Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Samantha L. Sundercombe, BSc (Adv) (Usyd), MB BS (Hons) (Usyd) (Medical student)a, Camille H. Raynes-Greenow, BA (Research methods) (ANU), Grad Dip PopHlth (ANU), MPH (UNSW), PhD (USyd) (Epidemiologist)b, Robin M. Turner, BSc (Hons) (University of Canterbury), PhD (University of Canterbury), MBiostat (Usyd) (Statistician)b, Heather E. Jeffery, MB BS, PhD, MPH, FRACP (Professor of International Maternal and Child Health)b,n a b

Sydney Medical School, University of Sydney, Sydney, Australia Sydney School of Public Health, University of Sydney, Sydney, Australia

art ic l e i nf o

a b s t r a c t

Article history: Received 6 January 2014 Received in revised form 6 April 2014 Accepted 16 April 2014

Objective: to establish how well postnatal ward neonatal hypoglycaemia guidelines facilitate breast feeding and adhere to UNICEF UK Baby Friendly Initiative (BFI) recommendations, and to compare compliance with different recommendations. Design: an appraisal of guidelines obtained via email survey using a UNICEF UK BFI checklist tool. Information about Baby Friendly Health/Hospital Initiative (BFHI) accreditation status was obtained by email questionnaire. Setting: tertiary neonatal centres in Australia and New Zealand. Participants: 22 guidelines were returned from 23 centres eligible to participate. Findings: guidelines generally scored poorly. On a scale ranging from 31 to 124 of overall guideline quality, the median score was 71. On a scale of 9 to 36 for adherence to recommendations to facilitate breast feeding, the median guideline score was 20. Compliance with the recommendation to promote skin-to-skin contact and early breast feeding was poor across all centres, achieving a score of 59 out of 88. Nine of 22 guidelines mentioned skin-to-skin contact after birth and 14 advised feeding within one hour of birth. The recommendation about discussing artificial milk supplementation with parents received a score of 44 out of 88. Fourteen guidelines listed Large for Gestational Age (LGA) infants to be at risk of hypoglycaemia. Few guidelines included up-to-date references or flowcharts. Key conclusions: guidelines need to recommend early skin-to-skin contact and discussion with parents before artificial milk supplementation. Guidelines suggest LGA neonates are being screened unnecessarily. Implications for practice: guidelines need constant revision as evidence for best practice expands. The UNICEF UK BFI checklist provides a readily available quality improvement tool. & 2014 Elsevier Ltd. All rights reserved.

Keywords: Hypoglycaemia Breast feeding Guideline Protocol

Introduction Neonatal hypoglycaemia is associated with poor neuro-developmental outcomes, brain damage and death (Cornblath and Reisner, 1965; Tam et al., 2012; Boardman et al., 2013). Guidelines to identify and treat neonatal hypoglycaemia are recommended to reduce risk. Clinical guidelines facilitate consistent practice and the translation of research findings into patient care (Bhutta et al.,

n Correspondence to: Sydney School of Public Health, Edward Ford Building, A27, The University of Sydney, NSW 2006, Australia. E-mail address: [email protected] (H.E. Jeffery).

2013) and may improve clinical outcomes (Yeh et al., 2013). However, there is limited evidence on optimal management of hypoglycaemia and the impact of treatment on outcomes (Boluyt et al., 2006; Hay et al., 2009; Rozance and Hay, 2012). Hypoglycaemia screening can unnecessarily increase mother infant separation and compromise breast feeding if not done with care and multidisciplinary collaboration. Clinical guidelines need to balance harms and benefits of hypoglycaemia screening to prevent a rare but devastating event whilst minimising over-intervention in healthy babies. The Baby Friendly Initiative (BFI) promotes evidence-based practices to support successful breast feeding (World Health Organization, 1998). To facilitate breast feeding UNICEF UK BFI has developed a checklist that provides guidance

http://dx.doi.org/10.1016/j.midw.2014.04.004 0266-6138/& 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Sundercombe, S.L., et al., Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.004i

