The EngagED Midwife
The EngagED Midwife
From Vernix To Vitals: What Modern Newborn Care Gets Right
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Day-one decisions shape a newborn’s first week, and small changes can prevent big problems. In this episode, Cara and Missi dig into what’s truly evidence-based now—delayed bathing to protect vernix and temperature, uninterrupted skin-to-skin to reduce energy burn, and clear thresholds for when to check and treat low blood sugar. Along the way, we unpack how updated NRP guidance simplifies early care: extend cord clamping to at least 60 seconds when possible, start term babies on room air, broaden ventilation rates to 30–60 per minute, and skip routine suctioning unless the airway needs clearing. Less fuss means warmer babies, steadier vitals, and fewer glucose crashes.
Cara and Missi clear the fog around GBS prophylaxis. Penicillin remains the standard, with cefazolin for low-risk penicillin allergy and vancomycin when high-risk reactions are present or clindamycin sensitivity isn’t confirmed. That clarity matters for maternal safety and newborn outcomes, especially in units where ampicillin lingers from past shortages. If your patients report a penicillin allergy early in pregnancy, consider formal evaluation to avoid unnecessary second-line antibiotics later.
Finally, we connect physiology to practice. Newborns lose the maternal glucose “buffet” at birth and lean on glycogen and brown fat to bridge the gap; cold stress accelerates that burn, making hypothermia and hypoglycemia frequent partners. We outline who needs screening—IDMs, SGA, LGA, late preterm, and resuscitated infants—and how to manage lows with a calm, stepwise approach: warm the baby, feed early and often, use donor milk or glucose gel when indicated, and escalate to IV dextrose for symptomatic cases. It’s a practical, exam-friendly, and family-centered guide to safer newborn care. #Baby #Newborn #BabyBabyAreYouOkay #Resuscitation #EatingAtThePlacentaBuffet #BloodSugar #NRP #SkinToSkin #GBSProphylaxis
Gray Skies And Setting The Stage
SPEAKER_00Welcome to the Engagement Advice Podcast. This is Missy. And this is Kara. Um I am tired of gray skies in the winter in the Midwest.
SPEAKER_02I hear you. It's pretty gray today, but it was beautiful and sunny but crisp yesterday in Missouri.
SPEAKER_00Yeah, I feel like both of us just had like our first full spring. Yeah. Because we had like pretty weather for a few days.
SPEAKER_02I had deficiting weather for a couple of days and it was glorious, but it is. It's like first spring and it's like the first of four because there will be more winter. I am certain.
SPEAKER_00Yeah, I also thought it was really hard for us to come home from the beach where at least the sky was blue every single day, and then come home to like gray Midwesternness.
SPEAKER_02See, I think this is where you romanticize. It was not blue every single day. We had every type of weather imaginable while we were in Florida. Um, it just you you romanticize it in your head.
SPEAKER_00There were a lot of times when I looked out the window or went outside and the sky was blue. I agree. I hear you. Let's just be clear. And my mental health and my vitamin D level certainly need needed some sunshine.
SPEAKER_02It will happen again. If you don't like the weather, just wait a few minutes, right?
SPEAKER_00Like in the Midwest, especially, right? Yeah, yeah. I also think given my my new diagnosis of osteoporosis, I should move someplace where I can get vitamin D all the time.
SPEAKER_02Sounds fabulous. Right? Like I know somewhere that's kind of like that.
SPEAKER_00Yeah.
SPEAKER_02Yeah.
SPEAKER_00I know lots of places that are kind of like that. I think yacht life under chopper blade sounds real good.
SPEAKER_02Oh yeah. I was gonna suggest like Arizona, but you know, whatever.
SPEAKER_00I know some people in Arizona.
Why Newborn Topics Matter For Practice And Exams
SPEAKER_02Yeah, yeah.
