Hypoglycaemia

Hypoglycaemia is a low blood sugar level.  WHO recommends 2.6 mmol/l as cutoff. Routine screening of this is supposedly being phased out of maternity wards, but not fast enough...

What babies are at risk?

Newborns at risk of hypoglycaemia
• Preterm (<37 weeks gestation)
• SGA
• Low birth weight (< 2.5kgs at birth)
• Maternal diabetes
• Sever intrapartum asphyxia,
resuscitation at birth
• Ill babies ( e.g. infection)
• Hypothermia
• Maternal use of ß blockers

and that's it..

I for one had experience of 2 hourly blood tests on my poor little baby when he was born (perfectly healthy).. and this was completely uncesessary... ah if I only had known, I could have saved him from lots of nasty needles in his poor little heel..

In a nutshell : routine testing is NOT recommended except in diabetic mothers. If your baby has been tested, and supplementation is recommended, they are generally incorrect.  Hypoglycaemia can ONLY be correctly diagnosed on a proper blood test, not on a strip at the bedside. Your baby should only be tested if they display any of the following: Apnoea, cyanosis, jitteriness, convulsions or altered level
of consciousness.

The best thing for your baby is breastmilk/ colostrum, not formula.

Treatment flow chart:

http://www.babyfriendly.org.uk/pdfs/hypo_policy.pdf

Read on...!

Even when hypoglycemia is present, the best treatment is usually breastfeeding.  As noted above, colostrum has plenty of lactose to help raise the baby's blood sugar, but more importantly it has lots of protein to help stabilize those blood sugars as well.  Protein and lactose together are important to help slow and stabilize the rise in blood sugar. With lactose or glucose alone, the baby's blood sugars tend to rise and then crash later, a fluctuation that can also be harmful.  

Unless hypoglycaemia is severe, frequent breastfeeding is usually sufficient to treat most cases, plus it has the added benefits of immunological protections. 

On the other hand, while it is clear that routine supplementation of caesarean babies is unnecessary, sometimes treatment for hypoglycaemia can become necessary. However, just how aggressive surveillance and treatment should be will depend on the cause and circumstances of the case. 

Possible Causes of Hypoglycemia

Babies who have been through a long or stressful labour can sometimes have low blood sugar at birth, especially if they were deprived of oxygen at some point.  Although all babies with hypoglycemia need to be watched, most cases that result from moderate stress respond well to treatment and stabilize quickly.  For these babies, frequent breastfeedings and close observation is sufficient treatment most of the time. If the baby is symptomatic, not breastfeeding well, or does not respond to breastfeedings, then supplementation may sometimes be necessary.  Usually, however, aggressive testing and routine supplementation is not necessary unless the baby's stress has been severe.

Another baby that is often aggressively supplemented is the macrosomic ('big') baby.  Although definitions vary, macrosomia is loosely defined as any baby at or over 9 lbs.  Because a percentage of macrosomic babies do experience hypoglycemia, many hospitals routinely require automatic testing and/or supplementation of babies over 9 lbs.  This is rarely necessary, as most of these cases respond well to early and frequent breastfeeding, and simple observation is usually all that is required.

Extra-small babies ('Small for Gestational Age') may also experience higher rates of hypoglycemia, and often are supplemented too. These babies must be carefully watched because there is a potential for problems, and if the baby does not maintain a stable blood sugar level, supplementation may become necessary.  However, most SGA babies stabilize well if they are nursed early and frequently.  

Babies of diabetic mothers, on the other hand, need careful testing and observation because neonatal hypoglycemia is a real risk.  Because these babies tend to receive higher levels of blood sugar in utero, they respond by producing high levels of insulin.  After birth, the mother's blood sugar is taken away but the baby's insulin production takes a while to adjust, and thus unstable blood sugar is common.  This is most prevalent in babies of poorly controlled diabetics but can sometimes also occur even with well-controlled diabetes.  

In the past, most babies of diabetics were automatically given IV glucose and/or formula supplementation, but recent research has shown that many of these babies do very well on breastfeeding alone, with careful monitoring.  So while some babies of diabetic mothers are going to need supplementation, automatic supplementation should be replaced by a more selective approach (Cordero 1998).  And even if a baby of a diabetic pregnancy needs supplementation, there is no reason it has to be given by bottle.  Breastfeeding and non-bottle supplementation methods should be combined to help these babies stabilize their blood sugar while also stimulating the mother's milk supply and giving the baby those all-important antibody protections.   

Babies of mothers with gestational diabetes used to be treated exactly the same as those with overt diabetes, with extremely aggressive testing and supplementation protocols.  However, it is questionable whether this is truly necessary in most cases.  If the mother needed insulin, then careful testing is probably justified, and supplementation may sometimes become necessary.  If the mother did not need insulin and had excellent control, then routine testing may not be needed at all; careful observation and promotion of early and frequent breastfeeding may be sufficient.  However, just how much testing and what protocols are important is subject to a great deal of debate, and standards will vary considerably from hospital to hospital. 

