The Consequences of Prior Initiation of Breast Feeding on Blood Glucose Levels in Neonates Born In a Tertiary Care Hospital

Background: Hypoglycemia is the most common event of failure of metabolic adjustments in the newborn. Changes in maternal and fetal monitoring techniques, administration of glucose-containing solutions during labor, delivery and early feeding in neonates significantly alter blood glucose concentrations during the first week of postnatal life. Subjects and Methods: A total of 90 healthy (60 born by FTND, 30 born by LSCS) term, AGA infants were longitudinally evaluated at birth, at one hour after feeds (post feed), and after 6 hours of life. Plasma glucose was estimated from Heel Prick capillary samples by glucometer method. The influence of mode of delivery, the interval between feeds, sex, birth weight, on blood glucose was analyzed. Results: The way of delivery did not affect the plasma glucose concentration in neonates. There was a substantial increase in blood glucose concentration after the first feed irrespective of their birth weight. It was found that female babies had a higher blood glucose concentration than male babies during our study period. All babies maintained normal blood glucose with the continuation of breastfeeding. Conclusion: Plasma glucose levels are satisfactorily maintained in healthy term infants without resort to pre-lacteal feeds and mode of delivery did not influence plasma glucose. There is no need to check blood glucose levels routinely in an asymptomatic, healthy, term, breastfed infants.


Introduction
Early initiation of breastfeeding within half an hour to one hour after birth is one of the essential ways to have successful feeding. [1,2] If the feeding is started early, the dual benefits of colostrums and the budding relationship between mother and baby can be established. [3,4] Considerable attention has been given to the adoption of internal feeding and its role in the prevention of hypoglycemia. [5,6] Changes in maternal and fetal monitoring techniques, administration of glucose-containing solutions during labor and delivery and, early feeding in neonates significantly alter blood glucose concentrations during the first week of postnatal life. [7][8][9] Hence this study is done to evaluate the blood glucose level in full-term neonates before and after the first breastfeed.

Subjects and Methods
A Prospective study of a total 90 healthy, term (37-41 weeks of gestational age) born at Al-Ameen medical college hospital, who weighed between 2.500 kg and 3.999 kg, and were selected on simple random technique.

Exclusion criteria
1. Neonates of mothers with hurdles of pregnancy such as toxemia, anemia, diabetes, hypertension, prenatal infection, fetal distress, or use of any drugs during the last four weeks of pregnancy. 2. Mothers who had received dextrose containing fluids 5. Infants born by instrumental or breech delivery were also excluded from the study Blood samples were taken by heelprick (capillary blood), the warmed foot being sufficiently vasodilated to allow free flow without compression.
The First sample was collected on the first day within 10 minutes of birth (pre-feed); the second sample was taken after one hour of feeding (post-feed), i.e., at one hour of age; the third sample was taken at 6th hour of life.
The estimation of blood glucose was done by using the glucose strip method. The results interpreted by the color change on the strip by visual and measured the value with a glucometer.
We have compared the blood glucose values estimated by this method (glucose strip method) to the values determined by the conventional laboratory method before beginning the study and whenever doubts arose from this method on the study period. We found that there was a good correlation between the two ways.Immediately after the estimation of blood glucose within 10 minutes after birth (pre-feed), the baby was put to the breast for feeding in the labor room.
After 1 hour of feeding, the second sample of blood was estimated for the glucose level (post-feed)., At the end of 6 hours, the blood glucose levels were determined once again.
Thus the blood glucose level was determined, one at pre-feed second, after one hour (post-feed), and third at the sixth hour of age.

Results
Ninety full-term infants (gestational age between 37-41 weeks) were included in this study. Sixty infants were delivered vaginally, and thirty infants by cesarean section as shown in [Table1].
The mean (±SD) birth weight of the 60 neonates delivered by vaginally was 2.94 ± 0.274 mg/dL. Range was 2.5-3.7 kg. The mean gestational age was 38.05 ± 0.723 mg/dL, the mean (± SD) APGAR score at 1 minute was 7.567 ± 0.499 and at 5 minutes was 8.75 ±0.436. The mean ± SD birth weight of the 30 neonates delivered by cesarean section was 3.126 ± 0.32 range was 2.5-3.75 kg. The mean gestational age was 38.8 ± 0.781 weeks. The mean APGAR score at one minute was 7.467 ± 0.507 and at five minutes was 8.633 ± 0.490.
The Blood glucose values during the first 6 hours of life in full-term normal Delivery and LSCS as shown in [Table 2] The mean (± SD) blood glucose value for infants delivered by vaginally at birth was 79.9 ± 11.579 mg/dL (pre-feed). The range was 36-102 mg/dL. A significant rise occurred after the first feed, the mean increment at one hour being 11.48 mg/dL (mean blood glucose value at 1 hour of age was 91.383 ± 10.984 mg/dL) range was 57-116mg/dL (p<0.05). At 6 th hour of age, them ean blood glucose level was 67.01 ± 7.40 mg/dL range was 52-88 mg/dL.
The mean (± SD) blood glucose value for infants delivered by LSCS at birth was 75.8 ± 15.454 mg/dL (prefeed). The range was 38-102 mg/dL. A significant rise occurred after the first feed, the mean increment at one hour being 10.36 mg/dL, mean blood glucose value at 1 hour of age was 86.167 mg/dL, which range from 50-118 mg/dL. At the 6th hourof age, the mean blood glucose level was 69.267 ± 12.068mg/dL.

