The Impact of Implementation of Oral Dextrose Gel on the Incidence of Multiple Hypoglycemia Events in the Well Newborn Nursery

The Impact of Implementation of Oral Dextrose Gel on the Incidence of Multiple Hypoglycemia Events in the Well Newborn Nursery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Impact of Implementation of Oral Dextrose Gel on the Incidence of Multiple Hypoglycemia Events in the Well Newborn Nursery Lakshmy Vaidyanathan, Davika Reid, Yingchao Yuan, Alan Groves This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3912442/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jun, 2024 Read the published version in Journal of Perinatology → Version 1 posted 9 You are reading this latest preprint version Abstract Objective: Evaluate the impact of 40% oral dextrose gel (DG) for management of neonatal hypoglycemia (NH) on the incidence of multiple hypoglycemic events in the well-baby nursery. Study Design: A retrospective chart review of 738 at-risk infants in 2 cohorts before (Cohort 1) and after (Cohort 2) DG implementation. Primary outcome was the incidence of ≥2 hypoglycemic episodes. Secondary outcomes were median number of hypoglycemia events per infant, lowest median glucose level, and incidence of NICU admission. Results: There were 384 and 354 at-risk newborns in Cohorts 1 & 2. Incidence of multiple hypoglycemia episodes decreased following DG implementation [62(42.5%) vs 29(25.9%), p =0.0058]. Median (range) number of hypoglycemic episodes per infant also decreased [1 (1-6) vs 1 (1-5), p =0.046]. There were no differences in lowest glucose level [37 (14-45) vs 37 (10-45), p =0.31] or NICU admission rate [31 (21.2%) vs 21 (18.8%), p =0.62]. Conclusions: Implementation of DG lowers the incidence of subsequent multiple hypoglycemia events. Health sciences/Medical research/Outcomes research Health sciences/Health care/Paediatrics Figures Figure 1 Introduction Glucose is the main energy source for the newborn brain, such that recurrent and sustained periods of neonatal hypoglycemia (NH) can lead to neuronal injury. 1,2 Screening of newborns at risk for developing hypoglycemia and timely treatment for those who develop hypoglycemia is accepted as best practice. 3,4 Our institution has had a long-standing, robust newborn hypoglycemia management protocol in the well-baby nursery. Our protocol, which closely follows The American Academy of Pediatrics (AAP) recommendations, 3 aims to achieve prompt and effective correction of hypoglycemia, preservation of breastmilk feeding, and parent satisfaction. Maternal expressed breast milk and pasteurized donor human milk are recommended as the first line for supplemental feeds to treat asymptomatic hypoglycemia. In randomized controlled trials, provision of 40% oral dextrose gel (DG) has been shown to improve outcomes in neonates who developed NH. 5 Implementation of DG has shown to decrease treatment failures, reduce admission to NICU for hypoglycemia, decrease frequency of separation of the mother/baby dyad, and increase exclusive breastfeeding rates. 5 However, results from clinical trials may not always readily translate to clinical practice. 6 In 2019, 40% oral DG was added to our institution’s neonatal hypoglycemia management protocol. The goal of the present study was to assess whether addition of DG to the hypoglycemia protocol impacted short-term outcomes of at-risk newborns who developed any hypoglycemia. We hypothesized that administration of 40% oral DG to treat neonatal hypoglycemia would decrease the number of hypoglycemic events in at-risk newborns who developed any hypoglycemia and decrease the need for transfer to NICU. Design/Methods This retrospective observational cohort study was conducted at a tertiary maternity/neonatal hospital in an urban academic setting. Following IRB approval with waiver of consent, chart reviews were performed on infants admitted to the well-baby nursery who were placed on the Hypoglycemia Screening and Management protocol. Criteria for inclusion into the neonatal hypoglycemia screening protocol included the presence of any of these risk factors: late prematurity (35 0/7–36 6/7 weeks' gestation), birth weight 4000 grams, any maternal diabetes mellitus, symptoms of hypoglycemia (jitteriness, hypothermia, poor feeding, or lethargy), maternal intrapartum terbutaline administration, or infants with midline defects. Exclusion criteria were newborns < 35 weeks' gestation and who required transfer to the NICU immediately after birth. The hypoglycemia screening algorithm of at-risk newborns included point-of-care (POC) glucose measurements performed 30 minutes after the first feeding, three subsequent pre-feeding POC glucose checks, and POC glucoses at 24- and 36-hours of age. Blood samples were obtained by a heel-prick procedure and samples were analyzed using the Nova glucometer (Nova Biomedical, MA, US) after warming the newborns’ heels. POC glucoses of < 25 in the first 0–4 hours of life and < 35 during 4–48 hours of life were confirmed with the Epoc Blood Analysis System (Siemens Healthineers, DC, US). The DG for treatment of neonatal hypoglycemia was incorporated into the hypoglycemia management protocol in August 2019. We completed our retrospective chart review of at-risk newborns admitted to the well-baby nursery from April 1 to July 31, 2019 (Cohort 1) and those admitted from April 1 to July 31, 2020 (Cohort 2). All clinically stable newborns ≥ 35 weeks born via vaginal delivery were immediately placed skin to skin (STS) with mother following delivery, while delayed cord clamping was performed. Stable infants remained engaged in STS and breastfeeding was initiated within the first hour of life unless mother declined. Newborns in Cohort 1 who developed asymptomatic hypoglycemia (defined as a POC glucose of \(\le\) 40 mg/dl at 0–4 hours of age and ≤ 45 mg/dl at 4–48 hours of age) were given supplemental feeds with mother’s expressed breast milk, pasteurized donor human milk, or formula, in addition to breastfeeding. Supplemental feeding volumes for management of hypoglycemia were based on recommendations from The Academy of Breastfeeding Medicine's supplementation protocols. 