EBB 335 – Evidence on Newborn Baths and Screening for Low Blood Sugars

Dr. Rebecca Dekker:

Hi everyone, on today’s episode we’re going to talk about the evidence on two common newborn procedures, baby’s first bath and the blood sugar screening. 

Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. 

Hi everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast. My name is Dr. Rebecca Dekker, and I will be your teacher for today’s episode. Today, I’m so excited to bring you some brand-new evidence-based information, all for our listeners, about the newborn bath and newborn blood sugar screening. But before we get started with this content, I have a really big announcement for you. We’ve been working on a secret project here at Evidence Based Birth® this year, and we are almost ready to make that project available to the public. And the secret is, drum roll please, we have been writing and designing a brand new pocket guide all about the evidence on newborn procedures so that new parents or birth workers who work with parents can easily access all the information they need to know about everything that might happen to a baby while they’re in the hospital after birth. So the pocket guide to newborn procedures is about the size of my hand, a little bit smaller. It is going to be color printed, laminated, so it’s cleanable, reusable, and it’s on this handy little key ring so you can keep it packed in your birth bag or hanging at the nurse’s station or tucked into your purse or backpack. In this brand new pocket guide, we’re going to cover everything from how the baby’s body changes during the birth process, from life on the inside of the womb to life on the outside, the evidence on more than 20 common newborn procedures, and how to advocate for your baby. We’ll give a brief overview of each procedure so you know exactly what it is and why it might be done, and then we’ll dive into the research evidence on the effectiveness of that procedure, benefits, risks, and alternatives. We’re going to cover the research on things like the Apgar test, newborn bath, blood sugar testing, cord clamping, cord blood banking, going home early from the hospital, eye ointment, formula supplementation, pacifiers, the hepatitis B vaccine, jaundice screening, and so much more. Many of these topics are things we’ve never published about here at Evidence Based Birth®. So getting this pocket guide is going to be your first chance to get our research teams take on some of these important newborn procedures. In addition to all of the research on the procedures, we’re going to include some really amazing tips inside the pocket guide, including tips for parents of NICU babies, tips for going home from the hospital with a new baby, and how to find a pediatric provider. 

This is something that I would always want to have on hand at a prenatal visit or a birth because you have all the most important information at your fingertips about so many things related to caring for a newborn baby. And of course, like with our other pocket guides, you’ll get a special password-protected resource page where you can get access to a repository of videos, podcasts, and direct links to all of the scientific studies that we referenced when creating this guide. So we are super excited. We cannot wait to get this newborn pocket guide into your hands. And we know from past experience that whenever we launch a new pocket guide that it will sell out. So that’s why we’re encouraging you to get on the wait list. We will give special information about how the pocket guide will be available if you join the wait list. So just go to evidencebasedbirth.com/pocketguide and you can get on the wait list and you’ll receive an email shortly afterwards with all the details about the date and the time. 

So to celebrate this upcoming release of the pocket guide to newborn procedures, which we’ve been working on all year, I’m going to share with you some of the new research on newborn procedures that we’ve never published before at EBB. This is information that’s included in several pages of the pocket guide. And I wanted to make sure that you got this information before the pocket guide was published. I personally had a lot of fun digging into the research evidence on things like, the newborn’s first bath and the evidence on screening for low blood sugar in newborns. So today you’re going to learn some details on the evidence, the benefits, the risks, and alternatives of these two common newborn procedures. There’s going to be so much information in today’s podcast that we’ve never published before. And I can’t wait to get this research into your hands. So are you ready? Great. Let’s go. 

So I want to start today’s episode about newborn procedures by giving you a little bit of info about what’s in the introduction, or the beginning pages, of the pocket guide to newborn procedures. So in the first few pages, we’re going to be talking about the baby’s shift to life outside the uterus, the importance of the golden hour, how you can get informed consent and refusal for any procedures that are offered to your baby, and how you can keep your baby comfortable if or when your baby is having an uncomfortable or painful medical procedure. And that’s what I want to talk about a little bit first before we go into the newborn procedures themselves. 

