HYPOGLYCAEMIA IN HIGH RISK NEONATES ON EXCLUSIVE

BREASTFEEDING

Subhash Chandra Shaw2, Subhasis Sardar1, Amit Devgan2, Karthik Ram Mohan1, Shuvendu Roy1

1Department of Pediatrics, Command Hospital, Kolkata, West Bengal, India2Department of Pediatrics, Armed Forces Medical College, Pune, Maharashtra, India

Background• Hypoglycaemia is one of the commonest metabolic problems in

neonates

• In the presence of certain risk factors like small for date, large for gestational age, infants of diabetic mothers, and late prematurity, the chances of hypoglycaemia further increases

• Severe and prolonged neonatal hypoglycaemia is associated with a risk of long term neuro developmental sequelae

• Even though recommendations are there to exclusively breast feed all neonates roomed in with their mothers, it is imperative that babies with risk factors roomed in with their mothers are not without risks

Tiwari, S., Bharadva, K., Yadav, B. et al. Infant and young child feeding guidelines. Indian Pediatr. 2016

Objectives

• Primary objective : To estimate the incidence of hypoglycaemia in ‘at risk’ neonates on exclusive breastfeeding

• Secondary objectives

• To document the time of presentation of hypoglycaemia

• To describe the symptomatology at presentation of hypoglycaemia

• Associations of the maternal and neonatal risk factors for developing hypoglycaemia.

Methodology

• Observational study in a tertiary care teaching hospital in Eastern India between January 2017 and June 2018

• All the neonates delivered by normal or caesarean section roomed in postnatal wards with their respective mothers, having certain high risk factors like low birth weight neonates, preterm neonates, small for gestational age neonates , infants of diabetic mothers, large for gestational age, neonate born to mothers with gestational hypertension, neonates born to mothers receiving therapy with terbutaline/ propranolol/ labetalol/ oral hypoglycaemic agents, neonates with Rh-haemolytic disease, and polycythaemia (venous Haematocrit> 65%) were included

• Neonates admitted in neonatal intensive care unit, gross congenital anomalies, birth asphyxia, sepsis and shock were excluded

Methodology (cont.)

• Informed written consent was obtained from the either of the parents

• The study was approved by the Institute Ethics Committee

• Anticipated maximum hypoglycaemia in normal neonates being 15%*, with absolute precision of 5%, and power of 95%, the sample size was calculated to be 196

• Data entry was done in Microsoft excel worksheet and statistical analysis was performed with the help of SPSS Version 22 software

• P value of < 0.05 was considered statistically significant

*Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. 2000; 105:1141–5

Methodology (cont.)

• Breastfeeding was initiated at birth, as early as possible, but definitely within half an hour for all deliveries whether vaginal or caesarean sections

• Breast feeding counseling and support for all the mothers was provided by the nursing students and nurses in postnatal wards

• The neonates were fed on demand and every 2 to 3 hourly, including night feeds

• Blood glucose levels (mostly pre feed) were monitored at 2, 6, 12, 24, 48 and 72 hrs of life or whenever clinical features suggested hypoglycaemia, using glucometer strips

• Laboratory confirmation of hypoglycemia was done by drawing of blood through venipuncture, whenever glucometer reading was in hypoglycemic range

Study FlowFigure 1 STUDY FLOW

Babies excluded as per Exclusion criteria

At risk neonates on exclusive breastfeeds

Enrolled high risk

neonates (n=250)

Blood glucose monitoring by

glucometer at 2, 6, 12, 24, 48, 72 hours of birth or whenever clinical features

suggestive of hypoglycemia

Blood glucose <4 6 mg% at any point of time Blood glucose >45 mg%

Continue breast feeding &

monitoring as per protocol

Venous blood

sample was sent for

laboratory confirmation of

hypoglycemia (<46 mg/dl)

Treatment as per protocol.

Incidence, Symptomatology, Time at

presentation recorded

• Newborn if developed asymptomatic hypoglycemia with blood sugar level between 25 and 45 mg/dL, was breastfed, and/or was given expressed breast milk (EBM) and blood sugar level was repeated after 1 hour

• If blood glucose remained in the range of 25-45mg/dL, the newborn was supplemented with infant formula in addition to breast feeds/EBM

• However, the neonate was treated with intravenous dextrose, if the blood glucose level ever recorded <25 mg/dL and /or blood glucose was <46 mg/dL even after two trials of feeds, and/or hypoglycemia was symptomatic

• Once the blood glucose was > 45 mg/dL, then 6 hourly monitoring of blood sugar was done, till the newborn crossed 72 hours of age or 48 hours after the episode of hypoglycemia whichever was later

Results

• The mean (SD) birth weight of the enrolled neonates was 2863 (603) g and mean (SD) gestational age was 37 (1.5) wk.