7 Newborns in Cohort 2 who developed asymptomatic hypoglycemia first received DG (Glutose15 gel lemon flavor, Padagis US LLC) at a dose of 0.5ml/kg prior to the feeding regimen as described in Cohort 1. DG drawn up in a syringe was smeared on the buccal mucosa of the newborn and administered in 2 equal aliquots. The operational thresholds and devices used for diagnosis of neonatal hypoglycemia remained the same in both cohorts. Data collected included maternal age, gravida/parity, singleton/multiple birth, maternal gestational/pre-existing diabetes mellitus, mode of delivery, birth weight, gestational age, number of hypoglycemic episodes and lowest blood glucose value. Failure to normalize glucose levels after 2 consecutive doses of DG plus supplemental feeds or requiring > 4 doses of DG in a 24-hour period was defined as treatment failure requiring transfer to NICU for further management. The primary outcome measure was the incidence of 2 or more hypoglycemic episodes. Secondary outcome measures were median number of hypoglycemia events per newborn, lowest measured glucose level and incidence of NICU admission. Statistical Methods Descriptive analysis was conducted to examine the sample characteristics. Normality was checked by using the Shapiro-Wilk and Kolmogorov–Smirnov tests. Mann-Whitney U and χ2 tests were utilized where appropriate. Results were deemed statistically significant at P < .05. All analyses were performed using SAS V9.4 [SAS Cary Institute Inc., Cary, N.C.] Results The total number of newborns admitted to well-baby nursery during both study periods were 1585 and 1584 respectively. No statistically significant difference was found in baseline maternal and infant characteristics between cohorts other than a decreased frequency of multiple births in Cohort 2 ( p = 0.01; Table. 1). Rates of exclusive breastfeeding/breastmilk feeding were similar in both cohorts (54% vs. 58%). Out of all the at-risk newborns screened, 146 (38%) and 112 (32%) newborns developed at least one episode of hypoglycemia in Cohort 1 and 2 respectively. Total number of hypoglycemic events were 249 in Cohort 1 & 156 in Cohort 2 (Table 2). The incidence of multiple episodes of hypoglycemia per infant in Cohort 2 decreased following DG implementation [62 (42.5%) vs 29 (25.9%), p = 0.0058] (Figure. 1). Median (range) number of hypoglycemic episodes per infant decreased following DG implementation [1 ( 1 – 6 ) vs. 1 ( 1 – 5 ), p = 0.046]. There were no differences in median lowest glucose levels [37 (14–45) vs. 37 (10–45), p = 0.31] or NICU admission rate [31 (21.2%) vs. 21 (18.8%), p = 0.62] (Table. 2). Discussion NH is a common and widespread clinical problem that poses many challenges in clinical management. 8 DG has a relatively low barrier to implementation, is well tolerated by newborns, and is easy to administer. Our study supports the addition of 40% oral DG into protocolized management of neonatal hypoglycemia. There is growing evidence to support the benefits of addition of DG to the management of NH. In our study, there was a statistically significant reduction in the incidence of multiple hypoglycemic episodes and a reduction in the number of hypoglycemic episodes per infant after the incorporation of DG in the management of NH. In the randomized control Sugar Baby trial, Harris et al. demonstrated that 40% DG led to a decreased frequency of treatment failures defined by continued occurrence of hypoglycemic episodes. 5 Our study had similar findings and demonstrated that there were fewer recurrent NH episodes in the cohort that received DG treatment. No other study has reported a reduction in the actual number of hypoglycemia episodes per infant when oral DG is used for treatment. A quality improvement study conducted by Walravens et al., showed incorporating DG into a clinical pathway for NH management was associated with a sustained reduction in the number of interventions, use of supplemental milk, and need for IV glucose. 9 Parappil et al., reported that oral DG decreased NICU admissions and IV dextrose treatment. 10 In our study, while Cohort 2 did not experience a reduction in the need for NICU admission, however, they did experience a clinical and statistically significant reduction in the overall burden of hypoglycemia. Further, a Cochrane Review meta-analysis by Edwards et al., concluded that oral DG decreases the risk of NH in at-risk infants and likely reduces the risk of adverse neurological outcomes at two years of age or greater, when compared to placebo gel. 11 This supports our use of dextrose gel in initial management of NH. It is widely appreciated that results from clinical trials do not always translate to improvements in outcomes in routine clinical practice. Further, Harding et al., conducted a multicenter double-blinded placebo-controlled randomized trial which showed that when babies at risk for hypoglycemia were randomized to DG or placebo at one hour of life, prophylactic DG did not reduce NICU admissions, but did reduce the incidence of hypoglycemia. 12 However, based on the Cochrane Review published in 2023 by Roberts et al., authors conclude that prophylactic administration of oral DG should not be incorporated into routine clinical practice until information from large follow-up studies looking at the neurological disabilities are available. 13 A retrospective population-based cohort study conducted by Kaiser et al. showed that early transient newborn hypoglycemia was associated with lower achievement test scores at age 10 years. 