So one of the things that I’ve found in talking with parents is that a lot of people have fears related to things that might be done to their baby, such as having an injection or a blood draw or anything that might cause their baby pain or discomfort because the last thing any new parent wants to see is their precious little newborn baby in pain. And so, that’s why we included a whole page in the pocket guide about ways you can help as the parent or as a birth worker or healthcare worker keep a baby comfortable during procedures. There’s actually a lot of research evidence on ways you can keep a baby comfortable. Now, sometimes parents think they just need to hand over the baby for the staff to do procedures to the baby But, did you know that there’s evidence that parents can do a lot for their baby to keep them comfortable, and one of those things can be to hold their own baby during a procedure. Newborn pain and discomfort is a really fascinating topic because some providers used to believe that newborns did not experience pain, that they were not developed enough or mature enough human beings to experience pain. And so, it might be scary to hear this, but surgery and invasive procedures, including circumcision, were performed with no anesthesia or minimal anesthesia up until the 1980s. That means if you know someone who had a newborn circumcision before the 1980s or in the early 1980s, it’s highly likely that they were provided zero pain management during that very painful procedure. 

So today when we ask the question, do newborns experience pain? We can definitively say yes, newborns experience pain. And so current standard practice is for nurses and other healthcare staff to assess newborn pain on a regular basis, but sometimes newborn pain might be difficult to measure accurately. Symptoms can be vague. Some more obvious symptoms might include crying or changes in facial expressions. I think we can all picture a baby that we’ve seen really upset about something. Their body movements may change, their heart rate, breathing, blood pressure, and oxygen levels may change in response to stress or pain. Newborns who experience severe or prolonged pain may also have something called a freeze response. This is where the newborn suddenly looks passive with limited to no body movements and no expression on their face. 

Now, pain management is especially important for babies who are in the NICU, who are experiencing on average 14 painful or invasive procedures per day in the first two weeks of their stay. Another common procedure that can be painful for a newborn is a heel stick. This is when they prick the bottom of the baby’s foot to get a few drops of blood for various tests. And this is actually shown to be more painful than drawing blood from a vein. But of course, it’s a little bit easier and less invasive than having to access a baby’s vein. Now, the squeezing of the heel after the prick to squeeze out the blood drops is the most painful part of this test. And this is something that’s part of a blood sugar screening. It’s also used for a genetic screen, which we cover in the pocket guide, and sometimes for a jaundice screen, which we also cover in the pocket guide. So here are some comfort measures that can be used for newborns when they’re undergoing procedures. So one of the most important is skin-to-skin care, also known as kangaroo care, which we talk about in depth in the pocket guide and in the Evidence Based Birth® blog. We also have something called tucking in, where you gently tuck in the baby’s arms and legs while holding the baby close to you. Rocking, holding, these are ancient but pretty effective techniques for helping calm a baby. Using swaddling in a hip-healthy manner, breastfeeding or chest feeding, and something called non-nutritive sucking, such as with a pacifier or offering your baby the parent’s clean thumb or finger or knuckle to suck on. Massage, acupressure, acupuncture, and music all have research on them as ways to help keep a newborn comfortable. Another way that’s been highly researched is putting a drop of glucose, sucrose, or another sweetener on a pacifier. Acetaminophen has often been used and has research showing it’s effective for pain after a procedure, say they had some kind of surgery or other invasive procedure where there’s lingering pain afterwards, acetaminophen can help with that. 

And then there are local and topical anesthetic medicines, such as a numbing cream used before an intravenous blood draw or lidocaine injections before a circumcision. There are also the option of using opioids and or other sedatives, and these are usually used in the NICU or with really invasive procedures, and these would require accurate doses and very close monitoring. So one of the reasons it’s important to treat newborn pain and to manage a newborn’s comfort during procedures, not only is it ethical and what you would want as a parent, but many studies have shown that untreated pain during invasive newborn procedures can lead to increased risks of short-term and long-term bad health outcomes, especially for babies in the NICU. At the same time, on the other end of the spectrum, unnecessary or long-term use of pain medications such as opioids or other sedatives for newborns can increase the risk of harm. So, we need to try and find a balance. But I think it’s really encouraging for parents to know that during painful procedures such as heel sticks and blood draws, skin-to-skin care has been shown to decrease crying and stress, while breastfeeding, sucking on a pacifier, and or sucking on something with sweeteners has also been shown to lower pain and increase natural pain-relieving hormones. Infant massage has been shown to be safe and effective for use with minor pain and alongside medications for severe pain. And there’s also this fascinating area of research where it shows that a combination of looking at your baby and gently talking to them while stroking or massaging their face or back is more effective for mild to moderate pain than giving sweeteners on a pacifier. 

