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Research Article Open Access
Neonatal and Pediatric Medicine
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ISSN: 2572-4983
Macedo Lima et al., Neonat Pediatr Med 2017, 3:2
DOI: 10.4172/2572-4983.1000140
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
A Concept Map of Neonatal Hypoglycemia
Macedo Lima G1,2*, Lima Cabral Martins ACPM1,2, Moraes Barbosa AD1,2 and Figueiredo Jr I1,2
1Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
2Maternal and Child Department, Faculty of medicine, Antônio Pedro University Hospital, Fluminense Federal University, Brazil
Abstract
Objectives: To analyze current management of neonatal hypoglycemia and establish a concept map based on
testimonials from physicians who use capillary blood glucose tests to guide management.
Methods: This was an observational, descriptive, mixed qualitative and quantitative study. A questionnaire was
administered to physicians, seeking to characterize their responses to neonatal hypoglycemia in pregnancy, labor and
delivery, and the immediate neonatal period. Data collection was performed with two groups of Brazilian physicians:
neonatologists (group GN) and pediatricians (group GP). A Likert-type scale was used to collect responses. The
Mann-Whitney test and Fisher’s exact test were used for statistical analysis of continuous and categorical variables
respectively. Statistical signicance was accepted at 5%. Principal components analysis with varimax rotation and
Kaiser normalization was used to verify the structure of question/answer factors in the two groups of professionals. A
concept map was constructed using the Cmap Tools Knowledge Kit, version 5.05.01.
Results: Of the 98 questionnaires analyzed, 34.7% were completed by neonatologists (n=34/98) and 65.3% by
pediatricians (n=64/98). Mean age in the two groups (GN and GP) was 42.4 years (SD: 11.78; 95% CI: 40.10, 44.88;
p=0.597), with a signicant difference in age in men (mean=50 years; SD: 10.35; 95% CI: 45.20, 54.90; p<0.001); 79.2%
of respondents (n=78/98) were women. Overall, 32.7% of respondents (n=32/98) claimed they did not currently work
with neonates. Respondents in GN had completed more postgraduate courses (p=0.38). The two groups responded
similarly to all questions. The responses highlighted the importance of values lower than 40 mg/dL in the diagnosis
of neonatal hypoglycemia, as well as the indication of intravenous infusion when glucose was below 40 mg/dL in
symptomatic neonates. Immediate institution of periodic capillary blood glucose measurement was recommended for
the following groups of neonates: those born to diabetic mothers, those with intrauterine growth restriction, small for
gestational age, large for gestational age, preterm neonates, septic neonates, and those with birth asphyxia.
Conclusions: Capillary blood glucose is part of routine neonatal management, especially preventive, in light of
the possibility of neonatal hypoglycemia. Our ndings highlight that, in high-risk gestational groups, the entire neonatal
team should be focused on the risk of hypoglycemia. The development of management algorithms based on the use of
peripheral blood glucose test strips has contributed to streamlining the management of neonatal hypoglycemia.
*Corresponding author: Macedo Lima G, Fluminense Federal University, Niterói,
Rio de Janeiro, Brazil, Tel: 55 21 999720893; E-mail: glauciamacedo@id.uff.br
Received October 14, 2017; Accepted November 16, 2017; Published November
27, 2017
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD,
Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat Pediatr
Med 3: 140. doi: 10.4172/2572-4983.1000140
Copyright: © 2017 Macedo Lima G, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Keywords: Hypoglycemia; Newborn; Maps; Practice guideline;
Principal components analysis
Introduction
Hypoglycemia is a matter of heated debate in neonatology,
particularly regarding its clinical denition and the optimal timing
for intervention [1]. It is noteworthy that high levels of blood glucose
can also cause damage during infant development, depending on
the preference for glycolysis, oxidative and/or ketone metabolism,
time, energy demand, deposition, etc. as discussed by Adamkin [2,3].
e current evidence base for glucose screening and treatment of
asymptomatic infants includes reducing the risk of achieving higher-
than-desirable glucose levels, which may be associated with glucose
instability and, perhaps, adverse neurological outcomes with non-
ketotic hyperglycinemia.
