BREASTFEEDING MEDICINEVolume 1, Number 3, 2006© Mary Ann Liebert, Inc.

ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and

Treatment of Hypoglycemia in Breastfed NeonatesRevision June, 2006

NANCY WIGHT, KATHLEEN A. MARINELLI, AND THE ACADEMY OFBREASTFEEDING MEDICINE PROTOCOL COMMITTEE

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A central goal of the Academy of Breastfeeding Medicine is the development of clinical proto-cols for managing common medical problems that may impact breastfeeding success. These pro-tocols serve only as guidelines for the care of breastfeeding mothers and infants and do not de-lineate an exclusive course of treatment or serve as standards of medical care. Variations intreatment may be appropriate according to the needs of an individual patient.

normal term human infants, even if early enteralfeeding is withheld, this phenomenon is self-limited, as glucose levels spontaneously risewithin 2 to 3 hours.1–3 This early self-limited pe-riod of hypoglycemia should not be consideredpathologic. There is little practical value in mea-suring, or treating, the blood glucose concentra-tions of asymptomatic, normal term babies inthe first 2 hours after birth.4–6 Furthermore, evenin those situations in which low blood glucoseconcentrations do develop secondary to pro-longed intervals (>8 hours) between breastfeed-ings,2 a marked ketogenic response occurs Theenhanced capability of the neonatal brain to useketone bodies provides glucose-sparing fuel tothe brain, protecting neurologic function.2,7–9

Studies have not shown that treating tran-siently low blood glucose levels results in better short- or long-term outcomes comparedwith no treatment, and in fact there is no evi-dence that asymptomatic hypoglycemic infantsbenefit from treatment at all.10 Koivisto et al.11

ABM Protocols

PURPOSE

TO PROVIDE GUIDANCE in the first hours/daysof life to:

• Prevent hypoglycemia in breastfed infants• Monitor blood glucose levels in at risk term

and late-preterm breastfed infants• Manage documented hypoglycemia in

breastfed infants• Establish and preserve maternal milk supply

during medically necessary supplementa-tion for hypoglycemia

BACKGROUND

Physiology

The term hypoglycemia refers to a low bloodglucose concentration. Transient hypoglycemiain the immediate newborn period is common,occurring in almost all mammals. In healthy,

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found no difference in neurologic outcome be-tween asymptomatic hypoglycemic infants andeuglycemic control infants, with 94% and 95%of each group normal on 1- to 4-year follow-up.There was a significant (12%) increase in neuro-logic abnormalities in symptomatic hypo-glycemic infants and a 50% incidence of neuro-logic abnormalities when seizures were present.The compensatory provision of alternate fuelsconstitutes a normal adaptive response to tran-siently low nutrient intake during the establish-ment of breastfeeding,2,12 resulting in breastfedinfants tolerating lower plasma glucose levelswithout any significant clinical manifestationsor sequelae.12 Therefore, the monitoring ofblood glucose concentrations in healthy, appro-priately grown neonates is unnecessary, and po-tentially harmful to parental well-being and thesuccessful establishment of breastfeeding.4,6,13,14

Definition of hypoglycemia

The definition of hypoglycemia in the new-born infant has remained controversial becauseof a lack of significant correlation among plasmaglucose concentration, clinical symptoms, andlong-term sequelae.12,15,16 In addition, bloodglucose test results vary enormously with thesource of the blood sample, the assay method,and whether whole blood, plasma, or serum glu-cose concentration is determined. Plasma orserum glucose concentrations are 10% to 15%higher than in whole blood.17

Breastfed, formula-fed, and mixed-fed in-fants follow the same pattern of glucose valueswith an initial fall in glucose over the first 2hours, followed by a gradual rise in glucoseover the next 96 hours, whether fed or not.1,18,19

Breastfed infants tend to have slightly lowerglucose and higher ketone bodies than artifi-cially fed infants.2,18,20,21

The incidence of “hypoglycemia” varies withthe definition.22 Many authors have suggestednumeric definitions of hypoglycemia, usuallybetween 30 and 50 mg/dL (1.7 to 2.8 mmol/L)and varying by postnatal age.1,4,15,18,22–26 Corn-blath et al.12 summarized the problem:

Significant hypoglycemia is not and can notbe defined as a single number that can beapplied universally to every individual pa-

tient. Rather, it is characterized by a value(s)that is unique to each individual and varieswith both their state of physiologic matu-rity and the influence of pathology.