So some of the procedures that we talk about in the new pocket guide to newborn procedures, are painful such as heel sticks and different kinds of injections, while some of the procedures in the new pocket guide are painless like the pulse ox screen or the hearing screen. And so one of the things that I think it’s helpful for parents to know is that it might be impossible to avoid all painful procedures in the days after birth, but it is possible for you as the parent and for birth workers and healthcare workers caring for babies to help minimize pain and provide comfort with a variety of comfort measures. So one of the big things I wanted to do with this new pocket guide and with this podcast episode is help alleviate some of your fears towards parenting or caring for a newborn. It might be helpful to remember that each newborn procedure is simply a tool. All tools have benefits, risks, and alternatives. Sometimes it’s really clear that a newborn procedure is really beneficial and that the benefits outweigh the risks. And other times there might be some gray areas where it’s not really so clear.

Also, some procedures have gotten a really bad rap on social media and have many myths circulating about them. As a reminder here at EBB, we believe in helping provide accurate information to assist people in their informed decision-making, but we don’t believe in telling parents what to do with their babies. As the parent, you get to have the informed choice or informed refusal about these procedures. Just remember there are ways to help keep babies comfortable during procedures and it’s important for you to remember that you have the power to accept or decline newborn procedures and you have the power to comfort and console your baby during and after most procedures. So again, that’s just some information from the introduction section of the new Pocket Guide to Newborn Procedures. So next I want to move on to the newborn bath. So we’re going to be covering two specific procedures today in this episode, the newborn bath and blood sugar screening. 

So in terms of newborn baths, you might be asking yourself, how could there possibly be research evidence on a bath? Well, there is research and there’s a lot of it. And this is because a lot of nurses, midwives, and even some pediatricians have long running concerns about baby’s first bath. And they’ve been doing a lot of research to see how we can make this a better experience for the baby and for the whole family. If you’ve ever seen a newborn baby get their first bath before, it was likely a sponge bath and you also likely noticed that the baby did not like it. They might have cried, screamed, or shivered. Their skin might change color and they just might be inconsolable for a little while afterwards. So yes. Baby’s first bath in the hospital is a procedure because it’s something that can be done or not done while you’re there in the hospital. And there are different ways to do the bath. There’s also different timing of when the first bath can be done. And there’s research evidence on all of these things. The bath is also just something that kind of means a lot to you and your baby. 

I’ll never forget for my first baby when she was born, they kind of did her bath without asking me. If you’ve heard my story before, I was separated from my baby for about three hours after the birth. And one of the times when I had the call light on asking to have my baby back, they said, oh, we’re so sorry. You know, we can’t bring her to your room right now. She just had a bath and her hair is all wet. And I was just kind of justifying everything in my head. And I said, you’re right. Like she was born with a lot of hair, so it would make sense. She would need to stay in the warmer. And that was kind of my first experience, my baby’s first bath. I didn’t even get to be involved. But then when my second baby was born, I was walking to the bathroom with my midwife and I said, you know, when do we give him a bath? And she said, Rebecca, honey, he’s your baby. You can give him a bath whenever you want. And it was the first time that I realized as a new parent that, yes, like I am the parent. I get to make these kinds of decisions. While I’m caring for my baby. And it was really empowering to know that it was in my hands and it was my decision, not the hospital staff’s decision. 