SPEAKER_00All right, miss, what are we talking about today? Okay, so we have been like running around the circle of doing some newborn blood trigger, blood trigger management like podcasts for some time now. But before we get to that, I just feel like there are some newborn update kinds of things that newborn is like a topic that some of us don't deal with ever because we never touch newborns. But some of us actually do use our full scope of care and take care of newborns up to you know 28 days of life. And so I think updating on some newborn topics is important. Also, I always say to students that a great place to make up ground on the exam and learn a lot about that's like high impact is newborn because you're only gonna have 10 or 11 newborn questions that count. But then if you get those right, you know, it's like a very little amount of information to study for like high yield questions, getting a lot of questions right.
SPEAKER_02Yeah, I agree. Um, there are a lot of my students and certainly graduates over the years that are like, I'm never gonna do newborns or in hospital-based practices, pediatricians take care of all the newborns, that kind of thing. But it is still important to remember it's part of our scope of practice. And I, for any of us that have done um mom-baby care, if you did couplet care after labor and birth and you took care of newborns, I feel like the midwife scope of practice is really similar to what I did as a nurse because it's escalating things when something's not normal, is really what we need to be able to do. Yeah.
SPEAKER_00It's um did you when you were a nurse, did you do babies?
Then Vs Now: Couplet Care And Old Routines
SPEAKER_02Yeah, I I mean, I would have told you I was a labor delivery nurse, but we did um couplet care and we would I was all the way from level two nursery to postpartum to we even did a little bit of GYN surgery, that sort of thing. But yeah, I I enjoyed it when I could take care of a couplet that I had been the labor nurse.
SPEAKER_00That was my favorite. So my one of my labor and delivery jobs, um when I was in mid-wiffery school, actually was an LBRP. And so like we kept our couplets, right? Like you labored them and delivered them, and then you took care of them until they got discharged, or you took care of their babies and did all that. So that was the only nursing job that I had that I did a lot of newborn stuff. Um, although let me just say that back in the day when you and I were nurses, we didn't have a lot of, I didn't have at least a lot of nursery nurses that were coming in to do things post-delivery. Like we were like mom's nurse and baby's nurse and oh yeah, no, we didn't we didn't have the like team right approach that I think we have now.
SPEAKER_02Um you know, I was at a pretty low risk. We did have a level two nursery, but we didn't have a like level three NICU or anything like that. But I mean, we back in the day when we were like into bathing babies from meconium and all, I mean, like we did it all. Like another labor nurse, because we were cross-trained in all the areas, yeah, uh would step into your delivery and catch your baby, maybe if there was enough staffing.
SPEAKER_00But if not, you were listening to the doctor or or midwife, like asking you for things while you were also trying to stabilize your baby, while you were also trying to like we did all the things. It was like you had to be like an octopus back in the day.
SPEAKER_02But you also were doing the entire baby transition, bathing them, getting them their meds, everything within the hour or two before you had to transfer your couplet to postpartum status, but you had to do all of these things so fast. It was crazy.
Delayed Bathing And Thermoregulation Evidence
SPEAKER_00I know. I could think people now like they think, God, what you guys were like nurses in like the dark ages. Like, not really. We just have changed the standard of care. And so I guess that's a great lead into some of the things that have changed. And that's what we want to talk about at the beginning of this. So, one of the things that I think has changed so significantly, and I don't know how this is happening in a lot of hospitals across the country, but I want to emphasize this for people who are in places that aren't doing this is the evidence around bathing babies after delivery.
SPEAKER_02Yeah, like I said, we had to do it so fast.
SPEAKER_00And how how many of us though are also like, um, oh my gosh, we like, yes, like we're answering questions from families where they're like, well, when's the baby gonna get a bath? Yeah, right? That's like a most popular question.
SPEAKER_02I had a friend that didn't want to hold her baby until it had been bathed because she thought it was gross.
SPEAKER_00Well, okay, so let's like do some myth busting. Okay. One of them is that like there is good evidence now that says that waiting to bathe your baby for greater than 24 hours is actually like a biologic mechanism by which they keep their vernix on their skin. It's good for them biologically in terms of long-term outcomes. So that's what the evidence says. So a lot of hospitals now, and mine included, we aren't giving our first baths until 24 hours, unless for some reason a parent, a you know, a couplet, it like a mom is insistent that her baby be bathed. Or I think, you know, in the, and this is all like what I would consider normal newborn, right? In the absence of any complications. Right, right.
