Sugar. While most adults spend their life controlling their sugar intake, it is a vital chemical for brain development in children. Low blood sugar or hypoglycemia in newborns can have devasating consequences. It is thought to affect between 5-15% of all infants (Hay et al., 2012). Using UNICEF estimates of an annual birth of 125 million children per year, a conservative rate of 5% would yield around 5 million children affected by neonatal hypoglycemia annually.
Take a minute to absorb that statistic. 5 million children. As a point of comparison, diabetes, the silent killer, is estimated to have killed around 2 million individuals in 2019. While 5 million children affected annually is not the same as 2 million deaths, it is worth noting that the outcome for a large proportion of these 5 million children is far from normal.
Children with neonatal hypoglycemia are at a higher risk for developmental delay, brain injury, drug resistant epilepsy, visual disturbances, poor academic functioning and autism. According to estimates by Glasgow and colleagues (2021), neonatal hypoglycemia results in a loss of NZ$180,000 (INR 92.9 lakh) over the life of the child. Clearly, neonatal hypoglycemia is something that warrants our attention, especially since it is largely preventable.
How does hypoglycemia impact a child?
Blood glucose is essential for adequate brain functioning, and lack thereof is not surprisingly, associated with an increased risk of brain injury. Even within the brain, the posterior regions, namely the parieto-occipital areas of the brain are most susceptible to hypoglycemic damage. These brain areas are particularly important in basic vision and vision-related skills such as depth perception.
Children with visual difficulties in turn are likely to have academic issues on account of a limited ability to build literacy skills. In severe cases, children with visual difficulties may bang into objects around them when walking and have trouble learning daily living skills we take for granted such as dressing and grooming oneself, folding clothes etc.
Many of these difficulties may only be noticed after the first few years of life when the child is expected to independently engage in tasks. Studies with short, 2-year follow ups of children with neonatal hypoglycemia (NHG) have typically presented an encouraging picture, with these children reported to be no different to their same age peers.
Around 4.5 years of age though, the NHG group may fall below their same age peers with regard to their visuospatial and executive skills (abilities such as planning, organisation, problem solving).
Of note, even isolated episodes of hypoglycemia have been associated with poorer literacy skills in 4th grade and reduced numerical proficiency at 10 years of age. Many children with NHG may also develop a a comorbid condition such as cerebral palsy, epilepsy or autism spectrum disorder. In severe cases, children may develop epilepsy that fails to respond to multiple medications. Their epilepsy may manifest as falls that occur multiple times a day, resulting in significant injury to themselves.
As a consequences of these falls and progressive electrical dysfunction arising from drug-resistant epilepsy, many a times these children become functionally dependent on others, requiring assistance for their daily living skills and further adding to the financial burden of the family.
Why does NHG go undetected?
Low blood sugar in adults is relatively easily detected as fatigue, sudden falls, sweating etc, but may not be easily picked up in neonates. Limited activity in the early days of life means that a change in activity may go undetected in the absence of external monitoring.
External monitoring in turn, is contingent on adequate staff in maternity wards to regularly check the blood sugar levels of neonates. The Indian Public Health Standards guidelines recommends that there be 1 staff nurse for every 2-3 newborns with one auxiliary nurse midwife for every 20 babies. Recent studies report a 75% deficit in the nursing staff employed at hospitals (Shivam et al., 2014). One study focused on maternity wards reported a deficit of 9 staff from the required number (Das et al., 2013). Multiply that manifold to get an estimate of what the state of care for the entire nation would look like.
Low detection rates in turn translates to children not receiving timely intervention. Consider the report by Surana et al. (2010) where a quarter of the cases identified as having experienced a neonatal hypoglycemic brain injury had no documented history of low blood sugar levels (Surana et al., 2010). That is, their sugar disturbance was only identified in retrospect, through behavioural changes and neuroimaging evidence consistent with the condition.
It would come as no surprise then that better perinatal care in developed countries, which includes regular monitoring of blood glucose levels, is an important reason for differing rates of hypoglycemic brain injury between developed and developing nations.
A second reason for high rates of the condition could be broadly ascribed to feeding. The only energy source for a newborn is their feed, be it breastmilk or formula. An Indian study spanning 94,401 mothers from 2015-16 noted that only 41.5% of mothers started breastfeeding their infant within the first hour after birth (Senanayake et al., 2019).
Caesarean deliveries are found to be one of the major reasons for delayed intiation of breast feeding, and there has been a significant increase in the rate of Caesarean deliveries in all but 3 Indian states from 2015 to 2019. Delayed initiation of breastfeeding however, is only problematic if absence of the same is not replaced by top feed or formula. In fact, Cordero et al. (2013), found early access to breast or formula milk helped correct neonatal hypoglycemia in around 85% of children.
On paper, this seems like a reasonable solution – ensure that every pregnant mother has access to formula to supplement the energy requirement obtained through breast feeding. Cultural norms however may prove to be a hindrance. A qualitative study in Delhi reported mothers to be completely against bottle feed stating that “using the bottle is to be avoided at all costs” (Tuli, 2012, p.84). Further, mothers that used bottle feed were reported to experience significant guilt and feelings of inadequacy around the same (Tuli, 2012).
Possible solutions moving forward
Better staffing in hospitals with a smaller staff to child ratio would certainly aid in better monitoring although psychoeducation is perhaps the easiest and most affordable means of addressing neonatal hypoglycemia. Generating awareness amongst obstetricians to regularly assess for hypoglycemia in the newborn, as well as creating awareness in parents to evaluate for signs of hypoglycemia would
be beneficial in early detection and timely intervention. Education drives that dispel the myths around formula milk and promote formula as an acceptable means of feeding supplementation would also prove helpful. Most importantly, professionals and laypeople need to be aware of the serious consequences associated with neonatal hypogylcemia so that everyone can work together to avoid the potentially catastrophic consequences of this condition.
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