So there’s kind of that ethical approach or, you know, that empowering approach of making this parenting decision for your baby. But there’s also a lot of info. And it was a good question I asked my midwife. Like, you know, what is the evidence on bathing your baby? When do you give them their first bath? So let’s talk about newborn skin. So the skin is actually the largest organ in your body. And a newborn skin is very sensitive to the environment. Babies born in the third trimester may be born with a creamy white substance on their skin called vernix. Vernix has been shown to be antimicrobial and water repelling. It’s made of 80% water, 10% protein, and 10% fatty lipids. And it can be rubbed into the baby’s skin like lotion. At full term, a newborn’s skin is ready and there to help protect them from infectious bacteria and fluid loss. Skin helps regulate temperature, it helps with their immune function, and it’s very sensitive to touch. Holding a newborn skin-to-skin with their birthing parent also helps with temperature regulation. Also, during the birth and shortly after, the baby’s skin becomes colonized with beneficial bacteria. This microbiome of the skin helps protect the skin and creates a barrier against infectious or harmful bacteria. And babies born via a vaginal birth have higher levels of beneficial bacteria than babies born via Cesarean. 

So what’s the history of the newborn bath? Well, when birth moved to the hospitals in the early to mid-1900s, newborns were kept apart from their parents in a central nursery. And staff believed that unbathed babies were contagious or infectious, that they could spread bacterial infections to staff and to other babies in the crowded nursery. So newborns were bathed quite soon after birth, typically with a sponge bath in the first hour. And the thought was that you wanted to avoid an immersion bath or putting the baby in a bathtub because that could increase the chances of the umbilical cord stump becoming infected. So for many years, that’s how most of us, you know, were bathed after birth with a sponge bath in a central nursery, parents not being involved at all. In the 1980s, the Centers for Disease Control in the U.S. recommended early newborn bathing primarily to remove blood and prevent HIV and hepatitis B transmission. This is kind of during the height of the fears related to the HIV epidemic. In the 2010s, some staff began to question these practices, in particular, the question of immediately bathing the baby as soon as possible after the birth. They found research showing that bathing a newborn too early could drop the baby’s temperature, which could lead to stress, low blood sugar, low blood oxygen, and difficulty feeding. In addition to the early bath or immediate bath being questioned, staff began questioning the sponge bath, where you just kind of wipe the baby down with a wet washcloth and then dry them off, part of their body at a time. And that’s because research started showing that immersing the baby in a tub reduced the problems with low temperature or the temps dropping, reduced crying, and was less stressful than a sponge bath. 

Today, the Association for Women’s Health and Obstetric and Neonatal Nursing recommends tub baths for babies and that they should take place no earlier than 6 to 24 hours. And the World Health Organization now recommends that the first bath be delayed until at least 24 hours. So what is the research evidence behind these new recommendations? Well, multiple randomized controlled trials have found that putting a newborn in an immersion tub bath. Or swaddling them and putting them into a tub bath, reduces hypothermia, reduces the chances their temperature will drop, and it lowers stress and crying for infants. So with this kind of immersion tub bath, the entire body except for the head and neck are immersed into warm water at about 38 degrees Celsius, which is 100.4 degrees Fahrenheit. These studies found no difference in rates of infection with the umbilical cord stump between an immersion bath and a sponge bath. And I will link in the show notes to a review of all those randomized trials. Some people ask, Rebecca, how does the bath affect the newborn’s microbiome? We mentioned the importance of the beneficial bacteria on the baby’s skin. I’ve only seen one randomized trial on this topic. There were 140 vaginally born newborns at term. They were randomly assigned to either have a bath with mild soap and water, and the other group had a bath with water alone. They tested them for bacteria before and after, and they found no difference between groups in terms of which bacteria were growing. In other words, bathing did not remove or prevent bacteria from growing, and that immediate bathing was not necessary unless parents desired it for cultural or aesthetic reasons. So as this research was coming out about the benefits of delaying the first bath, there started to be a lot of research published from various hospitals, who were reporting that they were also seeing really big benefits from delaying the first bath. So I’m going to share some of those findings here. 

