7.2 Hypoglycemia; Jaundice
Pathologic Neonatal Hypoglycemia
Physiology
There are two times of crisis in the neonates life regarding energy (glucose) needs. Both crises are managed by the infant'snormal metabolic adaptation using alternative fuel sources. (ie gluconeogenesis and glycogenolysis)
- The first crisis occurs after birth when the cord stops pulsing and the maternal supply of glucose to the newborn is discontinued. 1 2
- blood glucose concentration reaches its nadir in the first 1 - 2 hours
- blood glucose concentration then rises to a steady state within 2 - 3 hours
- feeding the infant may cause small transient rises in blood glucose concentration, but it is not feeding that maintains euglycemia
- blood glucose concentration reaches its nadir in the first 1 - 2 hours
- The second crisis will occur if lactation is delayed. 3 4 5
- Fat breakdown occurs, releasing ketone bodies that provide glucose-sparing fuel to the neonatal brain, protecting neurologic function.
Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth.
In the term, healthy newborn this dynamic process is self-limiting and is not considered pathologic.6
Routine glucose screening
Clinically significant (ie pathologic) hypoglycemia does NOT occur in well, full term babies. The baby's physiology protects him against this by using metabolic processes to maintain steady-state glucose concentration. 7 2
Unnecessary routine screening results in the misidentification and misdiagnosis of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir.
Following this unforgiveable error, further surveillance and unnecessary, aggressive treatment interventions will follow that are harmful to the neonate's normal adaptive processes and interferes with breastfeeding, further risking the infant's health.

Routine glucose screening is poor practice!

Unnecessary interventions
Routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based. 6 8
The practice contributes to increased stress for the parents and infant, unnecessary painful procedures for the infant and causes a serious disruption of the initiation process and duration patterns of lactation.
Diagnosing pathologic neonatal hypoglycemia
Diagnosis is made when
- neurological signs are present, and
- blood glucose concentration is low. 9
This is a very serious condition which could lead to neurological impairment.
Which infants are at risk?
Infants at risk of symptomatic hypoglycemia include: 10
- Infants of diabetic mothers - hyperinsulinemia as a result of poor maternal control during pregnancy will cause hypoglycemia until stabilised.
- Infants who are preterm or late preterm with metabolic immaturity.
- Infants who have few fat reserves, eg small for gestational age infants
- Infants who have experienced severe stress, eg. perinatal stress, cold stress, sepsis7
Infants in these categories require frequent observation for neurological signs and blood screening for glucose concentration at intervals according to evidence-based medical protocols.
Clinical signs to observe for:
The most important observation you will make is the infant's level of consciousness. Disturb the infant - if he wakes easily, great! If he doesn't: pick up the infant, talk to him, wake him up. A limp infant you cannot wake is a bad sign.
Other clinical manifestations7
- irritability, tremors, jitters
- tachypoena (rapid respiration)
- exaggerated Moro reflex
- high-pitched cry
- lethargy, limpness, hypotonia
- apnea or irregular breathing
- cyanosis
- hypothermia, temperature instability
- poor or inadequate sucking reflex
- vasomotor instability
- seizures

But of course ...
ANY infant who exhibits any of these neurological signs will require urgent referral for medical review and blood glucose estimation.

Workbook Activity 7.3
Complete Activity 7.3 in your workbook.
You can prevent pathologic hypoglycemia!
- stabilise the infant's temperature (no requirement to burn fat for heat)
- stabilise the infant's cardio-respiratory system
- stimulate metabolic adaptation
- initiate the first phase of the enteric nervous system (facilitating intestinal function)
- reduce stress (release of cortisol initially causes a surge in blood glucose concentration, then a fall)
- facilitate early and frequent breastfeeding (preventing the delay in lactation which would precipitate the infant's second energy 'crisis')
While this won't, unfortunately, eliminate hypoglycemia, it will prevent it from developing in a significant number of infants.

