The fear of low blood sugar of the newborn has become the new
“acceptable” reason to separate mothers and babies and give babies supplements
of formula in the immediate hours and days after the baby’s birth. The reason
paediatricians and neonatologists are worried about low blood sugar is that it
can cause brain damage, so there truly is a concern. However, there has
developed a sort of ‘hyper’-concern about low blood sugar that is simply not
warranted. 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.
Some truths about hypoglycæmia of the newborn
1.
The best way to prevent low blood sugar is to feed the baby with milk. However,
formula and breastmilk (specifically colostrum in these early days) are not
equivalent and colostrum is far better to prevent and treat low blood sugar
than formula (See point #5 below). A little bit of colostrum maintains the
blood sugar better than a lot of formula.1,2,3
2.
Having the baby skin to skin with the mother immediately after birth
maintains the baby’s blood sugar higher than if the baby is separated from her. (See the
information sheet The Importance of Skin to Skin Contact).
3.
There is no lowest level of blood sugar that is universally accepted
as meaning the baby has low blood sugar. Because of this atmosphere of hyper-concern
about low blood sugar, the level of sugar keeps being raised to absurd levels.
In many hospitals now, 3.4 mmol/L (60 mg %) is now considered the lowest
acceptable blood sugar. This is patently aberrant and there is no evidence to
back up such a level as the lowest acceptable blood sugar concentration.
4.
There is no reliable method of measuring the blood sugar outside the
laboratory. The use of paper strips to measure the blood sugar is not reliable.
Paper strips tend to underestimate the true value. Only the laboratory gives a
reliable measure of plasma glucose or sugar (plasma is the part of the blood
which does not contain red blood cells and which is what we are really
interested in, but we’ll leave this aside).
5.
If the baby’s blood sugar is low, it does not mean he will be brain
damaged. This is due to the fact that other constituents released by the
baby’s body will protect his brain. These include compounds called ketone
bodies, as well as lactic acid and free fatty acids. In fact, babies who are
receiving colostrum or breastmilk have much higher levels of ketone bodies, for
example, than formula fed babies or even breastfed babies with supplements of
formula.¹
6.
Babies born of a normal pregnancy and normal birth and who are at term
and of a good weight do not need to be tested for low blood sugar. Yet, so
pervasive is the anxiety about low blood sugar that more and more postpartum
units are testing every baby at birth for low blood sugar. This is painful for
the baby, anxiety producing for the staff and parents, costly, useless and
contrary to evidence.²
7.
It is normal for the blood sugar to drop in the first hour or two
after birth. Yet many babies are tested first at birth then an hour later and
given formula because the blood sugar has dropped. Babies are being tested
without reason, then given formula for a normal situation! Incidentally, even
if the baby is not fed, the blood sugar will rise after the initial (normal)
drop.¹,³
8.
A baby is not at risk of low blood sugar just because he weighs a lot
at birth, if his mother is not diabetic. Yet many hospitals have protocols that call for
automatic testing of a baby, and some even automatic feeding of formula
(unbelievable) if the baby weighs more than 4 kg (8lb 12oz); others use 4.5 kg
(10 lb). This approach seems to have been started because infants of diabetic
mothers tend to be born very large. In fact, large babies whose mothers are not
diabetics are not at increased risk of low blood sugar². In fact, they are
at less risk because their livers are full of glycogen (glucose molecules connected
together in long chains) ready to be called into action by the need for more
sugar, and they also have lots of fat ready to be called into action to produce
ketone bodies, lactic acid and free fatty acids.
9.
A baby who is born small for the length of the pregnancy (under 2.5
kg or 5lb 8oz if born at term is one definition) maintains his blood sugar just
as well if breastfed or formula fed². Of course, it’s important the baby
is breastfeeding. Also see the video clips of young babies breastfeeding.
How should we prevent low blood sugar?
1.
