gel
Infants cared for in a neonatal unit with hypoglycemia requiring IV treatment
Continue to monitor GG prior to feeds.
Maintain care in the neonatal unit until levels ?2.6 mmol/L on two consecutive GG checks and infant showing no symptoms of hypoglycemia after 6 hours of age
Assess the baby before transfer to mother/baby unit and notifies the receiving care provider of transfer
Continue to monitor blood glucose
5. Audit methodology
5.1. Audit population
The source populations for the audit are all care providers who work in the maternity ward and NICU in GUH.
5.2. Audit sample size and sampling technique
Thirty care providers will be observed. Simple random sampling technique will be employed.
5.3. Data collection
Audit proforma will be prepared as data collection tool from the standards prepared by Neonatal clinical practice guideline in Winnipeg Regional Health Authority: Hypoglycemia in newborns and direct observation of the management protocol will also be used as a data collection technique. Data is collected by audit project team from January 05- 15, 2018.
The finding will be discussed with the department of pediatrics heads, staffs, and stakeholders, then the team will present to the higher officials and concerned body of the hospital.
6. Operational definitions
Ø Babies at risk of hypoglycemia: Babies who fulfill the following criteria are considered as at risk of neonatal hypoglycemia. Large for gestational age (LGA) with birth weight greater than the 90th percentile on the infant growth chart, Small for gestational age (SGA) with birth weight less than the 10th percentile on the infant growth chart, Infant of diabetic mother (IDM) Infants at risk of having carnitine palmitoyltransferase-1 (CPT-1) deficiency, including those with known family history and all neonates of Inuit families. (6)
Ø Care providers: physician, nurse practitioner, clinical assistant/physician assistant or midwife with prescriber responsibility in the care of the newborn.
Ø Infant: the age range from birth to one year.
Ø Neonate: the age range from birth to twenty-eight days.
Ø Newborn: the age range from birth to seven days.
Ø Symptoms of hypoglycemia: jitteriness or tremulousness, apathy, episodes of cyanosis, limpness, lethargy, difficulty feeding, eye rolling/seizures, apnea or tachypnea, weak or high-pitched cry, episodes of sweating, pallor, hypothermia and cardiac failure/arrest. (6)