It is known that some neonates are more likely to develop
hypoglycemia than others [4], and that low blood glucose levels can
lead to permanent central nervous system damage [5]. e cut o
level which should prompt treatment remains unclear, especially in
asymptomatic neonates [6].
Cut o points for diagnostic and management considerations have
been discussed since the 1930s [7], including in preterm neonates
[8], the most important factor to bear in mind is that glucose meters
overestimate the actual plasma level of glucose [9]. Glucose levels in
arterial blood are 10-15% higher than in venous blood, and levels in
plasma are 10-15% higher than in whole blood [10].
In low-complexity neonatal units, screening for hypoglycemia
is done using test strips, which allow rapid bedside quantication of
glucose levels. e specimens collected for test-strip reading in standard
glucose meters are usually obtained from capillary blood. Any capillary
glucose level <40 mg/dL should prompt conrmation of actual plasma
glucose levels as soon as possible. A recent study measured capillary
blood glucose levels using three dierent glucose meters and compared
these measurements to levels quantitated by the hexokinase method.
e authors concluded that none of the devices yielded satisfactory
results. However, they noted that the overestimation of glucose levels
by these devices could enable early detection of hypoglycaemia [9].
Obtaining immediate accurate measurements of actual blood
glucose has long been dicult or even impossible in low-complexity
settings, considering that symptomatic hypoglycemia – especially in
high-risk groups – must be addressed quickly, and that the decision to
infuse glucose intravenously (or not) must be made immediately.
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD, Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat
Pediatr Med 3: 140. doi: 10.4172/2572-4983.1000140
Page 2 of 7
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
Starting from the premise that all newborns are vulnerable to
declines in blood glucose levels, we presumed that physicians acting
in the perinatal setting would be able to contribute with descriptions
of their practical attitudes toward suspected cases of neonatal
hypoglycemia, and that these descriptions could be used to develop a
owchart for management of this condition based on samples obtained
from rapid capillary blood glucose testing.
Within this context, the present study sought to construct a concept
map of neonatal hypoglycemia based on the testimonials of specialist
physicians whose management of this condition is based on point-of-
care capillary blood glucose testing.
Subjects and Methods
is was a mixed qualitative/quantitative, descriptive, observational
study. A semi-structured questionnaire was administered to specialized
physicians in order to collect information on their attitudes toward
management of neonatal hypoglycemia.
e sample included two groups
Generalist pediatricians and specialist neonatologists, all agreed to
take part in the study, in accordance with Brazilian National Health
Council Resolution No. 466/12.
e questionnaire was divided into two parts. e rst part was
designed to collect general data, including age, sex, month and year of
medical school graduation, and whether the respondent had pursued
postgraduate studies in Neonatology aer completing training in
Pediatrics.
e second part of the questionnaire was subdivided into
two stages
Eight multiple-choice questions with three to ve possible answers
each, followed by two open-ended questions. One open-ended question
inquired as to management practices for asymptomatic neonatal
hypoglycemia, regardless of cause; the second such question asked the
respondent to identify any variable they regarded as important when
deciding how to manage neonatal hypoglycemia which had not been
addressed in the questionnaire.
e questionnaire then collected information on several factors
related to neonatal hypoglycemia, including maternal problems related
to hypoglycemia (Diabetes, Hypertensive disease, Systemic disease,
Breastfeeding), delivery (Route of delivery: Vaginal, Surgical), neonatal
factors (Gestational age/Birth weight: SGA, AGA, LGA; Neonatal
conditions: sepsis, asphyxia, IUGR, congenital infections), and
analytic factors (Capillary glucose level deemed diagnostic of neonatal
hypoglycemia; Level deemed to prompt oral supplementation of
breastfeeding; Level deemed to prompt intravenous glucose infusion).
