Breastfeeding Medicine

Physicians blogging about breastfeeding

Newly Published! ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, Revised 2014

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It is with great excitement that I announce that the long awaited publication of the 2014 Revision of the Academy of Breastfeeding Medicine Protocol #1 Hypoglycemia in Breastfeeding Medicine Volume 9, Number 4, 2014! The previous version was released in 2006. The authors, Nancy Wight MD, IBCLC, FABM and Kathleen Marinelli MD, IBCLC, FABM remain the same.

There have not been any earth shattering changes in the field since the last protocol was published. Importantly in fact there has been no progress in the definition of clinically relevant “hypoglycemia.” An expert panel convened in 2008 by the U.S. National Institutes of Health concluded that there has been no substantial evidence-based progress in defining what constitutes clinically important neonatal hypoglycemia, particularly regarding how it relates to brain injury, which is what concerns us all the most. We reiterate that the literature continues to support that transient, single, brief periods of hypoglycemia are unlikely to cause permanent neurologic damage. Therefore, the monitoring of blood glucose concentrations in healthy, term, appropriately grown neonates is unnecessary and potentially harmful to parental wellbeing and the successful establishment of breastfeeding.

However this protocol has been updated with some newer references, and has an additional Table, #2, page 174. This table, “Operational Thresholds for Treatment of Plasma Glucose Levels”, describes how to translate blood glucose levels in at-risk babies into guidelines for clinical intervention that we did not previously spell out as clearly. As in our previous protocol, we kept Table 1, which demonstrates data for the statistical nadirs of blood glucose over time in a healthy AGA population of formula-fed infants, demonstrating how low blood glucose can normally go. We further comment that breastfed infants routinely demonstrate lower blood glucose levels than formula-fed infants, so may in fact be even lower normally than this table documents, with other substrates such as ketone bodies maintaining normal brain homeostasis.

We have also attempted to clarify some points for clinical care throughout the protocol based on feedback we have received from those who use our protocols. For example, previously we had suggested that at risk infants have a blood glucose drawn before a feed. We were told that infant feeds are being delayed, in some places for extremely long times, because staff are taking us at our word and if not available to check a blood glucose, don’t feed the baby! This, of course, does not make sense especially in light of trying to maintain normoglycemia! We have clarified this in the body of the protocol to read “If staff is unavailable to check blood glucose and an infant has no clinical signs, breastfeeding should never be unnecessarily delayed while waiting for the blood glucose level to be checked.“ (page 177)

Another clinical issue that has been brought to our attention is the frequency of feedings, especially in the first 24 hours after birth. Usual recommendations are that feedings should be frequent, at least 10–12 times per 24 hours in the first few days after birth. However, it is not unusual for term infants to feed immediately after birth in that sacred first hour or two, and then sleep quite a long time (up to 8–12 hours) before they become more active and begin to suckle with increasing frequently. There is always great fear in the postpartum unit when this occurs that all infants, including those with no risk factors for hypoglycemia, will drop their blood sugars. However, normal infants mount protective metabolic responses throughout this time so it is not necessary to try to force-feed them. However, an unusually, excessively drowsy baby must undergo clinical evaluation for other conditions that might be at play. This requires good clinical judgment and assessment so that every normally drowsy infant in those first hours after birth does not undergo any unnecessary work-up that could in addition negatively affect the breastfeeding relationship.

The bottom line upheld throughout the world continues to be: “(1) early and exclusive breastfeeding is safe to meet the nutritional needs of healthy term infants and that (2) healthy term infants do not develop clinically significant hypoglycemia simply as a result of a time-limited duration of underfeeding.” Take a look at this new protocol. It can be found both in Breastfeeding Medicine and on the Academy of Breastfeeding Medicine website at under the “Protocol and Statements” tab.

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the United States Breastfeeding Committee.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by kmarinellimd

June 9, 2014 at 3:01 pm

3 Responses

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  1. […] Newly Published! ABM Clinical Protocol #1: Guidelines for <b>Blood</b> <b>…&… […]

  2. Thank you for a long awaited update. I can’t wait to share it with my hospital based collegue-LCs. I do have one remark, though, about the statement that a period up to 8-12 hours after the initial 2 hours postpartum, might be normal and does not cause reason for intervention. I have always wondered how scientifically sound this is. Do we see this as normal in a culture where it is also normal to separate mothers and children, even if this is only in a bassinet next t mothers bed? Might is be that it is just ”common” and not ”normal”. Has there been research done to evaluate this in children who stay into physical contact with their mothers, as would be the biological normal situation?


    June 10, 2014 at 3:14 am

  3. […] Newly Published! ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of …. […]

    Suiker | Eurolac!

    June 12, 2014 at 3:47 am

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