Association between newborn hypoglycemia screening and breastfeeding success in an Ottawa, Ontario, hospital: a retrospective cohort study

Michael Saginur; Joseph Abdulnour; Eva Guérin; Xaand Bancroft; Daniel J. Corsi; Vincent Della Zazzera; El Mostafa Bouattane

doi:10.9778/cmajo.20210324

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Figure 1:
Study inclusion flow diagram. Exclusion criteria were as follows: sick newborn = a newborn with an illness (e.g., transient tachypnea of the newborn requiring admission to intensive care); early discharge = discharge before 24 hours of life; pregnancy risk = a pregnancy-related condition (e.g., twin pregnancy, birth at gestational age < 35 wk); maternal complications = maternal obstetrical complications or treatment (e.g., sepsis or admission to intensive care); congenital/birth condition = newborn congenital malformations (e.g., cleft palate), global conditions (e.g., Down syndrome) or birth complications (e.g., long-bone fracture).

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Table 1:

Glucose measurements recorded per newborn for all babies and by screening indication

No. of glucose measurements	Screening indication; no. (%) of newborns
No. of glucose measurements	All newborns n = 10 965	Large for GA n = 1253	Small for GA n = 151	Premature n = 159	Birthing parent with diabetes n = 560
0	8124 (74.1)	432 (34.5)	11 (7.3)	9 (5.7)	30 (5.4)
1	580 (5.3)	117 (9.3)	6 (4.0)	8 (5.0)	49 (8.8)
2	309 (2.8)	130 (10.4)	3 (2.0)	7 (4.4)	52 (9.3)
3	363 (3.3)	162 (12.9)	7 (4.6)	12 (7.5)	86 (15.4)
≥ 4	1589 (14.5)	412 (32.9)	124 (82.1)	123 (77.4)	343 (61.3)

Note: GA = gestational age.

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Table 2:

Characteristics of newborns^*

Characteristic	No. (%)^†
Characteristic	All newborns n = 10 965	Screened n = 1952	Unscreened n = 9013
GA, wk, mean ± SD	39.3 ± 1.2	39.0 ± 1.4	39.4 ± 1.1
Birth weight, g, mean ± SD	n = 10 855 3458 ± 453	n = 1936 3411 ± 721	n = 8919 3468 ± 369
Apgar score, mean ± SD	n = 10 122 8.39 ± 0.90	n = 1815 8.32 ± 0.99	n = 8307 8.41 ± 0.88
Birthing parent with diabetes	560 (5.1)	429 (22.0)	131 (1.5)
Premature	159 (1.5)	135 (6.9)	20 (0.2)
Weight for GA	n = 10 860	n = 1936	n = 8924
Normal	9456 (87.1)	1231 (63.6)	8225 (92.2)
Large	1253 (11.5)	574 (29.6)	679 (7.6)
Small	151 (1.4)	131 (6.8)	20 (0.2)
Exclusively breastfed at 24 h	n = 10 096 4325 (42.8)	n = 1772 543 (30.6)	n = 8324 3782 (45.4)
Birth year
2014	2527 (23.0)	342 (17.5)	2185 (24.2)
2015	2610 (23.8)	385 (19.7)	2225 (24.7)
2016	2353 (21.5)	475 (24.3)	1878 (20.8)
2017	2314 (21.1)	497 (25.5)	1817 (20.2)
2018	1161 (10.6)	253 (13.0)	908 (10.1)
Antenatal parity ≥ 1	5821 (53.1)	996 (51.0)	4825 (53.5)
Hypertension or pre-eclampsia	684 (6.2)	181 (9.3)	503 (5.6)
Obesity	1431 (13.1)	365 (18.7)	1066 (11.8)
Smoking by the birthing parent	766 (7.0)	145 (7.4)	621 (6.9)
Social issues or perinatal inpatient drug screening	167 (1.5)	42 (2.2)	125 (1.4)
Marital status divorced, single or widowed (v. married or common law)	818 (7.5)	148 (7.6)	670 (7.4)
Pyrexia	219 (2.0)	30 (1.5)	189 (2.1)
Induced	2984 (27.2)	705 (36.1)	2279 (25.3)
Mode of birth
Simple vaginal	7262 (66.2)	1232 (63.1)	6023 (66.8)
Assisted vaginal	971 (8.9)	190 (9.7)	781 (8.7)
Elective cesarian	1341 (12.2)	234 (12.0)	1107 (12.3)
Emergency cesarian	1391 (12.7)	291 (14.9)	1100 (12.2)
5-minute Apgar score
≤ 7	176 (1.6)	34 (1.7)	142 (1.6)
≥ 8	10 578 (96.5)	1878 (96.2)	8700 (96.5)
Brief postnatal CPAP	392 (3.6)	100 (5.1)	292 (3.2)
Newborn cardiorespiratory issue	394 (3.6)	96 (5) (4.9)	298 (3.3)
Laceration
None	4483 (40.9)	827 (42.4)	3656 (40.6)
First or second degree	6064 (55.3)	1047 (53.6)	5017 (55.7)
Third or fourth degree	418 (3.8)	78 (4.0)	340 (3.8)
Postpartum hemorrhage or anemia	952 (8.7)	184 (9.4)	768 (8.5)
Birthing parent obstetric complication	5592 (51.0)	997 (51.1)	4595 (51.0)

