Type of feeding provided with dextrose gel impacts hypoglycemia outcomes: comparing donor milk, formula, and breastfeeding

Effectiveness of hospital-based oral dextrose gel in prevention and treatment of asymptomatic newborns at risk of hypoglycemia

OBJECTIVE

To evaluate the effectiveness of using hospital-based 40% dextrose gel (DG) in preventing and treating asymptomatic hypoglycemia in infants of diabetic mothers (IDM), large for gestational age (LGA), and macrosomic neonates.

METHODS

A medical chart review was conducted to compare data between before (April 2018 to March 2019, epoch 1) and after (September 2020 to November 2021, epoch 2) 40% DG implementation. DG, prepared by the hospital pharmaceutical unit, was applied within 30-45 min after birth, and three additional doses could be repeated during the first 6 h of life in combination with early feeding. The primary outcome was the rate of intravenous dextrose administration. Secondary outcomes were the incidence of hypoglycemia, first capillary blood glucose concentrations, and the length of hospital stay.

RESULTS

Six hundred forty-three at-risk newborns were included (320 before and 323 after implementation of DG). Maternal and neonatal baseline characteristics were not different between the two epochs. The incidence of hypoglycemia was not different (17.8% in before versus 14.6% in after implementation, p = 0.26). The rate of intravenous dextrose administration after DG implementation was significantly lower than that before DG implementation (3.4% versus 10.3%, p < 0.001, risk reduction ratio = 0.33, 95% CI = 0.17-0.64). The length of hospital stay was not different between the two epochs.

CONCLUSIONS

Implementing a protocol for administration of hospital-based 40% DG can reduce the need of intravenous dextrose administration among IDM, LGA and macrosomic neonates.

Donor human milk versus infant formula for low-risk infants: a systematic review

BACKGROUND

There is an increasing acceptance and use of donor human milk (DHM) in healthy infants. This review investigates the benefits and risks of mothers' own milk (MOM) supplementation with DHM compared to infant formula (IF) in moderate-late preterm (MLP) and early term (ET) infants.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL and clinical trial registries were searched for studies published up to September 2023. The primary outcome was rates of exclusive breastfeeding (EBF). Certainty of evidence was assessed using GRADE framework. RoB1 and EPHPP were used to assess risk of bias for controlled trials and observational studies, respectively.

RESULTS

Eleven studies involving total of 10,147 infants and six ongoing trials were identified. Studies were of low quality, and the certainty of evidence was assessed as very low. Three studies suggested benefits of DHM compared to IF on EBF at discharge, while two suggested no difference. No clear effect was observed on EBF duration, any breastfeeding, hypoglycemia and morbidity. No health risks were reported.

CONCLUSION

The effect of supplementing MOM with DHM instead of IF on EBF and other health outcomes is unclear. High-quality studies are required to determine the potential benefits or risks of DHM supplementation in this population.

IMPACT

We identified 11 relevant studies reporting on supplementation of mothers' own milk (MOM) with donor human milk (DHM) compared to infant formula (IF). Studies were of low quality, had heterogeneous outcome definitions and were geographically limited; all except two were observational studies. Limited evidence showed no clear difference on rates of exclusive breastfeeding and other health outcomes. No potential risks were reported. The increasing acceptance and use of DHM in healthy infants highlights the need for future high-quality studies.

Neonatal hypoglycaemia

Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.

Implementation and outcomes of a standard dose dextrose gel protocol for management of transient neonatal hypoglycemia

OBJECTIVE

The use of oral dextrose gel (DG) reduces IV dextrose use. Prior studies used weight-based dosing (WD), though barriers exist, and are mitigated using standard dosing (SD). Our outcomes include IV dextrose use, NICU admissions, breastfeeding, adverse events, and assessment of WD vs SD.

STUDY DESIGN

Retrospective chart review comparing pre-DG, WD, and SD in 16490 newborns (1329 hypoglycemic) ≥ 35 weeks admitted to the nursery over 3 years.

RESULTS

There was reduction in IV dextrose use 10.9% vs 6.5% (p = 0.004) and NICU admissions 27.9% vs 16.1% (p < 0.001) associated with DG use, and increased rate of breastfed infants 33.8% vs 43.5% (p = 0.001), with no difference between WD and SD. No difference noted in adverse events across the study period.