SPEAKER_02But you know, I think about, and and not only is it just better biologically for their skin, it's better for thermoregulation. Because I think about how many babies that we bathed, we had to make sure their temp was okay before we bathed them, but then they would stay under the radiant warmer for a bit after their bath. And then how many of them got cold stress and we'd be wrapping them in three warm blankets with a hat on? And now it's just one, not only delaying a bath helps, but then we do so much skin to skin. Um, and that golden hour, and you know, that kind of thing that it's just babies are maintaining their temperatures so much better than they did when we were stressing the heck out of them.
SPEAKER_00So this goes back to the conversation that I always have about symptom clusters, right? You are like Missy is the symptom cluster queen, right? So hypoglycemia and hypothermia love each other. And the research that I was just talking about, it actually was a really good systematic review that was done in 2022 of all of this research on bathing. And basically the outcomes are better because babies don't have cold stress, because they don't get hypoglycemic, and then add on the piece about the biologic burnox, like it's that trifecta of things, right? That makes delayed bathing better. And there's some good research too that says, like, is it six hours? Is it 24 hours? There's been a lot more research done on delayed bathing post 24 hours. And so a lot of hospitals are also moving towards that. Now, I think some of the exceptions are like if your baby has choreo, like your baby is probably gonna get bathed faster because your baby, like you were diagnosed with choreo intrapartum, or your patient was diagnosed with choreo intrapartum. But um, yeah, the bathing thing is it is new, um, new-ish and has good literature to support it.
Infection Prevention And GBS Antibiotics
SPEAKER_02Well, so let's talk a little bit about preventing infection. You mentioned choreo, and I know GBS is not always the implication, but we're trying to prevent infections in newborns and that sort of thing. Let's talk about one of the things about people with penicillin allergies in GBS and how we try to prevent infection.
SPEAKER_00And you know how much how crazy this makes me. This this topic literally will make me like want to lose my mind because I want to be like, somebody make up your mind about what you want to do. Because I feel like the recommendations for this have changed so they are so vague. All the time I'm hearing like, well, we do this or we do that, or this could be okay, or that might be okay. And I'm always like, what does the CDC say?
SPEAKER_02Okay, so we know the number one antibiotic that we use for everyone with GBS positive, if there is no allergy, is penicillin. The answer is the answer is not ampicillin, it's penicillin.
SPEAKER_00And as a backstory, a tragic backstory to why AMP was a thing, is when you and I were baby nurses 20 plus years ago, there was a penicillin shortage. And that forever. I mean, like it was for a long time. Yes, for a very long time, there was a penicillin shortage, and we couldn't give penicillin. So everybody went to AMP. And now there are still hospitals using AMP, which is not evidence-based, but it wasn't because AMP was the best drug, it's because we couldn't get penicillin. So let's like again, myth busting right there.
SPEAKER_02And it is like patients complain about penicillin because it hurts when it's infusing. Yeah, it does. So there were reasons, but the answer on a test is penicillin. So now um there's so many people that think they have a penicillin allergy. They were told that they had a penicillin allergy, some like brother, sister, cousin twice removed had a penicillin allergy. And so what they say now is what was the reaction to the penicillin allergy? If they did not have anaphylapsis, they didn't have angioedena, they did not have a broad article, you know, high reaction, then they are at very low risk of having a true penicillin allergy. And in that case, we should use cephalozolin or enceph. We sometimes avoid cephalosporins because there's a cross reaction, but they're saying if they truly are low risk for anaphylaxis, do the cephalin, it's every eight hours. It's uh a similar kind of dosing in that it's two grams initially and then one gram every eight hours. So that's kind of more closely related to how we do our penicillin dosing than before, but you get the idea. But um, that works really nicely. If they're at risk for anaphylaxis, then we either use clindomyosin or bank. But what's the issue with clindomyosin? So if they have a true penicillin allergy, you have to have sensitivities back. And then if it does, if it is not sensitive to Clinda, you would do bank, and bank, unfortunately, is every 12-hour goosing.
