POLICY/PROCEDURE TITLE:
INFANT OF THE DIABETIC MOTHER –
MEDICATION CONTROLLED
Women & Infant Services
RELATED TO:
[ ] Medical Center Policy (MCP)
[ ] Nursing Practice Stds.
[ x ] TJC
[ ] Patient Care Stds.
[ ] QA
[ ] Other
[ ] ADMINISTRATIVE
[ x] CLINICAL
Effective date: 03/04
Revision date: 01/04, 03/04,
04/04, 05/04, 06/05, 5/10, 7/10
Reviewed: 04/08, 5/09
Unit/Department of Origin: ISCC
[ ] Title 22
Other Approval: L&D, FMCC, Birth Center
POLICY STATEMENT:
I.
PAGE 1 OF4
To provide guidelines for early identification and appropriate management of the term
infant of a medication controlled diabetic mother.
A.
Infants of Diabetic mothers have increased incidence of:
 Stillbirth
 Congenital malformations
 Premature delivery
 Perinatal mortality
 Neonatal mortality
 Infant mortality
 Cerebral palsy
B.
Possible effects on the baby of maternal hyperglycemia:
 Fetal hyperinsulinism
 Macrosomia and subsequent birth injury
 Respiratory distress
 Hypoglycemia
 Hypocalcemia
 Hypomagnesemia
 Polycythemia
 Hyperbilirubinemia
 Thrombotic events
C.
Care of the IDM infant:
Review Maternal History
 Type of diabetes
 Degree of maternal control
 Prior OB history
 Other pregnancy complications
 Maternal medications, especially insulin or oral hypoglycemic agents.
 Intrapartum meds, glucose drip, insulin, etc.
 Fetal assessment
UCSD Medical Center
IDM – MEDICATION CONTROLLED
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In the DR, assess for:
 ABC’s
 Macrosomia
 Birth injury
 Anomalies (cardiac, musculosketetal, CNS)
 Respiratory distress
D.
Who Goes to the ISCC?
 Any symptomatic hypoglycemic infant
 Any asymptomatic infant unable to maintain adequate glucose on oral feeds
(see Hypoglycemia Policy & Procedure)
 Any infant with significant malformation
 Any birth injury causing compromise
E.
All Infants in the ISCC need:
 A physical exam by provider
 Glucose monitoring
 Ca, Mg, after 24 hrs if still in ISCC
 Bilirubin testing if indicated
 Cardiac echo if indicated (most of the Type 1 mothers have a prenatal fetal
cardiac echo)
 CR Monitor & oximeter until glucose testing complete
 Begin feeds by 1 hour of birth, and feed q 3 hours (see attached IDM feeding
guidelines – Appendix A).
F.
Glucose/Blood Sugar (BS) monitoring protocol:
Testing:
 Check BS within 30 min of delivery, at 1 hour of life, at 2 hours of
life, and thereafter ac. Infant will need 4 stable blood sugars prior to
discontinuing BS checks.
Treatment:
BS > 45
 If BS normal x4 (consecutively), no further testing required.
BS 30-45 and baby is asymptomatic
 Initiate appropriate feeding:
Breastfeeding: Put baby to breast, if breast feeds well repeat BS in 30
min
o If > 45, continue BS testing and age appropriate feeding
o If < 45 or baby not breastfeeding well give 10-15 ml standard
term formula by SNS or finger feed(may bottle feed if not able
to SNS/FF) and repeat BS in 30 min
o If < 45 after formula, transfer infant to ISCC, begin IV glucose
infusion of D10W at 4ml/kg/hr (7mg/kg/min of glucose), notify
MD, and repeat BS in 30 min
o If Not Breastfeeding: give 10-15 ml standard term formula by
bottle and repeat BS in 30 min:If > 45, continue BS testing and
age appropriate feeding
o If < 45, transfer infant to ISCC, begin IV glucose infusion of
D10W at 4ml/kg/hr (7mg/kg/min of glucose), notify MD, and
repeat BS in 30 min
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IDM – MEDICATION CONTROLLED
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BS < 30, or < 45 and baby is symptomatic
 Transfer infant to ISCC
 Administer IV glucose bolus of 2 ml/kg of D10W, and begin IV glucose
infusion of D10W at 4ml/kg/hr (7mg/kg/min of glucose), notify MD for
increased glucose requirement & schedule of glucose monitoring.
 Recheck BS in 30 min (after bolus)
o If BS > 45, re-check in 1 hr & resume q 3 hour testing
o If BS < 45, repeat 2ml/kg D10W bolus and increase D10W IV
rate by 1ml/kg/hour, repeat BS in 30 min and continue bolus/IV
increase with q 30 min BS checks until BS remains > 45.
When giving > 6 ml/kg/hr consider switching to D12.5 or the
placement of a central catheter (to allow for the infusion of an
elevated concentration of glucose) so as to avoid fluid
overload.