The comparison of blood glucose levels in an infant born by LSCS & vaginally as shown in [Table 3]
The mean (± SD) blood glucose values in babies delivered by cesarean section at birth (75.8 ± 15.45 mg/dL) were similar to those delivered by vaginally (79.9 ± 11.57 mg/dL) range was 38-102 mg/dL. At one hour of age, mean blood glucose values in cesarean section, babies were 86.167 ± 16.80 mg/dL range was 50-118 mg/dL with a mean increment of 10.36 mg/dL. After six hours of age, the mean blood glucose value was 69.267 ± 12.06mg/dL.No significant difference was found between infants delivered by vaginally and cesarean section any time during the study period. (p>0.05) The Mean blood glucose values concerned to birth weight as shown in [Table 4] 60 babies delivered vaginally were divided into 3 groups by birth weight 32 babies weighed 2.5 to 2.99 kg, 25 babies weighed between 3.0 to 3.49 kgs and 3 babies. Weighed between 3.5 to 3.99 kgs. Babies with birth weight between 2.5-2.99 kgs had a mean blood glucose level of 78.78 ± 13.29 mg/dL at birth. After the first feed, at one hour of age the blood Glucose level rise to 91.218 ± 11.732, a mean increment being 12.438 mg/dL. At six-hour of Age they showed mean blood glucose of 66.156 ± 7.025mg/dL. The mean blood glucose value for Neonate, whose birth weight between 3.0-3.49 kgs at birth was 81.12 ± 9.879 mg/dL. After the first Feed, at one hour of age, meanbloodglucoselevelwas91.76±10.899mg/dL with a mean Increment of 10.64 mg/dL. After 6 hours of age, the blood glucose value was 67.76 ± 8.14 mg/dL. Those babies who weighed 3.5 to 3.99 kghad a blood glucose value of 82.00±0.00mg/dL At birth, after one hour of age, the blood glucose value was 90.66 ± 1.154 mg/dL with mean       A significant rise in the mean blood glucose level occurred in each group after the first feed (p < 0.05), however newborns with birth weight between 2.5 to 2.99 kg were shown maximum increment in the rise of blood glucose level as occurred with FTND babies. Although no significant difference was found between each group (FTND and LSCS), the mean increment of blood glucose level after the first feed (p>0.05). From this result, it was found that mean blood glucose value increases as the birth weight of the newborns' increases. No statistically significant difference in blood glucose level was found at 6th hour of age in all the groups. The mean blood glucose levels in comparison to sex, as shown in [ Table 6].
36 of 60 babies delivered vaginally were males, and 24 were females. It was found that mean blood glucose value for females at birth was 81.20 ± 11.32 mg/dL as compared to male babies whose mean blood glucose value was 79.11 ± 11.89. After one hour of age, the mean blood glucose value for female babies was 93.16 ± 11.32 as compared to male babies, 90.55 ± 11.3 mg/dL. From this study, it is found that mean blood glucose values were higher in female babies both in FTND and LSCS born babies throughout our study period, but statistically was not significant (p > 0.05).
In this study, one baby born by FTND had a blood glucose value of 36 mg/dL at birth. One baby born by LSCS had a blood glucose value of 38 mg/dL at birth. Both these babies were asymptomatic. These babies were given breastfeeds frequently. They maintained blood glucose levels with additional breastfeeding. The comparison of blood glucose levels at different time intervals, as shown in [ Table  7].

Discussion
Hypoglycemia is an essential complication in the newborns, initiation of early feeding has immense value in safeguarding against hypoglycemia. [10,11] Organizations like WHO, UNICEF and Breastfeeding Promotion Network of India (BPNI) are working hard for the last few years to promote exclusive breastfeeding in newborns and encourage the establishment of baby-friendly hospitals all over the world. [12,13] The comparison of mean blood glucose levels in infants born by vaginally & cesarean section, as shown in [ Table 8].
In our study, the mean blood glucose values of female babies were slightly higher than the male babies delivered by FTND and LSCS. The incidence of healthy term infants with blood glucose levels in various studies14as shown in [ Table 9].
In our study, 2 babies (2.2%) (One from Full Term Normal Delivery group and the other baby from LSCS group) had blood glucose concentration below 40 mg/dL. As these babies were asymptomatic, they were given breastfeeding. After 1 hour of breastfeeding, their blood glucose values were normal. With demand feeding, all babies maintained normal glucose levels throughout our studyperiod. The results of our study confirmed that the early initiation of breastfeeding i.e. colostrum increases the blood glucose level within one hour, and euglycemic state was maintained by continuing breastfeeds in infants irrespective of their birth weight, type of delivery and sex of the babies. [14] Conclusion Plasma glucose levels are satisfactorily maintained in healthy term infants without resort to pre-lacteal feeds and mode of delivery did not influence plasma glucose. There is no need