Responses were scored on a Likert-type scale {Completely disagree (1);
Disagree (2); Neither agree nor disagree (3); Agree (4); Completely
agree (5); or Never (1); Occasionally (2); Sometimes (3); Oen (4);
Always (5)}.
During the study (2013), questionnaires were delivered personally
by one of the investigators to Pediatrics and Neonatology departments
in the state of Rio de Janeiro, Brazil. Prospective respondents were
asked to reply by e-mail. ey received an example questionnaire
demonstrating how the research instrument should be completed.
roughout the data collection period, the investigator was available
to clarify any doubts regarding proper completion of the instrument.
Initially, each respondent was identied only by level of prociency
in neonatal care, divided into two groups: non-neonatologist
pediatricians (GP) and neonatologists (GN). e latter group
comprised pediatricians who had completed a residency program
in Neonatology, and/or had at least 5 years’ experience working in a
specialized neonatal unit, and/or were board-certied as neonatologists
by the Brazilian Society of Pediatrics.
e demographic variables collected were gender (male or female),
time since graduation (<10 years or >10 years), postgraduate medical
studies (residency/specialist training), setting of postgraduate studies
(university hospital or otherwise), and whether the respondent
currently works at a service that provides Neonatology training (yes
or no).
e eight statements concerning neonatal hypoglycemia were
scored from 1 to 5 on the aforementioned Likert-type scale of agreement.
e wording of questionnaire items was guided by keywords selected
on the basis of the recent literature on the topic. Multiple-choice
questions were also based on the literature [10-26].
To construct the concept map, a graphic-based tool was used
to organize and represent content. Concepts were represented by
circles or boxes, and relationships between them were denoted by
lines. Respondents’ answers to the research instrument were the basic
substrate for plotting the concept ow.
Our analysis strategy consisted of rst calculating Cronbach’s
alpha coecients, which dene the reliability of dierent respondents’
answers on the same measurement scale by displaying the mean
correlation between questionnaire items. Cronbach’s alpha values
range from 0 to 1, and are deemed to represent consistency that is
very good (>0.9), good (0.8-0.9), fair (0.7-0.8), poor (0.6-0.7), or
unacceptable (<0.6).
e Keiser-Meyer-Olkin (KMO) test measure of sampling
adequacy shows the strength of connection between variables. High
values (0.5-1.0) are indicative of appropriateness of analysis. Values
below 0.5 suggest the factor analysis may be inadequate.
Bartlett’s test of sphericity tests the null hypothesis that the
correlation matrix is an identity matrix (variables are not correlated;
correlation coecients would be zero). In this case, principal
component analysis cannot be performed. We want this test to be
signicant and have a value less than 0.05. Principal components
analysis was used to evaluate the association between the constructed
model and the degree of agreement between respondents. e core
purpose of this analysis was to establish, in a homogeneous group
with a strong correlation between variables, a coecient without the
initially existing correlation. e rst component corresponds to the
axis with the greatest variability, and the second component, to the
axis with the second greatest variability. ese exploratory models are
based on the total variance of responses, and the two rst components
explain the largest percentage of response variability. Eigenvectors
are a set of axes (components) extracted from a similarity matrix.
Eigenvalues correspond to the length of the eigenvectors, and, thus, to
their importance to explaining total variance in the data. Orthogonal
Varimax Rotation maximizes the loading of each variable onto the new
components and minimizes the number of variables that have high
loadings on each component.
Principal component analysis was used to evaluate the association
between the constructed model and the degree of agreement between
respondents. e concept maps themselves were built in Cmap Tools
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD, Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat
Pediatr Med 3: 140. doi: 10.4172/2572-4983.1000140
Page 3 of 7
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
Knowledge Kit – version 5.05.01 – Institute for Human and Machine
Cognition. A University Aliated Research Institute.
e return rate of completed questionnaires during the study period
fell short of expectations. However, there were enough instruments to
establish two groups for comparative purposes and to serve as inputs
for construction of the concept map.
