Pediatrics and Neonatology (2018) 59, 368e374

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Original Article

Incidence of hypoglycemia in newborns at

risk and an audit of the 2011 American
academy of pediatrics guideline for
hypoglycemia
Nihan Hilal Hosagasi a,c, Mustafa Aydin b,*,
Aysegul Zenciroglu a,c, Nuran Ustun a,c, Serdar Beken a,c

a
Department of Neonatology, Dr. Sami Ulus Maternity and Children Hospital, 06000, Ankara, Turkey
b
Department of Neonatology, Firat University School of Medicine, 23119, Elazig, Turkey

Received Dec 1, 2016; received in revised form Aug 22, 2017; accepted Nov 10, 2017
Available online 15 November 2017

Key words Abstract Background: Hypoglycemia is low blood glucose level that may negatively affect
Neonatal neurological and developmental prognosis. The American Academy of Pediatrics (AAP), Com-
hypoglycemia; mittee on Fetus and Newborn defined the safe glucose concentrations in the 2011 guideline
Incidence; for newborns at risk for hypoglycemia. This study aimed to investigate the incidence and asso-
Risk factors; ciated risk factors for hypoglycemia in newborn infants having risk and to assess compliance
American academy of with the AAP guideline.
pediatrics Methods: According to 2011 AAP guideline for hypoglycemia, the newborns at risk for hypogly-
guideline; cemia included in this study were divided to four groups [infant of diabetic mother (IDM),
Breastfeeding; large-for-gestational-age (LGA) infants, small-for-gestational-age (SGA) infants, and late pre-
Blood glucose term infants (LPI)].
checking; Results: Of the 207 newborn infants, there were 12 cases in IDM group (5.7%), 79 cases in LGA
Newborn group (38.1%), 66 cases in SGA group (31.8%) and 50 cases in LPI group (24.1%). The incidences
of hypoglycemia in these four groups were 2 (16.6%), 10 (12.7%), 8 (12.2%) and 17 (34%),
respectively. Although the gender, delivery method, birth weight and 5-min Apgar score at
5-min were not found to be associated with hypoglycemia (P > 0.05), lower gestational age
was determined to be associated with higher incidence of hypoglycemia (P Z 0.02). Median
first feeding time was 55 min and time between first nutrition and blood glucose measurement
was 30 min in all cases.

* Corresponding author. Department of Pediatrics-Neonatology, Firat University School of Medicine, 23119, Elazig, Turkey. Fax: þ90 (424)
238 80 96.
E-mail addresses: nihanhilal@gmail.com (N.H. Hosagasi), dr1mustafa@hotmail.com (M. Aydin), azenciroglu@gmail.com (A. Zenciroglu),
drnuranus@gmail.com (N. Ustun), serbeken@gmail.com (S. Beken).
c
Fax: þ(90) 3123170353

https://doi.org/10.1016/j.pedneo.2017.11.009
1875-9572/Copyright ª 2017, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Hypoglycemia incidence in newborns at risk
Conclusion: Highest risk for hypoglycemia in early postnatal period was present especially in
LPI group. Our compliance levels with the AAP guideline was found to be satisfactory.
Copyright ª 2017, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
1. Introduction
Although hypoglycemia represents a low level of blood
glucose that can negatively affect neurological and devel-
opmental prognosis, its numerical definition is a rather
complicated and controversial issue. Hypoglycemia often
does not produce clinical signs because the newborn brain
does not have enough maturity.1 Studies conducted to
determine the lowest acceptable glucose value for
asymptomatic hypoglycemia are insufficient to establish a
consensus. Though it is not possible to give exact glucose
values that define hypoglycemia, the American Academy of
Pediatrics (AAP), Committee on Fetus and Newborn defined
safe glucose concentrations in the 2011 guidelines for
newborns at risk of hypoglycemia.2 In the guide, the
glucose levels which required intervention to prevent brain
damage in newborns were determined based on Cornblath
and Ichord3 guideline in 2000. Based on metabolic adapta-
tion, the guide separated the first 24 h into two sections
and the operational threshold values were determined
accordingly.
This guideline offered an easy plan to implement and
gave clinicians the chance to act on their initiative over
certain values. Early identification of at risk infants and the
use of prophylactic measures to prevent neonatal hypo-
glycemia was recommended as a pragmatic approach. In
the guideline, breastfeeding of asymptomatic infants at risk
in the first hour after birth, and a check of blood sugar
30 min after breastfeeding was recommended. Operational
thresholds for hypoglycemia and severe hypoglycemia in
asymptomatic infants at the first 4 h were defined as 40 and
25 mg/dL, respectively. Thereafter, checking of blood sugar
before each breastfeeding and an intervention if the blood
sugar fell below 45 or 35 mg/dL was recommended.
In our study, we applied the AAP hypoglycemia approach
protocol to prevent hypoglycemia and provide earlier
intervention to newborns that had a risk of transient hy-
poglycemia on the first day after birth.
The primary goal of this study was to determine the
incidence of hypoglycemia and the associated factors with
hypoglycemia for each group of infants at risk. Our sec-
ondary goal was to assess the level of compliance with this
guideline.
2. Material and methods
In this study, the application results and compliance with
the guideline, as recommended by AAP, Committee on
Fetus and Newborns in 2011 for monitoring newborns at risk
of hypoglycemia2), was evaluated. This prospective cohort
study was conducted in the Dr. Sami Ulus Maternity and
369
Children Hospital between 1 March 2013 and 1 January
2014. The investigation was started after the approval by
local ethics committee (ethics committee approval num-
ber: B.10.4.ISM.4.06.68.49). Written consent was obtained
from families of the cases those included in the study.
i. Inclusion criteria (according to the AAP guideline for
approaching to newborns at risk of hypoglycemia)
 Small-foregestational-age (SGA) infants: birth
weight 10 percentile [according to the Fenton
growth curve]4
 Low-birth-weight babies: birth weight 2500 g
 Large-for-gestational-age (LGA) infants: birth
weight 90 percentile [according to the Fenton
growth curve]4
 Macrosomic infants: birth weight 4000 g
 Infant of diabetic mother (IDM): maternal type 1 or
type 2 diabetes mellitus or gestational diabetes
mellitus [according to the American Diabetes As-
sociation 2010 criteria]5
 Late preterm infant (LPI): a premature infant born
between 34-366/7 gestational weeks
ii. Exclusion criteria
 Healthy term infants
 Babies with congenital malformations
 Newborns suffering perinatal asphyxia
 Babies who are not able to be enterally fed in the
first hour, Infants who can’t be fed through the
enteral route in the first hour after birth
 Infants with sepsis
 Infants with polycythemia
 Presence of maternal preeclampsia
 Presence of maternal hypertension
iii. Grouping
In order to avoiding overlap of patients in grouping, in-
fants of diabetic mothers were included in the IDM group
regardless of birth weight. LPI group was constituted ac-
cording to gestational age regardless of the babies’ SGA or
LGA status.
iv. Feeding
Infants’ feeding, blood glucose testing and treatment
plans were made according to the AAP guideline. It was
planned that these babies would be breastfed in the first
hour after birth. Some infants who could not be breastfed
were fed with formula. Infants who could not be fed orally
because of various reasons, such as respiratory distress,
lethargy, etc., were fed by gastric tube. Formula amount
was calculated as 60e100 cc/kg per day. First feeding time
370 N.H. Hosagasi et al

and feeding type were recorded. Formula is calculated as
60e100 cc/kg per day. The first feeding time and type of
feeding were recorded.
v. Blood glucose testing
Capillary blood samples were taken after the heels of
the babies were heated. Blood glucose concentrations were
determined using the “On Call Platinum Glucometer”
(ACON Laboratories INC.eUSA) and test strips. Glucometer
was calibrated monthly. The glucometer was set to convert
whole blood glucose concentrations to plasma equivalents.
If low blood glucose concentration was detected, it was
confirmed by laboratory testing. First blood glucose tests in
babies were made half an hour after feeding. The babies
were fed every 2e3 h for 24 h and the blood glucose was
checked before each feeding.
vi. Definition and classification of hypoglycemia
1. Within the first postnatal 4 h
 Hypoglycemia: blood glucose 40 mg/dL
 Severe Hypoglycemia: blood glucose 25 mg/dL
2. In the postnatal 4e24 h
 Hypoglycemia: blood glucose 45 mg/dL
 Severe hypoglycemia: blood glucose 35 mg/dL
3. Prolonged hypoglycemia: the baby is still hypogly-
cemic after 1 h of intervention
4Recurrent hypoglycemia: more than one hypo-
glycemia episode
vii. Evaluating compliance with guideline
The time of first feeding, the time of first blood glucose
testing, the duration between first feeding and first blood
glucose testing time, and the number of blood glucose tests
for each baby were recorded.
viii. Evaluating blood glucose testing results
Blood glucose testing was evaluated according to the risk
groups. In each risk group, rates of hypoglycemia and se-
vere hypoglycemia, rates of prolonged and recurrent hy-
poglycemia, occurrence of symptomatic hypoglycemia, and
presented symptoms were recorded according to the time
of hypoglycemia.
ix. Statistical analysis
“Statistical Package for the Social Sciences” program
(SPSS version 16.0, Inc. Chicago, Illinois, USA) was used to
analyze the data. Descriptive statistics were presented as
number of observations and percentage (%). The data were
analyzed by the “KolmogoroveSmirnov Test” to define if
they met the normal distribution. Parametric data were
expressed as mean  standard deviation (SD), and
nonparametric data as median (minemax). Kruskal Wallis
test for statistical analysis and “ManneWhitney U Test” for
two group comparisons were used. “Chi-square test” was
applied for comparison of categorical values. The results
with P < 0.05 were considered as statistically significant.
3. Results
i. The sociodemographic characteristics of cases
A total of 207 newborn infants at risk for hypoglycemia
were enrolled into the study, 93 of whom (44.9%) were
female and 114 (55.1%) male. When the distribution of
cases according to risk groups was examined, LGA was
found in 79 (38.1%), SGA in 66 (31.8%), LPI in 50 (24.1%), and
IDM in 12 (5.7%). The sociodemographic characteristics of
the cases according to the risk groups are summarized in
Table 1.
When IDM and LPI groups were categorized according to
their weight, there were 8 AGA infants (66.7%), 3 LGA in-
fants (25%) and 1 SGA infant (8.3%) in IDM group. However,
there were 40 AGA infants (80%), 8 LGA infants (16%) and 2
SGA infants (4%) in LPI group. There were 90 LGA infants
(43.4%), 69 SGA infants (33.3%) and 48 AGA infants (23.1%)
in total.
ii. Incidence of hypoglycemia
A total of 1725 blood glucose tests were performed
during the study period. Of the all testing, a total of 55
hypoglycemia episodes (3.2%) were seen. There was no
difference between the groups with respect to number of
hypoglycemia episodes (P Z 0.33).
Thirty-seven of all infants enrolled into the study (17.8%)
had hypoglycemia in the first 24 h. According to the result
of post-hoc test, the LPIs had highest risk of developing
hypoglycemia.
Recurrent hypoglycemia was seen in 5.3% of all patients
(30% of all hypoglycemic infants). There was no relationship

Table 1 Distribution of socio-demographic characteristics of the patients according to risk groups.

All newborns IDM group LGA infants SGA infants LPIs
Number of newborns, n (%) 207 (100) 12 (5.7) 79 (38.1) 66 (31.8) 50 (24.1)
Male gender, n (%) 114 (55.1) 6 (50) 54 (68.4) 30 (45.5) 24 (48)
Gestational age (weeks)a 38 (34 42) 39 (34 41) 40 (37 42) 38 (37 42) 35 (34 36)
Birth weight (g)a 2670 (1930 5000) 3030 (2230 4190) 4110 (3800 5000) 2395 (1930 3800) 2410 (1950 3800)
Apgar score at 5 minutesa 10 (8e10) 10 (9 10) 9 (8 10) 10 (9 10) 10 (8 10)
Cesarean delivery, n (%) 135 (65.2) 9 (75) 56 (70.9) 32 (48.5) 38 (76)
OGTT rates in mothers, n (%) 130 (62.8) 11 (100) 55 (70) 36 (54.5) 31 (62)
n: number of patients; OGTT: Oral glucose tolerance test; IDM: Infant of diabetic mother; LGA: Large-for-gestational-age; SGA: Small-
for-gestational-age; LPI: Late preterm infant.
a
The median (minemax).
Hypoglycemia incidence in newborns at risk 371

between groups concerning severe, prolonged and recur-
rent hypoglycemia (P Z 0.31, P Z 0.11 and P Z 0.28,
respectively). Distribution and comparison of the incidence
of severe, prolonged and recurrent hypoglycemia according
to risk groups are given in Table 2. Furthermore, the num-
ber of episodes of hypoglycemia for each patient in each
group is demonstrated in Table 3.
iii. Hypoglycemia and severe hypoglycemia incidence
according to hypoglycemia occurrence time
The time was evaluated according to when hypoglycemia
was seen in the groups. Thirty-seven (17.8%) of all infants
included to study had hypoglycemia. Most of them [n Z 28
(13.5% of total)] had hypoglycemia in the first 4 h and hy-
poglycemia recurred in 4e24 h in 5 of them (2.4%). In 9 of all
newborns (4.3%), hypoglycemia developed only in 4e24 h. In
the first 4 h, when the groups were compared to each other,
the difference between them was significant (P Z 0.022).
Symptomatic hypoglycemia was seen in 5 of all newborns
(2.4%). Observed hypoglycemia symptoms were jitteriness
in 2 infants, poor feeding in 2 infants and lethargy in one
infant. Hypoglycemia and severe hypoglycemia incidence
and occurrence times according to risk groups is shown in
Table 4.
iv. Evaluating factors that affect hypoglycemia
When the factors affecting the hypoglycemia were
evaluated, it was observed that gender, type of delivery,
birth weight, gestational age, 5-min Apgar scores, and
additional risk factors (LGA or SGA status in IDM or LPI
groups) had no effect on the hypoglycemia and severe hy-
poglycemia incidence (Table 5), (P > 0.05).
v. Evaluating compliance with the guidelines
Median first feeding time was found to be 55 min (range:
10e90 min) in all newborns. No difference was found be-
tween the groups concerning the first feeding time
(P Z 0.29). The rates of feeding with formula in addition to
breastfeeding were found to be as high as 22% in LPI group
(n Z 11). However, there was no difference between the
groups regarding rates of feeding with formula (P Z 0.112).
Median time between first nutrition and blood glucose
checking was 30 min (range: 5e140 min) in all newborns.
The duration between the first feeding and first blood
glucose testing according to risk groups is presented in
Table 6.
4. Discussion
This study was conducted to determine the incidence and
risk factors of hypoglycemia and to evaluate compliance
with the guideline of the AAP, which included suggestions
about managing infants at risk of hypoglycemia. In present
study, the incidence of hypoglycemia was found as 17.8% in
all newborns, and also the incidence of hypoglycemia var-
ied between study groups.

Table 2 Distribution and comparison of the incidence of hypoglycemia according to risk groups.
All newborns IDM group LGA infants SGA infants LPIs P£
(n Z 207) (n Z 12) (n Z 79) (n Z 66) (n Z 50)
Hypoglycemia, n (%) 37 (17.8) 2 (16.6) 10 (12.7) 8 (12.2) 17 (34) 0.008
Severe hypoglycemia, n (%) 11 (5.3) 1 (8.3) 2 (2.5) 3 (4.5) 5 (10) 0.31
Prolonged hypoglycemia, n (%) 15 (7.2) 1 (8.3) 5 (5.1) 2 (3) 7 (14) 0.11
Recurrent hypoglycemia, n (%) 11 (5.3) 1 (8.3) 1 (1.2) 4 (6.1) 5 (10) 0.28
n: number of patients; IDM: Infant of diabetic mother; LGA: Large-for-gestational-age; SGA: Small-foregestational-age; LPI: Late
preterm infant; £: Chi-square test P values.

Table 3 The number of episodes of hypoglycemia for each patient with recurrent hypoglycemia in each group.
Case no IDM group LGA infants SGA infants LPIs
Case 1 (n: 2) at 5the14th hours
Case 2 (n: 2) at 2nde7th hours
Case 3 (n: 2) at 10the20th hours
Case 4 (n: 2) at 8the21st hours
Case 5 (n: 2) at 9the13th hours
Case 6 (n: 2) at 2nde14th hours
Case 7 (n: 3) at 1ste3rde7th hours
Case 8 (n: 2) at 2nde24th hours
Case 9 (n: 2) at 5the12th hours
Case 10 (n: 2) at 9the12th hours
Case 11 (n: 4) at 2nde4the9the20th hours
n: number of the hypoglycemia episodes; IDM: Infant of diabetic mother; LGA: Large-for-gestational-age; SGA: Smallefor-gestational-
age; LPI: Late preterm infant.
372 N.H. Hosagasi et al

Table 4 Distribution of the hypoglycemia according to the risk groups and hypoglycemia occurrence time.
IDM group LGA infants SGA infants LPIs Total n (%)
n (%) n (%) n (%) n (%)
Hypoglycemia within first 4 h 1 (8.3) 10 (12.7) 4 (6.1) 13 (26) 28 (13.5)
Hypoglycemia in 4e24 h 1 (8.3) 1 (1.3) 5 (7.6) 7 (14) 14 (6.7)
Severe hypoglycemia within first 4 h 1 (8.3) 2 (2.5) 1 (1.5) 3 (6) 7 (3.4)
Severe hypoglycemia in 4e24 h 2 (3) 2 (4) 4 (1.9)
Symptomatic hypoglycemia 1 (1.4) 4 (8) 5 (2.4)
n: number of patients; IDM: Infant of diabetic mother; LGA: Large-for-gestational-age; SGA: Small-for-gestational-age; LPI: Late pre-
term infant.

The incidence of hypoglycemia varies according to the
definition of hypoglycemia, the feeding status and timing of
blood glucose testing. This rate was found to be 12e4% for
healthy term newborns in various studies when a blood
glucose level of <47 mg/dL was accepted as the reference
value for hypoglycemia.6e8
Heck and Erenburg9 detected hypoglycemia in 16% of
healthy term infants when a blood glucose level of <40 mg/
dL was accepted as the reference value for hypoglycemia. In
a recently published article which assessed the incidence of
neonatal hypoglycemia in similar risk groups to those of our
study, the threshold plasma glucose concentration (PGC)
was accepted as 2.6 mmol/L (47 mg/dL), so half of the in-
fants studied were found to have hypoglycemia.10 In that
study, the limit for severe hypoglycemia was defined as
having a blood glucose level of <2.0 mmol/L (36 mg/dL) and
accordingly the incidence of severe hypoglycemia was found
to be 19%. Researchers explained these high incidence rates
of hypoglycemia in their studies by the strict blood glucose
checking, testing method, and high limits of hypoglycemia.
In our study, the blood glucose testing was made around each
feeding and we could accept that adequate number in

Table 5 Effect of cases characteristics on the hypoglycemia and severe hypoglycemia.

Hypoglycemia Severe hypoglycemia
Yes (n Z 37) No (n Z 170) P Yes (n Z 11) No (n Z 196) P
£
Male gender, n (%) 20 54 94 45 1 5 45 109 55 0.54£
Cesarean delivery, n (%) 24 64.8 111 65.3 1£ 7 63.6 128 65.3 1£
Birth weight (g)a 2710 (1960e4440) 2660 (1930e5000) 0.147p 2370 (2150e4200) 2675 (1930e5000) 0.14p
Gestational age (weeks)b 37.2  2.1 38.2  1.9 0.02p 37.4  2.0 38.0  1.9 0.34
Formula feeding, n (%) 6 16.2 23 13.5 0.378£ 2 18.1 27 13.7 0.331£
Apgar score at 5-mina 10 (9e10) 10 (8e10) 0.814p 10 (9e10) 10 (8e10) 0.45p
Additional risk factorsc 5 9 0.072p 1 13 0.518p
n: number of patients; p: ManneWhitney U test p values; £: Chi-square test P values.
a
The median (minemax)
b
mean  SD
c
LGA or SGA status in IDM or LPI groups;

Table 6 Comparison of the cases’ first feeding and blood glucose testing intervals according to risk groups.
All newborns IDM group LGA SGA LPIs PU
(n Z 207) (n Z 12) (n Z 79) (n Z 66) (n Z 50)
First feeding time (minute)a 55 (10e90) 52.5 (30e90) 55 (20e85) 50 (10e60) 60 (30e80) 0.29
First blood glucose checking 70 (40e135) 60 (40e140) 65 (40e135) 75 (60e120) 80 (45e125) 0.187
time (minute)a
Time interval between first 30 (5e140) 10 (5e60) 30 (5e105) 32.5 (5e140) 20 (5e105)
feeding and blood glucose
checking (minute)a
Formula support 29 (14) 2 (16.6) 5 (6.3) 11 (16.6) 11 (22) 0.112
n (%)
IDM: Infant of diabetic mother; LGA: Large-for-gestational-age; SGA: Small-for-gestational-age; LPI: Late preterm infant; U: Kruskal
Wallis test P values.
a
The median (minemax).
Hypoglycemia incidence in newborns at risk
accordance with the AAP recommendation. The higher
accepted glucose cut-off value for hypoglycemia means the
greater incidence of hypoglycemia; and this would also
cause healthy newborns to be considered hypoglycemic and
subject to unnecessary intervention. Another reason for the
difference in the incidence of hypoglycemia is that while a
study by Harris et al.10 did check the first blood glucose at 1 h
regardless of feeding status, in fact we might check blood
glucose levels after first feeding.
In a recent study conducted in Australia with similar risk
groups to evaluate compliance with hypoglycemia guideline
where PGC was accepted 2.5 mmol/L (47 mg/dL) for hy-
poglycemia, the incidence of hypoglycemia was found to be
8%.11 In that study, the guideline recommended checking
the first blood glucose level within the first 7 postnatal
hours; therefore they found a lower hypoglycemia inci-
dence to that of our study because of a median first blood
glucose testing time ranging from 34 min to 6 h and
checking the PGC after feeding.
The hypothesis supporting that LGA infants have higher
hypoglycemia risk is based on possible hyperinsulinism
caused by undetermined maternal diabetes or prediabetes.
Although several studies support this hypothesis, other
studies showed no difference in hypoglycemia incidence to
that of healthy term AGA infants.7,8 In a large-scale study
supporting routine glucose monitoring, Schaefer et al.12
found that 16% of LGA infants had blood glucose level of
30 mg/dL in the first 24 h, and this rate dropped rapidly in
the first few hours. In their study hypoglycemia incidence
was 9.2% in the first hour, 3.5% in 2e5 h and 2.4% later. In
our study, the incidence of hypoglycemia in LGA infants was
found to be 12.7% and the rate of severe hypoglycemia was
2.5%. None of these babies had hypoglycemia that started
after the 4th hour. Only a baby with hypoglycemia in the
first 4 h repeated hypoglycemia at 7th hour. Although the
incidence of hypoglycemia was not high, we could not
argue that glucose monitoring is unnecessary in LGA babies
because 5 out of 10 babies developing hypoglycemia had
prolonged hypoglycemia. However, after the first 4 h there
was no evidence that monitoring should continue. We can
assume that infants with hyperinsulinism will be diagnosed
within the first 4 h, even though the risk could not be
detected in IDM group in which 70% of mothers had OGTT. In
the study of Holtrop,13 hypoglycemia occurrence time in
LGA infants was detected as a median of 2.9 h (range:
0.8e8.5 h); therefore it was speculated that glucose
checking should not be continued after 12 h in LGA infants.
Van Howe and Storms14 designed a study which hypoth-
esized that if LGA infants had hypoglycemia risk, hypogly-
cemia incidence should be correlated with birth weight.
However, they had found no correlation between hypogly-
cemia incidence and birth weight in LGA infants. In that
study, researchers concluded that aggressive feeding rather
than routine glucose monitoring would be a more accurate
approach for the reason that the proportion of infants with
PGC of <30 mg/dL was only 5.9%.
Of all hypoglycemia infants, those with lower gestational
age had more hypoglycemia. Because this study showed
highest risk for hypoglycemia in the early postnatal period
(between selected groups) was in the LPI group, it was not
surprising to have lower gestational age associated with
hypoglycemia.
373
With the aim of assessing our compliance with AAP
guideline, we recorded the first feeding time and first
glucose checking time. We observed that over half of the
babies were fed within the first hour after birth. The me-
dian time between the first feeding of infants and the blood
glucose testing was the recommended 30 min.
In the Canadian hypoglycemia guideline published in
2004, it was suggested that the first blood glucose testing
should be performed at 2 h. In a study which evaluated
compliance with this guideline, the first blood glucose
checking of SGA infants was 2 h 44 min and that of LGA
infants was 3 h 4 min.15,16 In our study, the time interval
between feeding and blood glucose testing was in line with
the recommendations. However, in fact, checking blood
glucose in the first 2 or 3 h, when blood glucose decreases
physiologically, may lead to false hypoglycemia diagnosis.
Nonetheless, there is no consensus on the first blood glucose
testing time. In the study of Alkalay et al.17 in which they
researched the plasma glucose thresholds for term healthy
infants, PGC for 5th percentile was determined as 28 mg/
dL for the first 2 h. Therefore, if low blood glucose is
detected in the first hours, hypoglycemia may be difficult to
distinguish from physiological low postnatal blood glucose,
which may lead to unnecessary intervention.18,19
In a workshop report on the proposal of neonatal hypo-
glycemia in 2009, it was stated that grade, duration and
frequency of the hypoglycemia should be determined in
order to determine the long-term effects of asymptomatic
hypoglycemia.20 In our study, the rate of prolonged hypo-
glycemia was found to be 7.2% of all infants and 40.5% of all
hypoglycemia cases. Since control of postprandial blood
glucose is done at 1 h intervals, the duration of prolonged
hypoglycemia was accepted as being 1e2 h in this study.
However, it is not possible to give a definite period of hy-
poglycemia with intermittent blood glucose measurement.
Further new studies with continuous glucose monitoring in
this regard may provide more accurate information than
intermittent glucose monitoring.
Recurrent hypoglycemia, which is considered to have
long-term adverse neurological effects, was seen in 5.3% of
all patients (30% of all hypoglycemic infants). One third of
hypoglycemic LPIs had recurrent hypoglycemia, even if it
was not statistically significant. Duvanel et al.21 showed
that recurrent hypoglycemia of mild grade (PGC of <47 mg/
dL), which they found in 30% of SGA preterm infants,
caused low scores in psychomotor tests and marked head
circumference smallness at 3.5 years. That study also
showed that recurrent hypoglycemia was more significant
than one severe hypoglycemia in terms of neurological
damage. As a result of the study, they recommended that
strict blood glucose monitoring should be performed in SGA
infants and even mild hypoglycemia should warrant quick
intervention.
Our study has some limitations and recommendations.
Assessment of compliance with guidelines gives an oppor-
tunity for demonstrating the applicability of guidelines and
enabling researchers undertake their own evaluations. The
initiation of our study and the initiation of the AAP hypo-
glycemia protocol in our hospital coincided. This research
and application of AAP protocol started simultaneously at
our hospital. For this reason, the healthcare personnel
were observed to be deficient in implementing this
374
protocol. All infants could not feed within the first hour and
although the number of blood glucose testing was very high,
some babies could not be checked for blood glucose level
before each feeding. This study showed that health pro-
fessionals should be informed again about the follow-up of
infants bearing the risk of hypoglycemia. Another result of
this study was that the rates of feeding with formula were
found to be higher than preferred. Although the formula
feeding rates of healthy infants in our hospital are not
known, the risk of hypoglycemia in the babies included into
study might cause a tendency to feed with formula. Since
the high prevalence of hypoglycemia in the LPI group may
be related to nutritional deficiencies with decreased
glycogen storage, the recommendation that health pro-
fessionals to be trained in the feeding of LPIs can be
considered as a contribution to the clinical practice of this
study.
Because the PGC cut-off values that cause to hypogly-
cemic brain damage and the effect of asymptomatic hy-
poglycemia on neurodevelopment are unknown, the use of
guidelines is currently the most appropriate method to
determine safe blood glucose levels.
Conflicts of interest
The authors declare that they have no financial or nonfi-
nancial conflicts of interest related to the subject matter or
materials discussed in the manuscript.
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