So one hospital changed their protocol from the newborn bath at two hours, followed by being placed under a warmer, to the first bath being at 12 hours, followed by skin-to-skin care with the parent. They found that the baby’s core temperature dropped about 1.5 degrees Celsius or 2.7 degrees Fahrenheit with the two-hour bath, that is a pretty significant drop in the baby’s temperature, and that the cold temperatures could increase stress and impair infant feeding. And infants who had the 12-hour bath were more likely to breastfeed and more likely to exclusively breastfeed. Another hospital changed their protocol from a staff-provided sponge bath at two to four hours to a parent participatory bath in the tub at 24 hours. And they found that newborns were more likely to be able to maintain their normal temperature with a 24-hour bath. Another study I found really interesting was one where they looked at nine Air Force hospitals where they implemented a 24-hour parent-involved immersion bath policy. Previous to this time, all of the babies at these hospitals had a staff-performed sponge bath at two to four hours. And when they compared babies born before and after the policy change, they found that fewer babies had a post-bath hypothermia. 1% versus 9% before they changed the policy. And comments that they collected from the parents were overwhelmingly positive about how much they enjoyed and how important it was for them to be involved in that first bath. 

Another hospital in Canada began a new policy to delay the newborn bath for 24 hours. So they looked at a random sample of babies born before and after the policy change. So prior to the policy change, nurses used to take babies to the nursery, do a tub bath at about three and a half hours after the birth, and then place babies under a radiant warmer. After the policy change, the parents performed the bath in the patient’s room at an average of 30 hours after the bath. After the bath, skin-to-skin care was done with the parents and the babies. So they were able to examine results for more than 1,200 newborns. And after the policy changed to be the parent-involved delayed bath at 30 hours, there was a greater chance that babies had exclusive breast milk up until hospital discharge. There were lower rates of hypothermia, lower rates of problems with low blood sugar. And they also mentioned the possibility that vernix contains pheromones that can help with bonding and that amniotic fluid smell is supposed to help with breastfeeding. So by keeping the baby unbathed for at least the first 24 hours of life, that could theoretically lead to some positive outcomes with baby-parent bonding. 

Another hospital that reported their results was a single military hospital where they also changed their policy. They compared the old policy, which was staff-performed sponge baths at two hours, to the new policy, which was parent-performed immersion tub baths at 24 hours. Babies were less likely to have hypothermia with the 24-hour tub baths. Interestingly, they were looking at the parents’ experience in this study. They said 44% of parents had never bathed a baby before. And after doing the parent-performed bath, 89% of the parents said it was an important part of their experience. They also found in the study that staff said, do you want to do your infant’s bath? Parents were more likely to be tentative and say no and be afraid to help with the bath. But if the staff engage them by saying, I’m going to go gather the supplies and tub, and then we can do your baby’s first bath together, if that’s okay with you, parents more likely to want to participate. So how the staff framed the bath as a positive thing that the parents would be involved in was important. And some of the researchers have also emphasized that bath time at the hospital, when the parents are involved, this is a great opportunity for parents to learn how to bathe their infant and to care for their baby’s skin.

A few other interesting studies I found when reviewing this topic. Like I said, you might not believe how much research there is on the baby’s first bath, but there’s quite a bit. There was a literature review published in 2018 by Cook et al, where they were reviewing all of the studies published up until 2015. Most of the studies were published between 2000 and 2015, and they were mainly focused on the type of cleaners used in the newborn bath. And they found no difference in outcomes between water only. So only bathing the baby with water versus using a baby shampoo such as Johnson and Johnson’s. And they found there was no difference in outcomes between bathing a baby just with water or bathing a baby with a shampoo such as Johnson and Johnson’s. Another interesting item that I learned is that guidelines now state that blood and meconium can be gently removed using cotton swabs soaked in boiled warm water, followed by drying to avoid infection. So if parents are worried about their baby having a little bit of blood or maybe they have a little bit of meconium on them, but not enough to do a full tub bath, you can just use these cotton balls soaked in boiled warm water. Researchers also recommend that when you’re doing a bath, you can use massage and soothing talk. 

Remember when I mentioned earlier that looking your baby in the eyes, gently talking to them, singing to them, stroking their face or their back is very soothing and would make the bath experience even better for the baby. Lots of researchers have been saying that water alone is sufficient for newborn bathing unless there are concerns about water quality. Mild soap-free cleansers might be needed to remove urine or fecal matter. And I’ll also link in the show notes to an article about ingredients in infant cleansers. One more tidbit about infant baths is there is research as well on emollients. So emollients are a substance that help hydrate and soothe the skin while creating protective barrier to trap moisture. So there is some growing research on this subject. And so far, researchers have found that sunflower seed oil is an effective emollient for newborn skin and may help lower the risk of newborn infections. 