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on the development of hypoglycaemia guidelines (UNICEF, 2013) (Appendix A). It is unknown whether this checklist is used. Including breast feeding and hypoglycaemia management together is important. Though breast-fed babies have lower blood glucose levels than artificial milk-fed babies (Hawdon et al., 1992), breastfeeding facilitates counter-regulation to low blood glucose levels (Ward Platt and Deshpande, 2005), enabling newborns to utilise alternative substrates to glucose (de Rooy and Hawdon, 2002) and preventing cerebral energy failure. There are a number of expert recommendations on how to practice screening and management of neonatal hypoglycaemia (Williams, 1997; Aziz and Dancey, 2004; Hewitt et al., 2005; Jain et al., 2010; Adamkin, 2011; Hawdon, 2011), including recommendations on breast feeding (Hawdon et al., 1993; Eidelman, 2001; Ashmore, 2002; Chantry, 2005; Wight, 2006) and other methods of prevention (Joanna Briggs Institute, 2007). There are also previous surveys describing how different centres define hypoglycaemia (Koh et al., 1988; Bonacruz et al., 1996; Koh and Vong, 1996) and identify and treat hypoglycaemia according to guidelines (Harris et al., 2009). However there is little published research assessing whether actual clinical practice guidelines adhere to the BFHI recommendations for guideline content and facilitate breast feeding. Therefore the aim of this study was to survey tertiary hospitals with neonatal units in Australia and New Zealand on their hypoglycaemia guidelines for term neonates on postnatal wards. Objectives included using the UNICEF UK BFI checklist tool to assess how well the guidelines fit BFI recommendations overall and specifically whether they encourage early and frequent breast feeding, are structured around breastfeeding times and identify appropriate neonates as at risk for hypoglycaemia. We also sought to assess how up-to-date and user-friendly the guidelines are, the blood glucose levels at which hypoglycaemia is defined and how and when blood glucose levels are measured.

Data analysis Information about hypoglycaemia screening from guidelines received was coded according to the recently published UNICEF UK BFI neonatal hypoglycaemia checklist (UNICEF, 2013) (Appendix 1). For each of the 31 ‘essential points’ (29 essential points are numbered but points 23 and 24 are repeated), a score of 4, 3, 2 or 1 was given. 4 out of 4 represented ‘completely covered’, 3 represented ‘partially covered’, 2 represented ‘ambiguous’, and 1 represented ‘not covered’. Before assessing the guidelines, criteria for allocating each score to each essential point were decided. For example for ‘essential point’ 12 on skin-to-skin contact and early breast feeding, a score of 4 indicated the guideline mentioned both skin-to-skin contact and breast feeding within one hour after birth, a score of 3 indicated skin-to-skin contact and ‘early’ breast feeding without stating feeding should occur within one hour after birth, a score of 2 indicated mention of early breast feeding or skin-to-skin but not both and a score of 1 indicated that neither early breast feeding nor skin-to-skin contact was mentioned. Each of the 22 guidelines was thus given an overall quality score between 31 (1  31) and 124 (4  31). They were also given a score between 9 (1  9) and 36 (4  9) for compliance to recommended practices to support breast feeding, essential points 12–20. To decide which of the ‘essential points’ were followed by the most guidelines, each ‘essential point’ was also given a score ranging between 22 (the minimum score of 1 for all 22 guidelines) and 88 (4  22). Additional information not covered in sufficient detail by the UNICEF UK BFI appraisal criteria but deemed relevant, for example whether centres screened wasted babies, was also obtained from the guidelines and analysed. Descriptive statistics were used to present data from the 22 guidelines. As guidelines were thought to reflect postnatal ward practice more accurately than the neonatologist survey responses (which sometimes differed), the only information utilised from the survey was BFHI accreditation status.

Methods

Ethics

A survey of neonatal hypoglycaemia management in tertiary neonatal hospitals in Australia and New Zealand was conducted from March to May 2012, which included obtaining hypoglycaemia guidelines. Management on the postnatal ward, rather than nursery, was assessed because newborns admitted to the nursery are observed closely and so unlikely to have an unrecognised episode of hypoglycaemia and because keeping mothers and their well babies, who may experience hypoglycaemia, together is a priority. Tertiary centres were chosen because they tend to lead practice.

Participation in the survey was voluntary. The Human Research Ethics Committee of Royal Prince Alfred Hospital (a tertiary maternity hospital in Sydney) reviewed the project and had no ethical objections to this research.

Data collection The Heads of Department of all 23 tertiary neonatal units in the Australian and New Zealand Neonatal Network with postnatal wards were contacted by email. Contact details were obtained from the 2011 Directory of Neonatal Intensive Care Units within Australia and New Zealand. The Head of Department was requested to reply with a copy of the unit's hypoglycaemia guideline and a completed questionnaire (Appendix 2). The questionnaire was developed following a review of the literature and input from experienced neonatologists. If no response was received within approximately two weeks another neonatologist from that unit was emailed, and so on until a response was received. All data were handled confidentially.

