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## Complete Summary

#### GUIDELINE TITLE

Guidelines for glucose monitoring and treatment of hypoglycemia in
breastfed neonates.

#### BIBLIOGRAPHIC SOURCE(S)

Wight N, Marinelli KA, Academy of Breastfeeding Medicine Protocol
Committee. ABM clinical protocol #1: guidelines for glucose monitoring
and treatment of hypoglycemia in breastfed neonates. Breastfeed Med 2006
Autumn;1(3):178-84. \[39 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661596)

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version from 1999.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypoglycemia in breastfed neonates

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Screening\
Treatment

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Gastroenterology\
Nursing\
Nutrition\
Obstetrics and Gynecology\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To facilitate optimal breastfeeding practices

-   To provide guidance in the first hours/days of 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 supplementation for hypoglycemia

#### TARGET POPULATION

Breastfed infants, including ones who are healthy, at-risk for
hypoglycemia, and/or diagnosed with documented hypoglycemia

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Blood glucose screening and monitoring of at risk infants

2.  Establishment of breastfeeding, including initiation and on demand
    feeding, skin-skin contact of mother and infant, and frequent
    feedings

3.  Supplementation (expressed breast milk, pasteurized donor human
    milk, elemental formulas, partially hydrolyzed formulas, routine
    formulas)

4.  Intravenous (IV) glucose therapy

5.  Expression and feeding of expressed breast milk

6.  Documentation of signs, physical examination, screening values,
    laboratory confirmation, treatment and changes in clinical condition

#### MAJOR OUTCOMES CONSIDERED

-   Plasma glucose levels

-   Hypoglycemia-related morbidity

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in
the past 20 years in the fields of medicine, psychiatry, psychology, and
basic biological science is undertaken for a particular topic. Once the
articles are gathered, the papers are evaluated for scientific accuracy
and significance.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I Evidence obtained from at least one properly randomized controlled
trial

II-1 Evidence obtained from well-designed controlled trials without
randomization

II-2 Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could
also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience,
descriptive studies and case reports; or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An expert panel is identified and appointed to develop a draft protocol
using evidence based methodology. An annotated bibliography (literature
review), including salient gaps in the literature, are submitted by the
expert panel to the Protocol Committee.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft protocol is peer reviewed by individuals outside of lead
author/expert panel, including specific review for international
applicability. Protocol Committee\'s sub-group of international experts
recommends appropriate international reviewers. Chair (co-chairs)
institutes and facilitates process. Reviews submitted to committee Chair
(co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine
(ABM) Board for review and approval. Comments for revision will be
accepted for three weeks following submission. Chair (co-chairs) and
protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s)
to make final suggestions and ascertain whether to maintain lead
authorship.

Final protocol is submitted to the Board of Directors of ABM for
approval.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Risk Factors for Hypoglycemia**

Neonates at increased risk for developing neonatal hypoglycemia should
be routinely monitored for blood glucose levels irrespective of the mode
of feeding. At risk neonates fall into two main categories:

1.  Excess use of glucose, which includes the hyperinsulinemic states

2.  Inadequate production or substrate delivery (Cornblath & Ichord,
    2000)

The infant categories as shown in the Table below are at increased risk
for hypoglycemia (Eidelman, 2001; Cornblath et al., 2000; Cornblath &
Ichord, 2000; Cowett & Loughead, 2002; de Lonlay et al., 2004; Sunehag &
Haymond, 2002).