Data were processed in SPSS Statistics for Windows, Version
22.0 (Armonk, NY: IBM Corp.). Continuous variables were evaluated
descriptively to yield means, medians, standard deviations, variance,
and ranges (minimum and maximum). e quantitative continuous
variables of interest were age (in years), time since completion
of medical training (in years), and ordinal responses to the eight
questionnaire items on hypoglycemia (scored on a scale of 1 to 5).
e Kolmogorov-Smirnov or Shapiro-Wilk methods were used as
appropriate to test for normality of data distribution in both groups
(GP and GN), and ranked means of these variables were compared by
the Mann-Whitney U test. To test for association between categorical
variables, the chi-square test and Fisher’s exact test were used. e
signicance level was set at 5% for all hypothesis tests.
Divergence in answers to the eight questionnaire items was
observed and the two groups were separated to test for associations
and examine percent agreement and disagreement, mode, mean, and
standard deviation in each group.
Using the principal components analysis method, a model was
constructed for probabilistic weighting of variables related to the full
set of questions about neonatal hypoglycemia and cluster analysis
of responses regarding blood glucose cut o levels, routes of glucose
administration, variables related to intrauterine growth, and maternal
and delivery variables. e soware was set to describe coecients
using the Pearson correlation matrix and conduct Kaiser-Meyer-Olkin
(KMO) and Bartlett tests. For extraction, a table was created showing the
variance explained by each set of answers, for eigenvalues >1. Varimax
rotation was selected and results were ranked by weight. Values below
0.66 were suppressed in the interest of clarity and better visualization.
To facilitate analysis, the soware was set to generate factor loadings
(including plot generation) only on the rst two components.
Results
Of the 223 questionnaires sent out, 98 were completed and
returned; 34.7% were completed by neonatologists (GN=34/98) and
65.3% by generalist pediatricians (GP=64/98).
e mean age of respondents across the two groups was 42.4
years (SD: 11.66; 95% CI: 40.10, 44.78), with no signicant dierence
in ranked means between the two groups (GN mean=42.91; GP
mean=42.19; p=0.597).
Regarding gender, 79.6% of respondents (n=78/98) were female.
ere was a signicant age dierence between men and women (male
mean=50.05, SD=10.35; 95% CI: 45.20, 54.90; female mean=40.49,
SD=11.22; 95% CI: 37.96, 43.02; p<0.001). ere was no association
between gender and group allocation (p=0.431). ere was also
no signicant between-group dierence (p=0.455) in time since
graduation (GN mean=17.88; GP mean=16.47).
Overall, 84.7% (n=83/98) of respondents claimed to have completed
a residency program and 75.5% (n=74/98) claimed to be board-certied
in Pediatrics and/or Neonatology by the Brazilian Society of Pediatrics.
ere was a signicant association between belonging to either group
(GP=25/34; GN=58/64) and having completed residency (p=0.038), as
well as a signicant association between being board-certied by the
Brazilian Society of Pediatrics and belonging to group GP (n=58/64).
Table 1 reports the main results for the two groups. e reliability
of responses was acceptable (GN=0.814; GP=0.793). As shown by
the median and mode, both groups provided bery similar responses.
