Neonatal Hypoglycemia: Is There a Sweet Spot?

Maternal ethnicity and gestational age at birth predict hypoglycaemia among neonates of mothers with gestational diabetes

AIM

Hypoglycaemia is common in neonates born to mothers with gestational diabetes mellitus (GDM). We aimed to determine predictors of hypoglycaemia among neonates of women with GDM and association with short-term outcomes.

METHODS

We conducted a secondary cohort analysis of data from a multi-centre randomised trial (the TARGET trial) conducted across ten maternity hospitals in New Zealand between May 2015 and November 2017. Data were analysed using univariate analysis and multivariable forward stepwise logistic regression.

RESULTS

Among 1085 neonates, those born to Asian mothers had reduced odds of hypoglycaemia (OR [95% CI]: 0.54 [0.38, 0.75], p = 0.001), as did those born at higher gestational ages (0.76 [0.68, 0.85], p < 0.001). Neonates born to Pacific mothers had increased odds of hypoglycaemia (OR [95% CI]: 1.57 [1.04, 2.39], p = 0.034). Neonates who experienced hypoglycaemia were more likely to experience neonatal intensive care unit admission (8.3% vs. 2.1%; p ≤ 0.001), hyperbilirubinaemia (8.6% vs. 3.3%; p ≤ 0.001) and receive respiratory support (11.4% vs. 4.8%; p ≤ 0.001) and less likely to be breastfed at discharge (92.4% vs. 96.2%; p = 0.009).

CONCLUSION

Among neonates of women with GDM, maternal ethnicity and gestation at birth are independent predictors of hypoglycaemia, and hypoglycaemia is associated with short-term comorbidities. Additional surveillance may be appropriate for neonates in these high-risk groups.

Incidence and risk factors for early hypoglycemia in very preterm infants: The hyporisk study

PURPOSE

To determine incidence, timing and potential risk factors associated with hypoglycemia in the first day of life in very premature infants.

METHODS

Retrospective cohort study including all infants born before 32 weeks of gestation between 1 July 2017 and 31 December 2020 in the Erasmus MC Sophia Children's Hospital (Rotterdam, the Netherlands). Excluded were those who died within 24 h after birth or with no glucose data available. We collected maternal and neonatal characteristics from patient files, as well as all routine glucose values for the first 24 h. Hypoglycemia was defined as blood glucose value below 2.6 mmol/L. Risk factors were selected using univariable and multivariable logistic regression with stepwise backward elimination. Kaplan-Meier survival analysis was performed to examine time-to-event after birth.

RESULTS

Of 714 infants included (median gestational age 29.3 weeks, mean weight 1200 g), 137 (19%) had at least one episode of hypoglycemia, with a median time-to-event of 126 min [95%-CI 105-216]. Relevant independent risk factors for hypoglycemia included two maternal (insulin-dependent diabetes [OR 2.8; 95%-CI 1.3-6.1]; antenatal steroid administration [OR 1.7, 95%-CI 1.1-2.7]), and four neonatal factors (no IV-access in delivery room [OR 6.1, 95% CI-3.2-11.7], gestational age in weeks [OR 1.3, 95% CI-1.2-1.5], small-for-gestational-age [OR 2.6, 95%-CI 1.4-4.8], and no respiratory support (versus non-invasive support) [OR 2.3, 95%-CI 1.0-5.3]).

CONCLUSION

Six risk factors were identified for hypoglycemia in the first 24 h of life in very preterm infants, that can be used for development of prediction models, risk-based screening and updating guidelines.

[Electroencephalogram features in children with congenital hyperinsulinism treated according to the international protocol in Russian Federation]

BACKGROUND

Congenital hyperinsulinism (CHI) is a rare life-threatening disease characterised by persistent hypoglycaemia as a result of inappropriate insulin secretion, which can lead to irreversible neurological defects in infants.

AIM

To evaluate neurophysiological characteristics of central nervous system in children with congenital hyperinsulinism treated according to the international protocol in Russian Federation.

MATERIALS AND METHODS

Our retrospective, prospective cohort study included 73 patients who received treatment for CHI according to the current international protocol at different departments of the Almazov National Medical Research Centre from 2017 to 2022. All patients underwent a comprehensive examination, including electroencephalography (EEG).