14 Any reduction in the burden of hypoglycemia does, therefore, has the scope to produce significant benefits on a population level. Limitations Our study, like all retrospective cohort studies, has some limitations. The influence of different enteral feeding types and volumes in the correction of hypoglycemia were not examined as this data was unavailable. The effects of confounding variables such as additional metabolic demands, non-initiation of early feedings, and lack of skin-to-skin placement of mother and infant on the occurrence and severity of NH were not studied. Follow-up studies to compare the neurodevelopmental outcomes between both cohorts was not completed. Conclusion Incorporating 40% oral DG into protocolized NH management strategies in infants at risk of neonatal hypoglycemia may have a significant public health value by reducing the incidence of multiple neonatal hypoglycemic episodes. Declarations Conflict of Interest: The authors declare that they have no competing financial interests in relation to the work described in this study. Acknowledgements We would like to acknowledge the research volunteers who contributed to our study: Safa Maknojia, Insha Ali, Valeria Guillen, Lorenzo Argao and Harini Shanmugam References McKinlay CJ, Alsweiler JM, Ansell JM, Anstice NS, Chase JG, Gamble GD, Harris DL, Jacobs RJ, Jiang Y, Paudel N, Signal M, Thompson B, Wouldes TA, Yu TY, Harding JE; CHYLD Study Group. Neonatal glycemia and neurodevelopmental outcomes at 2 years. N Engl J Med. 2015;373(16):1507–18. Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics. 2008;122(1):65–74. Adamkin, DH. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575–9. Wight NE, Stehel E, Noble L, Bartick M, Calhoun S, et al. ABM Clinical Protocol #1: Guidelines for glucose monitoring and treatment of hypoglycemia in term and late preterm neonates, Revised 2021. Breastfeed Med. 2021;16(5). Harris Dl, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomized, double-blind, placebo-controlled trial. Lancet [Internet]. 2013;382(9910):2077-83. Available from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736( 13(61645-1/fulltext Heneghan C, Goldacre B, Mahtani KR. Why clinical trial outcomes fail to translate into benefits for patients. Trials. 2017;18(1):122. doi: 10.1186/s13063-017-1870-2 . Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C. ABM clinical protocol #3: Supplementary feedings in the healthy term breastfed neonate, Revised 2017. Breastfeed Med. [Internet]. 2017;12(4):188–198. Hubbard EM, Hay WW Jr. The term newborn: Hypoglycemia. Clin Perinatol. 2021;48(3):665–679. doi: 10.1016/j.clp.2021.05.013 . Walravens C, Gupta A, Cohen RS, Kim JL, Frymoyer A. Fewer glucose checks and decreased supplementation using dextrose gel for asymptomatic neonatal hypoglycemia. J Perinatol. 2023;43(4):532–537. doi: 10.1038/s41372-023-01638-z . Parappil H, Gaffari M, Ahmed J, Skaria S, Rijims M, Chandra P, et al. Oral Dextrose gel use in asymptomatic hypoglycemic newborns decreases NICU admissions and parenteral dextrose therapy: A retrospective study. J Neonatal Perinatal Med. 2023;16(1):111–7. Edwards T, Liu G, Hegarty JE, Crowther CA, Alsweiler J, Harding JE. Oral dextrose to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev. 2021;2021(5). doi: 10.1002/14651858.CD012152.pub3 . Harding JE, Hegarty JE, Crowther CA, Edlin RP, Gamble GD, Alsweiler JM. Evaluation of oral dextrose gel for prevention of neonatal hypoglycemia (hPOD): A multicenter, double-blind randomized controlled trial. PLoS Med. 2021;18(1):e1003411. doi: 10.1371/journal.pmed.1003411 . Roberts L, Lin L, Alsweiler J, Edwards T, Liu G, Harding JE. Oral dextrose gel to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev. 2023;2023. doi: 10.1002/14651858.CD012152.pub4 . Kaiser JR, Bai S, Gibson N, Holland G, Lin TM, Swearingen CJ, Mehl JK, et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: A population-based study. JAMA Pediatr. 2015;169:913–2. doi: 10.1001/jamapediatrics.2015.1631 . Tables Table 1 – Maternal and Infant Characteristics Overall Cohort 1 (No DG) Cohort 2 (DG) P-Value b N - N % N % Overall 738 - 384 100.0% 354 100.0% - Maternal Age 32.0 (27.0, 35.0) 32.0 (27.0, 35.0) 32.0 (26.0, 36.0) 0.48 Gravida 0.19 Primiparous 215 - 120 31.3% 95 26.8% Multiparous 523 - 264 68.8% 259 73.2% Maternal pre-existing diabetes mellitus 33 - 13 3.4% 20 5.6% 0.14 Maternal GDM 0.07 A1GDM 154 - 68 17.7% 86 24.3% A2GDM 105 - 60 15.6% 45 12.7% Multiple birth 0.01 Singleton 704 - 359 93.5% 345 97.5% Multiple 34 - 25 6.5% 9 2.5% Mode of Delivery 0.42 Vaginal 437 - 222 57.8% 215 60.7% C-Section 301 - 162 42.2% 139 39.3% Gestational Age 39 (37.3, 39.4) 38.7 (37.1, 39.6) 39.0 (37.4, 39.3) 0.78 Late Preterm (35 0/7- 36 6/7 weeks) 138 - 78 20.3% 60 16.9% Term (>37 0/7 weeks) 600 - 306 79.7% 294 83.1% Birth Weight gms 3390 (2830, 4080) 3375 (2810, 4090) 3390 (2850, 4050) 0.68 4000 grams 229 - 126 32.8% 103 29.1% a Mann–Whitney U test; b Chi-square test. Table 2: Outcomes in Cohorts 1 & 2 Cohort 1 (No DG) Cohort 2 (DG) p- value Number of infants who developed any hypoglycemia event 146 112 - Number of infants who developed ³ 2 hypoglycemia events 62 (42.5%) 29 (25.9%) 0.0058 b Number of hypoglycemic episodes per subject 1 (1-6) 1 (1-5) 0.046 a Median lowest glucose level 37 (14-45) 37 (10-45) 0.31 a NICU admission 31 (21.2%) 21 (18.8%) 0.62 b Results are reported as number (%), or median (range). a Mann–Whitney U test; b Chi-square test Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 26 Jun, 2024 Read the published version in Journal of Perinatology → Version 1 posted Editorial decision: revise 07 Mar, 2024 Review # 2 received at journal 04 Mar, 2024 Review # 1 received at journal 18 Feb, 2024 Reviewer # 2 agreed at journal 16 Feb, 2024 Reviewer # 1 agreed at journal 05 Feb, 2024 Reviewers invited by journal 04 Feb, 2024 Submission checks completed at journal 31 Jan, 2024 First submitted to journal 30 Jan, 2024 Editor assigned by journal 30 Jan, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3912442","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":271001578,"identity":"b348a4d8-061f-438b-a6fd-c16be18e98b7","order_by":0,"name":"Lakshmy