A Dab of Sugar Gel for Newborns: Helpful, but Not a Cure-All

What a large study of 2,149 babies (the hPOD trial, published in PLoS Medicine in 2021) tells families about preventing low blood sugar

A large international study found that giving a small dab of sweet sugar gel to newborns at risk of low blood sugar slightly lowered how often those babies developed the problem, but did not reduce how many ended up needing care in the neonatal intensive care unit. The gel was safe, did not interfere with breastfeeding, and was easy to give. For families, the takeaway is reassuring but measured: it is a gentle, low-risk step that helps a little, not a treatment that changes whether a baby needs special care.

Why low blood sugar in newborns matters

In the first hours and days after birth, a baby has to take over a job the placenta used to do: keeping blood sugar (glucose) steady. Most babies manage this smoothly. But some are more likely to run low — particularly babies of mothers with diabetes, babies born a few weeks early, and babies who are unusually small or large [1]. Among these at-risk babies, roughly half will have at least one low blood-sugar reading [2].

Why are these particular babies more prone to it? Before birth, a baby receives a steady stream of glucose from the placenta. At the moment of birth that supply is cut off, and the newborn has to switch on its own systems for making and releasing glucose. Most babies make this switch easily. But a baby whose mother had diabetes has often been used to higher sugar levels in the womb and produces extra insulin, which can drive the blood sugar down quickly after birth. A baby born early or born small may simply have smaller energy reserves to draw on while the switch is happening. None of this means something is wrong with the baby — it is a normal adjustment that, in these groups, sometimes needs a helping hand.

Doctors pay close attention to this because the brain runs almost entirely on glucose. Studies that followed children over many years have linked low blood sugar in newborns to later differences in learning and thinking [3]. One careful study even found that babies whose low blood sugar was caught and treated still showed small differences in certain mental skills at four and a half years of age [4]. That finding raised an important possibility: if treating low blood sugar after it happens may not fully protect the brain, perhaps it would be better to stop it from happening in the first place.

The idea behind the sugar gel

For years, hospitals have treated low blood sugar by rubbing a sweet dextrose (sugar) gel inside a baby's cheek. It is cheap, gentle, and works well as a treatment [5]. Researchers wondered: if the gel can treat low blood sugar, could giving it ahead of time prevent it? An earlier, smaller study suggested the answer was yes — a single dose did reduce how often at-risk babies developed low blood sugar, and it helped pinpoint the best dose [6].

But preventing a low reading on a monitor is not the same as making a real difference to a baby's care. The researchers wanted to know whether the gel could keep babies out of the neonatal intensive care unit (NICU) — the kind of outcome that truly matters to families, because admission means separation from the mother and disruption to early bonding and breastfeeding. To answer this properly, they designed a large, carefully run study [7].

What the researchers did

The study, called hPOD, involved 2,149 newborns across 18 hospitals in New Zealand and Australia between 2015 and 2019 [1]. All the babies were at risk of low blood sugar but were otherwise well — born at 35 weeks or later, a healthy weight, less than an hour old, and not already needing special care. Each baby was given either the real dextrose gel or a look-alike gel with no sugar (a placebo), chosen completely at random. Neither the families nor the hospital staff knew which gel any baby received until the study was over. This "blinding" is what makes the results trustworthy, because it prevents expectations from coloring the findings.

The dose was a single small amount (half a milliliter per kilogram of the baby's weight) of 40% dextrose gel, gently massaged inside the cheek at about one hour of age and followed by a feed. The main question the researchers set out to answer was simple: did fewer babies need to be admitted to the NICU?

What they found

The honest answer was no — at least not for NICU admission. About 10 in every 100 babies were admitted whether they got the sugar gel or the placebo (10.4% versus 9.4%), a difference small enough to be due to chance [1]. So the gel did not achieve its main goal.

It did, however, do something. Fewer babies given the gel developed low blood sugar: 37 out of 100, compared with 42 out of 100 with the placebo. Put another way, about 21 babies would need to receive the gel to prevent one episode of low blood sugar. The gel also nudged that first blood-sugar reading a little higher. But the benefit was limited — it did not reduce the most severe drops in blood sugar, and it did not reduce admissions to the NICU specifically for low blood sugar.

Just as importantly, the gel did no harm. It did not interfere with breastfeeding, either in the hospital or six weeks later. It did not cause high blood sugar. It was comfortable and well tolerated by nearly every baby (97%), and the small number of deaths in the study (two among the gel babies and two among the placebo babies) had nothing to do with the gel. Nearly all the mothers said they would recommend taking part in the study to a friend.

What this means for families

If your baby is offered prophylactic dextrose gel, this study offers genuine reassurance about its safety: it is gentle, it will not disrupt breastfeeding, and it carries no known downside. At the same time, families deserve an honest picture of how much it helps. It slightly lowers the chance of a low blood-sugar reading, but it does not appear to keep babies out of intensive care or to prevent the most serious drops. It is a small, helpful nudge — not a guarantee.