RESULTS

Among 73 patients with CHI, 35% (23) had focal form of the disease, 65% had non-focal form (49% (39) - diffuse form, 16% (11) - atypical form). All patients with focal form of CHI had a recovery as an outcome.Analysing the EEG data we found that paroxysmal activity was recorded in 23 patients (32%), 50 patients did not have paroxysmal activity (68%). Diffuse changes were observed in 47 patients (64%), whereas 26 patients (36%) were absent of it. By constructing Kaplan-Meier curves we found that the alpha rhythm is formed significantly (p=0.026) earlier in patients with a focal form of CHI.

CONCLUSION

CHI patients treated according to the international guidelines in Russian Federation show rather positive neurological outcome. We established that alpha rhythm earliest formation is associated with focal form of CHI.

Hipoglucemia persistente, un hallazgo poco frecuente y subestimado

La hipoglucemia persistente es un trastorno metabólico caracterizado por la incapacidad de autorregulación de la glucemia sérica posterior a las 72 horas de vida, secundario a un rango amplio de patologías, dentro de las cuales se encuentran: alteraciones metabólicas secundarias a patologías maternas (como la restricción del crecimiento intrauterino), los errores innatos del metabolismo (como los trastornos de almacenamiento del glucógeno), los trastornos de la betaoxidación y la alteración en las hormonas contrarreguladoras (como la deficiencia de la hormona de crecimiento). Su diagnóstico representa un reto debido a que, en ocasiones, los recién nacidos no presentan manifestaciones clínicas o estas son inespecíficas. La muestra crítica, un conjunto de exámenes paraclínicos séricos tomados en el periodo de hipoglucemia, permite la identificación rápida de las patologías causantes más comunes que requieren algún tratamiento específico. En el artículo se lleva a cabo una revisión narrativa de las patologías más comunes asociadas con la hipoglucemia persistente y la utilidad de la muestra crítica en su diagnóstico.

Continuous Glucose Monitoring in Preterm Infants: The Role of Nutritional Management in Minimizing Glycemic Variability

Glycemic variability (GV) is common in preterm infants. In the premature population, GV is a risk factor for morbidity and mortality. Both hypo- and hyperglycemia can impair neurodevelopment. We investigated the impact of continuous versus intermittent tube enteral feeding on GV. In our prospective observational study, 20 preterm infants with a gestational age ≤ 34 weeks at either continuous or intermittent bolus full enteral feeding. For five days, continuous glucose monitoring (CGM) was utilized, which was achieved through the subcutaneous insertion of a sensor. A total of 27,532 measurements of blood glucose were taken. The mean amplitude of glycemic excursions did not differ between the two cohorts statistically. Continuous feeding resulted in higher positive values, increasing the risk of hypo- and hyperglycemia. Subjects who were small for their gestational age had a higher standard deviation during continuous feeding (p = 0.001). Data suggest that intermittent bolus nutrition is better for glycemic control than continuous nutrition. Nutritional management optimization of preterm infants appears to be critical for long-term health. In the future, CGM may provide a better understanding of the optimal glucose targets for various clinical conditions, allowing for a more personalized approach to management.

Yenidoğan hipoglisemisine güncel yaklaşım

Neonatal hipoglisemi yenidoğan döneminde sık görülen, yaşamın ilerleyen dönemlerini de etkileyen bir sağlık sorunudur. Hipoglisemi akut ve kronik komplikasyonlara neden olarak yenidoğan bebeğin büyümesi ve gelişmesinde kalıcı ve geri dönüşümsüz nörolojik sorunlara yol açabilmektedir. Hipoglisemiyi saptamak için en duyarlı test halen plazma glukozu ile ölçümü olsa da, yıllardır kullanılan geleneksel glukoz ölçüm yöntemleri ile birlikte son yıllarda noninvaziv glukoz ölçüm yöntemlerindeki gelişmeler ile riskli bebeklerde hipogliseminin tanı ve tedavisinde bu teknolojik ölçüm yöntemleri yaygın kullanılmaya başlamıştır. Glukometre, kan gazı analizatörleri, laboratuvarda enzimatik ölçüm geleneksel ölçüm yöntemleri iken, sürekli glukoz ölçüm sistemleri yeni nesil glukoz ölçümünde yer almaya başlayan yeni bir tekniktir. Hipoglisemi gelişimini engellemek için koruyucu önlemler alırken erken dönemde anne sütü ile emzirme desteği sağlanmalı ve teşvik edilmelidir. Hangi durumların hipoglisemi için risk oluşturduğu, hangi glukoz eşik değerinde tedavi vermek gerektiği ve son kullanılan yeni nesil glukoz ölçüm yöntemlerinin etkileri ve güncel tedaviler bu derlemede tartışılmıştır. Riskli bebeklerde kan şekeri ölçümleri ve klinik bulguların gözlenmesi yanında hipoglisemide ayırıcı tanı yapılarak tedavinin yönetilmesi de prognozda önemli bir yer tutar.

