Neonatal Hypoglycemia and Breastfed Babies
Edie Orr and Betty Crase
From: LEAVEN, Vol. 28 No. 3, May-June 1993, pp. 36-7
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
Important Points about Hypoglycemia
- Breastfeeding early and often will stabilize blood glucose levels.
- Routine glucose supplements are not necessary for all newborns.
- Glucose IVs during labor can increase the risk of hypoglycemia in the newborn.
- If supplements are needed, they can be given by IV, dropper, or cup to avoid nipple confusion.
The pregnant woman is sitting quietly during your La Leche League meeting, absorbing the wealth of information the mothers in your Group have to share. At the end of the discussion on childbirth and the early weeks of breastfeeding, you ask if there are any questions. The expectant mother asks, "Do I have to give my newborn sugar water to prevent hypoglycemia? That's what my friend's pediatrician told her." You take a deep breath and explain that while you are not qualified to give medical advice, you do know that breastfeeding early and often will almost always prevent hypoglycemia in newborns. Hypoglycemia is the technical term for low blood sugar (low concentrations of glucose, the sugar found in blood). When the body's rate of use of glucose is greater than the rate of glucose production, the plasma glucose concentration falls (Rudolph 1982). If it falls too far, too fast in the newborn period, hypoglycemia results. Symptoms may include lethargy, limpness, sweating, jitteriness, tremors, refusal to eat, feeding difficulties, rapid respiration, and pallor. Symptomatic neonatal hypoglycemia is largely due to delayed or inadequate feeding and is more likely to occur when mother and baby are separated after birth. Instead of being allowed to nurse soon and often, some newborns are given sugar water on the erroneous assumption that this will prevent hypoglycemia. Instead, giving glucose water causes a sudden rise in the blood glucose levels, which in turn stimulates the secretion of insulin by the pancreas. This results in an equally sudden drop in glucose levels. It is interesting to note that the treatment for hypoglycemia in adults is small, frequent, high protein meals. That is exactly what the baby gets when he is allowed to nurse on demand from birth.
Colostrum and human milk play a vital role in the prevention and treatment of hypoglycemia. Immediate and frequent feedings of colostrum, preferably ten to twelve feedings per day in the first few days, stabilizes blood glucose levels. Undiluted breast milk is the feeding of choice, particularly for pre-term infants (Smallpiece 1964). For comparison's sake, a 5% glucose solution (20 calories/dl) is a poor nutritional substitute for human colostrum, which contains not only 6.4% lactose, but also 3% fat, 2-3% protein, and 55 calories/dl (Pagliara 1973; Rudolph 1982).
Infants at risk for hypoglycemia include those who are small- or large-for-gestational age, pre-term, have some type of neonatal infection, are oxygen deprived, chilled, show meconium staining, have a central nervous system abnormality, congenital glucose metabolic problems, and other perinatal stress (Sexson 1984). If left untreated, symptomatic hypoglycemia does need to be taken seriously.
Researchers and physicians have differing opinions of what blood glucose levels constitute hypoglycemia. The most current research-based definition of hypoglycemia in any newborn in the United States is a serum plasma blood glucose concentration lower than 40 mg/dl (whole blood glucose level lower than 35 mg/dl). The limit is allowed to go lower by some physicians in the absence of symptoms—whole blood concentrations of 30 mg/dl for full-term, and 20 mg/dl for premature or small-for-gestational age babies. In one study, asymptomatic (except for jitteriness) newborns with blood glucose levels below 20 mg/dl were given breast milk alone. These children were neurologically tested a number of years later and found to have no problems (Gentz 1969).
You may also want to stress to the pregnant women in the Group the importance of finding a health care provider who will truly support and encourage breastfeeding. Healthy full-term babies need no foods or fluids other than colostrum and human milk in the early days after birth. In addition to its ability to provide nourishment, colostrum is rich in antibodies to help the baby fight off infection.
Pregnant women who have healthy diets and avoid smoking lower the risk of newborn hypoglycemia by having healthier babies. However, there are some maternal risk factors which may increase the chances of newborn hypoglycemia such as diabetes (including gestational), toxemia, drug ingestion, pregnancy-induced hypertension, glucose IVs, or a difficult labor.
