This is always a difficult area for neonatologists who are breastfeeding
advocates.

Infants who are large for gestational age (over 4.2kg or so at term) are
more likely to be infants of gestational diabetic mothers.  If the mothers
do have high sugars in pregnancy the infant produces more insulin in utero.
 The result is an increased risk of low blood sugar in the first 2 to 3
days of life.  Traditional pediatric thinking is that low blood sugar is
dangerous and can result in neonatal seizures with poor long term outcome -
this is most probably true and has been demonstrated in different age groups.

As a consequence many centres have policies that large for dates infants
should be checked for low blood sugar/hypoglycemia at regular intervals in
the first 24 to 72 hours of life.  If the sugar is low and/or the baby has
neurological signs of hypoglycemia extra calories in some form are
indicated:  here is where the problem arises.  How should we augment
calorie supply in an infant in whom breastmilk supply is not established?
If anyone has any ideas about this please contact me because it is a
dilemma.  The options are:

1.  Banked breast milk
2.  Oral glucose
3.  Intravenous glucose
4.  Other breastmilk substitute

There are a few problems with this course of action.  The first is that
most large-for-dates infants are completely normal and do not need any
intervention:  good clinical judgement should rescue most of these infants
from unnecessary heel-pokes (not always the easiest thing to do in this
medicolegally-orientated world).  Secondly, glucose solutions may increase
insulin production, aggravating the problem some hours later.  Thirdly, fat
(found in all milks), in the form of ketones, is a useful source of energy
for the infant brain.  Fourthly, we are not sure what is the lower limit of
normal for blood glucose in a well baby.  Finally, for various reasons, we
have a shortage of breast milk banks.

I don't know the right answer here.  Intuitively I feel that infants who
look and behave normally should not be treated abnormally.  I believe that
supplementation is a medical treatment that requires medical indications
that the parents should understand and approve.  Infants who are sick (ie
signs of hypoglycemia) need urgent evaluation and treatment.  I usually
explain the reasoning behind the sugar testing to the parents and, if
treatment is indicated, I explain the options (depending on the infant's
condition).

I would be interested to know what lactation consultants feel on this issue
as it would help me make up my mind on the best approach.


Khalid Aziz
Memorial University of Newfoundland