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Alleged Failure to Properly Monitor Newborn's Glucose Levels Leads to Hypoglycemia and Brain Damage; $9.6M Arbitration Award in California
by: Radha V. Bachman, Esq.
Buchanan, Ingersoll & Rooney, P.C.
News: A pregnant woman at full term presented to the hospital for the birth of her son. The baby was delivered via Caesarean section. Normal tests were conducted on the newborn, and all seemed to be in order. While the mother wanted to breast-feed the baby, attempts at breast-feeding were unsuccessful. Two days after birth, the baby was found to have lost almost 8% of his birth weight. Formula was administered to the baby to ensure that he was taking in sufficient nutrients and calories. The next day, the baby's weight was found to have decreased even further, and hospital policy required the administration of additional formula. When hospital personnel arrived to check on the baby, they noticed that he was not breathing. The baby was diagnosed with hypoglycemia and was witnessed having seizures. Approximately two weeks later the baby was discharged. At the age of three, the child is not able to walk, crawl, or use his hands or arms in a deliberate manner. The child was also experiencing daily seizures and is required to take food via a tube. An arbitration award was entered in favor of the plaintiff in the amount of $9.6 million.
Background: At full term, a pregnant woman with gestational diabetes entered a hospital for delivery of her son. Due to some fetal distress during delivery, the baby was born via nonelective C-section. Appearing normal at birth, the baby weighed in at 7 lbs. and had normal APGAR scores. Due to the diabetes, the glucose levels of the baby were checked on four different occasions. The first and last measurements were at the lower level of normal, but within normal ranges.
The mother planned to breast-feed the child but was unable to do so successfully on the baby's first day of life. During the first day of life, the baby was supplemented with formula. A lactation consultant was unable to assist the mother and baby in developing a proper latch and noted this in the patient's chart. The next morning, the baby was found to have lost 7.8% of his body weight, which signaled an abnormality. Hospital policy required additional supplemental feedings if a baby loses more than 7% of body weight and exhibited lethargy or inability to empty the mother's breast. In accordance with the policy, formula was administered at 1 a.m., 4:30 a.m. and again at 6 a.m.
Chart notations indicated that successful latching had occurred on several occasions, but the mother testified that the baby did not breast-feed effectively for the first two days of life. At 53 hours of life, the baby's weight was found to have dropped 10.4% since birth. Hospital policy again required supplemental feedings, which were administered every four to six hours. The policy also required that the mother be provided an electric pump with which to express breast milk. At 1:20 a.m., the baby received 15 mL of formula. No other food was provided to the baby between that time and 7:30 a.m. The mother was also not provided an electric pump.
Later that morning, a hospital employee who came to the room for a routine checkup noted that the infant was not breathing. The baby was taken to the well-baby nursery, where a bedside glucose check indicated a severely low reading of 15 mg/dl. The baby was transferred to a special care nursery, where seizure activity was observed. Shortly after the seizure activity, the baby's glucose level was noted as 7 mg/dl and the baby was diagnosed with hypoglycemia. The baby required two times the normal amount of glucose to maintain steady blood levels for more than 50 hours. Chart notations indicated the baby had no ketones in his urine and that his insulin levels were low. A subsequent MRI of the baby's brain showed bilateral occipital infarction.
Two weeks after birth, the baby was discharged. At the age of three, the child is unable to walk, crawl, or speak. He experiences seizures on a daily basis, despite being medicated. Due to an inability to swallow safety, the child takes in all food from a feeding tube.
The parents of the child alleged that the nursing care at the hospital fell below the standard of care in the following ways: failure to properly assess, monitor, and act on the baby's inability to breastfeed effectively; failure to notify the nurse practitioner and/or physician regarding excessive weight loss; failure to timely recheck blood and glucose levels; and failure to timely and properly deal with the discovery of the baby not breathing. The plaintiff further alleged that had the blood levels not fallen to such dangerously low levels, the child would not have suffered brain damage.
The defense countered that the hypoglycemia was not anticipated due to the monitoring of blood glucose levels at birth and vital signs. They further contended that the baby was given formula supplements in accordance with hospital policy, and there were no other signs of hypoglycemia prior to the onset of seizures. A lactation expert who spoke on behalf of the defense testified that situations in which newborns are denied nutritional intake, hypoglycemia, and subsequent brain damage do not typically occur.