SPEAKER_00Yeah, and I think that for the purposes of the test, we are not gonna see, like if you're a student and you're listening to this and you're like, I don't know what to choose. I think that your choice is penicillin, and they will tell you if the patient has a true penicillin allergy, and then the set then the answer is bank. The goal of the exam is not ever to trick you, right? It's to give you the right amount of information so that you can make the right decision. Um, this would feel like an obscure way to write a question if it was like this patient's got a penicillin allergy, and then it gave you Klinda and Vank as choices.
Penicillin Allergy Pathways And Testing
SPEAKER_02The other thing that it does say is if someone tells you in early pregnancy that they have a penicillin allergy, you could do true penicillin testing to see if it's true allergy. But I don't know many places doing that, but that that is one of the options as well.
SPEAKER_00Well, I will also say on that note, when we talk about syphilis, we know what the treatment for syphilis is. And if you have syphilis, do you know what they're doing if you have a penicillin allergy? Yeah, you're being put in the hospital and being desensitized to it. You are getting desensitation, desensitized to your penicillin allergy if you have syphilis, because penicillin is the treatment period.
SPEAKER_02Usually in the ICU. I mean, it's a big deal.
NRP Updates: Cords, Oxygen, And Suction
SPEAKER_00So, yes. So the whole like thing about this penicillin allergy, and I also was a penicillin allergy girl. Like, I had penicillin once when I was young. I had a really terrible head-to-toe rash that was very itchy, and my pediatrician was like, never penicillin again. So I've always had like always been like it's always been penicillin, whatever. And then one of my kids had a similar reaction. And now the more that we know about these kinds of reactions, I've sort of been like, right, is it, is it not? Um, you know, the things. So, but that's a great update too. So another update that I want to share is the NRP guidelines changed, changed, they changed um in 2026. And these are not significant changes, meaning the algorithm looks a lot like it did before. Um, but if you are a student and you're learning NRP or you've not worked as a nurse and you don't know NRP, there are some things that are important. These are the ninth edition NRP guidelines. And here's the reason. What happened was is NRP wanted to be really more closely aligned with like how we do adult resuscitation and looking at why we have good outcomes with adult resuscitation. And one of those things has to do with the chain of like survival, right? We have this chain of survival that comes from the American Heart Association, and now we have this neonatal chain of care, right? And it focuses on three big things. And none of this should be a surprise. It focuses on prevention, meaning, do we know what the risk factors are for this baby potentially not transitioning well, right? The second one is on effective resuscitation, right? It's the same thing with adults. We know that if we're doing compressions at the proper heart rate, right, that that circulation and ventilation are the things that are going to be effective resuscitation. And then three is how do we stabilize and do post-resuscitation care? So the that part is not rocket science. But what I do want to say is there are a couple of changes in the NRP guidelines that I think are important. One of them is that the old guidelines said that you should wait 30 seconds for cord clamping. Now it's saying you can do at least 60 seconds in term and preterm babies that don't require immediate resuscitation. Um, I know most of us are doing two minutes because that's what the standard of care is, but NRP has never said like, they've never come out and been like, everybody needs two minutes. They said 30 seconds, and now they have extended that to 60 seconds.
SPEAKER_01Interesting. Yeah.
SPEAKER_00Another good, another important change is there is a grid on your NRP algorithm that has the what the oxygen saturation should be at like one minute, five minute, 10 minute, 15 minutes of life. They have actually removed the one minute line. Um, and and it's really because they want you to focus more on the initial steps and the cord management versus like, does a baby need to get, you know, an immediate one minute um spO2? Because it's not necessary, right?
SPEAKER_02Correct.