Findings All 23 neonatal units participated in the study (100%) including 18 from Australia and five from New Zealand (NZ); we received 22 hypoglycaemia guidelines and 21 completed surveys (the remaining two respondents requesting that we complete the survey using their guidelines). Two centres submitted the same state-based guideline, which was counted twice in analysis to represent each centre equally. Two survey responses were received from two centres and the first survey returned was used for analysis. Overall guideline quality based on UNICEF UK BFI checklist Scores for each guideline are listed in Table 1. The highest possible score was 124 and the lowest 31. The highest actual guideline score was 90 and the lowest 46. The median guideline score was 71. The median score was 71 for Australian guidelines and 72.5 for NZ guidelines. Compliance scores with the various recommendations in the checklist are listed in Table 2. The highest possible score for an individual recommendation was 88 and the lowest was 22.

Please cite this article as: Sundercombe, S.L., et al., Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.004i

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The median recommendation score was 50 of 88. Three of the 22 guidelines cited the 2007 version of the UNICEF UK BFI checklist (UNICEF, 2007).

Do the guidelines facilitate breast feeding? Fifteen of the 23 (65%) centres surveyed reported being Baby Friendly Health/Hospital Initiative (BFHI) accredited and eight did not report being BFHI accredited (Table 1). All five NZ centres surveyed were accredited (Table 1). The median guideline score for adherence to recommended practices to support breast feeding was 20 out of 36. The median scores for NZ and Australia were 23.5 and 20, respectively. The median BFHI accredited and non-BFHI accredited centre scores were 20 and 20.5, respectively. The recommendation about skin-to-skin contact and early feeding, essential point 12, received a score of 59 of 88. Regarding early feeding, 14 (61%) of 21 guidelines explicitly stated that babies should be fed within the first hour of birth, and another eight implied babies should be fed early without specifying within the first hour. Nine guidelines mentioned skin-to-skin contact after birth. Three guidelines mentioned that mothers should be assisted with an early breast feed, and three other guidelines recommend ongoing skin-to-skin contact. One guideline mentioned that mothers should be taught to recognise early feeding cues. The recommendation about frequent feeding, essential point 15, scored 73 of 88 (Table 2). Fourteen guidelines stated that babies at risk of hypoglycaemia should be fed at least three-hourly, two that they should be fed 3–4 hourly, one that they should receive a minimum of five feeds in the first 24 hours after birth and one stated they should be fed ‘frequently’. No guideline explicitly stated that mothers should be supported with breast feeding at each feed. Table 1 Comparison of guideline quality scores for 22 centres in Australia and New Zealand. Centre Country

A B C D E F G H I J K L M N O P Q R S T U V W

Australia Australia Australia NZ NZ Australia Australia Australia Australia Australia Australia NZ Australia Australia Australia Australia Australia Australia Australia NZ Australia Australia NZ

BFHI accredited

Overall score /124*

Score for recommended practices to support breast feeding /36†

Yes No Yes Yes Yes Yes Yes Yes No No No Yes No No No Yes Yes Yes Yes Yes Yes No Yes

90 65 46 78 87 67 83 77 73 77 84 67 76 70 71 71 71 63 75 60 70 71 –♯

28 25 12 27 34 16 20 23 23 21 23 18 19 19 20 20 25 14 19 20 20 20 –

n Maximum potential score was 124 indicating full compliance to each BFHI recommendation (31 essential points  4/4 maximum score for each point). Minimum score was 31 indicating no compliance to any BFHI recommendations (31 essential points  1/4 minimum score for each point). † Maximum potential score was 36 (score 4/4 for the 9 essential points outlining recommended practices to support breast feeding, essential points 12– 20). Minimum score was 9 (score 1/4 times 9). ♯ Centre did not provide a guideline.

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Table 2 How many guidelines satisfied each criterion in the UNICEF UK BFI checklist? Essential point For all ‘at risk’ babies 1. Guideline has a review date 2. Guidelines apply to all staff 3. Guideline makes clear what documentation is required 4. Explanation for monitoring/audit included 5. Guideline contains flowchart? 6. Accurate list of babies at increased risk? 7. Guideline mentions babies with metabolic disorders, e.g. MCADD at risk 8. LGA babies not listed as at risk 9. Describes effective measures to monitor the wellbeing of the baby 10. Effective description of clinical signs of hypoglycaemia 11. Clear definition of jitteriness Recommended practice at birth 12. Skin-to-skin contact at birth and help with an early breast feed Recommended practices to support breast feeding 13. Ongoing skin-to-skin contact 14. Teaching mothers to recognise early feeding cues 15. Frequent feeds, at least 3 hourly 16. Mothers supported to breast feed at each feed 17. Expressed breast milk (EBM) for feeding if breast feeding not achievable 18. For hypoglycaemia, formula only used when breast/EBM doesn't work 19. If formula needed for hypoglycaemia, appropriate volume offered 20. Indications for formula discussed with parents and documented Care for formula fed babies 21. Ensuring the baby remains warm, including use of skinto-skin contact 22. Teaching mothers to recognise early feeding cues 23. Frequent feeds, sufficient volume 24. Mothers will be supported with bottle feeding technique Ensuring accurate and effective blood glucose monitoring 23. Blood glucose level at which hypoglycaemia is diagnosed conforms with WHO o 2.6, NICE guidelines or similar 24. First blood glucose to be measured prior to second feed not earlier than 2 h unless symptomatic 25. Ongoing pre-feed monitoring until baby is stable 26. Use of an accurate ward-based machine (not reagent strips) 27. Lab machine confirmation of low levels if ward machine not accurate? 28. Consider repeating one hour post-feed if BG below normal pre-feed 29. Severe (o 1.1 mM), persistent or recurrent hypoglycaemia requires urgent paediatrician management