Vaidyanathan","email":"data:image/png;base64,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","orcid":"","institution":"The University of Texas at Austin Dell Medical School","correspondingAuthor":true,"prefix":"","firstName":"Lakshmy","middleName":"","lastName":"Vaidyanathan","suffix":""},{"id":271001579,"identity":"c391ff48-628a-407d-bd4d-039b5a3cc54d","order_by":1,"name":"Davika Reid","email":"","orcid":"","institution":"The University of Texas at Austin Dell Medical School","correspondingAuthor":false,"prefix":"","firstName":"Davika","middleName":"","lastName":"Reid","suffix":""},{"id":271001580,"identity":"e4ec0f79-474a-4ce9-ab6c-5bc556a95a3e","order_by":2,"name":"Yingchao Yuan","email":"","orcid":"","institution":"The University of Texas at Austin, Dell Medical School","correspondingAuthor":false,"prefix":"","firstName":"Yingchao","middleName":"","lastName":"Yuan","suffix":""},{"id":271001581,"identity":"64d866bc-2b57-4c17-bf3d-a7242a16c747","order_by":3,"name":"Alan Groves","email":"","orcid":"","institution":"The University of Texas at Austin Dell Medical School","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"","lastName":"Groves","suffix":""}],"badges":[],"createdAt":"2024-01-31 03:50:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3912442/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3912442/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41372-024-02032-z","type":"published","date":"2024-06-26T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50748083,"identity":"b0cb302a-3509-4dd4-b617-196279f925a9","added_by":"auto","created_at":"2024-02-06 17:14:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33677,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of at-risk infants with multiple hypoglycemic episodes\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3912442/v1/c4d3df77a19269d4d902613c.jpg"},{"id":59165910,"identity":"c5af77b8-d14e-4fc5-bae7-3239b973ee91","added_by":"auto","created_at":"2024-06-27 07:08:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":598127,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3912442/v1/51020e5d-b68d-44f8-9505-b2dccfda4b50.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"The Impact of Implementation of Oral Dextrose Gel on the Incidence of Multiple Hypoglycemia Events in the Well Newborn Nursery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlucose is the main energy source for the newborn brain, such that recurrent and sustained periods of neonatal hypoglycemia (NH) can lead to neuronal injury.\u003csup\u003e1,2\u003c/sup\u003e Screening of newborns at risk for developing hypoglycemia and timely treatment for those who develop hypoglycemia is accepted as best practice.\u003csup\u003e3,4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur institution has had a long-standing, robust newborn hypoglycemia management protocol in the well-baby nursery. Our protocol, which closely follows The American Academy of Pediatrics (AAP) recommendations,\u003csup\u003e3\u003c/sup\u003e aims to achieve prompt and effective correction of hypoglycemia, preservation of breastmilk feeding, and parent satisfaction. Maternal expressed breast milk and pasteurized donor human milk are recommended as the first line for supplemental feeds to treat asymptomatic hypoglycemia.\u003c/p\u003e \u003cp\u003eIn randomized controlled trials, provision of 40% oral dextrose gel (DG) has been shown to improve outcomes in neonates who developed NH.\u003csup\u003e5\u003c/sup\u003e Implementation of DG has shown to decrease treatment failures, reduce admission to NICU for hypoglycemia, decrease frequency of separation of the mother/baby dyad, and increase exclusive breastfeeding rates.\u003csup\u003e5\u003c/sup\u003e However, results from clinical trials may not always readily translate to clinical practice.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 2019, 40% oral DG was added to our institution\u0026rsquo;s neonatal hypoglycemia management protocol. The goal of the present study was to assess whether addition of DG to the hypoglycemia protocol impacted short-term outcomes of at-risk newborns who developed any hypoglycemia. We hypothesized that administration of 40% oral DG to treat neonatal hypoglycemia would decrease the number of hypoglycemic events in at-risk newborns who developed any hypoglycemia and decrease the need for transfer to NICU.\u003c/p\u003e"},{"header":"Design/Methods","content":"\u003cp\u003eThis retrospective observational cohort study was conducted at a tertiary maternity/neonatal hospital in an urban academic setting. Following IRB approval with waiver of consent, chart reviews were performed on infants admitted to the well-baby nursery who were placed on the Hypoglycemia Screening and Management protocol. Criteria for inclusion into the neonatal hypoglycemia screening protocol included the presence of any of these risk factors: late prematurity (35 0/7\u0026ndash;36 6/7 weeks' gestation), birth weight\u0026thinsp;\u0026lt;\u0026thinsp;2500 grams or \u0026gt;\u0026thinsp;4000 grams, any maternal diabetes mellitus, symptoms of hypoglycemia (jitteriness, hypothermia, poor feeding, or lethargy), maternal intrapartum terbutaline administration, or infants with midline defects. Exclusion criteria were newborns\u0026thinsp;\u0026lt;\u0026thinsp;35 weeks' gestation and who required transfer to the NICU immediately after birth.\u003c/p\u003e \u003cp\u003eThe hypoglycemia screening algorithm of at-risk newborns included point-of-care (POC) glucose measurements performed 30 minutes after the first feeding, three subsequent pre-feeding POC glucose checks, and POC glucoses at 24- and 36-hours of age. Blood samples were obtained by a heel-prick procedure and samples were analyzed using the Nova glucometer (Nova Biomedical, MA, US) after warming the newborns\u0026rsquo; heels. POC glucoses of \u0026lt;\u0026thinsp;25 in the first 0\u0026ndash;4 hours of life and \u0026lt;\u0026thinsp;35 during 4\u0026ndash;48 hours of life were confirmed with the Epoc Blood Analysis System (Siemens Healthineers, DC, US). The DG for treatment of neonatal hypoglycemia was incorporated into the hypoglycemia management protocol in August 2019.