There is a new (1997) World Health Organisation publication
*Hypoglycaemia of the Newborn - Review of the Literature* put out by the Division of Child Health and Development and the Maternal and Newborn Health / Safe Motherhood groups.  I think it is a valuable, up to date reference.
The recommendations begin with"
1 Early and exclusive breastfeeding is safe to meet the nutritional needs of healthy term newborns worldwide.
2 Healthy term newborns who are breastfeeding on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids.
3 ...

I haven't studied my copy in detail yet, but it looks good.  There has been some discussion about the recommendation that "For newborns at risk who do not show abnormal clinical signs, the blood glucose level should be maintained at or above 2.6 mmol/l (47 mg/100 ml)".  The issue in many maternity settings here is that babies who are not at risk are managed in an aggressive manner, are not given early and frequent breast feeds, and the blood glucose levels are measured on equipment that is inaccurate (measures low) at low levels.  
Recommendation 13 is that "For newborns at risk, the blood glucose concentration should be measured at around 4-6 hours after birth, before a feed [not before the first feed], if reliable laboratory measurements are available.  Measurements using glucose-oxidase based reagent paper strips have poor sensitivity and specificity in newborns, and should not be relied upon as an alternative."

I think it is essential that anyone working with newborns has the best up to date evidence readily at hand in situations where inappropriate breastfeeding management and supplementation may occur.  Recently I (midwife) was attending a woman who had an emergency C/S.  I went with the baby to the nursery, and the Paed ordered immediate blood sugars and commencement of 3-hourly feeds of formula.  I challenged this, and told him that the woman wished to breastfeed.  The Paed was not used to being challenged on such an issue and told me that the baby might get brain damage if his orders were not followed.  This was a well baby, at term - I raised my eyebrows.  The indication for the Ceaser was fetal distress from a tonic contraction after the use of prostaglandin to induce labour.  Anyway the doctor agreed to wait and see, and the baby managed to maintain blood sugars within reasonable limits, and went to mother asap.  (sigh!)
I don't want to whinge about doctors.  Unless we who make breastfeeding our business are conscientious in presenting appropriate management options to both our clients and our colleagues, old learned patterns of management will be followed without question.
Best wishes to all out there.
Joy Johnston
Melbourne Australia
-----Original Message-----
From:   Khalid Aziz [SMTP:[log in to unmask]]
Sent:   Sunday, October 26, 1997 11:47 PM
Subject:        Low blood sugar

Hi!  I'm back from a long time away.

This issue of whom to screen and whom to treat for low blood sugar in the
neonatal period is contentious.  I cannot agree with the list:

"Blood glucose levels are drawn on babies considered at risk, i.e. <2500 gm,
meconium stained amniotic fluid, fetal distress, >4000 gm, temperature <97
degrees rectally."

Meconium-stained amniontic fluid (10% of normal deliveries), fetal distress
(difficult to define), >4000g (common in many populations) and temp >97
degrees rectally are NOT, in my mind, absolute indications for glucose
checking.  Even 2.5kg may not be appropriate in ethnic groups who have
smaller babies (probably appropriate in N America in general).

As a rule infants should be divided into sick and well.  Sick infants all
need a blood sugar checked.  Well infants only need a blood sugar check for
a proven risk factor.   My limited list would include:

1.  Infants of diabetic mothers
2.  Small or large for gestational age for a given population - the
implication being that these infants are either malnourished or infants of
undiagnosed diabetics.
3.  Infants admitted to ICU (symptomatic by definition)

In a well, asymptomatic child, even with a risk factor, the first response
should be to breast feed if the sugar is low (<2mmol/l or 40 mg/dl).  If
this fails alternative sources of calories should be discussed with the
parents.

Khalid

Khalid Aziz
Memorial University of Newfoundland