Physiology Of Newborn Glucose Transition
SPEAKER_00Well, and and right interfering with like skin to skin and interfering with bonding and you and I have the cords still attach. Right. Like, and we have talked some and and we talk in our review about like delayed lactogenesis and how breastfeeding can be interrupted when you interfere with that like first few hours of skin to skin bonding and and the delay in lactogenesis. Maybe we need to do another breastfeeding lactogenesis episode. Yeah. Um, but okay, so back to the NRP thing. I digress. Um, the initial oxygen concentrations, right? Um, for term babies. And that's what we need to know. Term babies, so over 35 uh the NRP guideline is over 35 weeks is 21% initial oxygen. That's room air, right? That's room air. Um, and then another two big other changes that I think are important for us as midwives are the ventilation rate used to be 40 to 60 per minute. Now they have expanded it to 30 to 60. It's just given it a little bit of a more broad range. And then the last one is this so we used to say um warm, dry, and suction, right? When our initial steps. And now they said that suctioning is really no longer an initial step in NRP. And the instruction is clear the airway if needed. And I was reading something the other day. I can't remember in what resource I was reading, but it basically was like, there's a reason that we don't suction right away. And then, and you know, when we do whether you do mouth or nose first, right? It has to do with how a baby may aspirate, right? Or have a reflex reaction to suctioning. Um, that could go along too with this why we don't need to suction. Now, do some babies come out and sound junky? That's the word my mom used to use, is like when she worked with babies, was like, this baby sounds junky, right? Yeah. Um, there's probably a way better medical term for that, but there are reasons where you need to clear an airway, but it doesn't mean you have to shove a bulb suction down a baby's throat just because we think it's part of initial stabilization because NRP says it's not. Talk about back in the day. Man, we used to stress these kids out. We would delete all these babies. We were delaying on the freaking perineum back in the day.
SPEAKER_02I hear you. I'm just thankful that I never had to use a delay with my mouth. Um, so we're not that old. Um, but we I mean we all the bulb suctioning on the perineum, we were delaying babies, we were intubating anybody wasn't. I mean, it's crazy to think about what we were doing. So these are all really good changes. And I feel like the changes that we see here are similar to what we see in our OB world of becoming more mismatchy.
SPEAKER_00Like Yep. I also want to say that the NRP, like the American Academy of Pediatrics, while they haven't changed their stance on circumcision or updated that since 2012, in 2026, they did launch three extra courses to address some gaps in training. One of those is is uh it's called NRP cardiac, and it's for managing newborns that have congenital heart disease. So um, I think you know, we've got a lot, we have a, you know, we do a lot of babies with um congenital hearts. And so that's an interesting addition. There's also a new course on resuscitation in the NICU that's specific for resuscitating older babies that are in the um in the NICU. And then now there's an additional course on neonatal education for pre-hospital uh professionals, so EMS and first responders. So instead of like requiring NRP for an EM, like an EMT or a paramedic, they can take this like now specialized pre-hospital course. So expanding resources, expanding educational opportunities for people who need them. Yeah, yeah.
SPEAKER_02These are all great. So I think this now ties in really nicely to what the goal of our initial conversation and what we thought like this is something students need help understanding is blood sugar management. And all of the things that we've talked about tie in. To thinking about maintaining blood sugar. It helps with temperature stabilization. It helps with babies that have been resuscitated. All of this, how babies burn up their sugar and use it, and then how that ties into their status and their health, it's all connected. It's important for us to understand.
SPEAKER_00Yeah, and again, symptom clusters. I'm just gonna like keep saying it. Like if you don't understand the symptom clusters and what babies look like as they're transitioning, those are things that you should know. Because I said it before already in this podcast, hypoglycemia and hypothermia go together. Um, and it's a physiologic piece, right? So, do you want to talk a little bit about the physiology of like blood sugar transition in babies?