Diabetes in the mother, particularly type 1 (insulin dependent,
juvenile), is a high risk situation for the baby. This is
due to the fact that at birth high insulin levels in the baby (as a result of
the baby’s being exposed to high sugars during the pregnancy) not only drop the
blood sugar but also prevent his body’s formation of ketone bodies, lactic
acid, and free fatty acids. Therefore the baby needs to be watched and may
require an intravenous to maintain the blood sugar.
◦
Good control of diabetes during the pregnancy can help prevent low
blood sugar.
◦
Good control of diabetes during the labour and birth also is
important.
◦
We, and postpartum departments all over the world (particularly in New
Zealand and Australia), have suggested to our prenatal patients whose babies
are at high risk to express their colostrum before the baby is born, starting
at about 35 or 36 weeks gestation. Most can get a few millilitres a day by hand
expression and a mother can often get 30 or 40 millilitres saved before the
baby is born. If the baby needs to be supplemented to control the blood sugar,
the baby is given colostrum, not formula.
2.
Intravenous fluids containing glucose (it is usual) given rapidly to
the mother should be avoided. If the mother’s glucose tolerance (her ability
to handle glucose) is impaired, a lot of glucose given her may increase her
blood sugar and provoke a similar response in the baby with a corresponding
rise in the baby’s insulin secretion.
3.
It is best to put the baby skin to skin with the mother immediately
after birth. As mentioned above and in the information sheet The Importance of
Skin to Skin Contact, the baby maintains his blood sugar better when skin to
skin with the mother. The baby should be dried off but not bathed before he is
put skin to skin with the mother. It is possible and desirable to put the baby
skin to skin with the mother even if she’s had a caesarean section.
4.
The baby should be encouraged to breastfeed as soon as possible after
the birth. Having the baby skin to skin with the mother helps a lot as the baby
may latch on all by himself. A good latch also helps, so the baby gets the
colostrum. Compression while breastfeeding gets more colostrum into the baby.
Also see the video clips.
Treating low blood sugar
If there is a concern about the baby’s blood sugar dropping too
rapidly or being too low and good breastfeeding doesn’t seem to be correcting
the problem, the baby should get an intravenous infusion of glucose
rather than formula. Babies often spit up formula in the first few days because
they get so much. If there is a real concern, taking formula by mouth does not
guarantee the blood sugar will be raised.
Every postpartum unit should have banked breastmilk available on site.
Banked breastmilk is preferable to formula as a supplement whenever the
supplement is truly necessary. Even if the baby needs treatment for low blood
sugar, there is rarely a reason for the baby not to breastfeed as well. A baby
can be at the breast even if he has an intravenous. A baby can get supplements
(preferably pre-expressed colostrum or banked breastmilk) even while being
breastfed.
References:
1.
De Rooy L, Howden J. Nutritional factors that affect the postnatal
metabolic adaptation of full-term small and large for gestational age infants:
Pediatrics Vol. 109 No. 3 March 2002, pp. e42
2.
Cornblath M, Hawdon JM, Williams AF Aynsley-Green A, Ward-Platt MP,
Schwartz R, Kalhan SC. Controversies regarding definition of neonatal
hypoglycemia: suggested operational thresholds. Pediatrics 2000;105:1141-5
3.
Hoseth E, Joergensen A, Ebbesen F, Moeller M. Blood glucose levels in
a population of healthy, breastfed, term infants of appropriate size for
gestational age. Arch Dis Child Fetal Neonatal Ed 2000;83:F117-9
See also the WHO document on hypoglycaemia at
https://www.who.int/child_adolescent_health/documents/chd_97_1/en/index.html
Information sheet Hypoglycaemia, Jack Newman MD, FRCPC, IBCLC, 2009©
Revised by Edith Kernerman, IBCLC, 2009©
All of our information sheets may be copied and
distributed without further permission
on the condition that it is not used in ANY context
that violates the
WHO International Code on the Marketing of
Breastmilk Substitutes (1981)
and subsequent World Health Assembly resolutions.