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Newborn Hypoglycemia

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Food for Thought - Treatment of Physiological Hypoglycemia May Be Harmful

Just-born babies have a very specialized form of nutrition.  Their bodies are designed to thrive with their predictable sequence of events after birth . . . about twenty minutes after birth (after they've mastered breathing and have initialized the visual part of the brain through gazing behavior), they follow their instinct to jump-start the production of breastmilk through suckling.  Their instincts lead them to suckle frequently and for long periods of time in the first few days to signal the mother's body that she has successfully birthed a healthy baby and that her body should continue the transition to full lactation.  Newborn bodies are perfectly adapted to thrive during this transitional period by metabolizing their specialized brown fat.  This brown fat has the amazing property that it can be metabolized directly by the brain, reducing the baby's need for blood sugar.  Thus, a lowered blood sugar level does not necessarily indicate a pathological condition; in fact, in the absence of clinical signs of hypoglycemic stress, a lowered blood sugar level may be healthy.  This non-symptomatic "hypoglycemia" should more accurately be referred to as "normal physiological neonatal hypoglycemia".

It is possible that nutritional supplementation for physiological hypoglycemia may actually be harmful to the newborn by disrupting the natural process--raising the newborn's blood sugar interrupts the newborn's metabolism of ketones and subsequent brain processes.  In particular, ketone metabolism in the newborn's brain may be part of the essential process of transitioning from intrauterine physiology to extrauterine physiology, and interference with ketone metabolism may disrupt this transition.

Those who study the production of ketones in fasting physiology know that ketones induce a noticeably different state of consciousness from glucose metabolism in the brain.  Since this is the state that the baby's body is expecting, interfering with this process may be harmful to the baby in ways we cannot guess.  These may be states of consciousness that are important in the establishment of familial bonding, learning about the environment, or other extrauterine adaptations.  We can even postulate that there is a secondary effect with disruption of ketone production that may increase the risk of autistic tendency through disruption of social bonding.

A bit of folk wisdom comes to mind - "If it ain't broke, don't fix it."  If a baby is maintaining body temperature and behaving normally, don't assume that a lower blood sugar level is an indication of a problem, and don't try to "fix it" through artificial nutritional supplementation or other unnecessary interference with the baby's metabolism.



BREASTFEEDING AND LOW BLOOD SUGAR from Dr. Jack Newman

"As a matter of fact, most of the babies who are tested for low blood sugar do not need to be tested and most of those who receive formula do not need formula. By giving the formula, especially as it almost always is given by bottle, we interfere with breastfeeding and give the impression that formula is good medicine."

from Jack Newman:
What about hypoglycemia (low blood sugar)?  There are so many questions around this issue it won't be easy to summarize them in this post.  However:
1. Doing routine blood sugars on every baby at birth is another example of how "worrying about being sued" causes damage to babies and creates unnecessary anxiety in the parents and results in unnecessary "treatment".  But many hospitals in the US have this policy and more and more in Canada.  Interestingly, most pediatricians and neonatologists don't seem to know what normal is.  They look at a number and say "give formula".
2. In fact, nobody agrees on what is a normal blood sugar in newborns.  Everyone has a different number they consider “too low”. 
3. The blood sugar in babies is more or less the same as the mother's at birth and then over the next 1 to 2 hours the sugar drops, for some babies into the range many would call "too low".  But this drop in the blood sugar is normal!  And the blood sugar rises again over the following hour or two even if the baby is not fed.  This has been shown not only in humans but also in all mammals that have been studied.  Treating "low blood sugar" in this circumstance is treating normal and thousands of babies across North America are being unnecessarily supplemented with formula for what is a normal blood sugar.
4. Skin to skin contact with the mother maintains a higher blood sugar in the baby than separation of the mother and baby.  Skin to skin contact also affords the baby an opportunity to feed at the breast.
5. The mother’s colostrum is the best milk and bank breastmilk the second best to prevent and treat low blood sugar in newborn babies.  For this reason, we recommend that mothers whose babies are at high risk for low blood sugar express and store their milk starting at 35 to 36 weeks gestation so the baby, if necessary, can get colostrum instead of formula.  There is no evidence that hand expression of milk at this stage increases the risk of premature birth.
6. There is evidence that babies who are fed at the breast immediately after birth are less likely to become clinically hypoglycemic and actually have higher blood sugars than babies fed formula.
7. There is no evidence that a baby who is born big (some hospital policies say 4 kg=8lb 12oz or higher) is at risk for low blood sugar if his mother is not diabetic.  On the contrary, such babies are at lower risk of hypoglycemia because they have lots of body fat that can be broken down into compounds called ketone bodies.
8. Ketone bodies protect the baby's brain from the effects of low blood sugar and ketone bodies are present in much higher concentrations in the blood of babies breastfed (or fed colostrum or breastmilk) than in the blood of babies formula fed.  Babies fed both breastmilk and formula have a lower but intermediate response.
9. There is no need for a baby at risk for low blood sugar (infants of diabetic mothers, both type 1 and type 2) to automatically go to special care.  They should stay with the mother, skin to skin, be fed on demand and get help from the nursing staff to make sure the baby feeds well at the breast.  Pre-expressed colostrum can be fed by spoon, syringe or lactation aid at the breast.
10. Bottom line?  There is a lot of hysteroglycemia out there and the "treatment" of it is causing many mothers and  babies to be unnecessarily supplemented with formula often with bottles.