CONCLUSIONS

DG utilization is associated with reduced IV dextrose use, NICU admissions, and improved breastfeeding rates without changes in adverse events. We offer SD as a safe alternative to WD.

Plasma-glycated CD59 as an early biomarker for gestational diabetes mellitus: prospective cohort study protocol

INTRODUCTION

The significant maternal and neonatal outcomes of gestational diabetes mellitus (GDM) make it a major public health concern. Mothers with GDM are at greater risk of pregnancy complications and their offspring are at higher risk of diabetes and obesity. Currently, GDM is diagnosed with glucose load methods which are time-consuming and inconvenient to administer more than once during pregnancy; for this reason, there is a recognised need for a more accurate and simpler test for GDM. Previous studies indicate that plasma-glycated CD59 (pGCD59) is a novel biomarker for GDM. We present here the protocol of a prospective cohort study designed to (1) determine the accuracy of pGCD59 as an early, first trimester predictor of GDM and gestational impaired glucose tolerance and (2) assess the associations between pGCD59 levels and adverse maternal and neonatal outcomes.

METHODS AND ANALYSIS

We will obtain discarded plasma samples from pregnant women at two time points: first prenatal visit (usually <14 weeks gestation) and gestational weeks 24-28. A study-specific medical record abstraction tool will be used to obtain relevant maternal and neonatal clinical data from the EPIC clinical database. The prevalence of GDM will be determined using standard of care glucose load test results. We will determine the sensitivity and specificity of pGCD59 to predict the diagnosis of GDM and gestational impaired glucose tolerance, as well as the associations between levels of pGCD59 and the prevalence of maternal and neonatal outcomes.

ETHICS AND DISSEMINATION

This study has been approved by the Mass General Brigham Institutional Review Board (protocol 2011P002254). The results of this study will be presented at international meetings and disseminated in peer-reviewed journals.

Supplementation-based hypoglycemia guidelines including donor breast milk reduce NICU admission

OBJECTIVE

To study the effects of a supplementation-based hypoglycemia guideline including donor (DM) on NICU admission, exclusive breastfeeding, and blood glucose concentrations in infants at-risk for neonatal hypoglycemia (NH).

PROJECT DESIGN

We integrated DM, feeding supplementation, and reduced frequency of blood glucose testing into an NH bundle for term and late-preterm newborns. We then examined NICU admission rates and rates of exclusive breastfeeding at discharge.

RESULTS

NICU admission rates were reduced to 6% (-10%). Exclusive breastfeeding rates increased to 55% (+22%). Median cost of DM utilization was $13.73 per patient with an average volume of 50.8 ml/infant. DM supplementation resulted in similar times to last hypoglycemic episode and greater increases in blood glucose compared to expressed breast milk or breastfeeding alone (+9.6 mg/dL, p < 0.05).

CONCLUSIONS

A supplementation-based hypoglycemia guideline including donor milk may be an effective way to reduce NICU admissions for asymptomatic hypoglycemia and support mothers in achieving breastfeeding goals.

ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical conditions 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.

Care of Infants Born to Women with Diabetes

PURPOSE OF REVIEW

Infants of women with diabetes are at risk for specific morbidities including congenital anomalies, abnormalities of fetal growth, neonatal hypoglycemia, electrolyte abnormalities, polycythemia, hyperbilirubinemia, and respiratory distress syndrome. Recent studies have shed light on long-term outcomes of these infants and presented advances in treatment. The purpose of this review is to outline the most common neonatal morbidities affecting infants of women with diabetes, the pathophysiology and prevalence of these conditions, and contemporary approaches to treatment.

RECENT FINDINGS

Recent investigative findings have led to advances in treatment approaches for these infants, particularly regarding risks of neonatal hypoglycemia. Optimizing maternal glycemic control during pregnancy is imperative to improving infant outcomes. However, on a population level, maternal diabetes still poses significant risks to the infant. Timely and appropriate treatment of infants of women with diabetes is imperative to decrease short- and long-term morbidity.