Regarding maternal problems, nearly 100% of respondents agreed with
blood glucose controls in case of diabetic mothers (GN=fabs 34/34,
median 5.0, mode 5; GP=fabs 60/64, median 5.0, mode 5); conversely,
few believed that route of delivery should mandate screening
(GN=median 1.0, mode 1; GP=median 2.0, mode 1). All major
neonatal problems, except for congenital infections, were also highly
regarded (GN=median 3.0, mode 3; GP=median 3.0, mode 3). Both
groups chose 20 mg/dL as the cuto for administration of IV dextrose
(GN=median 5.0, mode 5; GP=median 5.0, mode 5), and believed
that higher blood glucose values should prompt oral intervention for
prevention and/or treatment of neonatal hypoglycemia (GN=median
4.0, mode 4; GP=median 4.0, mode 4).
e Kaiser-Meyer-Olkin measure of sampling adequacy and
Bartlett test (GN=0.586/p=0.000; GP=0.586/p=0.000) supported
the use of principal components analysis on this database. All
measurements clearly showed that the two rst components explained
65.52% to 100.00% of absolute variance in GN and 65.52% to 100.00%
in GP, respectively.
In both groups, the contribution of each component showed
consistency between the loaded values and the absolute frequencies of
each item answered, both for the rst (1C) and for the second (2C)
component. Unlled elds corresponded to factor loadings <0.66.
ere was also an evident lack of correspondence of loadings in GN,
both regarding maternal diabetes – which respondents unanimously
(34/34) agreed should prompt blood glucose controls – and regarding
cuto blood glucose values that should prompt oral feeds and IV
dextrose. High factor loadings (>0.66) and a slightly higher variability
of responses in GN might explain these higher loads of responses
regarding blood glucose values >50 mg/dL.
In the subjective portion of the instrument, with open-ended
questions, when respondents were asked to describe their immediate
management of asymptomatic neonatal hypoglycemia, as determined
by a low capillary blood glucose measurement during rooming-in,
regardless of cause, GP responses agreed with GN responses regarding
encouragement of breastfeeding and/or complementary oral formula/
pasteurized pumped breast milk, in addition to measuring blood
glucose again aer management.
When asked whether any variables other than those covered in the
research instrument were important when deciding how to manage
neonatal hypoglycemia, and, if so, to describe these variables in their
own words, just over 26% of GN respondents and more than 53% of GP
respondents replied that no additional variables were needed other than
those already covered in the questionnaire. Among those who replied
that other variables were relevant, most noted that consideration of
the clinical picture/symptoms and of the possible causes of neonatal
hypoglycemia were important variables when deciding how to manage
such episodes.
e concept map constructed from the responses of physicians
involved in neonatal care is shown in Figure 1.
is map was constructed using pooled data from both groups, as
their responses were highly similar.
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD, Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat
Pediatr Med 3: 140. doi: 10.4172/2572-4983.1000140
Page 4 of 7
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
Groups GN (n=34) GP (n=64)
Cronbach’s alfa 0.814 0.793
KMO/B 0.586/p=0.000 0.628/p=0.000
Variable N(fabs) Median/Mode 1 C 2 C N(fabs) Median/Mode 1 C 2 C
Maternal problems ACG ACG
Diabetes 34/34 5.0/5 - - 60/64 5.0/5 0.968
Hypertensive disease 6/34 3.0/3 0.971 9/64 3.0/3
Systemic disease 8/34 3.0/3 0.927 8/64 3.0/3 0.878
