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Recommendations on treatment of hypoglycaemia 4.29
Sublingual administration of sugar in the treatment of hypoglycaemia
Sublingual sugar may be used as an immediate irst aid measure in managing hypoglycaemia in children in situations where intravenous administration of glucose
may be impossible or delayed.
Strong recommendation, low quality evidence
Recommendations on the choice of intravenous fluids 4.30
Choice of intravenous fluids for resuscitation and maintenance in children
a Resuscitation: Children severely dehydrated or with signs of shock should be resuscitated using isotonic intravenous IV solutions such as sodium chloride
0.9 or ringers lactate.
Strong recommendation, low quality evidence
b Intravenous maintenance luid: For children who require IV luids for maintenance, options include ringers lactate solution with 5 dextrose, sodium chloride 0.45
with glucose 5, sodium chloride 0.45 with glucose 2.5, or 0.9 sodium chloride with glucose 5.
Strong recommendation, low quality evidence
c Low sodium-containing solutions, such as sodium chloride 0.18 with glucose 4, or 5 glucose in water, should not be used as there is an increased risk of
hyponatraemia leading to cerebral oedema.
Strong recommendation, low quality evidence
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5. Evidence for recommendations on the newborn conditions
5.1 Vitamin K prophylaxis in newborns
1. All newborns should be given 1 mg of vitamin K intramuscularly IM ater birth i.e. ater the irst hour by which the infant should be in skin-to-skin contact with
the mother and breastfeeding should be initiated.
Strong recommendation, moderate quality evidence
2. Neonates requiring surgical procedures, those with birth trauma, preterm babies, and those exposed in utero to maternal medication known to interfere with
vitamin K are at especially high risk of bleeding and must be given vitamin K 1 mg IM.
Strong recommendation, moderate quality evidence
he panel put large value on the expected beneits of vitamin K prophylaxis which clearly outweigh the harms. It also noted that implementation was feasible, and the
cost afordable in most settings.
5.1.1 Evidence and summary of findings
he incidence of classical vitamin K deiciency bleeding in the absence of vitamin K prophylaxis ranges from 10 to 1500 per 100 000 neonates, and that of late Vitamin
K Dependant Bleeding VKDB ranges from 5 to 80 per 100 000. here is some evidence to indicate that the incidence of VKDB is at the higher end of the ranges
given above in less-developed countries. We found moderate quality evidence to show that vitamin K prophylaxis reduces the risk of bleeding in newborns.
Only two RCTs conducted in the 1960s looked at the impact of vitamin K supplementation 0.1 to 5 mg IM on bleeding in neonates [Vietti 1960, Sutherland
1967]. hese studies showed that vitamin K prophylaxis is efective in preventing post-circumcision 39 reduction, NNT 21, 95 CI 13 to 50 and non-circumcision
bleeding 43 reduction, NNT 80, 95 CI 42 to 714. One of the above studies showed that vitamin K prophylaxis resulted in an 81 reduction in moderate or
severe bleeding NNT 75, 95 CI 48 to 177 and a 97 reduction in severe bleeding NNT 140, 95 CI 90 to 500. here was no diference in groups given 0.1 mg or
5 mg of vitamin K. he quality of this evidence was graded as moderate to low
see GRADE table A7.1
.
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Vitamin K prophylaxis has been shown to reduce sub-clinical deiciency in the irst week of life measured as the presence of a protein induced by vitamin K deiciency,
or PIVKA. here was no signiicant diference between oral or IM vitamin K on subclinical deiciency in the irst week of life. Studies have also looked as prothrombin
time PT but none of the studies that included infants had a PT outside the normal range in the intervention and control groups. Two studies, which examined the efect
of vitamin K prophylaxis on prothrombin complex deiciency, reported that IM prophylaxis reduced deiciency by 72 and oral prophylaxis by 50.
Data from two observational studies showed that vitamin K prophylaxis – single dose administered at birth by either IM or oral route – reduces the incidence of late
VKDB substantially; prophylaxis by IM route was signiicantly better about 97 than that by the oral route 65–83 in reducing the incidence of late VKDB. Although
late VKDB is rare, about one third of infants with this condition die or have severe handicaps. he NNT estimated from two observational studies incidence with no
vitamin K prophylaxis, 6 per 100 000 is about 18 000. If the incidence were 30 per 100 000, the number needed to treat to prevent a case of late VKDB is about 3000. he
quality of this evidence was graded as low or very low.
5.1.2 Benefits and risks
Benefits Vitamin K prophylaxis signiicantly reduces the risk of bleeding in neonates. Twenty
neonates undergoing circumcision need to be given prophylaxis to prevent one case of bleeding ater circumcision. About 80 neonates need to be given prophylaxis to
prevent one case of non-circumcision bleeding. Late VKDB can be prevented with vitamin K prophylaxis – one case prevented per about 3000 infants treated.
Risks he irst report of a potential association between vitamin K prophylaxis and
childhood cancer appeared in 1990. Subsequent research has not substantiated this concern.
5.1.3 Acceptability and feasibility
Vitamin K intervention is efective but the disease it prevents is relatively rare. Current practice in most developed countries is to give vitamin K prophylaxis to
all newborn babies ater birth. he cost of the medicine itself is US 0.195 per 1 mg injection. Costs of the syringe and needle and the supply of vitamin K, etc. would be
additional. he costs for routine vitamin K administration may not be justiiable in low-resource settings.
5.2 Prophylactic antibiotics in newborns at risk of infection
A neonate with risk factors for infection i.e. membranes ruptured 18 hours before delivery, mother had fever 38 °C before delivery or during labour, or amniotic
luid was foul smelling or purulent should be treated with prophylactic antibiotics