A recent metaanalysis (studies published1986 to 1994) of low plasma glucose thresholdsin full-term normal newborns who were mostlymixed-fed (formula and breastfeeding) or for-mula-fed, presented recommended low thresh-olds for plasma glucose based on hours afterbirth (Table 1). The authors specifically notedthat given the lower plasma glucose levels innormal breastfed infants, the low thresholds forexclusively breastfed infants might even belower.27 Recommendations based on thisthreshold approach are provided in Table 1.

Given this information, it is clear that the rou-tine monitoring of blood glucose in healthy terminfants is not only unnecessary, but is potentiallyharmful to the establishment of a healthymother–infant relationship and successful breast-feeding patterns.6,13,14,28,29 This recommenda-tion has been supported by the World HealthOrganization,4 the AAP,30 and the NationalChildbirth Trust of the United Kingdom.31 Theyall conclude that early and exclusive breast-feeding is safe to meet the nutritional needs ofhealthy term infants and that healthy, full-terminfants do not develop symptomatic hypo-glycemia simply as a result of underfeeding.

Testing methods

Bedside glucose testing strips are inexpen-sive and practical, but are not reliable with sig-nificant variance from true blood glucose lev-els.14,26,32 Bedside glucose tests may be used forscreening, but laboratory levels must confirmresults before a diagnosis of hypoglycemia canbe made, especially in asymptomatic in-fants.4,14,17,28

TABLE 1. RECOMMENDED LOW THRESHOLDS: PLASMA GLUCOSE LEVEL

Hour after birth �5th Percentile PGL (mg/dL)

1–2 (nadir) 28 (1.6 mmol/L)3–47 40 (2.2 mmol/L)48–72 48 (2.7 mmol/L)

From Ref. 27.

RISK FACTORS FOR HYPOGLYCEMIA

Neonates at increased risk for developingneonatal hypoglycemia should be routinelymonitored for blood glucose levels irrespectiveof the mode of feeding. At risk neonates fallinto two main categories:

1. Excess use of glucose, which includes thehyperinsulinemic states

2. Inadequate production or substrate deliv-ery33

The infant categories as shown in Table 2 areat increased risk for hypoglycemia.5,12,33–36

CLINICAL MANIFESTATIONS OF HYPOGLYCEMIA

The clinical manifestations of hypoglycemiaare nonspecific, occurring with a variety of other

neonatal problems. Even in the presence of anarbitrary low glucose level, the physician mustassess the general status of the infant by ob-servation and physical examination to rule outother disease entities and processes that mayneed additional laboratory evaluation andtreatment. Some common clinical signs arelisted in Table 3.

A diagnosis of hypoglycemia also requiresthat symptoms abate after normoglycemia isrestored. Transient, single, brief periods of hy-poglycemia are unlikely to cause permanentneurologic damage.5,10,28

GENERAL MANAGEMENTRECOMMENDATIONS (TABLE 4)

Early and exclusive breastfeeding meets thenutritional and metabolic needs of healthy,term newborn infants. Healthy term infants donot develop symptomatic hypoglycemia sim-ply as a result of underfeeding.4,5,30

1. Routine supplementation of healthy, term in-fants with water, glucose water or formula isunnecessary and may interfere with estab-lishing normal breastfeeding and normalmetabolic compensatory mechanisms.2,20,30,31

2. Healthy term infants should initiate breast-feeding within 30 to 60 minutes of life andcontinue on demand, recognizing that cry-ing is a very late sign of hunger.30,37 Earlybreastfeeding is not precluded just becausethe infant meets the criteria for glucose mon-itoring.

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TABLE 2. AT-RISK INFANTS FOR WHOM ROUTINE

MONITORING OF BLOOD GLUCOSE IS INDICATED

Small for gestational age (SGA); �10th percentile forweight

Large for gestational age (LGA); �90th percentile forweight*

Discordant twin; weight 10% below larger twinInfant of diabetic mother, especially if poorly

controlledLow birth weight (�2500 g)Perinatal stress; severe acidosis or hypoxia-ischemiaCold stressPolycythemia (venous Hct �70%)/hyperviscosityErythroblastosis fetalisBeckwith-Wiedemann syndromeMicrophallus or midline defectSuspected infectionRespiratory distressKnown or suspected inborn errors of metabolism or

endocrine disordersMaternal drug treatment (e.g., terbutaline, propranolol,

oral hypoglycemics)Infants displaying symptoms associated with

hypoglycemia (see Table 3)

*This remains controversial. Some recommend in un-screened populations in whom LGA may represent un-diagnosed and untreated maternal diabetes.