Breastfeeding 2/34 3.0/3 0.782 3/64 2.0/2 0.880
Delivery route NCG NCG
Vaginal 21/34 1.0/1 0.913 34/64 1.0/1 0.905
Surgical 17/34 1.5/1 0.913 27/64 2.0/1 0.905
Weight-for-GA ACG ACG
SGA 30/34 5.0/5 0.845 50/64 5.0/5 0.844
AGA 2/34 2.0/2 0.964 2/64 2.0/1 0.992
LGA 30/34 5.0/5 0.842 56/64 5.0/5 0.875
Gestational age ACG ACG
<34 weeks 31/34 5.0/5 0.917 53/64 5.0/5 0.677
34-36 weeks 23/34 5.0/5 0.91 25/64 4.0/4 0.879
37-40 weeks 2/34 2.0/1 0.845 2/64 2.0/2 0.839
>40 weeks 1/34 1.5/1 0.847 3/64 2.0/2 0.716
Neonatal problems ACG ACG
Likely sepsis 21/34 5.0/5 0.696 46/64 5.0/5 0.875
Asphyxia 19/34 5.0/5 0.756 33/64 5.0/5 0.724
IUGR 27/34 5.0/5 0.881 33/64 5.0/5 0.925
Congenital infection 5/34 3.0/3 0.875 13/64 3.0/3
Hypoglycemia DV DV
<20 mg/dL 28/34 5.0/5 0.94 48/64 5.0/5 0.896
20-39 mg/dL 27/34 5.0/5 0.953 43/64 5.0/5 0.888
40-50 mg/dL 3/34 4.0/4 14/64 4.0/4 0.866
>50 mg/dL 2/34 1.0/1 0.77 3/64 2.0/1 0.860
ABM or PBM PO PO
<20 mg/dL 9/34 1.0/1 0.783 20/64 2.0/1 0.872
20-39 mg/dL 22/34 5.0/5 0.791 26/64 4.0/5 0.878
40-50 mg/dL 8/34 4.0/4 19/64 4.0/4 0.853
>50 mg/dL 2/34 2.0/1 0.912 8/64 2.0/1 0.850
IV glucose TA TA
<20 mg/dL 31/34 5.0/5 0.695 57/64 5.0/5 0.868
20-39 mg/dL 8/34 4.0/4 0.819 26/64 4.0/4 0.717
40-50 mg/dL 2/34 2.0/2 0.729 8/64 2.0/2 0.893
>50 mg/dL 2/34 1.0/1 0.885 1/64 1.0/1 0.863
Principal components analysis. Varimax rotation with Kaiser normalization. Factors extracted on the basis of eigenvalue >1. Cronbach: Cronbach’s alpha; KMO/B: Kaiser-
Meyer-Olkin/Bartlett tests; N(fabs): frequency of agreement; 1 C: Factor Loading of First Component; 2 C: Factor Loading of Second Component; ACG: Always Control
Glucose; NCG: Never Control Glucose; GA: Gestational Age; IUGR: Intrauterine Growth Restriction; SGA: Small for Gestational Age; AGA: Adequate for Gestational Age;
LGA: Large for Gestational Age; DV: Diagnostic Value for Hypoglycemia; ABM or PBM: Articial Baby Milk or Pumped Breast Milk; PO: per os; IV: Intravenous; TA: Treat
Always at this Cutoff Level.
Table 1: Agreement, Cronbach’s alpha coefcients, and two principal components solution with KMO/Bartlett statistics in the neonatologist (GN) and pediatrician (GP)
groups.
Proper assistance at the time of delivery is essential, as low vitality
(perinatal asphyxia) is associated with hypoglycemia. e pathological
changes caused by neonatal asphyxia can oen cause derangements in
glucose metabolism. Anaerobic glycolysis supervenes, with a decline in
energy production and increased glucose consumption. ese neonates
oen feed less and consequently absorb less nutrients, becoming more
susceptible to hypoglycemia aer rapid depletion of glycogen stores
[27,28].
Magnetic resonance imaging (MRI) suggests that the occipital
lobe may be particularly vulnerable to insults caused by hypoglycemia.
Other cerebral complications involve global visual perception (areas
within the dorsal visual cortex) and problems of executive function
(skills essential for learning, interaction with the environment, working
memory, reasoning, task switching, and problem-solving). At age 2
years, these neonates exhibit higher rates of sensorineural involvement,
processing diculties, and multiple secondary problems related to
growth and development. erefore, providers involved in neonatal
care must be ever vigilant to any potential inability of newborns to
consistently maintain preprandial glucose concentrations >50 mg/dL
up to 48 h of age and >60 mg/dL aer 48 h of age [1].
Discussion
Assessment of the clinical practices of physicians who provide
perinatal care revealed that both those trained as generalist pediatricians
and those trained as specialist neonatologists respond similarly to
neonatal hypoglycemia.