Note: CPAP = continuous positive airway pressure, GA = gestational age.
↵* As per the study protocol, preterm babies born earlier than 36 weeks were excluded from the study since they were observed and cared for in the special care nursery following birth. Appendix 1 (available at www.cmajopen.ca/content/11/2/E381/suppl/DC1) offers more information on variable definitions and source data.
↵† Unless stated otherwise.

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Table 3:

Methods of feeding used in the first 24 hours of life^*

Feeding method	No. (%) of newborns
Feeding method	Screened n = 1772	Unscreened n = 8324
At the breast only	506 (28.6)	3560 (42.8)
Expressed breastmilk and the breast	37 (2.1)	222 (2.7)
Breastmilk and formula	1144 (64.6)	4147 (49.8)
Formula only	85 (4.8)	395 (4.7)

↵* p value for difference < 0.001.

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Table 4:

Multipredictor model of exclusive breastfeeding (n = 9709)^*

Variable	OR (95% CI)
Screened (≥ 3 measures v. < 3 measures)	0.57 (0.51–0.64)
Birth year
2014	Ref.
2015	0.92 (0.82–1.04)
2016	0.70 (0.62–0.79)
2017	0.71 (0.63–0.80)
2018	0.92 (0.75–1.12)
Antenatal parity ≥ 1	1.88 (1.71–2.06)
Hypertension or pre-eclampsia	0.87 (0.72–1.05)
Obesity	0.83 (0.72–0.95)
Smoking by the birthing parent	0.76 (0.64–0.91)
Social issues or perinatal inpatient drug screening	0.57 (0.38–0.85)
Marital status divorced, single or widowed (v. married or common law)	0.65 (0.55–0.78)
Pyrexia	0.73 (0.53–1.00)
Induced	0.83 (0.75–0.91)
Mode of birth
Simple vaginal	Ref.
Assisted vaginal	0.86 (0.73–1.01)
Elective cesarian	0.80 (0.68–0.94)
Emergency cesarian	0.80 (0.67–0.95)
5-minute Apgar score ≥ 8	1.48 (0.99–2.22)
Brief postnatal CPAP	1.13 (0.79–1.62)
Newborn cardiorespiratory issue	0.94 (0.67–1.32)
Laceration
None	Ref.
First or second degree	0.95 (0.84–1.07)
Third or fourth degree	0.92 (0.72–1.18)
Postpartum hemorrhage or anemia	0.98 (0.84–1.13)
Birthing parent obstetric complication	0.91 (0.84–0.99)

Note: CI = confidence interval, CPAP = continuous positive airway pressure, OR = odds ratio, Ref. = reference category.
↵* The final step of the model is presented; 1256 newborns were omitted owing to missing data. The first model of the binary hierarchical logistic regression contained the confounder variables, and was significant over the null hypothesis, χ²(22) = 501 p < 0.001, with an Nagelkerke R square = 0.068. The second model added glucose screening (≥ 3 v. < 3 measures) on exclusive breastfeeding at 24 hours. The logistic regression was significant over null hypothesis (χ²(23) = 595; p < 0.001), and an improvement over the first model (χ²(1) = 94; p < 0.001) with an R square = 0.080.