Score/88n

46 48 41 27 67 63 38 43 35 77 57 59

43 26 73 23 64 65 69 44

29 22 58 22 80 50 66 36 66 79 76

n Maximum score was 88, indicating all centres were compliant (a score of 4/4 for 22 guidelines). Minimum score was 22, indicating no centres were compliant with this essential point (a score of 1/4 for 22 guidelines).

While there was consensus that symptomatic infants should have their blood glucose level measured immediately regardless of feeding status or time after birth, the timing of screening asymptomatic infants was often structured around the infant's feeding times (Table 3). The recommendation outlining when to commence blood glucose screening, the second essential point 24, received a score of 50 out of 88 and the recommendation that prefeed monitoring should continue until the infant was stable, essential point 25, received a score of 66 out of 88 (Table 2). Fifteen of 22 guidelines recommend glucose levels after the first level be measured before feeds in asymptomatic infants with no prior low glucose levels. Four guidelines recommend levels be measured after feeds. For all guidelines, extra feeding was the first line of intervention for asymptomatic hypoglycaemia with blood glucose levels 41.5 mmol/l. The recommendation outlining use of breast feeding

Please cite this article as: Sundercombe, S.L., et al., Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.004i

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Table 3 Blood glucose screening in asymptomatic infants at risk of hypoglycaemia according to guideline data.

Table 4 Reported screening of babies at risk of neonatal hypoglycaemia. Presentation of infant in hospital

Timing of screening

Hypoglycaemia guideline (n¼ 21*)

Number of centres (n ¼22)

First blood glucose level 1 hour After first feed 2 hours Prior to second feed After second feed 3–4 hours 4–6 hours

9 3 4 8 1 6 3

Frequency of blood glucose levels Before feeds After feeds 1 hour and 4 hours 6 hourly

15 4 2 4

Point at which blood glucose levels ceased in infants with no low levels 4 hours 2 12 hours 3 24 hours 5 2 normal levels 1 3 normal levels 5 4 normal levels 2 Point at which blood glucose levels ceased in infants with at least one low level 12 hours 3 24 hours 7 2 normal levels 1 3 normal levels 6 If the guideline gave two screening times for ‘high risk’ and ‘standard risk’ or IDM and IUGR newborns, both are recorded. If the guideline gave both a time- and feeding-directed instruction, for example ‘before the second feed, in the first four hours after birth (whatever comes first)’, both have been included.

and expressed breast milk for hypoglycaemia in preference to artificial milk, essential point 18, received a score of 65 out of 88 (Table 2). Eighteen guidelines listed expressed breast milk (EBM) as an option for complementary feeds. The recommendation about parental consent for artificial milk use, essential point 20, received a score of 44 out of 88. Eight of 22 guidelines stated the indications for artificial milk must be discussed with parents before giving it.

Preterm o 37 weeks Small for gestational age or ‘IUGR’ Clinical wasting Low birth weight Infant of diabetic mother Large for gestational age Hypothermia Infection/other illness Asphyxia or respiratory distress Maternal beta blockers Metabolic disorder Symptomatic

Screened

Not screened

18 18 6 15 21 15 15 18 16 9 6 21

3† 3♯ 15 6 0 6 6† 3† 5† 12 15 0

n One of the 22 guidelines contained no information about which infants were screened and was excluded. † Some of these infants may be managed in the NICU and thus not mentioned on postnatal ward guidelines. ♯ The centres that don’t screen SGA/IUGR newborns do screen LBW infants.

Guidelines – how complex and up-to-date? The recommendation that guidelines include a flowchart, essential point 5, received a score of 67 of 88 (Table 2), with 14 of 21 guidelines including a flowchart. Eight of these flowcharts were colour-coded. Assessing how up to date guidelines were, 18 of 22 guidelines listed a year released or updated and the median year was 2010. The oldest guideline was released in 2004. Ten guidelines were released in 2010 or afterwards. Three guidelines were still being developed and were sent as drafts. The median year of the latest reference cited in the guidelines was 2006. Few guidelines contained a review date and the overall score was 46 of a possible 88 for essential point 1 (Table 2).