Womb to World: A Metabolic Perspective by Suzanne Colson has a nice section on Neonatal Hypoglycemia, including, "A blood glucose concentration in isolation offers very little diagnostic information."


Hypoglycaemia of the Newborn - Review of the Literature, World Health Organization, Geneva, 1997
Here is a great link. It shows BF superior to formula for hypoglycemic infants and also refutes the notion that SGA, LGA infants need to be supplemented. There is data to show that testing procedures are flawed (heel sticks) and that there isn't a good basis for setting the BS number at 40,38,35.


Neonatal hypoglycaemia-blood glucose monitoring and baby feeding

Term babies, especially those who are breast fed, are prone to low blood glucose concentrations in the first 2-3 days after birth. However, in view of their ability to generate ketone bodies, which are used as alternative fuels for the brain, it is likely that this has no clinical implication for otherwise healthy and asymptomatic babies.

Womb to World: A Metabolic Perspective by Suzanne Colson - has a great section on Neonatal Hypoglycemia


I don't do blood sugar levels, I observe for hypoglycemia by seeing if the baby is jittery, lethargic, pale, can't hold his/her temp, etc.  In the face
of a healthy baby, sugar levels are ludicrous.   If the baby is NOT doing well, O2 and 10% glucose should do the trick.  I carry 10% and 5% in my stuff.  I've used it twice.


In order to avoid nipple confusion, we use a newborn "sippy cup" from La Leche League.  Or some midwives just rub some corn syrup or maple syrup on the baby's gums.  (Never use honey for newborns because of the risk of botulism spores in the honey.)


AAP Sets Guidelines for Neonatal Hypoglycemia [2011]

"Clinically significant NH is the result of an imbalance between glucose supply and other fuels such as ketone bodies, which are released from fat. Blood glucose concentrations often dip to 30 mg/dL within 1 to 2 hours after birth in healthy neonates, but they typically return to more than 45 mg/dL with normal feeding within 12 hours.

"According to the guidelines, the infants at highest risk for clinically significant NH are small for gestational age, large for gestational age, born to mothers who have diabetes, or late-preterm. Routine screening and monitoring of blood glucose is recommended only for infants who have these risk factors or who have clinical manifestations of NH such as jitteriness, cyanosis, seizures, an apneic episode, tachypnea, weak or high-pitched cry, floppiness, or lethargy, poor feeding, or eye-rolling.

"The guidelines call for immediate intravenous glucose for infants who are symptomatic and have glucose levels lower than 40 mg/dL.

"For asymptomatic at-risk infants, the initial feed should be within 1 hour of birth, with glucose screening 30 minutes after the first feed. Because there is no point-of-care screening method reliable enough to be used as the sole method for screening for NH, the blood or plasma glucose concentration must be confirmed by laboratory testing ordered stat.

[Ed: Take home message . . . breastfeeding is important and should be given priority over routine assessments and non-emergency treatments.  Honestly, I don't know what to think when I read things like, "Any kind of standardization that will get people to test more is a good thing."

How about "Any kind of standardization that will get people to consider the initiation of breastfeeding to be paramount is a good thing."

All this emphasis on meaningless lab numbers comes from a system that is focused on liability issues and does not have continuous care for new mothers and babies.  It is largely irrelevant at a homebirth, where the midwife observes the newborn constantly for the first hour and puts breastfeeding above everything else.]


PRACTICAL ISSUES IN MANAGEMENT OF NEONATAL HYPOGLYCEMIA


http://www.hultgren.org/kbems/ped_als.htm#Hypoglycemia

5. If glucose <60 by rapid blood glucose (<40 if newborn) or unable to measure and patient is clinically hypoglycemic[3], administer:
          Neonate: 0.5-1 g/kg = 5-10 ml/kg of D10W.[4]
          Infants & children: 0.5-1 g/kg = 2-4 ml/kg of D25W or 1-2 ml/kg D50W.[3]
          Adolescents and adults: 0.5-1 g/kg = 1-2 ml/kg of D50W.


Neonatal Hypoglycemia

 

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