\u003c/p\u003e \u003cp\u003e We completed our retrospective chart review of at-risk newborns admitted to the well-baby nursery from April 1 to July 31, 2019 (Cohort 1) and those admitted from April 1 to July 31, 2020 (Cohort 2). All clinically stable newborns \u0026ge; 35 weeks born via vaginal delivery were immediately placed skin to skin (STS) with mother following delivery, while delayed cord clamping was performed. Stable infants remained engaged in STS and breastfeeding was initiated within the first hour of life unless mother declined. Newborns in Cohort 1 who developed asymptomatic hypoglycemia (defined as a POC glucose of \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\le\\)\u003c/span\u003e\u003c/span\u003e40 mg/dl at 0\u0026ndash;4 hours of age and \u003cem\u003e\u0026le;\u003c/em\u003e45 mg/dl at 4\u0026ndash;48 hours of age) were given supplemental feeds with mother\u0026rsquo;s expressed breast milk, pasteurized donor human milk, or formula, in addition to breastfeeding.\u003c/p\u003e \u003cp\u003eSupplemental feeding volumes for management of hypoglycemia were based on recommendations from The Academy of Breastfeeding Medicine's supplementation protocols.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNewborns in Cohort 2 who developed asymptomatic hypoglycemia first received DG (Glutose15 gel lemon flavor, Padagis US LLC) at a dose of 0.5ml/kg prior to the feeding regimen as described in Cohort 1. DG drawn up in a syringe was smeared on the buccal mucosa of the newborn and administered in 2 equal aliquots. The operational thresholds and devices used for diagnosis of neonatal hypoglycemia remained the same in both cohorts. Data collected included maternal age, gravida/parity, singleton/multiple birth, maternal gestational/pre-existing diabetes mellitus, mode of delivery, birth weight, gestational age, number of hypoglycemic episodes and lowest blood glucose value. Failure to normalize glucose levels after 2 consecutive doses of DG plus supplemental feeds or requiring\u0026thinsp;\u0026gt;\u0026thinsp;4 doses of DG in a 24-hour period was defined as treatment failure requiring transfer to NICU for further management. The primary outcome measure was the incidence of 2 or more hypoglycemic episodes. Secondary outcome measures were median number of hypoglycemia events per newborn, lowest measured glucose level and incidence of NICU admission.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical Methods\u003c/b\u003e Descriptive analysis was conducted to examine the sample characteristics. Normality was checked by using the Shapiro-Wilk and Kolmogorov\u0026ndash;Smirnov tests. Mann-Whitney U and χ2 tests were utilized where appropriate. Results were deemed statistically significant at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. All analyses were performed using SAS V9.4 [SAS Cary Institute Inc., Cary, N.C.]\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe total number of newborns admitted to well-baby nursery during both study periods were 1585 and 1584 respectively. No statistically significant difference was found in baseline maternal and infant characteristics between cohorts other than a decreased frequency of multiple births in Cohort 2 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01; Table. 1). Rates of exclusive breastfeeding/breastmilk feeding were similar in both cohorts (54% vs. 58%).\u003c/p\u003e \u003cp\u003eOut of all the at-risk newborns screened, 146 (38%) and 112 (32%) newborns developed at least one episode of hypoglycemia in Cohort 1 and 2 respectively. Total number of hypoglycemic events were 249 in Cohort 1 \u0026amp; 156 in Cohort 2 (Table\u0026nbsp;2). The incidence of multiple episodes of hypoglycemia per infant in Cohort 2 decreased following DG implementation [62 (42.5%) vs 29 (25.9%), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0058] (Figure. 1). Median (range) number of hypoglycemic episodes per infant decreased following DG implementation [1 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) vs. 1 (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046]. There were no differences in median lowest glucose levels [37 (14\u0026ndash;45) vs. 37 (10\u0026ndash;45), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.31] or NICU admission rate [31 (21.2%) vs. 21 (18.8%), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.62] (Table. 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNH is a common and widespread clinical problem that poses many challenges in clinical management.\u003csup\u003e8\u003c/sup\u003e DG has a relatively low barrier to implementation, is well tolerated by newborns, and is easy to administer. Our study supports the addition of 40% oral DG into protocolized management of neonatal hypoglycemia. There is growing evidence to support the benefits of addition of DG to the management of NH. In our study, there was a statistically significant reduction in the incidence of multiple hypoglycemic episodes and a reduction in the number of hypoglycemic episodes per infant after the incorporation of DG in the management of NH.\u003c/p\u003e \u003cp\u003eIn the randomized control Sugar Baby trial, Harris et al. demonstrated that 40% DG led to a decreased frequency of treatment failures defined by continued occurrence of hypoglycemic episodes.\u003csup\u003e5\u003c/sup\u003e Our study had similar findings and demonstrated that there were fewer recurrent NH episodes in the cohort that received DG treatment. No other study has reported a reduction in the actual number of hypoglycemia episodes per infant when oral DG is used for treatment. A quality improvement study conducted by Walravens et al., showed incorporating DG into a clinical pathway for NH management was associated with a sustained reduction in the number of interventions, use of supplemental milk, and need for IV glucose.