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Table 5:

Multipredictor model of exclusive breastfeeding, screening status divided by indication (n = 8297)^*

Variable	OR (95% CI)
< 3 glucose measures, screen not indicated	Ref.
Screened (≥ 3 measures), preterm	0.23 (0.14–0.38)
Screened (≥ 3 measures), small for GA	0.25 (0.14–0.44)
Screened (≥ 3 measures), birthing parent with diabetes	0.57 (0.44–0.73)
Screened (≥ 3 measures), large for GA	0.72 (0.59–0.87)
Birth year
2014	Ref.
2015	0.89 (0.78–1.01)
2016	0.66 (0.58–0.76)
2017	0.71 (0.62–0.81)
2018	0.90 (0.72–1.11)
Antenatal parity ≥ 1	1.82 (1.64–2.01)
Hypertension or pre-eclampsia	0.85 (0.70–1.04)
Obesity	0.77 (0.67–0.90)
Smoking by the birthing parent	0.80 (0.66–0.96)
Social issues or perinatal inpatient drug screening	0.61 (0.40–0.94)
Marital status divorced, single or widowed (v. married or common law)	0.66 (0.55–0.80)
Pyrexia	0.70 (0.50–1.00)
Induced	0.85 (0.77–0.95)
Mode of birth
Simple vaginal	Ref.
Assisted vaginal	0.91 (0.76–1.08)
Elective cesarian	0.79 (0.66–0.93)
Emergency cesarian	0.80 (0.67–0.97)
5-minute Apgar score ≥ 8	1.55 (1.01–2.38)
Brief postnatal CPAP	1.32 (0.89–1.96)
Newborn cardiorespiratory issue	0.87 (0.59–1.26)
Laceration
None	Ref.
First or second degree	0.92 (0.80–1.04)
Third or fourth degree	0.81 (0.62–1.05)
Postpartum hemorrhage or anemia	0.96 (0.82–1.13)
Birthing parent obstetric complication	0.90 (0.82–0.99)

Note: CI = confidence interval, CPAP = continuous positive airway pressure, GA = gestational age, OR = odds ratio, Ref. = reference category.
↵* The final step of the model is presented; 2668 newborns were omitted owing to missing data. The logistic regression was significant over null hypothesis (χ²(26) = 499; p < 0.001), and a small improvement over the first model (Table 3) (χ²(4) = 96; p < 0.001) with an Nagelkerke R square = 0.078.

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Table 6:

Multipredictor model of exclusive breastfeeding, including screen status and screen indications (n = 9709)^*

Variable	OR (95% CI)
Screened (≥ 3 measures v. < 3 measures)	0.64 (0.56–0.73)
Screening indication
None	Ref.
Preterm	0.37 (0.23–0.58)
Small for GA	0.37 (0.22–0.63)
Birthing parent with diabetes	0.88 (0.69–1.10)
Large for GA	1.03 (0.89–1.19)
Birth year
2014	Ref.
2015	0.92 (0.82–1.04)
2016	0.70 (0.61–0.79)
2017	0.71 (0.62–0.81)
2018	0.92 (0.75–1.12)
Antenatal parity ≥ 1	1.86 (1.70–2.04)
Hypertension or pre-eclampsia	0.89 (0.74–1.07)
Obesity	0.82 (0.71–0.94)
Smoking by the birthing parent	0.77 (0.64–0.92)
Social issues or perinatal inpatient drug screening	0.57 (0.38–0.85)
Marital status divorced, single or widowed (v. married or common law)	0.65 (0.55–0.77)
Pyrexia	0.72 (0.52–0.99)
Induced	0.84 (0.76–0.93)
Mode of birth
Simple vaginal	Ref.
Assisted vaginal	0.85 (0.73–1.01)
Elective cesarian	0.80 (0.68–0.94)
Emergency cesarian	0.79 (0.67–0.94)
5-minute Apgar score ≥ 8	1.50 (1.00–2.24)
Brief postnatal CPAP	1.13 (0.79–1.61)
Newborn cardiorespiratory issue	0.93 (0.66–1.31)
Laceration
None	Ref.
First or second degree	0.94 (0.83–1.06)
Third or fourth degree	0.90 (0.70–1.15)
Postpartum hemorrhage or anemia	0.98 (0.84–1.13)
Birthing parent obstetric complication	0.91 (0.83–0.99)

Note: CI = confidence interval, CPAP = continuous positive airway pressure, GA = gestational age, OR = odds ratio, Ref. = reference category.
↵* The final step of the model is presented;1256 newborns were omitted owing to missing data. The tertiary binary logistic regression was also significant over null hypothesis (χ²(27) = 614; p < 0.001), and a small improvement over the second model (screening risk factors) (χ²(1) = 43; p < 0.001) with an Nagelkerke R square = 0.085.