+-----------------------------------------------------------------------+
| **Table. At-Risk Infants for Whom Routine Monitoring of Blood Glucose |
| Is Indicated**                                                        |
+=======================================================================+
| -   Small for gestational age (SGA); \<10^th^ percentile for weight   |
|                                                                       |
| -   Large for gestational age (LGA); \>90^th^ percentile for weight\* |
|                                                                       |
| -   Discordant twin; weight 10% below larger twin                     |
|                                                                       |
| -   Infant of diabetic mother, especially if poorly controlled        |
|                                                                       |
| -   Low birth weight (\<2500 g)                                       |
|                                                                       |
| -   Perinatal stress; severe acidosis or hypoxia-ischemia             |
|                                                                       |
| -   Cold stress                                                       |
|                                                                       |
| -   Polycythemia (venous hematocrit \[Hct\] \>70%/hyperviscosity      |
|                                                                       |
| -   Erythroblastosis fetalis                                          |
|                                                                       |
| -   Beckwith-Wiedemann syndrome                                       |
|                                                                       |
| -   Microphallus or midline defect                                    |
|                                                                       |
| -   Suspected infection                                               |
|                                                                       |
| -   Respiratory distress                                              |
|                                                                       |
| -   Known or suspected inborn errors of metabolism or endocrine       |
|     disorders                                                         |
|                                                                       |
| -   Maternal drug treatment (e.g., terbutaline, propranolol, oral     |
|     hypoglycemics)                                                    |
|                                                                       |
| -   Infants displaying symptoms associated with hypoglycemia (see     |
|     Table 3 in the original guideline document)                       |
+-----------------------------------------------------------------------+

\*This remains controversial. Some recommend in unscreened populations
in whom LGA may represent undiagnosed and untreated maternal diabetes.

From: Schaefer-Graf UM, Rossi R. Bührer C, et al. Rate and risk factors
of hypoglycemia in large-for-gestational-age newborn infants of
non-diabetic mothers. Am J Obstet Gynecol 2002;187:913--917; Cahill JB,
Martin KL, Wagner CL, Hulsey TC. Incidence of hypoglycemia in term large
for gestational age infants (LGA) as a function of feeding type. ABM
News Views 2002;8:20.

**General Management**

Early and exclusive breastfeeding meets then nutritional and metabolic
needs of healthy, term newborn infants. Healthy term infants do not
develop symptomatic hypoglycemia simply as a result of underfeeding
(Williams, 1997; Eidelman, 2001; Gartner et al., 2005).

1.  Routine supplementation of healthy, term infants with water, glucose
    water, or formula is unnecessary and may interfere with establishing
    normal breastfeeding and normal metabolic compensatory mechanisms
    (Hawdon, Ward Platt, & Aynsley-Green, 1992; Swenne et al., 1994;
    Gartner et al., 2005; National Childbirth Trust, 1997).

2.  Healthy term infants should initiate breastfeeding within 30 to 60
    minutes of life and continue on demand, recognizing that crying is a
    very late sign of hunger (Gartner et al., 2005; WHO/UNICEF, 1989).
    Early breastfeeding is not precluded just because the infant meets
    the criteria for glucose monitoring.

3.  Initiation and establishment of breastfeeding is facilitated by
    skin-to-skin contact of mother and infant. Such practices will
    maintain normal infant body temperature and reduce energy
    expenditure (thus enabling maintenance of normal blood glucose)
    while stimulating suckling and milk production (Durand et al., 1997;
    Gartner et al., 2005).

4.  Feedings should be frequent, 10 to 12 times per 24 hours in the
    first few days after birth. (Gartner et al., 2005)

Glucose screening should be performed only on at-risk infants and those
with clinical symptoms compatible with hypoglycemia.

1.  Routine monitoring of blood glucose in asymptomatic, term newborns
    is unnecessary and may be harmful (Williams, 1997; Eidelman, 2001;
    National Childbirth Trust, 1997; Nicholl, 2003; American Academy of
    Pediatrics \[AAP\] & American College of Obstetrics and Gynecology
    \[ACOG\], 2002).

2.  At-risk infants should be screened for hypoglycemia with a frequency
    and duration related to the specific risk factors of the individual
    infant (Eidelman, 2001). It is suggested that monitoring begin
    within 30 to 60 minutes for infants with suspected hyperinsulinemia,
    and no later than 2 hours of age for infants in other risk
    categories.

