Validation Study of: The Effect of Delayed Newborn Bath and Oral Dextrose Gel for Neonatal Hypoglycemia on Improving In-Hospital Exclusive Breastfeeding Rates

Mandy. Validation Study of: The Effect of Delayed Newborn Bath and Oral Dextrose Gel for Neonatal Hypoglycemia on Improving In-Hospital Exclusive Breastfeeding Rates. Res Background: Exclusive breastfeeding is defined as no other food or drink, not even water, except breast milk for 6 months of life, but allows the infant to receive ORS (oral rehydration solution), drops and syrups (vitamins, minerals and medicines). Studies have shown that in-hospital exclusive breastfeeding increases the likelihood of exclusive breastfeeding throughout the neonatal period [1]. Joint Commission requires reporting exclusive breastfeeding rate as a set measure (PC-05) among other perinatal care core measures. One of the factors that negatively affects exclusive breastfeeding is neonatal hypoglycemia as it was managed classically with formula. A recent study [2] recommended oral dextrose gel as first line of treatment for neonatal hypoglycemia as it was effective in managing hypoglycemia and it decreased the likelihood for NICU admission for that specific reason. Among other factors that negatively affect exclusive breastfeeding is early newborn bath as it interferes with breastfeeding initiation and skin to skin. Delayed bath has been shown to increase the likelihood of breastfeeding and in-hospital breastfeeding rates [3]. Objectives: This project aims to improve in-hospital exclusive breastfeeding rate by adopting recent recommendations for managing neonatal hypoglycemia and delaying the newborn bath for at least 12 hours of life for newborns admitted to the Mother/Baby Unit at University of Florida (UF) Health/Jacksonville. Study Design and Methods: Core measure PC-05 (in-hospital exclusive breastfeeding rate) was measured for 8 months before and after interventions. Interventions included implementation of oral dextrose gel use for hypoglycemia (started March2015) and delayed newborn bath to beyond 12 hours of age (started May2015). Results: Average monthly deliveries were 189 deliveries/month. Average PC-05 for 8 months pre-intervention was 20.6%. Average PC-05 for 8 months after intervention was 32.7%. PC-05 rate increased to 40% at the end of the intervention period. Remarkable increment in PC-05 noted as interventions are reinforced (learning curve). Conclusion: Oral Dextrose gel and delayed newborn bath did improve our in-hospital breastfeeding rates. Training of nursing staff was an integral part of the intervention implementation process. Hospitals should adopt oral dextrose gel as first line treatment for neonatal hypoglycemia and should delay newborn bath for 12 hours of life or beyond in Mother/Baby Units.


Introduction
While lower glucose values immediately after birth in healthy newborn can be normal when compared to older kids and adults, neonatal hypoglycemia is one of the most serious, important and yet complicated topics in newborn medicine. As it is concerning for substantial neurological morbidity. Risk factors for Neonatal Hypoglycemia are: prematurity, infant of diabetic mothers, Small of gestational age (SGA) and Large for gestational age (LGA). The American Academy of Pediatrics (AAP) set guidelines for neonatal hypoglycemia includes pre-prandial frequent Point of Care glucose check every 2-3 hours and intervene according to the glucose values.
If normal values, the neonate will be fed and glucose will be recheck prior to the next feed, however, if the glucose is low, the neonate feeding should be supplemented, traditionally with formula, and/ or the neonate with be transferred to the Neonatal Intensive Care Unit (NICU) for continuous intravenous Dextrose infusion.
Bathing the newborn shortly after birth, increases the risk of neonatal hypoglycemia even more by increasing the stress hormones that irreversibly decreased the newborn glucose which worsens by the increased sleepiness after the bass and the inability to feed a sleepy baby. Also newborn bath cause temperature instability. Therefore the baby uses a lot of energy to keep warm which decreases the blood glucose even more. Finally, delaying newborn bath will prevent interrupting skin to skin with the mother. A process that is essential in improving breastfeeding. Petrova et al. [1]. "In-hospital exclusive breastfeeding increases the likelihood of exclusive breastfeeding throughout neonatal period" On December 2012, The Joint Commission announced the expansion of its performance measurement reporting requirement for accredited general medical and surgical hospitals from a minimum of4 to 6 core measure sets. For Hospitals with 1,100 births or more per year, like our hospital, the Perinatal Care (PC) core measure set will become the mandatory fifth measure set. PC-01: Elective Delivery. PC-02: Cesarean Section. PC-03 Antenatal Steroids, PC-04: Health Care-Associated Bloodstream Infection. PC-05: Exclusive Breastfeeding.

Material and Methods
Core Measure PC-05 (in-hospital exclusive breastfeeding rate) was measured for 8 months before and after interventions. Interventions included: a) Implementation of oral dextrose gel use neonatal hypoglycemia. And b) Delayed newborn bath.
Oral dextrose gel was implemented in our newborn nursery following the AAP Neonatal hypoglycemia protocol ( Figures  1 & 2). All newborn were bathed at minimum of 12 hours of life unless parents requested sooner bath. We looked at all neonates that required oral dextrose gel for hypoglycemia per the protocol mentioned above, and we looked at the feeding for those neonates. Exclusive breastfeeding was defined as only breast milk feeding from the time of birth until the time of discharge home from the hospital.

Results and Discussion
( Figures 3 & 4) "Any approach to neonatal hypoglycemia management needs to account for the overall metabolic and physiologic status of the infant and should not unnecessarily disrupt the mother-infant relationship and breastfeeding" (Adamkin-APP clinical report 2011). Dextrose gel reduced the frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0•57, 95% CI 0•33-0•98; p=0•04) [2].  In the Literature a) Infants treated with dextrose gel were less likely to be separated from their mothers for treatment of hypoglycemia. (quality of evidence moderate) b) Infants treated with dextrose gel were more likely to be exclusively breast fed after discharge. (quality of evidence moderate) c) No evidence of a difference between dextrose gel and placebo gel for major neurosensory disability at two-year follow-up (quality of evidence very low).
Delaying the initial bath for 12 hours for the newborn may decrease rates of hypoglycemia by 50% in high-risk infants and can result in a similar reduction in hypoglycemia for low-risk infants (JOGNN 2015). In Summary, our data showed that using oral dextrose gel to manage asymptomatic neonates with hypoglycemia, and delay neonatal bath for at least 12 hours increase the exclusive breastfeeding rate in Mother/Baby unit. Until this day, exclusive breastfeeding rate continues to rise in our hospital among neonates with asymptomatic hypoglycemia managed with the oral dextrose gel, and also because of the 12 hours and beyond delay in neonatal bath. It was 51% on April 2018.