Article Text

Download PDFPDF

Dextrose gel treatment does not impair subsequent feeding
  1. Philip J Weston1,
  2. Deborah L Harris1,
  3. Jane E Harding2
  1. 1Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand
  2. 2Liggins Institute, University of Auckland, Auckland, New Zealand
  1. Correspondence to Dr Philip J Weston, Department of Paediatrics, Waikato Hospital, Pembroke St, Hamilton 3200, New Zealand; Phil.Weston{at}waikatodhb.health.nz

Abstract

Background Dextrose gel is increasingly used as first-line treatment for neonatal hypoglycaemia. Treatment with 400 mg/kg previously has been reported to impair subsequent feeding. We sought to determine if the recommended dose of 200 mg/kg altered feeding.

Methods Hypoglycaemic babies were randomised to 200 mg/kg dextrose gel or placebo and fed. Prefeed alertness, quality and duration of breast feeding, and the volume of formula taken were assessed on the next feeding.

Results Prefeed alertness scores were similar in babies (n=211) treated with dextrose or placebo gel (124 episodes, OR=1.30 (95% CI 0.62 to 2.77), p=0.49). Breastfed babies were more likely to have good feeding scores after dextrose gel (160 episodes, OR=3.54 (95% CI 1.30 to 9.67), p=0.01) but similar breastfeeding duration (57 episodes, median (range) 20 (3–90) vs 25 (2–80) min, p=0.62). Formula volumes taken were also similar (24 episodes, median (range) 4.6 (2.2–11.3) vs 6.4 (2.0–8.9) mL/kg, p=0.30).

Conclusions Treating hypoglycaemic babies with dextrose gel 200 mg/kg does not depress subsequent feeding and may improve breastfeeding quality.

Trial registration number ACTRN 12608000623392.

  • Infant Feeding
  • Metabolic
  • Neonatology

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

What is already known on this topic?

  • Dextrose gel administered buccally at a dose of 200–400 mg/kg is an effective treatment for neonatal hypoglycaemia in the first 48 hours of life.

  • Dextrose gel treatment has been previously associated with a depressant effect on the subsequent feeding in a small study using a dose of 400 mg/kg.

What this study adds?

  • Dextrose gel is not associated with reduced alertness prior to the subsequent feeding, nor any difference in breastfeeding duration or formula volume taken.

  • Dextrose gel at a dose of 200 mg/kg is associated with a better breast feeding on the subsequent feeding.

Background

Dextrose gel 200 mg /kg has been recommended for first-line treatment of neonatal hypoglycaemia in late-preterm and term babies within the first 48 hours after birth,1 and its use is increasingly widespread.2 3 An earlier small randomised trial, published only in abstract, used a higher dose of gel (400 mg/kg) and reported that treatment was associated with reduced milk intake on the subsequent feeding.4 We therefore sought to determine the effect on subsequent feeding behaviour of treatment with either dextrose (200 mg/kg) or placebo gel, using prospectively collected data from the Sugar Babies Study1.

Patients and methods

The Sugar Babies Study was a randomised, double-blind, placebo-controlled trial that enrolled eligible babies at Waikato Hospital between December 2008 and November 2010.1 Babies at risk for neonatal hypoglycaemia (infants of mothers with diabetes, late preterm, small (<2500 or <10th centile) or large (>4500g or >90th centile), and <48 hours old who became hypoglycaemic (<2.6 mM) were randomised to receive dextrose gel (200 mg/kg) or identical-appearing placebo gel massaged into the buccal mucosa, and were fed according to maternal choice. Blood glucose concentration was measured 30 min after treatment, and if <2.6 mM a repeat dose of the same gel was given and the baby was again encouraged to feed. All blood glucose concentrations were measured on a blood gas analyser (Radiometer, ABL800Flex, Copenhagen, Denmark) using the glucose oxidase method (reading range: 0.0–60 mM, coefficient of variation: 2.1%). An episode of hypoglycaemia was defined as any blood glucose <2.6 mM.

A nurse or midwife who was blinded to the gel treatment recorded details about each feeding, including the baby’s prefeed alertness level, using a 4-point grading system (1=awake and hungry; 2=awake and requiring encouragement to feed; 3=required waking for feeding; 4=too sleepy to feed). The quality of each breast feeding was recorded using the breastfeeding assessment tool in routine use at Waikato Hospital5 (A=offered but did not latch; B=offered — rooting but did not latch; C=latched but no sucking; D=latched on and off — few sucks; E=good rhythmical sucking; F=good rhythmical sucking and audible swallowing for >10 min). For analysis, prefeeding alertness scores were classified into alert (1 or 2) or sleepy (3 or 4), and quality of breastfeeding scores was classified into good (E or F) or poor feeding (A to D).

If the mother requested formula milk, only feedings that were administered by bottle or cup were included, as the baby could potentially influence the volume ingested.

Feedings were included in this analysis if they occurred within 4 hours of the last treatment (gel administration plus feed) of an episode of hypoglycaemia occurring in the first 48 hours after birth. Episodes treated with intravenous fluids were excluded.