\u003csup\u003e9\u003c/sup\u003e Parappil et al., reported that oral DG decreased NICU admissions and IV dextrose treatment.\u003csup\u003e10\u003c/sup\u003e In our study, while Cohort 2 did not experience a reduction in the need for NICU admission, however, they did experience a clinical and statistically significant reduction in the overall burden of hypoglycemia. Further, a Cochrane Review meta-analysis by Edwards et al., concluded that oral DG decreases the risk of NH in at-risk infants and likely reduces the risk of adverse neurological outcomes at two years of age or greater, when compared to placebo gel.\u003csup\u003e11\u003c/sup\u003e This supports our use of dextrose gel in initial management of NH.\u003c/p\u003e \u003cp\u003eIt is widely appreciated that results from clinical trials do not always translate to improvements in outcomes in routine clinical practice. Further, Harding et al., conducted a multicenter double-blinded placebo-controlled randomized trial which showed that when babies at risk for hypoglycemia were randomized to DG or placebo at one hour of life, prophylactic DG did not reduce NICU admissions, but did reduce the incidence of hypoglycemia.\u003csup\u003e12\u003c/sup\u003e However, based on the Cochrane Review published in 2023 by Roberts et al., authors conclude that prophylactic administration of oral DG should not be incorporated into routine clinical practice until information from large follow-up studies looking at the neurological disabilities are available.\u003csup\u003e13\u003c/sup\u003e A retrospective population-based cohort study conducted by Kaiser et al. showed that early transient newborn hypoglycemia was associated with lower achievement test scores at age 10 years.\u003csup\u003e14\u003c/sup\u003e Any reduction in the burden of hypoglycemia does, therefore, has the scope to produce significant benefits on a population level.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eOur study, like all retrospective cohort studies, has some limitations. The influence of different enteral feeding types and volumes in the correction of hypoglycemia were not examined as this data was unavailable. The effects of confounding variables such as additional metabolic demands, non-initiation of early feedings, and lack of skin-to-skin placement of mother and infant on the occurrence and severity of NH were not studied. Follow-up studies to compare the neurodevelopmental outcomes between both cohorts was not completed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIncorporating 40% oral DG into protocolized NH management strategies in infants at risk of neonatal hypoglycemia may have a significant public health value by reducing the incidence of multiple neonatal hypoglycemic episodes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors declare that they have no competing financial interests in relation to the work described in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the research volunteers who contributed to our study: Safa Maknojia, Insha Ali, Valeria Guillen, Lorenzo Argao and Harini Shanmugam\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcKinlay CJ, Alsweiler JM, Ansell JM, Anstice NS, Chase JG, Gamble GD, Harris DL, Jacobs RJ, Jiang Y, Paudel N, Signal M, Thompson B, Wouldes TA, Yu TY, Harding JE; CHYLD Study Group. Neonatal glycemia and neurodevelopmental outcomes at 2 years. N Engl J Med. 2015;373(16):1507\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics. 2008;122(1):65\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdamkin, DH. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWight NE, Stehel E, Noble L, Bartick M, Calhoun S, et al. ABM Clinical Protocol #1: Guidelines for glucose monitoring and treatment of hypoglycemia in term and late preterm neonates, Revised 2021. Breastfeed Med. 2021;16(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris Dl, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomized, double-blind, placebo-controlled trial. Lancet [Internet]. 2013;382(9910):2077-83. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(\u003c/span\u003e\u003cspan address=\"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e13(61645-1/fulltext\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeneghan C, Goldacre B, Mahtani KR. Why clinical trial outcomes fail to translate into benefits for patients. Trials. 2017;18(1):122. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13063-017-1870-2\u003c/span\u003e\u003cspan address=\"10.1186/s13063-017-1870-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C. ABM clinical protocol #3: Supplementary feedings in the healthy term breastfed neonate, Revised 2017. Breastfeed Med. [Internet]. 2017;12(4):188\u0026ndash;198.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHubbard EM, Hay WW Jr. The term newborn: Hypoglycemia. Clin Perinatol. 2021;48(3):665\u0026ndash;679. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clp.2021.05.013\u003c/span\u003e\u003cspan address=\"10.1016/j.clp.2021.05.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalravens C, Gupta A, Cohen RS, Kim JL, Frymoyer A. Fewer glucose checks and decreased supplementation using dextrose gel for asymptomatic neonatal hypoglycemia. J Perinatol. 2023;43(4):532\u0026ndash;537. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41372-023-01638-z\u003c/span\u003e\u003cspan address=\"10.1038/s41372-023-01638-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParappil H, Gaffari M, Ahmed J, Skaria S, Rijims M, Chandra P, et al. Oral Dextrose gel use in asymptomatic hypoglycemic newborns decreases NICU admissions and parenteral dextrose therapy: A retrospective study. J Neonatal Perinatal Med. 2023;16(1):111\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards T, Liu G, Hegarty JE, Crowther CA, Alsweiler J, Harding JE. Oral dextrose to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev. 2021;2021(5). doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD012152.