Recognizing Hypoglycemia And Hypothermia
SPEAKER_02Sure, a little bit. So, you know, babies are getting their glucose store, I mean their glucose, that sort of thing, from this constant buffet from mom, right? Like they're just getting, if they're a fetus, they're getting that constant blood sugar from their mom, that kind of thing. Um, babies also have brown fats. Um, and the reason to understand that is that once it's gone, it's gone. Um, and so as the baby is born and they come off of that like food source and constant buffet, once that cord is clamped, then they need to start using their own. They have to like start, okay, what are my own glucose stores? What how am I gonna use those? And so it is not uncommon, and it would be totally normal and understandable that their blood sugar is gonna drop in the first couple of hours after they're born because they took we took away that glucose source, and so now they have to start thinking about burning their own glycogen or glucose. Um, and so they break down um babies, break down the fat um and glycogen to make their sugar, and so if they're super cold, they will burn even more of that brown fat and get and that cold stress will cause their blood sugar to drop even more because they're burning that up. Um, and the brain obviously needs sugar. I say this all the time when people were talking about low-carb diets like we need carbs for our brains to work, we need sugar for our brains to work. So you can't go like no carb. Um, you want baby's brain functioning well, and all of this ties together. And the reason I said it ties in after resuscitation is that babies that are resuscitated are more likely to burn up some of that fat and the glucose because they're working so hard to maintain their respirations, they're working so hard to maintain their heartbeat, and those babies are more at risk of dropping their blood sugars too low. They're more at risk for cold stress, even if you just think about blow-by oxygen and all of those different things. These babies are more at risk. And so they're one of the classes of like when we think about, oh, who do we need to watch really close? We all know about our diabetic, infants of diabetic mothers, right? But it's also babies that have had any resuscitation. And then there's a few others, like our little teeny tiny babies and our big old fat babies. Those are all babies that typically will have some blood sugar monitoring after birth.
When To Check Sugars And Thresholds
SPEAKER_00I'm giggling at you because I love that you called it a blood sugar buffet. Yeah. I'm also I mean, it's all you can eat at the buffet. It's open 24-7. That's true. It's true. So the things that we're looking for. So I'm gonna go back to my symptom cluster, right? Signs and symptoms of babies who might maybe, maybe they're not meeting any risk-based criteria, right? Maybe their mom isn't diabetic, maybe they're not a small baby or a big baby, or maybe they're not preterm, right? Maybe it's just they got cold, right? Babies got cold, one of those mechanisms of heat loss, so convection or radiation or evaporation, right? Or convection, like they somehow have lost their heat and now they're experiencing cold stress. And so now they're also hypoglycemic. So we're looking for things like do are they jittery? So there's a difference between jitteriness and seizure activity, right? Right. But jittery, do they just look like they've got a little shake, right? Yeah. Are they particularly fussy, right? Um, I also say like the difference between a baby that looks like it's peacefully sleeping and a baby that's lethargic. Lethargic is bad, right? But like pink, sweet, shallow breathing babies are probably fine, right? Yeah. Lethargic babies who have left um who are jittery and have labor breathing are probably not okay.
SPEAKER_02Yeah, it's interesting to think about, you know, blood sugar, it could look like an irritable, jittery, trimmery kind of baby. Those are babies that are at risk, but it could also be that lethargy can't eat, can't stay awake enough to like get latched, you know, those kinds of it could be either one. And so those are those are things to watch for, but I agree. We typically think of those jittery kiddos as maybe being a little bit on the low side.
SPEAKER_00I I will keep reiterating that the hypothermia and the hypoglycemia are like kissing cousins, they rarely are without each other. And so when we talk about you recognize a baby potentially that has signs and symptoms of hypoglycemia, like what do we need to do? One of the things is you want to like make sure they're warm, right? Right, warmth matters. And while we don't routinely wrap babies in warm blankets and put hats on them and do all of those things, now we do a lot of you can actually get a lot of warmth from skin, skin to skin, right? Yeah, absolutely. Yeah. A hat still is not a bad thing. A hat will help keep warmth in, even skin to skin with mom, right? Right. And blankets over top of mom and baby potentially versus taking the baby away, separating, right? And putting the baby under the warmer. Now, I also say that with uh, is there a reason to take a baby away and put it on a warmer? Sometimes. Yeah. Yeah. Um, and this may be one of them, but um, but one of the things to think about is the cold stress, right? So you don't want them to use up all of their brown fat. You don't want them to go like dig deep into their oxygen and glucose stores. So getting a baby warm is important.