Some of the more common of these maternal factors are discussed below:
- Glucose IVs should be avoided during labor unless absolutely necessary. Glucose is transported across the placenta so that the fetal plasma glucose level closely approximates the maternal concentration. During pregnancy, the baby is not dependent on its own ability to produce glucose since it is being constantly supplied by the mother. If the mother receives a glucose IV during labor and delivery, the baby's glucose level also rises. Then, at birth, this constant source of glucose is abruptly cut off and the infant is placed in a position of being fully dependent upon his own resources unless he is supported, for example, by being put immediately to the breast (Pagliara 1973).
- A difficult labor can stress a newborn, depleting his glucose stores. Laboring women should be encouraged to walk, eat, change positions, and avoid epidural anesthesia to help labor progress. Women should also be encouraged not to lie on their backs during labor, because the pressure on the mother's inferior vena cave, a large blood vessel that carries oxygenated blood, can put stress on the fetus and increase the risk for hypoglycemia in the early hours after birth.
- Mothers with Insulin Dependent Diabetes Mellitis, or gestational diabetes, need to be aware that their infants may be at higher risk for hypoglycemia. If the mother had uncontrolled diabetes during her pregnancy, her baby is more likely to be premature, experience respiratory distress syndrome, or physiologic jaundice. The baby may be cared for in a neonatal intensive care unit or may not nurse well. Early and frequent colostrum feedings will help stabilize her baby's blood glucose level. If this baby needs supplemental feedings, they can be given to the baby by IV, with a dropper, or a small-cup so as not to cause nipple confusion. The mother may also want to ask her pediatrician or neonatologist not to order any supplement unless absolutely necessary. You may wish to share communicating techniques with the diabetic mother to help her feel comfortable discussing these points with her doctors. If the diabetic mother maintains a normal glucose level throughout pregnancy, labor, and birth, her baby is not likely to have serious problems.
In some hospital settings, newborns are at risk for developing hypoglycemia even after an uneventful labor and delivery. Babies who are not fed soon after birth, are left uncovered in a nursery warmer, or are left in a nursery to cry, are prone to stress. As a result they use up their stores of glucose, and are at risk for developing hypoglycemia. It is necessary to emphasize to the mothers the importance of putting the baby to breast immediately after birth, making sure the baby is kept warm and dry, preferably in the mother's arms, and not allowing long separations when the baby may be left to cry.
If a healthy, full-term baby is sleepy and not nursing well in the early days, the mother may wish to express her milk and feed it to him by methods other than with artificial nipples. Rooming-in with the baby or being at home will give her frequent opportunities to offer the breast to him. Nighttime feedings are important for milk stimulation. New mothers will also learn to recognize their newborn's hunger cues, such as hand-to-mouth movements and rooting, and take advantage of these times to offer the breast.
If the baby is at risk for hypoglycemia, the new mother may want to try some rousing techniques on the baby such as undressing him, changing a diaper, playing with her baby, rubbing the bottom of his feet or back, or giving him a sponge bath. It's important that the baby breastfeed efficiently and often in the early days. Avoiding the use of pacifiers will help prevent nipple confusion and aid in getting breastfeeding off to a good start.
The mothers in your Group need to know that hypoglycemia isn't a common health problem among newborn babies, and the baby who is not showing any symptoms of hypoglycemia does not need routine glucose supplements. The immediate and frequent feeding of colostrum and human milk to all infants continues to be the best recommendation for stabilizing blood sugar and preventing hypoglycemia.
Gentz, J et al. On the diagnosis of symptomatic neonatal hypoglycemia. Acta Paediatr Scand 1969: 58: 449-59.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK. La Leche League International, Franklin Park Illinois, 1991.
Pagliara, AS et al. Hypoglycemia in infancy and childhood. Part I. J. Pediatr 19733: 82(3): 365-79.
Riordan, J. and Auerbach, K.G. Breastfeeding and Human Lactation. Boston: Jones and Bartlett Publishers, Inc,1993.
Rudolph, AM et al. Pediatrics. Seventeenth Edition. Norwalk, Connecticut,1982: Appleton-Century-Crofts "Hypoglycemia" pp.283-88.
Sexson, WR. Incidence of neonatal hypoglycemia: A matter of definition. J. Pediatr 1984-7: 105(1): 149-50. Smallpiece, V et al. Immediate feeding of premature infants with undiluted breastmilk. Lancet 1964-12-26: 2: 1349-52.