From: Schaefer-Graf UM, Rossi R. Bührer C, et al. Rateand risk factors of hypoglycemia in large-for-gestational-age newborn infants of non-diabetic mothers. Am J ObstetGynecol 2002;187:913–917; Cahill JB, Martin KL, WagnerCL, Hulsey TC. Incidence of hypoglycemia in term largefor gestational age infants (LGA) as a function of feed-ing type. ABM News Views 2002;8:20.

TABLE 3. CLINICAL MANIFESTATIONS OF

POSSIBLE HYPOGLYCEMIA

Irritability, tremors, jitterinessExaggerated Moro reflexHigh-pitched crySeizures or myoclonic jerksLethargy, listlessness, limpness, hypotoniaComaCyanosisApnea or irregular breathingTachypneaHypothermia; temperature instabilityVasomotor instabilityPoor suck or refusal to feed

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3. Initiation and establishment of breastfeed-ing is facilitated by skin-to-skin contact ofmother and infant. Such practices will main-tain normal infant body temperature and re-duce energy expenditure (thus enablingmaintenance of normal blood glucose) whilestimulating suckling and milk produc-tion.21,30

4. Feedings should be frequent, 10 to 12 timesper 24 hours in the first few days afterbirth.30

Glucose screening should be performed onlyon at-risk infants and those with clinical symp-toms compatible with hypoglycemia.

1. Routine monitoring of blood glucose inasymptomatic, term newborns is unneces-sary and may be harmful.4,5,31,38,39

2. At-risk infants should be screened for hy-poglycemia with a frequency and duration

related to the specific risk factors of the in-dividual infant.5 It is suggested that moni-toring begin within 30 to 60 minutes for in-fants with suspected hyperinsulinemia, andno later than 2 hours of age for infants inother risk categories.

3. Monitoring should continue, until normal,preprandial levels are consistently ob-tained.

4. Bedside glucose screening tests must be con-firmed by formal laboratory testing.

MANAGEMENT OF DOCUMENTEDHYPOGLYCEMIA (TABLE 5)

Asymptomatic infant:

1. Continue breastfeeding (approximatelyevery 1 to 2 hours) or feed 3 to 5 mL/kg (upto 10 mL/kg)4 of expressed breast milk or

TABLE 4. GENERAL MANAGEMENT RECOMMENDATIONS

Early and exclusive breastfeeding meets the nutritional and metabolic needs of healthy, term newborn infants.1. Routine supplementation is unnecessary.2. Initiate breastfeeding within 30 to 60 minutes of life and continue on demand.3. Facilitate skin-to-skin contact of mother and infant.4. Feedings should be frequent; 10 to 12 times per 24 hours in the first few days after birth.

Glucose screening is performed only on at-risk or symptomatic infants.1. Routine monitoring of blood glucose in all term newborns is unnecessary and may be harmful.2. An at-risk infant should be screened for hypoglycemia with a frequency and duration related to the specific

risk factors of the individual infant.3. Monitoring continues until normal, preprandial levels are consistently obtained.4. Bedside glucose screening tests must be confirmed by formal laboratory testing.

TABLE 5. MANAGEMENT OF DOCUMENTED HYPOGLYCEMIA

Asymptomatic infant1. Continue breastfeeding (approximately every 1 to 2 hours) or feed 3 to 10 mL/kg of expressed breast milk

or substitute nutrition.2. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and stable.3. Avoid forced feedings.4. If glucose remains low despite feedings, begin intravenous glucose therapy.5. Breastfeeding may continue during IV glucose therapy.6. Carefully document response to treatment.

Symptomatic infant or infants with plasma glucose levels �20 to 25 mg/dL (�1.1 to 1.4 mmol/L)1. Initiate intravenous 10% glucose solution.2. Do not rely on oral or intragastric feeding to correct extreme or symptomatic hypoglycemia.3. The glucose concentration in symptomatic infants should be maintained �45 mg/dL (�2.5 mmol/L).4. Adjust intravenous rate by blood glucose concentration.5. Encourage frequent breastfeeding.6. Monitor glucose concentrations before feedings as the IV is weaned until values stabilize off intravenous

fluids.7. Carefully document response to treatment

substitute nutrition (pasteurized donor hu-man milk, elemental formulas, partially hy-drolyzed formulas, routine formulas).

2. Recheck blood glucose concentration beforesubsequent feedings until the value is ac-ceptable and stable.

3. If the neonate is unable to suck or feedingsare not tolerated, avoid forced feedings (e.g.,nasogastric tube) and begin intravenous (IV)therapy (see the following). Such an infantis not normal and requires a careful exami-nation and evaluation in addition to moreintensive therapy.

4. If glucose remains low despite feedings, be-gin IV glucose therapy and adjust intra-venous rate by blood glucose concentration.