Discussion Limitations of the study

Babies at risk of hypoglycaemia The recommendation about which babies should be screened for hypoglycaemia, essential point 6, received a score of 63 of 88 overall (Table 2). One guideline contained no information on the babies at risk of hypoglycaemia. All of the remaining 21 guidelines reported screening Small for Gestational Age (SGA) or IntraUterine Growth Restricted (IUGR) and/or Low Birth Weight (LBW) infants and Infants of Diabetic Mothers (IDM) and unwell babies (Table 4). Wasted infants were listed to be at risk of hypoglycaemia in six of 22 hypoglycaemia guidelines (Table 4). Wasting was defined qualitatively, for example as ‘clinically malnourished with little subcutaneous fat, loose skin folds and withered appearance’ or ‘low weight relative to length’. One guideline included images of wasted infants. The recommendation about avoiding screening Large for Gestational Age (LGA) infants, essential point 8, received a score of 43 of 88 (Table 2). LGA infants were listed as at risk of hypoglycaemia in 14 of 22 guidelines. LGA was defined as 490th percentile weight for gestational age at five centres, 495% percentile at one centre, 44500g at 11 centres, 4 4400g at one centre and from a weight for gestational age table at one centre. Three additional guidelines stated ‘macrosomia’ was a risk factor without giving a weight or percentile based definition but rather implied clinical recognition.

These guidelines represent only tertiary neonatal units with postnatal wards in Australia and New Zealand. Although the sample is small, the excellent response rate indicates that it is representative of practice. A cross-sectional survey such as this provides a snapshot of practice. Unfortunately the guidelines were written and collected before the most recent UNICEF UK BFI checklist was published. We believe it unlikely that many of the guidelines would have been updated between May 2012 and July 2013. Even if they had been updated, the authors may have still been unaware of the UNICEF UK BFI checklist. Only three of the 22 guidelines cited the 2007 version of the UNICEF UK BFI checklist despite the fact most (15) of them were written after 2007 (UNICEF, 2007). A related limitation is that the UNICEF UK BFI checklist consists of expert recommendations about guideline content which may be subject to political influences and has not to our knowledge been validated as for example the AGREE tool has been validated for critically appraising evidence-based guidelines (AGREE, 2003). Our literature search identified the UNICEF UK BFI checklist however as the only current list to specifically appraise neonatal hypoglycaemia guidelines. Unfortunately the checklist does not provide information about the level of evidence of each recommendation. Similar recommendations from other sources suggest there is Grade A evidence for early and exclusive breast feeding and

Please cite this article as: Sundercombe, S.L., et al., Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.004i

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skin-to-skin contact (Joanna Briggs Institute, 2007) and Grade C evidence for the groups of babies at risk of hypoglycaemia (Aziz and Dancey, 2004). As research in neonatal hypoglycaemia continues, UNICEF UK BFI recommendations and hypoglycaemia guidelines will need to be updated (Rozance, 2014). Unfortunately we have little information on whether the guidelines are understood by staff and adhered to and thus reflect actual practice. In an older study, only 37% of midwives in one institution surveyed were aware their institution had a hypoglycaemia protocol (Kane et al., 1997), and a more recent study suggested staff routinely test all newborns at birth for hypoglycaemia despite guidelines recommending targeted screening (Hoops et al., 2010). Hypoglycaemia recommendations similar to the UNICEF UK BFI ones have been labelled impractical (Mouzoon and Hayes, 2011). We suggest auditing postnatal ward practice to assess guideline implementation. Strengths of the study include this is the first study of which we are aware to appraise actual neonatal hypoglycaemia guidelines using UNICEF UK BFI recommendations. This is also the first study to assess whether the guidelines support breast feeding, including emphasis on skin-to-skin contact and early feeding, structuring blood glucose screening around feeding times. This is also the first study to assess screening of wasted infants and guideline format. Though a previous study describes some aspects of management at several of the same centres (Harris et al., 2009), nine of the 21 guidelines we analysed were updated after this study was published. Guideline quality The guidelines generally scored poorly according to the UNICEF UK BFI evaluation checklist (Table 1). The median score was 71 of a possible 124 (57%), comparable to the 47% mean score for content and context of guidelines produced by the Obstetrics and Gynaecological society of Canada in a similar study that used a different appraisal tool (McDonagh et al., 2002). The guideline with the highest score, 90 of 124, cited the 2007 BFHI recommendations for guideline development (UNICEF, 2007). The guideline with the lowest score of 46 was published in 2007 potentially before the BFHI recommendations were released and suffered from lack of detail, for example it did not list which babies were at risk of hypoglycaemia. NZ and Australian centres performed similarly, indicating that it was valid to combine the two countries and that we can make recommendations to both countries based on our data. Do the guidelines facilitate breast feeding? Guideline scores for recommended practices to support breast feeding were unacceptable (Table 1). The median score was 20 of 36. NZ hospitals had a higher median score than Australian hospitals (23.5 versus 20). This may reflect the success that NZ has had in promoting breast feeding and achieving widespread BFHI accreditation, with 74 of 77 (96%) maternity facilities accredited in 2011 (Martis and Stufkens, 2013), compared to 77 of 394 (19%) Australian maternity facilities (BFHI Australia, 2011). Interestingly however in our survey the 14 BFHI accredited hospitals performed marginally less on scoring than the 7 non-BFHI accredited hospitals. This may be because the non-accredited hospitals were in the process of becoming accredited and thus had improved breast-feeding practices. Unfortunately we do not know whether those hospitals were seeking accreditation or not. On the other hand, it suggests that even BFHI accredited hospitals in Australia and NZ cannot be complacent about adhering to recommended practices to support breast feeding.