Managing Low Glucose: Warmth, Feeding, Gel, IV
SPEAKER_02Yeah. With that skin to skin, I also think about let's get baby to breast. Let's get them to eat. I mean, especially, especially if they are a particularly small baby, so small for gestacial age or large for gestacial age, I'm wanting them to eat soon just to help maintain that sugar as well. Um, and if they that is, I should say that is if the parent is breastfeeding or chest feeding. Um, otherwise, you know, getting formula. Um gosh, there's another change from back in the day. I don't know if you, let's see, when you were a brand new nurse, did you guys do glucose water as your first feed?
SPEAKER_01Yeah, did we do like aspirate it?
SPEAKER_00I don't know why we did it. And it was, and we I think we stopped doing it. But I will tell you, we did a lot more formula supplementation for babies who like, I mean, um let's we'll get to I think we'll give and get to like actual management because right now we're really still, I think, talking about physiology, right? About getting all that thing, yeah. Getting something in there in their body, but yeah, um, so you know, the avoiding cold stress, fixing cold stress, getting a baby some food. So one of the things too is like that I think we haven't talked about at all is when do we actually need to like check a blood sugar on a baby? Yeah, and I I think one of them is like that symptomatic piece, right? They look symptomatic, we probably need to check a blood sugar. Right. If they meet risk-based criteria, right? Right. We should be checking a blood sugar.
SPEAKER_02Um go ahead. Well, so yeah, I mean, if they're symptomatic, that is a whole thing. You should definitely check them, intervene, or feed them, or do something, and then recheck. But the asymptomatic ones, I am used to saying like an hourly blood glucose for the first four hours. I don't know what every institution may have it slightly different, but our our kind of value of what would be too low is generally people will say 35 or 40 in those first couple of hours after birth. And then once we get past that, I tend to see it go up to more of like 45 or 50 as the cutoff. But generally you're checking a blood sugar, um or you're feeding and then checking a blood sugar, like it can be a little bit different depending on your algorithm, but it is kind of that routine and making sure that what making sure that they're able to stabilize in that initial four hours.
SPEAKER_00True or false. A baby can be hypoglycemic and like look totally normal. Yes. Right. And so that's the we screen at-risk babies even if they look like rock stars, right? Like if they're they got a nine-nine apgar, but they're like, you know, 34 weeks, or they have a nine-nine apgar, but they're only, you know, 2100 grams, they still could look amazing and still be hypoglycemic.
SPEAKER_02Well, and then maybe looking amazing because I mean, I guess I should say they look amazing because they are doing everything possible to burn up everything that they have to maintain their sugar at the level that it is, or they could be low and they're just deceptive little creatures that like just don't don't say they don't scream at us and say, Hey, I'm not feeling so good over here. We have to like be proactive.
Key Takeaways, Risk Criteria, And Resources
SPEAKER_00It's like kids and animals, right? Like, why can't you just tell me what's wrong? Like, use your words. It was my favorite part of parenting when my kids finally got to a place where they could like put words to how they were feeling. And now, and now that I have teenagers, now I'm like, I should be rethinking this because they have a lot of words about how they're feeling. Yeah, yeah. Do you want to I oh go ahead. No, I was just gonna say there is there are clinical algorithms that tell us essentially what to do. And I think that ties into the fact that we were talking about NRP before and um like what to do with the symptomatic baby, right? And when we screen and when we don't screen. But the biggest thing to remember is like if you have a symptomatic baby, you need to intervene quickly. And that can be glucose in some form. And and and that looks different in different places, right? Sometimes it's the baby needs an IV and they want to do IV glucose. Some of it's glucose gel, some of it's just breastfeeding. Like, can we get the baby's blood sugar up just by like putting them to the breast? No, we love some colostrum, but mom might not have much and it might not do enough to improve the baby's blood sugar.
SPEAKER_02I still feel like, I mean, and I think you feel similarly, is I want to try breastfeeding first, and then if I need to supplement, do that after. I don't want to go straight to formula if if at all possible. And and I know more and more places are actually going to human donor milk um in place of formula, even for well newborns when they need supplementation. So it's something to think about. Make sure you know what is happening in your place where you are providing care, but and what you have available. But there is glucose gel, there's always colostrum or breast milk, there's formula. Um, or as you said, you know, in severe cases, sometimes it is IV access and giving it to D5.
