Oral Dextrose Gel Reduces the Need for Intravenous Dextrose Therapy in Neonatal Hypoglycemia
Literature review
The article, “Oral Dextrose Gel Reduces the Need for Intravenous Dextrose Therapy in Neonatal Hypoglycemia”, is a retrospective chart review that was performed after a quality improvement project at the Regional Perinatal Center at the Women and Children’s Hospital in Buffalo, New York, and its associated nursery at Millard Fillmore Suburban Hospital. The objective of the study was two-fold. Primarily, the study examined the impact on neonatal intensive care unit (NICU) admission rates related to the need for 10% dextrose. Secondly, the study determined whether feeds in combination with 40% dextrose gel were more or less effective in treating neonatal hypoglycemia during the first 48 hours of life than feeds alone. Other objectives measured were the economic impact of 40% dextrose, and breastfeeding exclusivity at the time of discharge. The primary indication of treatment failure was transfer to the NICU for intravenous (IV) dextrose therapy.
Research method
The study was performed as a retrospective chart review, with regards to a quality improvement project. The primary outcome desired was to have less NICU admissions, which decreased skin-to-skin care between mother and newborn, increased costs related to hospitalization, and led to a decline in breastfeeding exclusivity at discharge. A new algorithm was defined for treating hypoglycemic babies with the first condition relying on symptoms. If the newborn was symptomatic, clinical management remained unchanged and the patient received a mini-bolus of 10% dextrose IV. If the patient was asymptomatic or at risk for hypoglycemia and asymptomatic, they received a 0.5 mL/kg dose of 40% dextrose applied to the buccal tissue for a maximum of three doses. Ultimately, if the newborn didn’t respond to the oral dextrose, they transferred to the NICU for the initiation of 10% dextrose IV.
The new protocol was introduced with an exhaustive process including a multidisciplinary committee, pharmacy reconciliation and packaging, and mandatory education sessions for nurses. The primary shortcoming of this research lies in the context of documentation. There were two populations, one in which feeds alone were attempted to increase blood glucose (05/01/2014 to 10/31/2014), and the other after the initiation of oral dextrose in combination with feeds to treat low blood sugars (11/01/2014 to 04/30/2015). The pre-intervention data was collected ex post facto, and before the grand rounds provided regarding hypoglycemia. The second population data was collected in real time and after exhaustive education regarding hypoglycemia, prospectively. A study reviewing the implementation of a quality improvement project lends to design bias, in that there is no data to collect prospectively until there is a designated procedure to move forward with. Rawat et al. (2016) did well to eliminate sample bias by considering all babies that were born between the time frame, creating a cohort population.
There were safety protocols implemented in the algorithm to protect the patients. For instance, if the baby’s glucose level ever fell below 25 mg/dl, then the baby was automatically transferred to the NICU for IV dextrose therapy. Also, even if the baby hadn’t received their third dose of oral dextrose, when they reached 48 hours of age they were no longer considered a candidate for oral dextrose. This is due to the change in physiological needs for babies at that age, in which glucose needs increase to 60 mg/dl compared to previously required 47 mg/dl. Babies that are past 48 hours old and persisting low blood glucose levels are at risk for persistent hypoglycemia which is not determined to be a part of this study. I believe that their methodology was impeccable in protecting the safety of their patients.
Results of Study
In conclusion, oral dextrose gel was more effective in raising glucose concentrations than without, decreased NICU admissions, decreased physician and hospital charges, and increased breastfeeding exclusivity at the time of discharge. The 40% dextrose gel raised glucose levels in 74% of the asymptomatic hypoglycemia babies, up from 58% with feeds alone. NICU admissions for IV dextrose therapy dropped from 42% pre-intervention to 26% post-intervention, proving the objective of the study satisfactory. Costs for treating asymptomatic hypoglycemia differed substantially; a hospitalization requiring oral dextrose gel had a mean cost reported to be $5,037, whereas NICU admission for IV dextrose therapy mean cost was reportedly $31,820. Lastly, the percentage of babies that were being exclusively breastfed climbed from 19% to 28% prior to discharge, largely due to rooming-in with the mother and continuity of skin to skin care.
Most of the babies given oral dextrose responded satisfactorily within the maximum doses allowed, three doses. Of the 250 patients, only 26% of them required IV dextrose due to not responding to the dextrose gel adequately. There were no adverse events or poor outcomes secondary to oral dextrose gel, including unintended hyperglycemia. Upon review, the babies that did not respond to oral dextrose, they were more likely to be large for gestational age, have lower blood glucose levels prior to intervention, or to be delivered by cesarean section (Rawat et al., 2016).
Implications for Nursing
This study supports protocol implementation that protects family centered care. With small healthcare centers that do require a transfer to the NICU for IV dextrose therapy, babies spend less time with the mother which inhibits skin to skin care and breastfeeding. Since some mothers can take days to express enough colostrum to support glucose requirements for their newborns, this study shows the importance of treating asymptomatic babies that are simply at risk for low blood glucose levels, and before the babies become symptomatic. Nurses should also be careful to use objective assessment data in determining whether a baby is symptomatic or not for hypoglycemia. This study did not state what symptoms qualified the babies for immediate transfer to the NICU for IV dextrose therapy. There were no adverse outcomes associated with the administration of oral dextrose in this study, so due to its cost effectiveness and low risk for harm, oral dextrose is undeniably useful in combination with feeds to decrease NICU admissions related to IV dextrose administration.
Interest
I found the statistical significance of the results in this study to be resounding. All the objectives that were defined by the study had marked improvement. With such a low-risk intervention and positive outcomes, babies in the first 48 hours of life stand a better chance to stay roomed-in with their mother. If there are any measures that can be taken to promote skin to skin care and easing transition into extra-uterine life, I believe they benefit the family unit, the mother and the baby. This study was the first to implement the protocol in the United States and to report their findings. I think the oral dextrose gel has an overlooked place in underserved communities with little resources and babies that are vulnerable to untreated hypoglycemia. According to Rawat et al., (2016), the cost per dose is approximately $1 per dose. As a very new approach to treating neonatal hypoglycemia, I agree with the Rawat et al., (2016) in that more research and reporting is needed to ensure patient safety and favorable long term outcomes, but that it shouldn’t be overlooked as a meaningful intervention to be used today.