IV glucose weaning
 ac BS q 3 hours
 Continue or initiate q 3 hour feeds until infant is in couplet care and
feeding well
 If ac BS is > 45, decrease IV rate by 1ml/kg/hr and continue to
decrease IV rate 1ml/kg/hr thereafter for each ac BS > 45. Some very
severe hypoglycemic infants may need to be weaned more slowly.
 Once IV glucose is discontinued, continue ac testing until 3 BS values
>45 indicate infant is ready to come off treatment protocol.
Readiness for transfer to Couplet Care
 Infant stable in regard to temp, cardiovascular, bili, etc.
 Infant feeding well orally and off IV glucose.
 Infants who have not required IV glucose may be transferred to FMCC
for the final ac BS check if 2 consecutive ac BS checks are >45.
 Infants who have needed IV glucose and have had 1 normal ac BS off
IV may be transferred to FMCC to complete 2 more ac BS check.
 If the baby requires supplementation of breastfeeds, please be sure
that the FMCC staff is aware of the feeding plan.
 Documented feeding plan by provider prior to transfer.
FMCC Care
 Feeding plan established in the ISCC will be continued until the
medical team or lactation specialist re-evaluates the baby’s feeding
needs.
 FMCC RN to notify HO if ac BS < 45
RESPONSIBLE PARTY: ISCC, L&D, FMCC Staff
EQUIPMENT:
2/13/2016
Bedside glucose meter
Chlorhexidine
Gauze with tape or bandaid
Safety flow lancet
Nipple and bottle
Formula
5 French gavage tube (for finger feeding)
10 syringe (if syringe feeding)
UCSD Medical Center
IDM – MEDICATION CONTROLLED
Page 4
PROCEDURE:
Perform bedside glucose test according to Blood Glucose Test for Point of Care Policy
and Procedure
and Blood Collection Heelstick / Fingerstick Policy and Procedure.
REFERENCES:
American Academy of Pediatrics; Policy Statement: Routine Evaluation of Blood Pressure,
Hematocrit, and Glucose in Newborns (RE9322). Pediatrics. 1993; 92: 474-476.
Deacon, J. and O’Neill, P. (1999). Core Curriculum for Neonatal Intensive Care Nursing (6th ed.)
Philadelphia. WB Saunders Co.
Cornblath, M., Hawdon, J., et al. Controversies Regarding Definition of Neonatal
Hypoglycemia: Suggested Operational Thresholds. Pediatrics. 2000; 105: 1141-1145.
Cowett, R. (2002). The Infant of the Diabetic Mother. NeoReviews; 3(9), p 173-189.
Korones, S. B.; Bada-Elizey, H. (1993). Neonatal Decision Making (1st ed.) U.S., Mosby Year
Book, Inc.
Massachusetts General Hospital (1997). Infant of Diabetic Mother (Gest. Age > 37 wks) Clinical
Pathway.
Merenstein, G.B., & Gardner, S.L. (2010). Handbook of Neonatal Intensive Care. (7th ed.) St.
Louis. Mosby.
Polin, R. & Yoder, M.C. (2007). Workbook in practical neonatology (4th ed.) Philadelphia.
Saunders.
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IDM – MEDICATION CONTROLLED
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APPENDIX A
IDM in the ISCC/FMCC
Feeding Guideline
First 4 Days of Life
To be used in conjunction with IDM – Medication Controlled Policy & Procedure
I.
Method
 Direct Breastfeeding q 1-3 hrs. whenever possible (MOB to be called whenever baby
is showing signs of feeding cues)
 Cup/finger/supplemental nursing system (SNS) if supplement needed
 May bottle feed if SNS unsuccessful
 Formula babies will be bottle fed
 If breastfed infant requires supplement for:
 If asymptomatic hypoglycemia (blood sugar <45) have infant breastfeed,
and re-check blood sugar in 30 minutes.
 If BS<30 or if <45 and the infant is symptomatic, give formula.
**See Hypoglycemia Policy & Procedure and/or IDM – Medication Controlled policy &
Procedure.
II.
Nutrient
 Breastmilk
 Formula babies will receive 20 calorie term formula
 Breastfed babies needing supplementation should receive 20 calorie term formula
 Mother should be pumping minimally q 3 hrs (6-8x/24 hrs) if unable to breast feed.
III.
Frequency of Feedings
 0-24 hrs of life -- 6 - 8x
 25-48 hrs
-- 8-12x
 49-96 hrs
-- 8-12x
IV.
Quantity
 0-24 hrs of life -- 5-15 ml
 25-48 hrs of life -- 10-30 ml ad lib
 49-96 hrs of life -- 30-60 ml ad lib
V.
Evidence of Successful Feeding
 Normal blood sugar (BS) testing
 Voiding/Stooling -DOL 1 -- min. 1 void/1 stool
DOL 2 -- 2/2
DOL 3 -- 3/3
DOL 4 -- 6-8x/d
 <9%/day weight loss
 Baby content for 1-3 hrs after feeding
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