Premature babies often struggle to regulate their blood sugar, and supplementation often becomes truly necessary here.  A lot depends on just how premature the baby is, how well they are able to suckle (if at all), and whether there are other problems accompanying the prematurity.  There are too many variables in prematurity for any strict guidelines; consulting a board-certified lactation specialist is the best way to sort through all the information and know more reliably when supplementation is truly needed and when it is not.  

Babies who have an infection (or who are otherwise sick) often have hypoglycemia problems, and may have particular difficulty keeping their blood sugar steady.  Their blood sugar can shoot up and down like a roller coaster; keeping their levels steady can be very difficult.  This type of hypoglycemia is much harder to treat and often does necessitate supplementation, but should not rule out breastfeeding either.  Sick babies need the protective immunological elements in their mother's colostrum and milk the most, so supplements should never be used instead of breastmilk but in addition to it (preferably after breastfeeding).  However, as with premature babies, even if supplementation does become necessary, it does not mean that it has to be done by bottle.  There are many other options that can help preserve breastfeeding (see below). 

Finally, while it is clear that automatic bottles after caesareans should be abolished, some hospitals still cling to this outdated protocol under the assumption that any baby born by caesarean is going to be stressed and have low blood sugar.  Parents need to assertively make it clear that NO routine bottles should be given to their babies, and frequently remind staff of this during and after the caesarean.  The father or support person can request that the baby stay in the O.R. while the surgery is completed (where they can watch for supplements), or they can follow baby to the nursery and reinforce the message that no supplements are to be used unless hypoglycemia is shown to be a legitimate concern.  

Diagnosis and Treatment Issues

If low blood sugar is suspected, then it is possible that the baby may indeed need supplementation.  However, it is important that this be DOCUMENTED WITH LAB TESTS.  Unless the baby is severely symptomatic or there is reason to suspect a serious problem, frequent breastfeeding should be the only treatment to take place until lab results document that there is a problem.  Although there are occasional exceptions, early and frequent breastfeeding should be the treatment of choice before routine supplementation.

Lab tests are important to document blood sugar levels because most portable glucometers do NOT accurately measure blood sugar in a newborn.  Unless the monitor has been specially calibrated for differences in neonatal blood, it consistently underestimates a newborn's blood sugar levels.  Yet even though this is stated on the brochures of many glucometers, some hospitals still continue to use regular glucometers, leading to babies being diagnosed and treated for 'hypoglycaemia' that doesn't exist.  A regular glucometer can be used to rule out hypoglycaemia, but it cannot be used to diagnose it. 

On the other hand, if glucometer results are extremely low, then lab tests will undoubtedly confirm hypoglycaemia, and treatment should proceed immediately without waiting for lab results.  Even so, unless the hospital has a glucometer that is calibrated for neonatal blood, lab tests should still be run to find out the exact blood sugar levels of the baby.  Continuing treatment needs to be based on valid data.

At what point hypoglycemia should be diagnosed is a difficult question.  It depends on the circumstances. If the baby is ill, premature, or has some other special consideration, the guidelines used for diagnosis completely depend on the situation.  No guidelines can be presented here for scenarios of illness or prematurity because the cutoffs are so dependent on the situation. Consult a lactation consultant for guidelines specific to your situation.

How seriously these results are treated varies too; in some hospitals, a level of 2.6 is considered normal or 'borderline,' yet in others is considered seriously hypoglycemic. One hospital may require automatic supplementation with formula or glucose water at 37 mg/dl, yet another hospital may require nothing more than frequent breastfeeding, observation, and retesting in an hour or two.  Because opinions and requirements vary so much, no absolute guidelines can be set out, and each mother should consult a board-certified lactation consultant to discuss the implications of any specific situation they encounter.

Hypoglycaemia Summary

Hypoglycemia is a potentially serious problem for a newborn if it is severe or if the blood sugar is unstable. If untreated, it can result in brain damage and other problems, and it is totally understandable that hospital personnel are concerned about it.  However, it is clear that routine supplementation protocols of the past are outdated and should be abandoned.  

In the normal term baby with no symptoms of hypoglycemia, automatic supplementation is not needed.  Breastfeeding about every 2 hours is usually enough to prevent hypoglycemia.  In the baby at increased risk for hypoglycemia, more frequent breastfeeding is indicated.  Supplementation is usually not necessary for most of these babies; careful observation and periodic testing is usually all that is needed.  However, babies that are symptomatic or born with special concerns like prematurity, illness, or maternal diabetes may need closer observation and more aggressive treatment.

If treatment is needed, it should be based on valid data (instead of on assumptions about risks, or on data from invalid sources), should take into account the specific circumstances of each unique situation, and should be based on the latest research instead of on tradition.  If supplementation does become necessary, preserving breastfeeding should still be an important priority, alternative methods should be used whenever possible, and frequent breastfeeding should be among the treatment options utilized.  Whenever there are concerns about hypoglycemia, consultation with a PROFESSIONAL lactation consultant for treatment decisions is vital.  

