title: Nursing and midwifery management of hypoglycaemia in healthy term neonates.
abstract: EXECUTIVE SUMMARY:
  
  
  OBJECTIVE
  The primary objective of this review was to determine the best available evidence for maintenance of euglycaemia* in healthy term neonates, and the management of asymptomatic hypoglycaemia in otherwise healthy term neonates.
  
  
  METHODS
  TYPES OF STUDIES: The review included any relevant published or unpublished studies undertaken between 1995 and 2004. Studies that focus on the diagnostic accuracy of point-of-care devices for blood glucose screening and/or monitoring in the neonate were initially included as a subgroup of this review. However, the technical nature and complexity of the statistical information published in diagnostic studies retrieved during the literature search stage, as well as the considerable volume of published research in this area, suggested that it would be more feasible to analyse diagnostic studies in a separate systematic review.
  
  
  METHODS
  The review focused on studies that included healthy term (37- to 42-week gestation) appropriate size for gestational age neonates in the first 72 h after birth.
  
  
  METHODS
  •  preterm or small for gestational age newborns; •  term neonates with a diagnosed medical or surgical condition, congenital or otherwise; •  babies of diabetic mothers; •  neonates with symptomatic hypoglycaemia; •  large for gestational age neonates (as significant proportion are of diabetic mothers). TYPES OF INTERVENTION: All interventions that fell within the scope of practice of a midwife/nurse were included: •  type (breast or breast milk substitutes), amount and/or timing of feeds, for example, initiation of feeding, and frequency; •  regulation of body temperature; •  monitoring (including screening) of neonates, including blood or plasma glucose levels and signs and symptoms of hypoglycaemia. Interventions that required initiation by a medical practitioner were excluded from the review.
  
  
  METHODS
  Outcomes that were of interest included: •  occurrence of hypoglycaemia; •  re-establishment and maintenance of blood or plasma glucose levels at or above set threshold (as defined by the particular study); •  successful breast-feeding; •  developmental outcomes. TYPES OF RESEARCH DESIGNS: The review initially focused on randomised controlled trials reported from 1995 to 2004. Insufficient randomised controlled trials were identified and the review was expanded to include additional cohort and cross-sectional studies for possible inclusion in a narrative summary.
  
  
  METHODS
  The major electronic databases, including MEDLINE/PubMed, CINAHL, EMBASE, LILACS, Cochrane Library, etc., were searched using accepted search techniques to identify relevant published and unpublished studies undertaken between 1995 and 2004. Efforts were made to locate any relevant unpublished materials, such as conference papers, research reports and dissertations. Printed journals were hand-searched and reference lists checked for potentially useful research. The year 1995 was selected as the starting point in order to identify any research that had not been included in the World Health Organisation review, which covered literature published up to 1996. The search was not limited to English language studies. ASSESSMENT OF QUALITY: Three primary reviewers conducted the review assisted by a review panel. The review panel was comprised of nine nurses with expertise in neonatal care drawn from senior staff in several metropolitan neonatal units and education programs. Authorship of journal articles was not concealed from the reviewers. Methodological quality of each study that met the inclusion criteria was assessed by two reviewers, using a quality assessment checklist developed for the review. Disagreements between reviewers were resolved through discussion or with the assistance of a third reviewer.
  
  
  METHODS
  Two reviewers used a data extraction form to independently extract data relating to the study design, setting and participants; study focus and intervention(s); and measurements and outcomes. As only one relevant randomised controlled trial was found, a meta-analysis could not be conducted nor tables constructed to illustrate comparisons between studies. Instead, the findings were summarised by a narrative identifying any relevant findings that emerged from the data.
  
  
  RESULTS
  Seven studies met the inclusion criteria for the objective of this systematic review. The review provided information on the effectiveness of three categories of intervention - type of feeds, timing of feeds and thermoregulation on two of the outcome measures identified in the review protocol - prevention of hypoglycaemia, and re-establishment and maintenance of blood or plasma glucose levels above the set threshold (as determined by the particular study). There was no evidence available on which to base conclusions for effectiveness of monitoring or developmental outcomes, and insufficient evidence for breast-feeding success. Given that only a narrative review was possible, the findings of this review should be interpreted with caution. The findings suggest that the incidence of hypoglycaemia in healthy, breast-fed term infants of appropriate size for gestational age is uncommon and routine screening of these infants is not indicated. The method and timing of early feeding has little or no influence on the neonatal blood glucose measurement at 1 h in normal term babies. In healthy, breast-fed term infants the initiation and timing of feeds in the first 6 h of life has no significant influence on plasma glucose levels. The colostrum of primiparous mothers provides sufficient nutrition for the infant in the first 24 h after birth, and supplemental feeds or extra water is unnecessary. Skin-to-skin contact appears to provide an optimal environment for fetal to neonatal adaptation after birth and can help to maintain body temperature and adequate blood glucose levels in healthy term newborn infants, as well as providing an ideal opportunity to establish early bonding behaviours.
  
  
  CONCLUSIONS
  The seven studies analysed in this review confirm the World Health Organisation's first three recommendations for prevention and management of asymptomatic hypoglycaemia, namely: 1 Early and exclusive breast-feeding is safe to meet the nutritional needs of healthy term newborns worldwide. 2 Healthy term newborns that are breast-fed on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids. 3 Healthy term newborns do not develop 'symptomatic' hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia, look for an underlying condition. Detection and treatment of the cause are as important as correction of the blood glucose level. If there are any concerns that the newborn infant might be hypoglycaemic it should be given another feed. Given the importance of thermoregulation, skin-to-skin contact should be promoted and 'kangaroo care' encouraged in the first 24 h after birth. While it is important to main the infant's body temperature care should be taken to ensure that the child does not become overheated.
authors.affiliation: Curtin University of Technology and The Western Australian Centre for Evidence-based Nursing and Midwifery (a collaborating centre of the Joanna Briggs Institute), Perth, Western Australia, Australia.
authors.forename: Vivien
authors.initials: V
authors.lastname: Hewitt
authors.forename: Robin
authors.initials: R
authors.lastname: Watts
authors.forename: Jeanette
authors.initials: J
authors.lastname: Robertson
authors.forename: Gaby
authors.initials: G
authors.lastname: Haddow