It may also help to understand why the gel reduced low blood-sugar readings without reducing intensive-care admissions. Babies end up in the NICU for many reasons — breathing difficulties, feeding problems, and others — and low blood sugar is only one of them. In this study, only about half of the babies who were admitted went in because of low blood sugar. So even though the gel prevented some low readings, there were still plenty of other reasons babies needed extra care, and the overall admission numbers barely moved. This is a good example of why a treatment can succeed at one goal (fewer low readings) while not changing a bigger, broader outcome (admissions). It is also why doctors are careful not to promise too much from a single measure.

If you are a parent in this situation, a few practical points may be reassuring. The gel does not replace the routine heel-prick blood-sugar checks your baby will still have; it works alongside them, and those checks remain the main way the team keeps your baby safe. Giving the gel does not require separating you from your baby and does not get in the way of skin-to-skin time or starting breastfeeding. And if your baby does develop low blood sugar despite the gel, the same dextrose gel — now used as a treatment rather than as prevention — is one of the gentle first steps the team can use before anything more involved is considered.

It is also worth knowing why doctors still disagree about whether to use it routinely. Because the real reason for preventing low blood sugar is to protect the developing brain, the most important question is whether babies who get the gel grow and learn any differently years later. So far, a follow-up of children from the earlier, smaller study found no clear difference — neither better nor worse — in their development at two years of age [8]. The larger group of children from this study is still being followed to give a clearer answer.

What researchers are working on next

The team behind hPOD has been clear that the verdict is not yet in. Their next and most important step is to follow the children from this large study as they grow, to see whether preventing some low blood-sugar episodes in the first days of life makes any lasting difference to how they think and learn. Researchers are also trying to understand which babies — among the many different reasons for being at risk — are most likely to benefit, since most babies in this study were born to mothers with diabetes and other at-risk groups may respond differently. And because the gel is inexpensive and safe, some have looked at whether using it could save money for health systems overall [9].

For now, the most balanced way to think about prophylactic sugar gel is as a safe, modest helper. It is reasonable for families and their care teams to discuss it openly — neither dismissing it nor expecting it to do more than the evidence shows. The careful, honest design of this study is exactly what allows parents and doctors to make that decision together with confidence [10].

References

  1. Harding JE, Hegarty JE, Crowther CA, Edlin RP, Gamble GD, Alsweiler JM, et al. Evaluation of oral dextrose gel for prevention of neonatal hypoglycemia (hPOD): A multicenter, double-blind randomized controlled trial. PLoS Med. 2021;18(1):e1003411. doi:10.1371/journal.pmed.1003411 ↩
  2. Harris DL, Weston PJ, Harding JE. Incidence of neonatal hypoglycemia in babies identified as at risk. J Pediatr. 2012;161:787–91. doi:10.1016/j.jpeds.2012.05.022 ↩
  3. Shah R, Harding J, Brown J, McKinlay C. Neonatal glycaemia and neurodevelopmental outcomes: a systematic review and meta-analysis. Neonatology. 2019;115:116–26. doi:10.1159/000492859 ↩
  4. McKinlay CJD, Alsweiler JM, Anstice NS, Burakevych N, Chakraborty A, Chase JG, et al. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr. 2017;171:972–83. doi:10.1001/jamapediatrics.2017.1579 ↩
  5. Harris DL, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial. Lancet. 2013;382:2077–83. doi:10.1016/S0140-6736(13)61645-161645-1) ↩
  6. Hegarty JE, Harding JE, Gamble GD, Crowther CA, Edlin R, Alsweiler JM. Prophylactic oral dextrose gel for newborn babies at risk of neonatal hypoglycaemia: a randomised controlled dose-finding trial (the Pre-hPOD Study). PLoS Med. 2016;13:e1002155. doi:10.1371/journal.pmed.1002155 ↩
  7. Harding JE, Hegarty JE, Crowther CA, Edlin R, Gamble G, Alsweiler JM. Randomised trial of neonatal hypoglycaemia prevention with oral dextrose gel (hPOD): study protocol. BMC Pediatr. 2015;15:120. doi:10.1186/s12887-015-0440-6 ↩
  8. Griffith RJ, Hegarty JE, Alsweiler JM, Gamble G, May R, McKinlay CJD, et al. Outcomes at two years after dextrose gel prophylaxis for neonatal hypoglycaemia: follow-up of the pre-hPOD randomised trial. Arch Dis Child Fetal Neonatal Ed. 2021;106:278–85. doi:10.1136/archdischild-2020-320305 ↩
  9. Glasgow MJ, Edlin R, Harding JE. Cost-utility analysis of prophylactic dextrose gel vs standard care for neonatal hypoglycaemia in at-risk infants. J Pediatr. 2020;226:80–96. doi:10.1016/j.jpeds.2020.06.073 ↩
  10. Kaiser JR, Bai S, Gibson N, Holland G, Lin TM, Swearingen CJ, et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: a population-based study. JAMA Pediatr. 2015;169:913–21. doi:10.1001/jamapediatrics.2015.1631 ↩