So what’s the bottom line on the baby’s bath? Well, the days of old when a baby was taken away from their parent or the staff themselves do a sponge bath with the baby at 1-2 hours of life, is no longer evidence-based. Immersion tub bathing is preferred over sponge baths. It keeps the baby warmer, helps them regulate their own temperature. It’s more comfortable for the baby, more calming. And randomized trials have found that immersion tub bathing is safe. It does not increase the risk of infection of where the umbilical cord stump was. It does not increase the risk of infection. And it does lower the chances of hypothermia. It also reduces crying from being uncomfortable. When hospitals have changed their policy to encourage a 24-hour or later parent-performed tub immersion bath, they’re seeing fewer cases of infant hypothermia, fewer cases of low blood sugar, decreased stress, less crying, and higher rates of exclusive breastfeeding. Comments from parents are almost always positive. An emollient can be used to hydrate and soothe the skin and baths are a great bonding time. You can add in some massage with emollient, you can sing or use soothing talk with your baby. This is much less stressful than watching your baby get cold while they are having an early sponge bath, so I really think this research is a win-win for everyone. For babies, for parents, and for healthcare staff. 

So, so far, we’ve talked about the new pocket guide to newborn procedures. We’ve talked about keeping babies comfortable and reducing pain during procedures and we’ve talked about the newborn bath. Next, I’d like to talk about something I’ve mentioned a little bit before, but we’ve never dived deep into before at EBB, and that is low blood sugar in babies. And should we be screening babies for low blood sugar? So I mentioned earlier that these kind of immediate baths with sponge baths can lower the baby’s blood sugar. And now we’re going to talk more about low blood sugar in general and what might cause it other than a bath. So low blood sugar or low blood glucose is also known as newborn hypoglycemia, and it can range from a normal low blood sugar to an abnormal low blood sugar. So normal low blood sugar is also called physiologic low blood sugar. This type of low blood sugar has no or very mild symptoms. It goes away on its own and it does not cause harm. Physiologic low blood sugars are a result of the shift from the baby receiving a continuous supply of glucose from the placenta to now that they’re on the outside. In the outside world, they have an on and off supply of glucose from feedings. So abnormal low blood sugar, on the other hand, may or may not cause symptoms and it could lead to developmental delays or brain damage. An abnormal low blood sugar can be caused by health problems, including prematurity, being born small for gestational age, which is less than the 10th percentile for your gestational age, or being large for gestational age, side effects from maternal medications, stress during the delivery, maternal diabetes, or rare genetic disorders in the baby. Symptoms of low blood sugar can include no symptoms, sometimes there might not be any visible symptoms. Otherwise, you might see jitteriness, tremors, sweating, irritability, fast breathing, poor efforts at feeding, a high-pitched cry, a coma, or seizures. 

One of the problems with blood sugars in newborns is that they can be difficult to accurately measure. So the results using that point-of-care test, where they get a drop of blood from your baby and then enter it into the little machine at the bedside, can be lower than the actual levels in the baby’s blood plasma. Blood sugar levels naturally fall during the first two hours of the baby’s life and typically reach a low point of about 55 milligrams per deciliter, although some physiologic levels can be as low as 25. After birth, newborns can make glucose by breaking down glycogen that is stored in their liver, and they can also make their own glucose from the components of human milk or formula. Normally, blood sugar levels will begin to increase over the next 18 hours, and in a healthy baby with physiologic low blood sugar, the blood sugars are usually stabilized by 48 hours. So what might cause an abnormal low blood sugar? There could be not enough of the glycogen stored in the baby’s body, maybe because the baby was born preterm or they had fetal growth restriction, also known as IUGR. Maybe the baby has the decreased ability to make glucose. This might be from a congenital disorder or side effects from maternal medications such as beta blockers. 

