This guidance is intended for infants in the first 48 hours after birth during the transition period.

The following infants are at risk of impaired metabolic adaptation:

• Intrauterine growth restriction (birth weight ≤2^nd centile – see table 1 below), or clinically wasted
• Infants of diabetic mothers
• Infants of mothers taking beta-blockers in the third trimester and/or at time of delivery

Weight on 2^nd centile / kg

Table 1. Second centile weights for boys and girls by week of gestation (from BAPM Newborn Early Warning Trigger and Track Framework for Practice)

In addition infants with one or more of the following diagnoses or clinical signs should have a blood glucose measured and urgent medical review. If the babies are well and remain on the post natal ward, their blood glucose measurement should follow the guidance in this document. If they are admitted to NICU there is a separate guideline on how to manage hypoglycaemia:

• Perinatal acidosis (cord arterial or infant pH < 7.1 and base excess ≥ -12mmol/l)
• Hypothermia (<36.5 degrees C) and not attributed to environmental factors
• Suspected/confirmed early onset sepsis
• Cyanosis
• Apnoea
• Altered level of consciousness
• Seizures
• Hypotonia
• Lethargy
• High pitched cry

Infants at risk of hypoglycaemia (identified above) should commence flowchart A and should receive their first feed within 60 minutes of birth.

Provide parents with verbal and written information that explains: why their baby is receiving extra support and blood glucose monitoring; how the likelihood of hypoglycaemia can be minimized, the signs that could indicate that baby is becoming unwell; and how to raise concerns about their baby’s well-being or feeding pattern to staff (print off Appendix 1 (4 pages) to give to parents).

Blood glucose should be measured using one of the blood gas analysers on NICU/SCBU or labour ward. This is much quicker than sending a sample to the lab. Hand held glucometers are not always accurate and should not be used.

Based on the result of the first blood glucose (BG) measurement, place the baby on one of the following care pathways:

• FLOWCHART B: First pre-feed BG 1.0 – 1.9 mmol/l, and no abnormal signs
• FLOWCHART C: First pre-feed BG <1.0 mmol/l, and/or clinical signs consistent with hypoglycaemia at higher BG concentration

A newborn with persistent (more than 2 measurements <2.0 mmol/l within the first 48 hours after birth) or severe hypoglycaemia (<1.0 mmol/l at any time), and infants with signs of acute neurological dysfunction and blood glucose <2.5 mmol/l should be referred urgently to the neonatal team for assessment and the following investigations during the period of hypoglycaemia:

• Blood glucose, insulin, cortisol, growth hormone, fatty acids, ketone bodies, carnitine, acylcarnitine profile, ammonia, lactate, C-peptide
• Urine ketones and organic acids
• Consider evaluation for early onset sepsis

Further investigations should be based on the results of the initial screen and taken following specialist advice.

In cases of suspected or confirmed hyperinsulinism, aim to maintain blood glucose concentration >3.0 mmol/l for the first 48 hours after birth, increasing to >3.5mmol/l after 48 hours of age.

Infants with abnormal neurological signs should be admitted to NICU for neurocritical care investigations and monitoring.

A thorough clinical assessment should be made and documented within 6 hours after birth, at which time practitioners should differentiate between a well baby who is reluctant to feed versus a baby whose feeding pattern suggests an abnormal clinical state due to illness. Signs of reluctant feeding include not waking for feeds, not latching at the breast, not sucking effectively, and appearing unsettled. Skin to skin contact will stimulate the baby to use innate abilities and help his / her mother recognize feeding cues. Feeding support should be provided to reluctant feeders using Flowchart D and Appendix 2, and medical review should be prompt if there are concerns that feeding behaviours may reflect an abnormal clinical state. Blood glucose should be measured in all babies who are deemed to be reluctant feeders after a period of effective feeding or in a baby with abnormal clinical signs to ensure they are not hypoglycaemic.

British Association of Perinatal Medicine, April 2017, Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant – A Framework for Practice

Parent Information Sheet - link up later

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See flow chart D. 

Managing breastfed healthy term infants

Healthy term babies may feed enthusiastically at birth and then sleep for many hours. In order to prevent a potential negative effect on a baby’s wellbeing, establishment of feeding and the stimulation of lactation follow the flow chart overleaf from birth for all well, term babies.

Feeding Cues

Feeding cues indicate the beginning of feeding readiness when babies are more likely to latch on and suck and can occur during periods of light sleep as well as when a baby is awake. Cues include rapid eye movements under the eyelids, mouth and tongue movements, body movements and sounds, sucking on a fist. Crying can be a way of indicating that the feeding cues have been missed. Some babies will develop their readiness to feed following delivery. If this doesn’t occur, support should be provided and documented until effective feeding is established.

Syringe feeding

It is useful to give a baby small amounts of colostrum in a syringe. To give a syringe feed safely, the baby should be held in the mother’s arms slightly upright, not flat. The syringe is gently placed in between the gum and cheek and a little colostrum gently squirted in, no more than 0.2ml at a time. Allow the baby time to enjoy the milk. Move onto cup feeding once you have more than 5ml to give. If there is a clinical indication to provide formula or a mother makes an informed choice to provide formula this can also be given in a cup.

Boosting confidence

You can help and support the mother and boost her confidence by teaching her to hand express. Give her a supply of feeding syringes and feeding cups, encourage skin contact, especially in the laid-back position and help her to recognize her baby’s feeding cues. Encourage the mother to offer her breast to her baby when he/she is ready, and to feed her baby expressed breast milk until he/she is breastfeeding actively and effectively. Mother-led feeding will empower the mother as well as saving you time.

If the mother does not want to hand express

The length of labour and the type of birth may influence the mother’s feelings about hand expressing and giving colostrum intensively for the first few hours. The mother may ask to give formula instead (see below). Remember that in order to establish good milk supply, ideally the mother needs to start hand expressing within 6 hours of birth

If the mother chooses not to express colostrum

If the mother cannot, or chooses not to express her colostrum it is the responsibility of the midwife to ensure this is an informed decision based on awareness of the benefits of breastfeeding. This will be documented by the midwife in the woman’s notes. The milk should be given by cup in volumes appropriate to the baby’s age i.e. first day 5-10mls per feed, second day 10-15mls per feed, third day 20mls per feed. Formula should not exceed 20mls per feed once lactation is established.

Recognising effective feeding - ensuring mothers and staff are able to identify

Alert baby, actively sucking that is settled at the breast and ends breastfeeding spontaneously and remains settled for short periods. The feed should be pain free and the baby should demonstrate adequate wet and dirty nappies.

Use of glucose (dextrose)40% w/w gel Monograph - link up later

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