3.  Monitoring should continue, until normal, preprandial levels are
    consistently obtained.

4.  Bedside glucose screening tests must be confirmed by formal
    laboratory testing.

**Management of Documented Hypoglycemia**

*Asymptomatic Infant*

1.  Continue breastfeeding (approximately every 1 to 2 hours) or feed 3
    to 5 mL/kg (up to 10 mL/kg) (Williams, 1997) of expressed breast
    milk or substitute nutrition (pasteurized donor human milk,
    elemental formulas, partially hydrolyzed formulas, routine
    formulas).

2.  Recheck blood glucose concentration before subsequent feedings until
    the value is acceptable and stable.

3.  If the neonate is unable to suck or feedings are not tolerated,
    avoid forced feedings (e.g., nasogastric tube) and begin
    intravenous (IV) therapy (see the following). Such an infant is not
    normal and requires a careful examination and evaluation in addition
    to more intensive therapy.

4.  If glucose remains low despite feedings, begin IV glucose therapy
    and adjust intravenous rate by blood glucose concentration.

5.  Breastfeeding may continue during IV glucose therapy when the infant
    is interested and will suckle. Wean IV glucose as serum glucose
    normalizes and feedings increase.

6.  Carefully document signs, physical examination, screening values,
    laboratory confirmation, treatment and changes in clinical condition
    (i.e., response to treatment).

*Symptomatic Infants 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. Such an infant is not normal, and requires
    an immediate and careful examination and evaluation in addition to
    IV glucose therapy.

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 after the relief of symptoms.

6.  Monitor glucose concentrations before feedings as the IV is weaned,
    until values are stabilized off intravenous fluids.

7.  Carefully document signs, physical examination, screening values,
    laboratory confirmation, treatment, and changes in clinical
    condition (i.e., response to treatment).

**Supporting the Mother**

Having an infant who was thought to be normal and healthy and who
develops hypoglycemia is both concerning to the mother and family, and
may jeopardize breastfeeding. Mothers should be reassured that there is
nothing wrong with their milk, and supplementation is usually temporary.
Having the mother hand-express or pump milk that is then fed to her
infant can overcome feelings of maternal inadequacy as well as help
establish a full milk supply. It is important to provide stimulation to
the breasts by manual or mechanical expression with appropriate
frequency (eight times in 24 hours) until her baby is latching and
suckling well to protect her milk supply. Keeping the infant at the
breast, or returning the infant to the breast as soon as possible is
important. Skin-to-skin care is easily done with an IV and may lessen
the trauma of intervention, while also providing physiologic
thermoregulation, contributing to metabolic homeostasis.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=11218)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

The recommendations were based primarily on a comprehensive review of
the existing literature. In cases where the literature does not appear
conclusive, recommendations were based on the consensus opinion of the
group of experts.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate perinatal management to optimally support breastfeeding and
avoid hypoglycemia in healthy newborns

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Foreign Language Translations

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Wight N, Marinelli KA, Academy of Breastfeeding Medicine Protocol
Committee. ABM clinical protocol #1: guidelines for glucose monitoring
and treatment of hypoglycemia in breastfed neonates. Breastfeed Med 2006
Autumn;1(3):178-84. \[39 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661596)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2006)

#### GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

#### SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of
Health and Human Services

#### GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Contributors*: Nancy Wight, MD, Children\'s Hospital and Health Center
and Sharp Mary Birch Hospital for Women, San Diego, CA; Kathleen A.
Marinelli, MD, University of Connecticut, Hartford, CT (*Lead authors*)

*Committee Members*: Caroline J. Chantry, MD (*Co-Chairperson*); Cynthia
R. Howard, MD, MPH (*Co-Chairperson*); Ruth A. Lawrence, MD; Kathleen A.
Marinelli, MD; Nancy G. Powers, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version from 1999.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/protocol/hypoglycemia.pdf).

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Procedure for protocol development and approval. Academy of
    Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

Japanese, Korean, and German translations of the original guideline
document are available from the [Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/index.asp?menuID=139&firstlevelmenuID=139).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on October 24, 2007.
The information was verified by the guideline developer on October 31,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission
to be requested for use of multiple copies by e-mailing requests to
<abm@bfmed.org>. An official request form will be sent electronically to
person requesting multiple copy use.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/24/2008