BFHI is a global initiative of WHO and UNICEF. Hospitals implement infant feeding policies consistent with the 'Ten Steps to Successful Breastfeeding', and ethical marketing practices for the distribution of artificial milk formulas for babies.
Hypoglycaemia (low blood sugar) is the *diagnosis* under which many breastfed babies in Australian hospitals receive formula feeds in the first hours of their lives. Babies of mothers with poorly managed diabetes - that is, mothers whose blood sugar levels are abnormally high - can become very ill very quickly when their sugar supply is abruptly cut off at birth. Please refer to the Women's hospital CPG on infant management of Hypoglycaemia 1. for further review of definition and management guidelines. The brief comments I wish to make in this post will be made with consideration of that CPG as a statement of the way I understand contemporary practice.
Definition of terms
Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered). Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding.When BFHI assessors visit a hospital, we have a series of questionnaires that are designed to gauge the hospital's compliance with the global BFHI criteria. Midwives, doctors, and other staff who advise women on breastfeeding are asked to state three acceptable medical reasons for use of breastmilk substitutes. The usual response includes 'hypoglycaemia'. The assessor is required to explore the meaning of 'hypoglycaemia' further to check if the staff member is confident of what is an acceptable reason.
The BFHI acceptable medical reasons include
- newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age, or who have experienced significant hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.
Usually the hospital's own clinical practice guidelines will be quoted. The assessor is able to then check the hospital's guideline on management of babies with hypoglycaemia.
Why is this important?
The short answer: Diabetes.
A longer (incomplete) answer:
'Hypoglycaemia' is one of the main reasons for breastfed babies in hospital receiving formula feeds. Diabetes and hypoglycaemia are closely linked, and breastfeeding may prevent the development of diabetes later in the child's life.
A hospital that has a breastfeeding policy consistent with the BFHI '10 Steps to successful breastfeeding' is required to implement management guidelines for hypoglycaemia that are consistent with the breastfeeding policy. The 'steps' in which a hospital's management of suspected hypoglycaemia has a potential to interfere with the establishment of breastfeeding are:
Step 1: Have a written breastfeeding policy that is routinely communicated to all healthcare staff
"exclusive breastfeeding in the first six months of lifeStep 2: Train all healthcare staff in skills necessary to implement this policy
Breastfeeding during infancy is associated with
- protects against chronic conditions in the future such as type-1 diabetes, ulcerative colitis and Chron's disease
- ... lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life
..." [from BFHI Australia Booklet 1, p16]
Protecting, promoting and supporting the natural physiological processes in birth and nurture of a baby requires skill and commitment by all care providers.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding
Women who are well informed will be able to make informed decisions about any interventions that are recommended in the care of themselves or their babies. Those who know they are at risk of having babies who develop hypoglycaemia are able to take some measures to avert the need for breastmilk substitutes, including careful dietary measures and avoidance of sugary foods.
Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.
The hospital's definition of 'medically indicated' must be consistent with the BFHI acceptable medical reasons. Also, note the need for true blood sugar level to confirm hypoglycaemia.
Step 7: Practise rooming-in - allow mothers and infants to remain together 24 hours a day
Babies identified as 'at risk' who are asymptomatic should stay close to their mothers and breastfeed normally.
- infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L [Women's CPG]
Step 9: Give no artificial teats or dummies to breastfeeding infants
The hospital policy and guidelines need to be reviewed critically at regular intervals, by people who are well informed and who are skilled at asking good questions.
The protection of breastfeeding in potentially complex clinical situations is not a yes-no, black or white situation. Guidelines can, and often do, help us to avoid unnecessary and potentially harmful interventions into normal physiological breastfeeding situations.
For example, a baby weighing 4 Kg at birth may in some cases be at risk of hypoglycaemia, and in other cases be healthy, consistent with the size of his or her parents and siblings. In the latter case a clinical judgment would be made by the midwife, not to measure blood glucose levels as this baby is judged to be a well, term infant.
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