Recommendations for Prevention and Management (WHO)

1. Early and exclusive breastfeeding is safe to meet the nutritional needs of healthy term newborns worldwide.

2. Healthy term newborns who are breastfeeding on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids.

3. Healthy term newborns do not develop "symptomatic" hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia (see point 17), look for an underlying condition. Detection and treatment of the cause is as important as correction of the blood glucose level.

4. Thermal protection (the maintenance of normal body temperature) in addition to breastfeeding is necessary to prevent hypoglycaemia.

5. Breastfeeding should be initiated as soon as an infant is ready, preferably within 1 hour of birth. Immediately after birth the baby should be dried and held against the mother's chest with skin-to-skin contact to provide warmth and to facilitate the initiation of breastfeeding.

6. Breastfeeding should continue on demand. Healthy term newborns show signs of readiness to feed when they are hungry, but the interval between feeds varies considerably, particularly in the first few days of life. There is no evidence that long interfeed intervals adversely affect healthy newborns who are kept warm and who are breastfed when they show signs of hunger. An infant who shows no signs of hunger or is unwilling to feed should be examined to exclude underlying illness.

7. Newborns at risk of hypoglycaemia include those who are preterm and/or small for gestational age (SGA), those who suffered intrapartum asphyxia or who are sick, and those born to diabetic mothers.

8. In newborns at risk, hypoglycaemia is most likely to occur in the first 24 hours of life, as the infant adapts to extrauterine life. Hypoglycaemia which presents after the first day of life, or which persists or recurs, does not necessarily indicate inadequate feeding. It may indicate underlying disease such as infection, or a wide range of other conditions (see Table 3 of main document). Reference should be made to standard texts.

9. For newborns at risk, breastmilk is the safest and nutritionally most appropriate food. However it may need to be supplemented with specific nutrients for some very low birth weight infants.

10. At-risk newborns who have a gestational age of 32 weeks or more or who weigh more than 1500 g at birth, may be able to breastfeed sufficiently to satisfy their nutritional needs (but see also point 12). If healthy, they should be given the opportunity to breastfeed within 1 hour of birth like term babies.

11. At-risk newborns able to suckle sufficiently should continue to breastfeed when they show signs of hunger. However, they should not be allowed to wait more than 3 hours between feeds. Normal body temperature should be carefully maintained.

12. At-risk newborns not able to suckle adequately and obtain all the milk that they need from the breast, but well enough for oral feeds, can be fed expressed breastmilk (EBM), or if necessary an appropriate breastmilk substitute, by cup or by gavage (orogastric or nasogastric tube feeding). Feeds should commence within 3 hours of birth, and should continue at least 3 hourly thereafter.

[ Reference should be made to "standard texts" for details of the feeding of newborns who are less than 32 weeks gestational age, or who are very low birth weight, who are sick or born to diabetic mothers, or who are unable to feed enterally]

13. For newborns at risk, the blood glucose concentration should be measured at around 4-6 hours after birth, before a feed, if reliable laboratory measurements are available. Measurements using glucose-oxidase based reagent paper strips have poor sensitivity and specificity in newborns, and should not be relied upon as an alternative.

14. For newborns at risk who do not show abnormal clinical signs ("asymptomatic"), the blood glucose concentration should preferably be maintained at or above 2.6 mmol l-1  (47 mg /100 ml).

If the blood glucose concentration is below 2.6 mmol l-1:

§ The infant should be fed. This can be a breastfeed if the infant can suckle adequately. If not, EBM or an appropriate breastmilk substitute can be given by cup or gavage.

§ The blood glucose measurement should be repeated preferably after 1 hour and certainly before the next feed 3 hours later. If it is still below 2.6 mmol l-1, treatment with intravenous glucose should be considered.

§ If facilities for administering intravenous glucose are not readily available, a supplementary feed should be given by cup or gavage.

§ Breastfeeding should continue.

15. If reliable laboratory measurements of blood glucose are not available, newborns at risk should be kept warm and breastfed. If breastfeeding is not possible they should be given supplements of EBM or an appropriate breastmilk substitute by cup or gavage at least every 3 hours. The infant should continue to breastfeed as much as he or she is able.

16. If a newborn is unwell or shows signs of hypoglycaemia: apnoea, cyanosis, jitteriness, or convulsions ("symptomatic hypoglycaemia"), the above guidelines are superseded. Blood glucose should be measured urgently, and if it is below 2.6 mmol l-1, intravenous glucose should be administered as soon as possible.

17. For management of "symptomatic hypoglycaemia," when intravenous treatment is indicated and feasible, give 10% glucose intravenously. Monitor the blood glucose, and adjust the rate of infusion accordingly. Continue normal feeding as soon as possible.

18. If reliable blood glucose measurement is not possible, intravenous glucose should be reserved for the treatment of major complications associated with hypoglycaemia (e.g. convulsions) and for situations in which enteral feeds are contra-indicated. Enteral treatment is otherwise preferable.

WHO recommendations:

http://www.who.int/reproductive-health/docs/hypoglycaemia_newborn.htm

Further information for medical professionals – guidelines for newborn testing: http://www.babyfriendly.org.uk/pdfs/hypo_policy.pdf