This is really important!
Share your thoughts in the forum about how this simple, no-cost practice helps prevent hypoglycemia.
What about early feeding?
Healthy, full-term infants do not develop symptomatic hypoglycemia in the first 24 hours simply as a result of underfeeding. 12
Frequent, effective breastfeeding will, however, be protective after the first 24 hours. Beginning breastfeeding soon after birthing will ensure the infant is breastfeeding well and maternal lactation is becoming established by the time the infant is dependent on this source of energy.
Workbook Activity 7.4
Complete Activity 7.4 in your workbook.
Clinical management of pathologic hypoglycaemia
Inadequately treated symptomatic hypoglycemia has such a serious outcome that pediatricians agree that
“ the clinician should not rely on oral feeding (eg breastmilk or infant formula) for the correction of symptomatic hypoglycemia
” 12 and “ symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose .
” 10,7
During medical management breastfeeding should continue uninterrupted. The goal is to have an infant who suckles effectively at the breast and a mother's milk supply that is able to meet his needs when IV therapy is discontinued.
- continue breastfeeding, and skin-to-skin contact during treatment
- do not give water, glucose water or formula to the breastfed infant
- continue breastfeeding while weaning baby from IV glucose, monitoring carefully

Extend your knowledge


Unit Activity

What should I remember?

- How euglycemia is maintained in the first 24 hours, regardless of oral intake.
- The effect of unnecessary blood glucose monitoring on the full-term, healthy infant.
- The infants who are 'at-risk' of pathologic neonatal hypoglycemia.
- How to recognise signs of pathologic hypoglycemia.
- The best practice management to prevent symptomatic hypoglycemia for all infants.
- How to support breastfeeding during medical management of pathologic hypoglycemia.
Self-test quiz
Jaundice
The most common paediatric condition encountered in the first week is hyperbilirubinaemia. It is so common that it is termed "Physiological Jaundice" and reflects the normal physiological changes that occur as the neonate adapts to extrauterine life.
Normal serum bilirubin levels
The neonate is more susceptible to high serum bilirubin levels because13
- there is increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the greater number of erythrocytes in neonates.
- liver excretory ability is low because of the relative immaturity of the liver.
At birth neonates have a low serum bilirubin. The normal pattern is for a rise to a peak by the third day of life, followed by a plateau and drop in levels, or, for ⅔ of babies, a gradual rise to another peak on about the 10th day. After this the levels gradually drop until about the third week of life. (An exception to this is found in babies of Asian origin whose Day 3 levels peak nearly twice as high as found in non-Asian babies).
In some mothers, unidentified factors present in her breastmilk may contribute to increased enterohepatic circulation of bilirubin with harmless jaundice persisting for many weeks. This is an extension of physiologic jaundice known as breastmilk jaundice. No special treatment is required and continued breastfeeding is recommended. 14

Diagram © Health e-Learning

Food for thought
The physiology of the breastfed baby is the norm, and the standard that science strives to achieve for those infants artificially-fed.
Serum bilirubin has an antioxidant effect which it is thought cmpensates for the relative deficiency of endogenous antioxidants in newborns. While excessive serum bilirubin is dangerous, lower levels with a slow decline must have a purpose.
Causes of abnormal bilirubin levels
-
Abnormal weight loss : A weight loss of more than 7% in both artificially fed and breastfed infants is associated with higher serum bilirubin concentrations. Inadequate intake causes
- retention of meconium and reabsorption of previously excreted bilirubin back into the blood stream.
- Hemolytic processes : Blood group incompatibilities (Rh, ABO, and others) may increase bilirubin production through increased haemolysis. Nonimmune haemolytic disorders (spherocytosis, G-6-PD deficiency) also may cause increased jaundice through increased haemolysis.
- Non-hemolytic processes : A number of other nonhaemolytic processes can increase serum bilirubin levels. Accumulation of blood in extravascular compartments (cephalhaematomas, bruising, occult bleeding) may increase bilirubin production as the blood is absorbed and degraded. Increased bilirubin production also is seen in infants with polycythemia and in infants of mothers with diabetes. Increased reabsorption of bilirubin from the bowel leading to elevated bilirubin levels is seen in infants with bowel obstruction or ileus.
Physical appearance
Jaundice has a cephalocaudal (or cephalopedal) ie head to toe progression; it is evident first in the face, gradually becoming visible on the trunk. Jaundice seen below the level of the umbilicus and on the extremities reflects increasingly higher serum bilirubin levels. Jaundice disappears in the opposite direction.
Daylight on a clear day provides the best lighting for evaluation. Pressure applied on the skin using the finger pad will blanch the skin revealing the underlying colour.