The defense relied on the argument that the baby had an exceedingly rare, transient metabolic disorder that could not have been foreseen. This conclusion was based on the fact that the baby required twice the amount of glucose to maintain his blood sugar once he had been diagnosed, had no ketones in his urine, and had negative insulin levels.
The arbitrator ruled in favor of the plaintiff and awarded $9,629,246, based on the child's life expectancy of 38 years. An additional settlement was reached between the parties in the amount of $75,000, which precluded any future wrongful death claims.
What This Means to You: Hypoglycemia, also known as low blood sugar or low blood glucose, indicates a level of sugar in the body below normal or acceptable ranges. Glucose is the main source of energy for the brain. Glucose in insufficient amounts can impair brain function. Prolonged or severe hypoglycemia may result in seizures and brain injury.
Throughout pregnancy, glucose is passed through the placenta from the mother to the fetus. It is then stored in the form of glycogen in the placenta, fetal heart, muscles, and liver. The stored glycogen will supply the baby's brain with needed glucose during delivery and with nutrition after birth. Babies born to mothers with diabetes, gestational or chronic, inherently demonstrate an increased risk of developing hypoglycemia post-delivery. This occurs when the mother's blood, the source of glucose for the baby, is no longer available post-partum, and the baby's own insulin production metabolizes the existing glucose that was present at birth. The primary source of glucose is food, particularly carbohydrates; replenishment of the loss of glucose with new sources for the body to metabolize and fuel the brain is critical.
Potential causes of hypoglycemia in a newborn include but are not limited to inadequate prenatal nutrition in the mother, liver disease, birth asphyxia, mother and baby blood type incompatibility, birth defects, congenital metabolic diseases, and excess insulin in a baby produced by a diabetic mother. Symptoms of hypoglycemia in a newborn include but are not limited to poor body tone, cyanosis, jitteriness, hypothermia, lethargy, poor feeding, apnea, and seizures. Treatment of hypoglycemia in the newborn includes administration of a rapid-acting source of glucose such as a sugar/water mixture or early formula feeding. In acute, severe cases, IV administration of glucose may be required. Continuous monitoring of glucose levels is not only prudent but mandatory. While there is no specific means of preventing hypoglycemia in newborns, it is wise and cautious to monitor for symptoms and intervene as soon as symptoms are noted, especially in newborns with diabetic mothers.
Multiple points of failure ID'd
In this case as presented, multiple points of failure are identified, recognized by the parents and their attorney, and also by the arbitrator. This is evidenced not only by the settlement amount of $9.6 million but by the negotiation of an additional settlement of $75,000 to preclude any future wrongful death claims. Anticipation of a wrongful death claim in the future speaks volumes regarding the errors of the past and the resulting harm in the present. It is sad to note that this child, carried to full term and with normal APGAR scores at birth, now has a life expectancy of only thirty-eight years consisting of impaired activities of daily living that will require constant care and monitoring. Living with seizure activity on a daily basis will remain frightening for the child and his family.
The points of failure in this case may be summed up in three major areas: failure to assess, failure to monitor, and failure to follow policy and the standard of care. This newborn had a higher risk for developing hypoglycemia due to the mother's diagnosis of gestational diabetes. Wise and prudent caregivers should be alert to the need for close and constant monitoring. When attempts at breast-feeding were unsuccessful or tenuous at best, factored with fetal distress during the birth process and a progressive increase in weight loss postpartum, care providers should have been alert to and notified of any changes in the newborn's status, no matter how seemingly insignificant at the time.
Hindsight in these cases is 20/20, no doubt; but why, for example, was this infant not provided nourishment for a period of 6 hours and 10 minutes when his birth weight had already dropped by 10.4% in 53 hours and in consideration of the fact he was born to a mother with gestational diabetes, who was experiencing little to no success at breast-feeding? Hospital policy in this case required "additional supplemental feedings if a baby loses more than 7% of body weight and exhibited lethargy or inability to empty the mother's breast." When a policy and procedure is created within the standard of care, there is no defense when it is not followed. The fact this newborn had dangerously low, life-threatening glucose levels that required twice the normal amount of glucose to recover and maintain steady blood levels indicates the severity of the hypoglycemia. The MRI confirmed the subsequent bilateral occipital infarct and the lifelong impact of untimely resolution of prolonged hypoglycemia.
The outcome of this case speaks for itself.
What does this mean to you? Be diligent, adhere to policies and procedures, do not be afraid to err on the side of caution by assessing and monitoring on a more-than-perhaps-called-for basis, and support the need for continuing education for all caregivers.
1. Unknown California State Court.