There can also be high levels of insulin in the baby that can cause low blood sugar. This could be caused by their birthing parent having diabetes, fetal growth restriction, maternal medications, stress during the birth such as with preeclampsia, or the baby having low oxygen levels, or meconium aspiration syndrome, or a rare congenital disorder. One of the reasons blood sugar is considered an important issue with newborns is because researchers have found that children who experienced hypoglycemia or abnormally low blood sugars as infants are at higher risk of neurosensory problems at two years of age. Even if they were screened as a newborn and treated to maintain normal blood sugars for the rest of the newborn period. So first I’m going to talk about screening for low blood sugars and then we’ll talk about diagnosis and treatment. The guidelines for screening newborns for low blood sugar try to balance, you want to identify the abnormal low blood sugars that can cause harm while avoiding over screening and over treating babies who have normal physiologic low blood sugar. So there are some harms of over-screening or over-treatment. This would include being unnecessarily separated from your baby, unnecessary supplementation with formula, newborn pain and discomfort from having multiple heel prick blood tests, and interference with breastfeeding. 

So you can see how researchers have identified it’s important. We want to strike a balance. We want to screen the babies that are at the highest risk, and we don’t want to be causing unnecessary harm with over-screening. So where do we draw those lines? Well, there are some babies who are more likely to need screening. They call these at-risk newborns. So this would include babies who are preterm. They’re much more likely to have abnormal low blood sugars. Babies who are born small with their weight less than the 10th percentile for gestational age, or babies that are born large, their weight is greater than the 90th percentile for gestational age. Or if the birthing parent had diabetes or was on glucose-lowering medications. Infants are also likely to be screened if they appear to be sick at birth or if they had a really complicated birth. Now, up to 30% of all infants meet one of these conditions. So this makes blood sugar screening one of the most common newborn procedures. Now, I mentioned large for gestational age as an at-risk condition. This is actually controversial. Some researchers call it contentious, but it’s generally accepted that all the other groups that I mentioned should be screened. And the LGA or large for gestational age screening is controversial. 

On the other hand, healthy babies who are born without complications and do not have symptoms of low blood sugar should not be screened for low blood sugar. When it’s indicated, when the baby is either having symptoms or they have an at-risk condition, screening is typically done after the first infant feeding, which should occur within the first hour of life. Blood sugars are then typically checked again, if it’s indicated, every three to six hours for the first 24 to 48 hours of life, or until there’s at least three instances of blood sugars being over 50. Unfortunately, when we look at the evidence for screening, there is no evidence from randomized trials that screening improves long-term outcomes. However, it is considered standard practice because of the risks of very low blood sugar. So as I mentioned, typically the screening is done with the heel prick blood test. I do want to mention that adults and children with diabetes now have access to commercial sensor devices that continually monitor glucose. None of these systems were designed for newborns and they tend to have very poor accuracy among newborns. Another device out there is called a glucose spectrometer, which uses infrared readings to measure glucose in the tissue. That’s currently undergoing research, but we don’t have enough at this time to recommend it with newborns. 

So probably the most important research study on this topic is one called the children with hypoglycemia in their later development (CHYLD) or the child studies. In this study, they followed 477 at-risk infants born in the moderate to late preterm through term period. And they found that those babies with hypoglycemia were more likely to have developmental problems down the line at four and a half years. Those developmental problems were problems with executive function and poor visual motor function. But then as they kept following these children, they found that these differences no longer persisted at nine to ten years of life. The researchers found that overall at-risk newborns did have higher rates of poor educational achievement regardless of whether or not they experienced newborn low blood sugars. So they hypothesized that maybe it’s the underlying risk factors or conditions that contribute to the developmental differences and not the low blood sugars themselves. Just in case people are wondering, how do they measure educational achievement? Low educational achievement was defined as a score below or well below the normative curriculum level in reading or mathematics. So that’s the evidence on screening. Not the most helpful evidence. It’s not clear cut like the newborn bath evidence was. But I think it’s still interesting nonetheless. 