SPEAKER_00A lot of the algorithms to give you options between do you have a symptomatic baby, right? That needs something right now, right? So we need to call PEDs, we need to be like, hey, this baby is, you know, got is jittery, it has tremors, it's got temperature instability, you know, maybe it's really terrible and it's it's seizing, right? Those are the babies that need immediate things. But I think what we're talking more about is the asymptomatic babies whose blood sugar is low is when we can really talk about skin-to-skin contact, breastfeeding continuation, right? Rechecking blood sugar, and then not intervening until 90 minutes, you know, up to two to three hours afterwards to see if we can get their blood sugar up in a more like holistic way. Yeah. Yeah.
SPEAKER_02I think this has all been really good. What do you think, Missy, are some of like the biggest takeaway um messages that you would want our students to understand at new grads?
SPEAKER_00I think the American Academy of Pediatrics is the standard by which our new, like our students and our new grads should be like looking for information on this. This that's the place. Um and understanding that for them, the blood glucose range of normal changes. And so the takeaway is like under four hours, it's it can be the the range can be 25 to less than 25 to 40. And then that blood sugar goes that number goes up. Like by the time a baby's 24 to 48 hours old, we're looking at a blood glucose of under 45. So there are like, I think some little benchmark numbers to remember um when it comes to like when you want to treat versus like when you want to start looking at an algorithm to um to follow. I think the second one is the algorithm, right? Like if you are wherever it is that you're working, that if there's an algorithm for newborn blood sugar, then you should know it or know where to find it. I mean, I I will honestly say I think one of the biggest disservices that we do when we tell people to take a high stakes exam is not recognizing that there are all kinds of places that everyday midwives look things up. Yeah. Yeah. We look things up all the time. We look up pop management. We have an entire app that does pop management for us, but it's this kind of stuff where I'm like, when you're out practicing every single day, you look it up or you have an algorithm that you follow and it's easily accessible. And so we are not the nurses that my that my grandmother was 50 years ago, where you just had to know in your head all of the things. Um, and then I think, you know, my other big takeaway is the stuff that is always just going to be about symptom clusters, like understanding what your baby looks like, understanding what those signs and symptoms may mean, understanding um how we correct physiologic things like hypoglycemia and hypothermia when they are together, but also the risks, like what are the risks? And if you know what the risks are about whether or not your baby is going to be hypoglycemic, you'll be in a better position to treat it or recognize it when it happens. Yeah, yeah.
Closing Thoughts And Encouragement
SPEAKER_02So I think the other thing is um if in doubt, feed them, if in doubt, warm them, right? Like, I mean, those are some of the major ones. When you when I've mentioned earlier little babies and big babies, I should have said typically we're talking about babies less than 2,500 grams or more than 4,000 grams, right? So those are like our five and a half pounders or less, and then our almost nine pounders or more.
SPEAKER_00Yeah, understanding what babies meet that risk-based criteria, right?
SPEAKER_02Yeah, yeah, absolutely.
SPEAKER_01I think it's just been helpful. It's nice just to refresh on this sometimes.
SPEAKER_00Well, yeah, and it's like the idea that you like this is just a topic that we don't get to very often. Yeah. So um, we and it's not again, like uh you I've all you've always heard me complain that there's not a newborn book that has everything in it, that has like all the well newborn plus all of the lack of better word, unwell. Normal, normal newborn versus abnormal newborn is not ever all in one place. And it is not my life's work, that is not my passion. But if it is somebody else's passion, I want you to do that. Please put a newborn book together. Yeah. No, I have another project that I'm that I'm gonna make, but um, you know, I gotta be breast cancer first. Breast cancer needs to kick rocks, and then we will talk about passion projects. So that's right. This was a great, I think, update review just to give people some, you know, little stars to put in their head of like some, I think, updates of things that have come down the pipe in the last, you know, few years.
SPEAKER_02So yeah, and this was good. I think we sometimes avoid our newborn topics, um, but it's something that students and new grads maybe haven't had a ton of exposure to. So hopefully this was helpful for everyone.
SPEAKER_00Yeah. Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.