Transcutaneous bilirubin monitoring is non-invasive.
Management of hyperbilirubinemia
Prevention of hyperbilirubinemia due to inadequate intake involves early recognition of risk factors, good teaching and supervision of breastfeeding, and mothers who are able to recognize that good transfer of breastmilk to the infant is occurring.
Optimal breastfeeding behaviors results in lower serum bilirubin concentration in the first 5 days: 14
- initiation of breastfeeding in the first hour after birth
- continuous rooming-in with unlimited access to the breast
- a breastfeeding frequency of 10 to 12 times per day
- prompt responses to early hunger cues, and
- absence of all supplementation.
Ensure adequate intake for the infant:
- assess breastfeeding effectiveness
- stimulate and support an adequate milk supply
- frequent breastfeeds; 8-12 per 24 hrs
- offer supplemental feeds of expressed breastmilk, if necessary
- artificial infant formula is given only in the absence of adequate breastmilk volumes
- offer emotional support to the mother while her baby is receiving treatment
- continue all of the above feeding measures (additional insensible water loss will be met by breastmilk)
- Do NOT give water supplementation (increases serum bilirubin)

One of the Red Flags
Increasing jaundice is one of the 'Red Flags' you will discuss with all mothers prior to their discharge from hospital. (see 6.6 Discharge Planning )
Ensure that every mother knows
- that a degree of jaundice is normal in breastfed infants
- how to assess the level of jaundice in their infant
- that increasing jaundice after Day 3 MUST be reported immediately to their health care practitioner
- any jaudice below the level of the nipple line should be immediately reported to their health care practitioner.
- that high levels of jaundice are very dangerous, and therefore don't delay reporting it.

Workbook Activity 7.5
Complete Activity 7.5 in your workbook.

Extend your knowledge
Read and print the AAP Policy Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant.
This protocol from the Academy of Breastfeeding Medicine is also excellent: Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation

Unit activity
What is your Unit's policy on prevention, recognition and management of jaundice? Discuss the Unit policy with your colleagues, comparing it to the AAP recommendations and other evidence-based articles. Particularly note the importance of continued, frequent, effective breastfeeding in the prevention and management of jaundice.
What should I remember?

- Jaundice is a normal physiological process in the well full-term baby (physiological jaundice)
- The potential risk factors for problematic jaundice
- The optimal management that prevents an abnormal pattern of jaundice
- The importance of and what to teach mothers about jaundice before they are discharged with their babies.
Self-test quiz
Click and drag the missing words below into their correct place
The missing words are: breastfeeding breastmilk physiological supplementation tenth third
__________ jaundice is normal in most newborns. Bilirubin rises to a peak on the __________ day of life, followed by a further rise until the __________ day for most breastfed infants. A harmless form of jaundice that persists for many weeks is termed __________ jaundice.Prevention of hyperbilirubinemia is focused on frequent, effective __________ and the absence of all __________.
Notes
- # Hawdon JM (2010) Best practice guidelines: Neonatal hypoglycaemia.
- # Cornblath M et al. (2000) Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds
- # Hawdon JM et al. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week.
- # Edmond J et al. (1985) Ketone body metabolism in the neonate: development and the effect of diet.
- # Cotter DG et al. (2011) Obligate role for ketone body oxidation in neonatal metabolic homeostasis.
- # Haninger NC et al. (2001) Screening for hypoglycemia in healthy term neonates: effects on breastfeeding
- # Wight N et al. (2014) ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, Revised 2014.
- # Committee on Fetus and Newborn et al. (2011) Postnatal glucose homeostasis in late-preterm and term infants.
- # Hawdon JM (1999) Hypoglycaemia and the neonatal brain.
- # Jain A et al. (2010) Hypoglycemia in the newborn.
- # Csont GL et al. (2014) An evidence-based approach to breastfeeding neonates at risk for hypoglycemia.
- # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
- # Cohen RS et al. (2010) Understanding neonatal jaundice: a perspective on causation.
- # Gartner LM (2001) Breastfeeding and jaundice
- # Panburana J et al. (2010) Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement.