Effect of Formula and Breast Milk Feeding on Random Blood Sugar Values in Healthy, Full Term Babies, in 1st 48 hours after Birth.

It was found that whether in males or in females or all, there was no significant statistical difference in random blood sugar values at each specific time between babies who were formula-fed as compared to those who were breast-fed. The study showed also that random blood sugar is increasing with time by the effect of feeding .Of the 100 babies studied, only 6 suffered from hypoglycemia presented by jitteriness. However, there was no significant statistical difference between random blood sugar values of hypoglycemic babies who were breast-fed as compared to hypoglycemic babies who were formula-fed. The range at which hypoglycemia showed symptoms presented by jitteriness are around 35-40 mg/dl during the 1 st 10 hours after birth. However, the study also showed that hypoglycemia has no standard level but depends on signs and symptoms because some babies did not present with jitteriness at this level


Introduction
Neonatal hypoglycemia is a common phenomenon in the newborn infant diagnosed by an abnormally low level of blood glucose (sugar), the body's chief energy source (hence the term low blood sugar).Serum glucose levels less than 40 mg/dl (2.2 mmol/L) in the first 24 hours of life and 40-50 mg/dl (2.6 mmol/L) thereafter are considered low whereas 80-90mg/dl (4.4-5mmol/L) is considered normal [1].Glucose is an essential nutrient for the brain.Abnormally low levels can cause an encephalopathy and have the potential to produce long-term neurological injury in infants.The level at which this potential for longterm injury is reached is controversial.There is a normal dip in blood glucose 2-4 hours postnatally so the challenge is to be able to recognize a normal dip from true metabolism errors [2].
There are many causes behind neonatal hypoglycemia, for example: Hyperinsulinism or mal-adaptive hypoglycemia is most often caused by an over secretion of insulin from the pancreas triggered by stress, fasting, or disorders of the adrenal or pituitary glands, liver, or pancreas.In infants of diabetic mothers, it is not uncommon for the infant to remain in a hyperinsulinemic state after losing the maternal glucose supply.Fetal glucose levels correspond to maternal levels as glucose crosses the placenta.Insulin production in the fetus begins early in gestation; insulin does not cross the placenta.When the newborn is deprived of maternal glucose, the pancreas continues to produce insulin at the same fetal level and newborn glucose levels are rapidly depleted.This condition is usually transient and is treated either with early initiation of carbohydrate feedings or, at times, intravenous dextrose provided at a rate of 4-8 mg/kg/min but until the infant's metabolic adaptation is able to supply adequate amounts of glucose.On the other hand, hypoglycemia persisting or occurring after 1 week of life requires an evaluation [3].
In preterm infants and those born small for gestational age (SGA), adequate fetal glycogen storage has been interrupted or impaired, placing these infants at risk for hypoglycemia in the first several hours and days of life.Other perinatal events that may cause an increase in energy utilization (above those levels at which the newborn is able to supply glucose) include perinatal asphyxia, cold stress, respiratory distress, and prolonged labor.The newborn may also be at risk for hypoglycemia as a result of inborn errors of carbohydrate metabolism and amino acid metabolism.Hyperinsulinism due to nesidioblastosis (pancreas islet cell dysmaturation syndrome) in the early neonatal period also is a cause for neonatal hypoglycemia.Persistent Severe Hypoglycemia -Mal-adaptive hypoglycemia can usually be clinically separated from pathological hypoglycemia by the amount of glucose need to maintain a normal blood sugar.Once a baby needs more than 7.5mg/kg/min of glucose a pathological cause becomes more likely.Most of these conditions are inborn errors of metabolism such as glycogen storage diseases [4].
To determine the effect of type of feeding (Formula and Breast feeding) on random blood sugar values in healthy, full term newborn baby during the 1 st 48 hours after birth.

Materials and Methods
We have taken a sample containing 100 newborn babies .We have chosen these babies to be healthy, full term baby.So we excluded babies of diabetic mother or small gestational age babies.The study was done in different hospitals for Obstetric and Gynecology as Yarmook, Medical city, Al-Elweya, Habeebya hospitals and Al-Zahra'a Private hospital, Baghdad.The study was done during the time interval from February to July 2004.
For close follow-up, we have taken only those babies delivered by caesarean section as their mothers stay in the hospital postoperatively for follow-up and hence their babies will stay with them.
We have chosen 100 babies of 98 mothers; two of the latter gave birth of twin.We divided those babies into two groups: Group1: 48 babies are formula-fed i.e. given milk formula usually Dialac or Kikoz.
History was taken from mother and enquiries included the prenatal history (whether the mother has any disease during pregnancy as diabetes mellitus or hypertension), perinatal (fetal distress, premature labor, prolong labor) and postnatal history (cold stress, respiratory distress).
General examination was done for the neonate to exclude any congenital anomalies or coarse facies or macrosomia.Then, specific examination for any sign of hypoglycemia as jitteriness, drowsiness, irritability, lethargy or cyanosis.
Using a blood glucose monitor device called Glucutrend® 2, a type of an ACCU-CHEK® system devices, random blood sugar was measured for: 1-The mother 30 minutes after birth.2-The umbilical cord blood.
3-The baby after first feeding, 10 hours, 20 hours and 44 hours after birth.During the 1 st 48 hours after birth, we continued to monitor any sign of hypoglycemia as jitteriness, drowsiness, irritability, lethargy or cyanosis.
Using the Paired T Test and Independent T test, we calculated standard deviation, mean, and significance (P) for statistical difference between the two groups.Note that significant results are obtained when P < 0.05 [23].shows the relation between the random blood sugar measurements at different times with the type of feeding in male newborn babies.Each measurement with the maximum, minimum, mean values with the standard deviation.There was no significant relationship between mean RBS values for both types of feeding in males.5).It compared hypoglycemic babies with non-hypoglycemic babies; both were formulafed and found that there is no significant relationship between random blood sugar values at each specific time except at 10 hours at there was significant difference between both.7).It compared hypoglycemic babies with non-hypoglycemic babies; both were breast-fed and found that there is no significant relationship between random blood sugar values at each specific time except at 10 hours at which there was significant difference between both.To see whether the type of feeding may be a predisposing factor in causing hypoglycemia, we divided the 1st group who were breast fed and also the 2 nd who were formula fed into 2 groups: 1 st group are those who presented with jitteriness and the 2 nd are those who did not present with jitteriness.There was statistically significant difference in RBS values measured after 10 hours after birth between jittery and non-jittery which indicates that jittery babies were hypoglycemic.Then, we compared jittery babies who were breast-fed with those who were formula fed and we found that the difference was not statistically significant.This means that the state of hypoglycemia has no significant relation with the type of feeding.

Conclusions
1. Hypoglycemia in the newborn as a serious condition has been encountered in both types of feeding .So it must take enough attention of pediatricians.
2. Hypoglycemia in healthy full term baby has no relation with sex or type of feeding.
3.Hypoglycemia is symptomatic term rather than quantitative.

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Breast-feeding should be started immediately after birth.Babies of unconscious mother after caesarean section should be given an oral 30 ml of 5 % glucose to avoid hypoglycemia and dehydration fever until mother regains consciousness.

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Breastfeeding should be initiated as soon as an infant is ready, preferably within half an hour of birth.Immediately after birth the baby should be dried and held against the mother's chest with skin-to-skin contact to provide warmth and to facilitate the initiation of breastfeeding.

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Any baby shows signs and symptoms of hypoglycemia, should be admitted to the neonatal care unit for management and close observation.

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Mothers should be educated about signs and symptoms of hypoglycemia.
while seven neonates had plasma glucose level less than (1.7) mmol/l (=30.6 mg/dl) at birth.Only one neonate had persistent hypoglycemia from birth to 12 hours of age and required treatment.All other neonates had blood glucose level above 1.7 mmol/l (=30.6 mg/dl) at 24 and 48 hours of life.This means that the exclusively breastfed newborns have adequate glucose supply and are not at risk of having hypoglycemia in the first 48 hours of life.Again such finding goes with our study [26].Another study done in Japan aimed to examine the incidence of symptomatic and asymptomatic hypoglycemia during the early days of life; the blood glucose levels were analyzed in 38 healthy, full-term, breast-fed neonates cared for by rooming-in immediately after birth.Blood glucose levels were measured randomly using a blood glucose analyzer from birth to discharge.Preliminary results have shown that hypoglycemia (< 40 mg/dL) seldom occurred in healthy, full-term, breast-fed neonates when cared for in rooming-in with frequent suckling immediately after birth.Although the above study mentioned included only breast fed babies, the results go with our study [27].Other study done in United Kingdom measured RBS values only in the 1 st hour .In this study, 75 healthy full term babies divided into 3 groups: a group who were breast fed, a group who were formula fed and the 3 rd group was not fed.RBS was measured only in the 1 st hour.Statistical analysis found that mean RBS value have no significant difference between the 3 groups which means that the full-term infants are equipped with homeostatic mechanisms that preserve adequate energy substrate to the brain and other vital organs [28].