5. Breastfeeding may continue during IV glu-cose therapy when the infant is interestedand will suckle. Wean IV glucose as serumglucose normalizes and feedings increase.

6. Carefully document signs, physical exami-nation, screening values, laboratory confir-mation, treatment and changes in clinicalcondition (i.e., response to treatment).

Symptomatic infants or infants with plasmaglucose levels �20 to 25 mg/dL (�1.1 to 1.4mmol/L)

1. Initiate intravenous 10% glucose solution.2. Do not rely on oral or intragastric feeding to

correct extreme or symptomatic hypo-glycemia. Such an infant is not normal, andrequires an immediate and careful exami-nation and evaluation in addition to IV glu-cose therapy.

3. The glucose concentration in symptomaticinfants should be maintained �45 mg/dL(�2.5 mmol/L).

4. Adjust intravenous rate by blood glucoseconcentration.

5. Encourage frequent breastfeeding after therelief of symptoms.

6. Monitor glucose concentrations before feed-ings as the IV is weaned, until values are sta-bilized off intravenous fluids.

7. Carefully document signs, physical exami-nation, screening values, laboratory confir-mation, treatment, and changes in clinicalcondition (i.e., response to treatment).

SUPPORTING THE MOTHER

Having an infant who was thought to be normal and healthy and who develops hypo-glycemia is both concerning to the mother andfamily, and may jeopardize breastfeeding. Moth-ers should be reassured that there is nothingwrong with their milk, and supplementation isusually temporary. Having the mother hand-ex-press or pump milk that is then fed to her infantcan overcome feelings of maternal inadequacy aswell as help establish a full milk supply. It is im-portant to provide stimulation to the breasts bymanual or mechanical expression with appro-priate frequency (eight times in 24 hours) untilher baby is latching and suckling well to protecther milk supply. Keeping the infant at the breast,or returning the infant to the breast as soon aspossible is important. Skin-to-skin care is easilydone with an IV and may lessen the trauma ofintervention, while also providing physiologicthermoregulation, contributing to metabolic ho-meostasis.

RECOMMENDATIONS FOR FUTURE RESEARCH

1. Well-planned, well-controlled studies areneeded that look at plasma glucose concen-trations, clinical symptoms, and long-termsequelae so the levels of glucose necessaryfor intervention can be better understood.

2. The development of more reliable bedsidetesting methods would increase the effi-ciency of diagnosis and treatment of signif-icant glucose abnormalities.

3. A clearer understanding of the role of otherglucose-sparing fuels and methods to mea-sure them in a clinically meaningful wayand time frame would aid in understandingwhich babies are truly at risk of neurologicsequelae, and thus must be treated.

CONCLUSION

Healthy, full-term infants are programmedto make the transition from their intrauterineconstant flow of nutrients to their extrauterine

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intermittent nutrient intake without the needfor metabolic monitoring or interference withthe natural breastfeeding process.3 Homeo-static mechanisms ensure adequate energy sub-strate is provided to the brain and other organs,even when feedings are delayed. The normalpattern of early, frequent, and exclusive breast-feeding meets the needs of healthy full-term in-fants. Routine screening or supplementationare not necessary and may harm the normal es-tablishment of breastfeeding.

ACKNOWLEDGMENT

This work was supported in part by a grantfrom the Maternal and Child Health Bureau,Department of Health and Human Services.

REFERENCES

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2. Hawdon JM, Ward Platt MP, Aynsley-Green A. Pat-terns of metabolic adaptation for preterm and termneonates in the first postnatal week. Arch Dis Child1992;67:357–365.

3. Cornblath M, Reisner SH. Blood glucose in theneonate and its clinical significance. N Engl J Med1965;273:378–380.

4. Williams, Anthony F. Hypoglycaemia of the Newborn:Review of the Literature. World Health Organization,Geneva, 1997. Accessed June 28, 2006: http://www.who.int/child-adolescent health/New_Publications/NUTRITION/hypoclyc.htm.

5. Eidelman A. Hypoglycemia and the breastfedneonate. Pediatr Clin North Am 2001;48:377–387.

6. Hawdon JM, Ward Platt MP, Aynsley-Green A. Pre-vention and management of neonatal hypoglycemia.Arch Dis Child Fetal Neonatal Ed 1994;70:F60–F65.

7. Lucas A, Bayes S, Bloom SR, Aynsley-Green A. Meta-bolic and endocrine responses to a milk feed in 6 dayold term infants: Differences between breast andcow’s milk formula feeding. Acta Paediatr Scand1981;70:195–200.