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The Ten Steps to Successful Breast feeding are evidence based practices that increase breast-feeding initiation and duration (World Health Organization, 2003). Step 4 is skin-to-skin contact and early initiation of breast feeding (WHO/UNICEF, 1989). The recommendation score across all centres for essential point 12, skin-to-skin contact at birth and help with an early breast feed, was 59 of a possible 88 (Table 2), which is above the median score of 50 of 88, but less than ideal. Only nine of 22 guidelines mentioned skin-to-skin contact immediately after birth. The low scores for skin-to-skin contact support similar results from a study evaluating BFHI implementation in six American hospitals (Taylor et al., 2012), and may be because clinicians interpret Step 4 to involve only early feeding. Skin-to-skin contact improves neonatal physiology, increasing blood glucose levels 75–90 minutes after birth and enhancing thermoregulation and early breast feeding (Moore et al., 2012). Healthy term newborns placed in skin-to-skin contact with mothers immediately after birth display a series of innate behaviours which enable them to find the breast and suckle; allowing this process to occur without interruption assists mothers and babies to suckle effectively (Widstrom et al., 2011). There is a dose–response relationship between the duration of skin-to-skin contact after birth and exclusive breast-feeding rates while mother and infant are in hospital, stressing the importance of continued skin-to-skin contact (Bramson et al., 2010). Almost none of the guidelines stated that mothers should be assisted with breast feeding or taught to recognise feeding cues. Most guidelines advocated early feeding, two-thirds of them explicitly stating that feeding should begin in the first hour. Initiating breast feeding in the first hour after birth assists continued breast feeding and is associated with fewer feeding problems compared with two, three and greater than four hours after birth (Carberry et al., 2013a). Early compared to later feeding also reduces the rate of hypoglycaemia in infants of mothers with Gestational Diabetes Mellitus (GDM) (Chertok et al., 2009). This is not necessarily true for Small for Gestational Age neonates (Bragg et al., 2013). Even if early breast feeding does not raise blood glucose levels in all groups, it provides alternative energy substrates (de Rooy and Hawdon, 2002). Hence it is important that all neonatal hypoglycaemia guidelines should recommend early breast feeding and ongoing skin-to-skin contact after birth. This may however be only the first step to achieving skin-toskin contact and early feeding. Our previous work suggests that breast feeding within the first hour may not always occur despite guideline recommendations, for example babies delivered by Caesarean section (Carberry et al., 2013a). This requires auditing to ensure all well babies are provided optimal feeding irrespective of mode of birth. The use of a validated, modified feeding chart for all babies indicating time of first feed and quality of the feed scored from 1 to 6 has enabled easy auditing of the timing and quality of feeds, as well as information on complementary expressed breast milk (EBM) and artificial milk (Sundercombe et al., 2013). We found that only 44% of babies received any breast feed in the first hour and 39% received a nutritive feed in the first hour. Completing the audit cycle can improve clinical practice. Strategies for implementing BFI initiatives including education are described in the literature (Smith et al., 2012; Vasquez and Berg, 2012). A strategy involving surveying staff opinions about hypoglycaemia management for breast-fed babies, education with assessment and audit at one American hospital resulted in increasing the number of breast feeds and reducing the number of artificial milk feeds in babies at risk of hypoglycaemia (Csont, et al., 2014). An intervention at a separate American tertiary hospital improved rates of skin-to-skin contact after Caesarean section from 20% to 60% (Hung and Berg, 2011). Experienced nurse managers, assistant nurse managers and nurses with research