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012152.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarding JE, Hegarty JE, Crowther CA, Edlin RP, Gamble GD, Alsweiler JM. Evaluation of oral dextrose gel for prevention of neonatal hypoglycemia (hPOD): A multicenter, double-blind randomized controlled trial. PLoS Med. 2021;18(1):e1003411. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1003411\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1003411\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts L, Lin L, Alsweiler J, Edwards T, Liu G, Harding JE. Oral dextrose gel to prevent hypoglycaemia in at-risk neonates. Cochrane Database Syst Rev. 2023;2023. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD012152.pub4\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012152.pub4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaiser JR, Bai S, Gibson N, Holland G, Lin TM, Swearingen CJ, Mehl JK, et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: A population-based study. JAMA Pediatr. 2015;169:913\u0026ndash;2. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamapediatrics.2015.1631\u003c/span\u003e\u003cspan address=\"10.1001/jamapediatrics.2015.1631\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 \u0026ndash; Maternal and Infant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.406727828746178%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.712538226299696%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohort 1 (No DG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.01834862385321%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohort 2 (DG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal Age\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(27.0, 35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e(27.0, 35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(26.0, 36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGravida\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimiparous\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e31.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e26.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiparous\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e523\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e68.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e73.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal pre-existing diabetes mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal GDM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eA1GDM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e17.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e24.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eA2GDM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e15.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingleton\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e93.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e97.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e6.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of Delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e57.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e60.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eC-Section\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e301\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e42.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e39.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational Age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(37.3, 39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e(37.1, 39.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e39.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(37.4, 39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eLate Preterm\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(35 0/7- 36 6/7 weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e20.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e16.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTerm\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u0026gt;37 0/7 weeks)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e79.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e83.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Weight gms\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e3390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(2830, 4080)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e3375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e(2810, 4090)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e3390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e(2850, 4050)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.853211009174313%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;2500 grams\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.562691131498472%\" valign=\"bottom\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e12.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\" rowspan=\"3\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2500 grams\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e- 4000 grams\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e54.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e57.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.804123711340207%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;4000 grams\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.621993127147766%\" valign=\"bottom\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.965635738831615%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\n \u003cp\u003e32.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"bottom\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"bottom\"\u003e\n \u003cp\u003e29.