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD, Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat
Pediatr Med 3: 140. doi: 10.4172/2572-4983.1000140
Page 5 of 7
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
Among maternal problems occurring in the prenatal period
that should prompt periodic blood glucose controls in the neonate,
diabetes was cited most oen by respondents in both groups. Some
studies have reported improvements in the management of diabetes
with more appropriate drug combinations8, new proposed therapeutic
approaches [12] and even development of screening methods for
gestational diabetes [13]. ese advances are necessary, as glucose
imbalances during pregnancy can cause irreversible damage to the
fetus and newborn, neonatal hypoglycemia remains a leading cause
of morbidity [14]. Although neither group demonstrated a direct
concern with hypertensive disease of pregnancy, studies have raised
concerns regarding increasing body mass index in pregnant women
[15], and it is becoming increasingly clear that obesity and diabetes
go hand in hand [16]. It is also important to address the relationship
between pregnancy-induced hypertension and disorders of fetal
development, from intrauterine growth restriction (IUGR) [17,18] to
neonates large for gestational age (LGA) [19] and even preterm birth
[20,21] all of which facilitate the development of hypoglycemia. In
their answers to the open-ended questionnaire items, the respondents
also noted maternal medication use as an important factor, as many
drugs (beta blockers, chlorpropamide, tocolytics, benzthiazide) can
suppress the catecholamine response and prevent glycogenolysis,
or stimulate the pancreatic beta cells. An even greater concern is the
growing use of antidepressants during pregnancy, which may be
facilitating the development of neonatal hypoglycaemia [22]. Aer
birth, breastfeeding-related problems must be prevented, as they can
be a cause of metabolic disorders, including derangements in blood
glucose. is could be prevented by strict hypoglycemia prevention
protocols [23] or by existing, well-established programs (kangaroo
mother care) [24].
e mode of delivery had no inuence on the decision to screen
for hypoglycemia. Conversely, most respondents in both groups would
never request blood glucose controls on the basis of this factor alone.
ere was no surprise regarding management of SGA [16] and LGA
[17] neonates: respondents’ practices conrmed that inadequacy for
gestational age raises concerns with regard to hypoglycemia. Likewise,
preterm birth (<37 weeks GA) was concerning to all respondents as
a driving factor of hypoglycemia. Responses showed that, in clinical
practice, there is a trend to prescribe blood glucose controls when
neonates are born premature. GP respondents were more concerned
with the need to control blood glucose in preterm infants born at <34
weeks, whereas in GN respondents, the preferred cut o point was 37
weeks.
In both groups, when inquired as to the role of continuous blood
glucose control in the presence of neonatal morbidity, sepsis was the
situation most likely to prompt glucose measurement orders, despite
wide variance in responses. is was to be expected, as sepsis and
asphyxia are the leading causes of interfacility transfer of neonates
[25]. Secondary but still great importance was assigned to asphyxia
and intrauterine growth restriction, while in utero infections were
mentioned but less likely to prompt concern. It bears stressing that
perinatal asphyxia, especially in neonates with intrauterine growth
restriction, leads to poor metabolic adaptation in the rst hour aer
birth [26].
Most physicians in both groups dened hypoglycemia as a blood
glucose level <40 mg/dL, although they highlighted the importance
of assessing the clinical picture/symptoms as well as blood glucose
measurements alone to ensure more eective measurement. ere
is an increasing concern with optimal cuto values for diagnosis
of hypoglycemia and initiation of therapy, as the plasma glucose
concentration associated with neurological damage is still unknown
[25], although said damage is known to be permanent [5]. us, the
current trend would be to consider a diagnosis os hypoglycemia at
relatively higher glucose levels (<2.6 mmol/L or 47 mg/dL) [27]. So as
to select a wider population for intervention and decrease the likelihood
of failing to treat neonates who may develop future morbidity as a
result of undiagnosed hypoglycemia. Within this context, it bears
stressing that point-of-care test strips are known to overestimate
serum glucose levels [9], which should be taken into account when
addressing potential cases of hypoglycemia. Respondents revealed
Figure 1: Concept map of respondents’ answers to the research instrument (groups GN and GP).