Please cite this article as: Sundercombe, S.L., et al., Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding? Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.004i

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experience are important for extensive implementation of neonatal nursing care guidelines (Wallin et al., 2000). Frequent feeding is also recommended to prevent neonatal hypoglycaemia by providing a regular supply of nutrients (Hawdon et al., 1993). Eighteen of the 22 guidelines recommended frequent feeding and of the nine ‘Recommended practices to support breastfeeding’ in the UNICEF UK BFI checklist, essential point 15 about frequent feeding had the highest score, 73 of 88 (Table 2). Frequent feeding has the additional benefit of increasing milk supply on day three (Yamauchi and Yamanouchi, 1990). Our results suggest that the timing of hypoglycaemia screening is mostly structured around breast feeding (Table 3). Nineteen out of 22 guidelines recommend blood glucose measurements be taken before or after feeding times, rather than at set intervals, which may interrupt feeding. The score for essential point 25, which recommends ongoing pre-feed monitoring, of 66 of 88 was above average. Most (15) of the guidelines recommend glucose levels of asymptomatic neonates with no previous low levels be measured before feeds, but four guidelines recommend measuring after feeds (Table 3). Blood glucose levels are lower before feeds compared to afterwards (Lucas et al., 1981), and measuring prefeed levels is thus more sensitive for hypoglycaemia. Pre-feed measurement is also less disruptive to the mother and infant, as the feed can be used to soothe the pain of the heel-prick. Experts recommend that the first blood glucose level be taken before the second feed (de Rooy and Johns, 2010). This avoids the nadir of blood glucose levels which occurs in the first two hours after birth (Lucas et al., 1981). The recommendation about when to begin glucose measurement, essential point 24, had the median score of 50 of 88, with only eight of the guidelines recommending measurement before the second feed and nine guidelines recommending taking the first blood glucose level before two hours of age (Table 3). Two of the latter only tested ‘high risk’ or IDM infants, who have been shown to develop hypoglycaemia earlier than IUGR infants (Agrawal et al., 2000) before two hours and tested other at-risk infants later. Testing during the nadir is likely to identify more episodes of hypoglycaemia. This may lead to overtreatment as low levels in the nadir have not been demonstrated to cause harm in asymptomatic term newborns (Rozance and Hay, 2010). A recent multicentre study of healthy term infants however found that blood glucose concentrations are relatively stable in the first five hours after birth, casting doubt on the idea of a nadir for healthy term infants (Metzger et al., 2010). Thus most guidelines adhere to recommendations to structure glucose screening around feeding but there is variability in whether screening is conducted before or after feeds and when to begin blood glucose screening. Step 6 of the Ten Steps to Successful Breast-feeding states newborn infants should only be given breast milk unless medically indicated (WHO/UNICEF, 1989). Artificial milk supplementation in hospital has been associated with fewer breast feeds, low maternal milk supply and earlier termination of breast feeding, and if breast feeding is insufficient, UNICEF UK BFI recommends supplementation with the mother's own milk (World Health Organization, 2003). All guidelines listed extra feeding as the first line intervention for asymptomatic hypoglycaemia (with blood glucose levels 41.5 mmol/l), rather than intravenous dextrose therapy. Most guidelines included EBM as an intervention, and essential point 18 about using EBM rather than Artificial milk to treat hypoglycaemia had an above-average score of 65 of a possible 88 (Table 2). This compares favourably with a previous study which found poor implementation of Step 6 in six American hospitals (Taylor et al., 2012). Unfortunately however only eight guidelines stated that indications for artificial milk must be discussed with parents before giving it, and the score for essential point 20 was only 44 of 88 (Table 2). Discussion with parents before giving artificial milk provides the opportunity to explain the reason for temporary

