Physicians are required to provide the `skill and care ordinarily used in similar circumstances' -- a failure to do so is defined as negligence. Expert witnesses are expected to articulate this standard at trial. However, precedent exists for juries to decide that `a whole calling has unduly lagged', and confirm malpractice without deviation from `standard' care. Can we identify in advance conditions where `ordinary skill and care' are insufficient? We wondered whether the skill and care ordinarily used for i.v. glucose infusion was sufficient to protect infants from hypoglycemia in the NICU.

Patient Population: We reviewed the charts of 445 newborn infants admitted to our NICU. We noted birthweight; gestational age; birthtime; time, route, and volume of i.v. glucose infusion; and glucose values during the first 24 hours. Glucose concentration was determined by rapid bedside testing(Dextrostix, Accucheck, or Chemstrip).

Results: All infants were treated with intravenous D 10/W @ ≥ 60 ml/kg/day upon admission to the NICU. 62 (14%) infants had at least one glucose value below 30 mg%; 21 (5%) infants had at least one glucose value below 20 mg%. 14 infants had at least two glucose values below 30 mg% (3% of all admissions; 23% of infants with at least one glucose value below 30 mg%). In 43 infants, the lowest glucose value was obtained prior to the onset of i.v. infusion; 26 episodes occurred at least 30 minutes after i.v. glucose had begun. Glucose infusion was initiated more rapidly via peripheral i.v. (median time 58 minutes) than umbilical i.v. (median time 98 minutes; p < 0.01).

Conclusions: 1) Despite our adherence to published standards regarding glucose administration, 14% of infants had at least one episode of glucose < 30 mg%; `ordinary care in similar circumstances', though not negligent by definition, may be inadequate for some infants. 2) Roughly two-thirds of all episodes of hypoglycemia might be addressed by more rapid i.v. insertion, one-third by larger glucose dose. 3) Hypoglycemia may occur in the absence of negligence; experts must not declare normative care deviant -- juries must reserve this power for themselves.