8. Edmond J, Auestad N, Robbins RA, et al. Ketone bodymetabolism in the neonate: Development and the ef-fect of diet. Fed Proc 1985;44:2359–2364.

9. Yager JY, Heitjan DF, Towfighi J, et al. Effect of in-sulin-induced and fasting hypoglycemia on perinatalhypoxic-ischemic brain damage. Pediatr Res 1992;31:138–142.

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14. Hawdon JM, Ward Platt MP, Aynsley-Green A.Neonatal hypoglycemia: Blood glucose monitoringand infant feeding. Midwifery 1993;9:3–6.

15. Kalhan S, Peter-Wohl S. Hypoglycemia: What is it forthe neonate? Am J Perinatol 2000;17:11–18.

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17. Cornblath M, Schwartz R. Disorders of CarbohydrateMetabolism in Infancy, 3rd ed. Blackwell Scientific Pub-lications, Boston, 1991.

18. Heck LJ, Erenberg A. Serum glucose levels in termneonates during the first 48 hrs of life. J Pediatr 1987;110:119–122.

19. Hoseth E, Joergensen A, Ebbesen F, Moeller M. Bloodglucose levels in a population of healthy, breast fed,term infants of appropriate size for gestational age.Arch Dis Child Fetal Neonatal Ed 2000;83:F117–119.

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21. Durand R, Hodges S, LaRock S, et al. The effect ofskin-to-skin breast-feeding in the immediate recoveryperiod on newborn thermoregulation and blood glu-cose values. Neonat Int Care 1997;March–April:23–29.

22. Sexson WR. Incidence of neonatal hypoglycemia: Amatter of definition. J Pediatr 1984;105:149–150.

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24. Stanley CA, Baker L. The causes of neonatal hypo-glycemia. N Engl J Med 1999;3040:1200–1201.

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26. Alkalay AL, Klein AH, Nagel RA, Sola A. Neonatalnon-persistent hypoglycemia. Neonat Int Care 2001;14:25–34.

27. Alkalay AL, Sarnat HB, Flores-Sarnat L, et al. Popu-lation meta-analysis of low plasma glucose thresholdsin full-term normal newborns. Am J Perinatol 2006;23:115–119.

28. AAP Committee on Fetus and Newborn, AmericanAcademy of Pediatrics. Routine evaluation of bloodpressure, hematocrit, and glucose in newborns. Pedi-atrics 1993;92:474–476.

29. Haninger NC, Farley CL. Screening for hypoglycemiain healthy term neonates: Effects on breastfeeding. JMidwifery Women’s Health 2001;46:292–301.

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31. National Childbirth Trust, United Kingdom. Hypogly-cemia of the newborn: Guidelines for appropriate bloodglucose screening and treatment of breast-fed and bot-tle-fed babies in the UK. Midwives 1997;110:248–249.

32. Ho HT, Yeung WKY, Young BWY. Evaluation of“point-of-care” devices in the measurement of lowblood glucose in neonatal practice. Arch Dis Child Fe-tal Neonatal Ed 2004;89:F356–F359.

33. Cornblath M, Ichord R. Hypoglycemia in the neonate.Semin Perinatol 2000;24:136–149.

34. Cowett RM, Loughead JL. Neonatal glucose metabo-lism: Differential diagnosis, evaluation, and treatmentof hypoglycemia. Neonat Netw 2002;21:9–19.

35. de Lonlay P, Giurgea I, Touati G, Saudubray J-M.Neonatal hypoglycaemia: Aetiologies. Semin Neonatol2004;9:49–58.

36. Sunehag AL, Haymond MW. Glucose extremes innewborn infants. Clin Perinatol 2002;29:245–260.

37. WHO/UNICEF. Protecting, Promoting and SupportingBreast-Feeding: The Special Role of Maternity Services. AJoint WHO/UNICEF Statement. World Health Orga-nization, Geneva, 1989.

38. Nicholl R. What is the normal range of blood glucoseconcentrations in healthy term newborns? Arch DisChild 2003;88:238–239.

39. AAP & ACOG. Guidelines for Perinatal Care, 5th ed.American Academy of Pediatrics, 2002.

ContributorsNancy Wight, M.D.

Children’s Hospital and Health Center and Sharp Mary Birch Hospital for Women

San Diego, CA

Kathleen A. Marinelli, M.D.University of Connecticut

Hartford, CT

Protocol CommitteeCaroline J. Chantry, M.D., Co-Chairperson

Cynthia R. Howard, M.D., M.P.H., Co-Chairperson

Ruth A. Lawrence, M.D.Kathleen A. Marinelli, M.D.

Nancy G. Powers, M.D.

For reprint requests: abm@bfmed.org

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