I think there are a number of reasons why we are starting to see such bizarre
hypoglycemia protocols in US hospitals. The fear of litigation probably
drives most of the improper interventions. The mishandling of this situation
usually comes from a fundamental lack of understanding of glucose metabolism
in the newborn. At birth, the baby's supply of glucose it cut off and he must
rely on a complicated series of events called counterregulation to adapt to
the new environment. There is a normal dip in blood glucose in the first 2-4
hours post birth in the normal healthy full term low risk baby. Measuring
glucose at this time is pointless, especially with reagent strips. These
strips under-read by 5-15mg/dl with treatment not be undertaken unless
confirmed by a lab value.

Babies have a 12 hour supply of stored glycogen to mobilize as fuel for the
brain. After this they must make glucose and also create other alternative
brain fuels such as ketone bodies. Certain caretaking routines contribute to
using up the stored glycogen more quickly, such as separating the mother and
baby, allowing the baby to cry, imposing long intervals between feedings,
bathing the baby, giving mothers in labor glucose IVs, epidurals and
traumatizing the baby at birth. Babies separated from their mothers have
lower body temperatures, cry more, and have lower blood glucose levels.
Crying is bad for babies!

Babies make alternative fuels for the brain by drawing amino acids from their
muscle mass and fatty acids from their stored fat. They need the protein and
fat in colostrum which serve as the substrates for the making of the brain
fuels. Giving babies 5% dextrose by mouth will raise the blood sugar but it
is metabolized so rapidly that the baby may not have time to mount the
counterregulation before the levels drop again. Hence, the rebound
hypoglycemia and the problem with treating low blood sugar this way. Giving
5% dextrose arbitrarily when it is not needed causes the problem without
giving the baby the substrates he needs to make his own fuel.

Breast milk is more ketogenic than formula. If the baby cannot latch, have
the mother hand express colostrum into a spoon and spoon feed the baby
colostrum. Using a breast pump to express colostrum usually leaves little to
no colostrum available to feed to the baby as it sticks to the sides of the
bottle. Formula will also raise the blood sugar levels but introduces the
possibility of triggering allergy and diabetes in susceptible babies.
Hydrolyzed formula is what many units use to avoid those problems. Avoiding
formula use by using the hand expressed colostrum protects the baby and the
breastfeeding. Handling the baby and the breastfeeding correctly from the
start avoids most of the rest of it.

Marsha Walker, RN, IBCLC
Weston, MA

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