BF: Breastfeeding; CBG: Capillary Blood Glucose; DM: Diabetes Mellitus; GA: Gestational Age; IUGR: Intrauterine Growth Restriction; IV: Intravenous; LGA: Large
for Gestational Age; PBM: Pumped Breast Milk; SGA: Small for Gestational Age.
Citation: Macedo Lima G, Lima Cabral Martins ACPM, Moraes Barbosa AD, Figueiredo Jr I (2017) A Concept Map of Neonatal Hypoglycemia. Neonat
Pediatr Med 3: 140. doi: 10.4172/2572-4983.1000140
Page 6 of 7
Neonat Pediatr Med, an open access journal
ISSN: 2572-4983
Volume 3 • Issue 2 • 1000140
that, in clinical practice, they tend to prescribe complementary oral
feeding when blood glucose is 20-50 mg/dL in asymptomatic infants,
while prescribing IV dextrose in cases of blood glucose <20 mg/dL,
regardless of the presence of symptoms, or <40 mg/dL in the presence
of symptoms. It should be noted that the proportions of responses in
the GN group were in agreement as to this concept of prescribing oral
feeds vs. IV dextrose.
Several problems were encountered when conducting this study.
ese included resistance to diagnosing hypoglycemia on the basis
of capillary blood screening alone, considering that most clinical
algorithms mandate peripheral rather than capillary blood collection.
Traditionally, glucose measurements in peripheral blood are considered
the standard to dene bedside management. However, it is known
measurements in plasma from freshly centrifuged blood obtained
from a central venous catheter would be the gold standard for accurate
conrmation of low glucose levels. Other challenges included the low
response rate, which led to a sample size insucient for generalization
of our ndings. We believe that, in view of the small sample size, some
statistical tests may have behaved unexpectedly. e most rewarding
part of this study was the construction of a concept map based on the
opinions of experienced providers, which demonstrated the simple
response required in an oen harrowing clinical event (neonatal
hypoglycemia).
In conclusion, our ndings highlight the fact that, in high
gestational risk groups, the entire neonatal care team should be focused
on the risk of hypoglycemia. e use of certain specic drugs during
pregnancy should raise red ags of this risk. e development of an
algorithm for neonatal hypoglycemia management based on peripheral
blood samples and bedside screening using test strips and glucose
meters could contribute to streamlining management of neonatal
blood glucose levels. Based on the experience of our respondents,
we were able to conclude that intravenous glucose infusion is always
indicated in cases of capillary blood glucose <20 mg/dL, regardless of
the presence of symptoms, or <40 mg/dL if symptomatic.
What is already known on this topic:
• Hypoglycemia in newborns causes permanent damage to the
central nervous system.
• Problems related to pregnancy, birth conditions, and neonatal
and postnatal morbidity are all implicated in the development of
neonatal hypoglycemia.
• Although there is no consensus about the optimal serum glucose
cuto levels which dene hypoglycemia, procedures to address low
blood glucose in newborns (glucose gel) have been implemented at
several maternity facilities.
What this study adds:
• e presence of glucose disorders, feeding/dietary disorders, and/
or the use of specic drugs during pregnancy should alert the perinatal
care team to the risk of neonatal hypoglycemia.
• e development of neonatal hypoglycemia management
algorithms based on the use of peripheral blood glucose test strips can
contribute to streamlining the management of neonatal blood glucose
levels.
• In our respondents’ experience, intravenous glucose infusion
is indicated whenever blood glucose is <20 mg/dL, regardless of the
presence of symptoms, or <40 mg/dL when symptoms are present.
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