So moving on to diagnosis and treatment. So any low blood sugar identified by a point of care test should be confirmed with a blood draw. And a laboratory measurement of plasma blood glucose levels. Whether or not a baby receives treatment for low blood sugars depends on their age. So how many hours are they past the birth? What is the blood sugar level at that age? And do they have symptoms or not? So most guidelines recommend that newborn hypoglycemia, when it’s measured with a blood draw, requires treatment if there are symptoms plus blood sugar levels less than 50 at less than 48 hours of life or blood sugar levels less than 60 beyond 48 hours of life. If the baby does not have any symptoms of low blood sugar, they should be treated if their blood sugar levels are less than 25 at less than four hours, blood sugar levels less than 35 between four to 24 hours, blood sugar levels less than 50 between 24 to 48 hours, and blood sugar levels less than 60 at 48 hours or greater. I mentioned so you want to verify the blood sugar with the blood draw, but severe signs of low blood sugar, if the baby is showing severe signs, it should be treated with IV dextrose without waiting for a laboratory confirmation. Less severe symptoms, more mild symptoms should be treated with a dextrose gel put in the cheek, followed by regular feedings. 

And although this is considered standard treatment, the one large randomized trial on this found that it did not seem to reduce the risk of poor neurodevelopmental outcomes in later childhood. The first line treatment for low blood sugars where there’s no symptoms is infant feeding and monitoring would continue until blood sugars are maintained with normal feedings. Low blood sugars that do not resolve should have follow-up testing for potential genetic conditions. And it also might be helpful to know that some of the symptoms of low blood sugar can be confused with symptoms of other conditions. So sepsis, newborn withdrawal from opioids or other substances, newborn low blood sodium, birth injuries, and some congenital problems can mimic the symptoms of low blood sugar. So what’s the bottom line with the evidence on screening for low blood sugar? So there’s no evidence from randomized trials that screening for low blood sugar improves long-term health outcomes. However, it is considered standard or routine for at-risk infants because of the risks associated with abnormally low blood sugar. The first-line treatment for low blood sugars plus no symptoms is infant feeding per the parent’s desired feeding method. Milder symptoms are typically treated with a dextrose gel in the cheek followed by normal feedings. Severe symptoms should be treated with IV dextrose without waiting for laboratory confirmation. And hypoglycemia that does not resolve should have follow-up testing for genetic conditions. 

Remember, if your baby does have to have a heel prick test for any reason or repeated tests for low blood sugar, that some of the most evidence-based ways to keep your baby comfortable include skin-to-skin care, which you can do during the procedure as well as afterwards. Rocking, holding, tucking in your baby’s arms and legs. Massage, gentle soothing talk. And you know, just really showing your baby love and affection. Pacifiers and sucking, breastfeeding or non-nutritive sucking with a pacifier are also ways to help your baby stay more comfortable. And speaking of pacifiers, that is another subject that we went down the rabbit hole of research on. It used to be that parents were told not to use a pacifier with a newborn baby and I’m happy to be able to discuss the research on that subject in the new pocket guide. So take a deep breath with me. We’ve just gone over a lot of information. I gave you a preview of the newborn procedures pocket guide. Plus we did a summary on the evidence and benefits and risks of newborn baths and blood sugar screening. Two topics we’ve never talked about here on the EBB podcast. 

So that’s it for today’s episode. Thank you for joining me to learn about the research evidence on these procedures. Don’t forget to get on the wait list for the brand new pocket guide to newborn procedures that is coming out this November. There are only going to be a limited number of physical copies and you can get on the wait list by going to evidencebasedbirth.com/pocket guide. That’s all one word, lowercase / pocket guide. There is so much information in this pocket guide. I only pulled out two topics this week, plus a little bit of bonus information about pain management. Next week, we’re going to have some special guests from team EBB. They’re here to talk about tips for having a smoother transition from hospital to home with a newborn. So I’m really excited for this conversation. So stay tuned for next week when we talk about tips for taking baby home from the hospital and more sneak peeks from the pocket guide. Thanks everyone. Have a great rest of your week and I’ll see you next week. Bye. 

This podcast episode was brought to you by the book, Babies Are Not Pizzas. They’re Born Not Delivered. Babies Are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive evidence-based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies Are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Your copy today and make sure to email me after you read it to let me know your thoughts.