Data were analysed using Stata V.14 and are presented as number (per cent), median (range), mean (range) or ORs (95% CIs). ORs were calculated with adjustment for repeated episodes in the same baby. Groups were compared using t-tests and Mann-Whitney tests as appropriate.

The study was approved by the Northern Y Ethics Committee.

Results

Of the 237 hypoglycaemic babies originally randomised, subsequent feeding data were available for 211 (89%), with mean (range) birth weight 3056 g (1836–5270) and gestation of 37.7 weeks (35–42). A total of 279 episodes of hypoglycaemia were eligible for analysis. These occurred at a median (range) age of 5.8 hours (0.4–47.2), and the median (range) time to next feeding was 1.8 hours (0.0–4.0).

The proportion of babies reported to be alert on the next feeding was similar after hypoglycaemic episodes treated with dextrose or placebo gel (table 1). However, babies who received dextrose gel were more likely to have a good-quality breast feeding than those who received placebo gel (p=0.01). The duration of breast feeding and volume of formula milk taken on the next feeding were similar after treatment with dextrose and placebo gel.

Table 1

Measures of feeding after treatment of neonatal hypoglycaemia with dextrose or placebo gel

In 74 (35%) of the episodes, a second dose of gel was given because the blood glucose concentration remained <2.6 mM after the first dose of gel and feeding. After these episodes, there was no difference between babies treated with dextrose gel or with placebo gel in prefeed alertness, quality or duration of breast feeding, or volume of formula taken (table 1).

Blood glucose concentration remained <2.6 mM after the second dose of gel in 25 of the 74 episodes (34%). Excluding these episodes from the analysis did not alter the results. Results were also unchanged if the analysis was restricted to episodes occurring in the first 24 hours and in babies ≥36 weeks, analogous to the population previously studied4 (data not shown).

Discussion

Our findings show that subsequent feeding behaviour is not altered following treatment with dextrose gel (200 mg/kg). Indeed, overall, hypoglycaemic breastfed babies treated with dextrose gel were more likely to be reported to have a subsequent good breast feeding. These data provide reassurance to families and clinical staff that treatment of hypoglycaemia with dextrose gel does not impair subsequent feeding.

In the previous randomised trial4, which was neither placebo-controlled nor blinded, 75 hypoglycaemic babies (≤2.5 mM) who were ≥36 weeks’ gestation and <24 hours old were randomised to receive 400 mg/kg dextrose gel or not, and fed. The main finding was that dextrose gel did not significantly improve blood glucose concentrations. However, bottle-fed babies who received dextrose gel took a reduced volume of milk on the next feeding (mean (SE) 7.6 (1.0) vs 13.1 (1.1) mL/kg, p=0.001). The authors advised caution regarding the potential depressant effect of dextrose gel on the subsequent feeding.

The initial dose of gel used in the previous study (400 mg/kg) was higher than in the Sugar Babies Study (200 mg/kg), but in our study the treatment could be repeated, so that a third of episodes in our study (74) were treated with a total dose of 400 mg/kg. In this subgroup there was also no difference in subsequent feeding behaviour between babies treated with dextrose or placebo gel, suggesting that the total dose administered did not appear to explain our different findings. Our findings were also unchanged when the analysis was restricted to a group of babies similar to that of the previous study (≥36 weeks, <24 hours old).

Within the Sugar Babies Study, treatment with dextrose gel was associated with a greater likelihood of an increase in blood glucose concentration to above the treatment threshold of 2.6 mM, and it is therefore possible that the observed greater likelihood of a subsequent good breast feeding was related to improved glucose concentrations, resulting in improved infant alertness and better latching and sucking. However, excluding babies whose blood glucose concentration remained below the threshold did not alter our findings.

Treatment of neonatal hypoglycaemia with currently recommended doses of dextrose gel (200 mg/kg, repeated once if needed) does not impair feeding behaviour, and may improve breastfeeding quality on the next feeding. This simple, non-invasive treatment should be considered for first-line treatment of hypoglycaemic late-preterm and term newborns.

References

Footnotes

  • Contributors PJW wrote the first draft of the manuscript and contributed to the subsequent revisions. He also contributed to the study design, data collection, data analysis and interpretation.

    DLH contributed to the literature search, study design, data collection, analysis, interpretation and writing the manuscript.

    JEH contributed to the study design, data analysis, interpretation and writing the manuscript, in addition to having overall responsibility for the Sugar Babies Study.

  • Funding The Sugar Babies Study was funded by the Waikato Medical Research Foundation, the Auckland Medical Research Foundation, the Maurice and Phyllis Paykel Trust, the Health Research Council of New Zealand, and the Rebecca Roberts Scholarship.

  • Competing interests None declared.

  • Ethics approval Northern Y Ethics Committee, Ministry of Health, New Zealand.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional data may be available to researchers on application to the chair of the Steering Group, Professor Jane Harding.