supplementation and reassure mothers that there is nothing wrong with their milk, thus facilitating breast feeding (Wight, 2006). Babies at risk of hypoglycaemia None of the guidelines recommended all neonates be screened for hypoglycaemia, supporting that healthy, fully grown term newborns from pregnancies with no complications need not be screened for hypoglycaemia (de Rooy and Johns, 2010; Hoops et al., 2010). The overall score for essential point 6, 63 of 88 (Table 2), was above average, consistent with the consensus about which neonates are screened for hypoglycaemia (Harris et al., 2009). All guidelines surveyed agreed on maternal diabetes being a risk factor for hypoglycaemia, but a minority of guidelines mentioned that the level of maternal glycaemic control predicts the risk of hypoglycaemia. Our previous research indicates infants of well-controlled diabetic mothers have the same percentage of body fat as normal healthy term infants (Au et al., 2013), suggesting they have normal metabolic adaptation without hyperinsulinaemia. Thus we agree with previous recommendations that infants of well-controlled diabetic mothers can safely be managed on the postnatal ward, which prevents mother–infant separation (Mitanchez, 2010). This also emphasises the importance of multidisciplinary antenatal and postnatal management with endocrinologists, obstetricians, midwives and neonatologists working together. Macrosomic infants are at risk of hypoglycaemia and have the appearance of infants of poorly controlled diabetic mothers, with large amounts of subcutaneous fat, but may have no known history of maternal diabetes. LGA has been a simple way of identifying these newborns but is no longer recommended by UNICEF UK BFI (UNICEF, 2013). We found in previous work that in a well-controlled diabetic population, diabetes was not an explanatory factor for LGA, supporting that LGA is a crude indication of macrosomia (Donnelley et al., 2014). The current research suggests that LGA neonates are being screened unnecessarily (Table 4). We believe this is due to fear of missing macrosomic neonates and recommend that instead of attempting to identify them by weight or weight for gestational age thresholds, guidelines contain a clear description of ‘macrosomia’, which may include a photograph of a macrosomic infant to assist staff to identify these newborns. We found few guidelines listed wasted neonates as at risk of hypoglycaemia (Table 4). Centres may be reluctant to screen wasted neonates because they are difficult to identify. While guidelines listed qualitative clinical identifiers, there are a number of objective methods for identifying wasted newborns at risk of hypoglycaemia mentioned in the literature. Neonatal skin-fold thickness weighted by birth weight in term infants 42500 g was proportional to blood glucose levels at 4 hours of age (Oakley and Parsons, 1977). Similarly, the mid-arm circumference:head circumference ratio was significantly correlated to the number of episodes of blood glucose o2.00 mmol/l (p ¼0.025) in 65 full-term SGA infants (de Rooy and Hawdon, 2002). In a study in India, as the Ponderal Index (weight/length3) increased and the head circumference:birth weight ratio decreased, the risk of blood glucose o 2.0 mmol/l fell (Pal et al., 2000). These methods, although probably superior to clinical inspection, are operatordependent and have error; even length is fraught with measurement error (Wood et al., 2013). The accepted standard for identifying young infants with low fat stores is currently by the air displacement plethysmography method, where babies are placed in a PEA-PODs machine and their body composition is calculated from their density (Carberry et al., 2013b). This method is now used to identify wasted newborns at our hospital (a tertiary maternity hospital in Sydney) in order to begin

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hypoglycaemia screening. A photograph of a wasted infant may also aid identification. Guidelines – how user-friendly and up-to-date? Guidelines need to be user-friendly in order to be followed by busy staff. Only 14 of 22 guidelines included a flowchart as recommended by BFHI; the score for essential point 5 was 67 of 88. Eight of the flowcharts were colour coded. Colour-coded flowcharts quickly convey what clinical practices should be carried out and we recommend they be included in future guidelines. The guidelines were not up-to-date, with the median year of the latest reference 2006, four years before the median year of guideline release, and importantly before the 2007 version of the BFHI hypoglycaemia guidelines. This suggests guideline authors did not conduct thorough literature searches and that the guidelines do not contain the latest evidence. This casts doubt on our original assumption that the tertiary centres chosen for the study would lead practice in providing evidence based guidelines. Recommendations In conclusion, neonatal hypoglycaemia guidelines for postnatal ward management from 22 hospitals in Australia and New Zealand do not adhere sufficiently to UNICEF UK BFHI recommendations to facilitate breast feeding. Our survey suggests that guidelines need constant revision as evidence for best practice improves, especially in relation to protecting and promoting skin-to-skin contact, early frequent breast feeding and preventing mother–infant separation. The UNICEF UK BFI checklist provides a readily available quality improvement tool. Guidelines should contain flowcharts. To aid identification of wasted infants and macrosomic infants (and minimise unnecessary intervention in healthy LGA infants), guidelines could contain pictures.

Conflict of interest statement The authors have indicated they have no financial relationships relevant to this article to disclose and no conflicts of interests. RMT was supported by NHRMC Grant #633003 to the Screening and Test Evaluation Program.

Acknowledgements Thank you to the neonatologists who participated in the survey and to Lactation Consultant Carmel Kelly from RPAH for her assistance and commentary.

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Do neonatal hypoglycaemia guidelines in Australia and New Zealand facilitate breast feeding?

to establish how well postnatal ward neonatal hypoglycaemia guidelines facilitate breast feeding and adhere to UNICEF UK Baby Friendly Initiative (BFI...
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