January 15, 2014

DynaMed EBM Journal Volume 9, Issue 3

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: January 15, 2014

Expiration Date: January 15, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304159K


Last week 423 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 282 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Buccal Dextrose Gel for Hypoglycemia Reduces Admission to Neonatal Intensive Care Unit for Hypoglycemia
Reference:Lancet 2013 Dec 21;382(9910):2077 (level 1 [likely reliable] evidence)

Neonatal hypoglycemia is reported to occur in 5%-15% of otherwise healthy babies, and is considered a risk factor for brain injury or adverse neurodevelopmental outcomes. Many newborns with low blood glucose levels are separated from their mothers and admitted to the neonatal intensive care unit (NICU), where they receive intravenous dextrose. This separation may inhibit maternal bonding and disrupt the establishment of breastfeeding. The use of buccal dextrose gel in newborns with hypoglycemia was previously evaluated in a randomized trial that showed no significant difference in blood glucose concentrations compared to no treatment. However, this earlier trial did not evaluate patient-oriented outcomes. Now, a randomized trial compares buccal dextrose gel to placebo in newborns with hypoglycemia, and evaluates both glycemic outcomes and the need for admission to the NICU.

The study screened babies born at gestational age ≥ 35 weeks who were at risk of neonatal hypoglycemia. A total of 242 infants (gestational age 35-42 weeks) developed hypoglycemia, defined as blood or interstitial glucose level less than 2.6 mmol/L (46.8 mg/dL), and were randomized to receive dextrose 40% gel 200 mg/kg massaged into the buccal mucosa vs. placebo gel. Afterwards, infants were encouraged to feed. If feeding was poor, infants were given expressed breast milk or formula by syringe, according to maternal preference. Blood glucose levels were assessed at 30 minutes following the first treatment. If hypoglycemia persisted or recurred, infants received another dose, up to a maximum of 6 doses over 48 hours. Treatment failure was defined as blood glucose level < 2.6 mmol/L at 30 minutes following the second dose of study gel. Infants who met the criteria for treatment failure were admitted to the NICU and treated with open-label dextrose gel, infant formula, or intravenous dextrose, according to clinical guidelines and clinician preference.

Each group received a median of 2 doses of study gel. After excluding 5 infants who were randomized in error, 237 infants (98%) were included in a modified intention-to-treat analysis. The rate of admission to the NICU for hypoglycemia was 14% in the dextrose group compared to 25% in the placebo group (p = 0.03, NNT 10). The overall admission rate to the NICU was 38% with dextrose gel vs. 46% with placebo, but this difference was not statistically significant. Treatment failure occurred in 14% of infants receiving dextrose gel compared to 24% receiving placebo gel (p = 0.04, NNT 10). In addition, the need for other sources of dextrose (either open-label dextrose gel after treatment failure or intravenous dextrose) was 10% in the dextrose group compared to 24% in the placebo group (p = 0.01, NNT 8). There were no significant differences in the number of rebound or recurrent hypoglycemia episodes, and no serious adverse events occurred.

Many specialists agree that newborns with hypoglycemia and neurological symptoms should receive urgent treatment and glucose monitoring. In addition, several risk factors have been identified that might suggest increased neonatal risk, including maternal diabetes, obesity, and low birth weight. However, optimal management of neonatal hypoglycemia in other groups should find a proper balance between reducing the risk of long-term complications, while at the same time minimizing the effect of an abnormal screening result on neonatal adaptation and feeding. This new randomized trial shows that dextrose gel reduces admission to neonatal intensive care unit for hypoglycemia. In doing so, it minimizes the need for unnecessary interventions that separate newborns from their mothers. Furthermore, the gel is inexpensive and well tolerated.

For more information, see the Neonatal hypoglycemia topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Cardiology
Deputy Editor of Oncology
Medical Writer
Medical Editor
Associate Managing Editor