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.25993883792049%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eMann\u0026ndash;Whitney U test; \u003csup\u003e\u0026nbsp;b\u003c/sup\u003eChi-square test.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.868501529051988%\" valign=\"bottom\" style=\"width: 9.1744%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\" style=\"width: 13.4556%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.174311926605505%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.844036697247706%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.009174311926605%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Outcomes in Cohorts 1 \u0026amp; 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"654\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohort 1 (No DG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCohort 2 (DG)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of infants who developed any hypoglycemia event\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003e146\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003e112\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e-\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of infants who developed\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026sup3;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;2 hypoglycemia events\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e62 (42.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e29 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.0058\u003c/em\u003e\u003c/strong\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of hypoglycemic episodes per subject\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e1 (1-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e1 (1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e0.046\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian lowest glucose level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e37 (14-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e37 (10-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e0.31\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.69724770642202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNICU admission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e31 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e21 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.10091743119266%\"\u003e\n \u003cp\u003e0.62\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eResults are reported as number (%), or median (range). \u003csup\u003ea\u003c/sup\u003eMann\u0026ndash;Whitney U test; \u0026nbsp;\u003csup\u003eb\u003c/sup\u003eChi-square test\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3912442/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3912442/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eEvaluate the impact of 40% oral dextrose gel (DG) for management of neonatal hypoglycemia (NH) on the incidence of multiple hypoglycemic events in the well-baby nursery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design: \u003c/strong\u003eA retrospective chart review of 738 at-risk infants in 2 cohorts before (Cohort 1) and after (Cohort 2) DG implementation. Primary outcome was the incidence of ≥2 hypoglycemic episodes. Secondary outcomes were median number of hypoglycemia events per infant, lowest median glucose level, and incidence of NICU admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThere were 384 and 354 at-risk newborns in Cohorts 1 \u0026amp; 2. Incidence of multiple hypoglycemia episodes decreased following DG implementation [62(42.5%) vs 29(25.9%), \u003cem\u003ep\u003c/em\u003e=0.0058]. Median (range) number of hypoglycemic episodes per infant also decreased [1 (1-6) vs 1 (1-5), \u003cem\u003ep\u003c/em\u003e=0.046]. There were no differences in lowest glucose level [37 (14-45) vs 37 (10-45), \u003cem\u003ep\u003c/em\u003e=0.31] or NICU admission rate [31 (21.2%) vs 21 (18.8%), \u003cem\u003ep\u003c/em\u003e=0.62].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003eImplementation of DG lowers the incidence of subsequent multiple hypoglycemia events.\u003c/p\u003e","manuscriptTitle":"The Impact of Implementation of Oral Dextrose Gel on the Incidence of Multiple Hypoglycemia Events in the Well Newborn Nursery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 17:14:11","doi":"10.21203/rs.3.rs-3912442/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-03-07T17:54:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-03-04T14:54:17+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-02-19T02:50:27+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-02-16T18:47:34+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-02-05T23:31:52+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2024-02-04T22:30:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-31T14:23:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Perinatology","date":"2024-01-31T03:47:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-31T03:47:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f70f5da6-f84f-40c1-be85-5a1cd3dc364e","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":28559731,"name":"Health sciences/Medical research/Outcomes research"},{"id":28559732,"name":"Health sciences/Health care/Paediatrics"}],"tags":[],"updatedAt":"2024-06-27T07:08:10+00:00","versionOfRecord":{"articleIdentity":"rs-3912442","link":"https://doi.org/10.1038/s41372-024-02032-z","journal":{"identity":"journal-of-perinatology","isVorOnly":false,"title":"Journal of Perinatology"},"publishedOn":"2024-06-26 04:00:00","publishedOnDateReadable":"June 26th, 2024"},"versionCreatedAt":"2024-02-06 17:14:11","video":"","vorDoi":"10.1038/s41372-024-02032-z","vorDoiUrl":"https://doi.org/10.1038/s41372-024-02032-z","workflowStages":[]},"version":"v1","identity":"rs-3912442","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3912442","identity":"rs-3912442","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}