• Out of 250 enrolled neonates, 52 (20.8%)developed hypoglycaemia in first 72 hours

• Hypoglycaemia was detected in most at 2 hours with second peak at 48 hours of age

• Among the risk groups, there was significant association of hypoglycemia with prematurity, low birth weight status, and small for gestational age neonates

Incidence of hypoglycaemia

Risk groups (n=250) Number of

neonates with

hypoglycaemia

Percentage of

neonates with

hypoglycaemia

Preterm (n=49)17

34.69%

Low Birth Weight (n=89)25

28.08%

Small for Gestational Age (n=65)

20

30.76%

Large for Gestational age (n=48)

8

16.6%

Infant of diabetic mother (n=101)

19

18.8%

Gestational hypertension (n=37)

8

21.62%

Distribution of time of presentation of hypoglycaemia

Risk groups (n=250) 2

hrs

6

hrs

12

hrs

24

hrs

48

hrs

72

hrs

Preterm (n=49) 8 1 3 2 7 1

Low Birth Weight (n=89) 13 3 3 2 7 2

Small for Gestational Age (n=65) 11 1 2 2 7 2

Large for Gestational age (n=48) 7 2 1 0 1 0

Infant of diabetic mother (n=101) 12 3 2 2 1 1

Gestational hypertension (n=37) 6 2 0 1 2 0

Results (cont.)

• Out of all hypoglycemic neonates (n=52)• 40 (77%) neonates were managed with only breastfeeding/ (breastfeeding+ EBM)

• 14 neonates required supplementation of formula feeding

• 9 neonates needed IV dextrose

• 8 neonates were symptomatic with features of • Jitteriness (5)

• Poor feeding (3)

• Circum oral cyanosis (1)

• Tachypnoea (1)

• No seizures

Discussion

• The incidence varies with the method of hypoglycaemia screening, population characteristics, frequency of screening and feeding practices

• In the study from Turkey*, the overall incidence of hypoglycaemia was 17.8%, lower than our study possibly due to more formula feeding

• On the other hand, in a recent study from India#, the incidence of hypoglycaemia was 27%, possibly due to more low birth weight population (85.7%) in their studied population as compared to 35.6% in our study

• Study from New Zealand##, showed incidence of hypoglycaemia to be 51% with possible reasons to be regular screening using a consistent standardized approach, immediate analysis using glucose oxidase method and using higher threshold for hypoglycaemia as in our study

*Hosagasi NH, Aydin M, Zenciroglu A, Ustun N, Beken S. Incidence of hypoglycemia in newborns at riskand an audit of the 2011 American academy of pediatrics guideline for hypoglycemia. Pediatrics & Neonatology. 2018#Singh P, Upadhay A, Sreenivas V, Jaiswal V, Saxena P. Screening for hypoglycemia in exclusively breastfeed high risk neonates.Indian pediatrics, 2017##Harris DL, Weston PJ, Harding JE. Incidence of hypoglycemia in babies identified as at risk. J Pediatr. 2012

Discussion (cont.)

• Maximum episodes of hypoglycaemia occurred at 2 hours, and then the incidence decreased with time till 72 hours with a second peak at about 48 hours

• Only exception was LGA neonates, who had most of the episodes of hypoglycaemia in the first 12 hours. However, in other high risk groups, monitoring should continue till 72 hours and beyond

• There was significant association of prematurity, low birth weight status, and small for gestational age neonates with hypoglycemia in our study

• Other risk factors reported in literature are:• Male gender• Delay in initiation of breastfeeding for more than 2 hours• Birth asphyxia• Cold stress or hypothermia• Maternal oligohydramnios

Strengths

• Prospective study

• Strict protocol of exclusive breast feeding

• We supported mothers extensively and encouraged them in their attempts to breastfeed their neonates

Weaknesses

• The blood sugars were recorded at timed intervals only and not continuously measured

• We did not record blood sugars beyond 72 hours, and it is possible to have hypoglycaemia later on, particularly in low birth weight neonates

• We did not have a control group of otherwise normal breastfed neonates either, as it would have been unethical to do multiple pricks for blood sugar in them

• We looked at the short term outcomes only and did not follow up for neurodevelopmental outcome

Conclusion

• There is substantial risk of asymptomatic hypoglycemia in exclusively breast fed, high-risk newborns staying with mothers

• There is a need to closely monitor the blood glucose levels for at least first 48 hours

• Long term studies with adequate sample size is required to assess the neurodevelopmental outcome of asymptomatic hypoglycemia in these high risk neonates

Thank you