Neonatal hypoglycaemia and body proportionality in small for gestational age newborns: a retrospective cohort study

Small for gestational age (SGA) newborns are at risk of developing neonatal hypoglycaemia. SGA newborns comprise a heterogeneous group including both constitutionally small and pathologically growth restricted newborns. The process of fetal growth restriction may result in brain sparing at the expense of the rest of the body, resulting in disproportionally small newborns. The aim of this study was to discover whether body proportionality influences the risk of developing neonatal hypoglycaemia in SGA newborns. A retrospective cohort study was performed in 402 newborns who were SGA without additional risk factors for hypoglycaemia. Body proportionality was classified in two ways: (1) using symmetric (sSGA) or asymmetric (aSGA), defined as head circumference (HC) below or above the 10th percentile, respectively; (2) using cephalization index (HC/birth weight), standardized for gestational age. Hypoglycaemia was observed in 50% of aSGA and 40.9% of sSGA newborns (P-value 0.12). Standardized CI in newborns with hypoglycaemia was higher compared to newborns without hypoglycaemia (median 1.27 (1.21-1.35) versus 1.24 (1.20-1.29); (P 0.002)). Multivariate logistic regression analyses showed both CI and standardized CI to be associated with the occurrence of hypoglycaemia (OR 1.48 (1.24-1.77) and OR 1.44 (1.13-1.83), respectively). The majority of hypoglycaemic events (96.1%) occurred in the first 6 h after birth.   Conclusion: Body proportionality might be of influence, depending on the classification used. Larger prospective studies with a clear consensus definition of body proportionality are needed. What is Known: • Neonatal hypoglycaemia is an important complication in newborns. • Small for gestational age (SGA) newborns are more vulnerable to hypoglycaemia. What is New: • Higher incidence of hypoglycaemia was not observed in asymmetric SGA compared to symmetric SGA, but standardized cephalization index was associated with increased likelihood of hypoglycaemia. • Consensus-based definitions of body proportionality in newborns are needed.

Impact of glucose metabolism on the developing brain

Glucose is the most important substrate for proper brain functioning and development, with an increased glucose consumption in relation to the need of creating new brain structures and connections. Therefore, alterations in glucose homeostasis will inevitably be associated with changes in the development of the Nervous System. Several studies demonstrated how the alteration of glucose homeostasis - both hyper and hypoglycemia- may interfere with the development of brain structures and cognitivity, including deficits in intelligence quotient, anomalies in learning and memory, as well as differences in the executive functions. Importantly, differences in brain structure and functionality were found after a single episode of diabetic ketoacidosis suggesting the importance of glycemic control and stressing the need of screening programs for type 1 diabetes to protect children from this dramatic condition. The exciting progresses of the neuroimaging techniques such as diffusion tensor imaging, has helped to improve the understanding of the effects, outcomes and mechanisms underlying brain changes following dysglycemia, and will lead to more insights on the physio-pathological mechanisms and related neurological consequences about hyper and hypoglycemia.

Neonatal Hypoglycemia and Brain Vulnerability

Neonatal hypoglycemia is a common condition. A transient reduction in blood glucose values is part of a transitional metabolic adaptation following birth, which resolves within the first 48 to 72 h of life. In addition, several factors may interfere with glucose homeostasis, especially in case of limited metabolic stores or increased energy expenditure. Although the effect of mild transient asymptomatic hypoglycemia on brain development remains unclear, a correlation between severe and prolonged hypoglycemia and cerebral damage has been proven. A selective vulnerability of some brain regions to hypoglycemia including the second and the third superficial layers of the cerebral cortex, the dentate gyrus, the subiculum, the CA1 regions in the hippocampus, and the caudate-putamen nuclei has been observed. Several mechanisms contribute to neuronal damage during hypoglycemia. Neuronal depolarization induced by hypoglycemia leads to an elevated release of glutamate and aspartate, thus promoting excitotoxicity, and to an increased release of zinc to the extracellular space, causing the extensive activation of poly ADP-ribose polymerase-1 which promotes neuronal death. In this review we discuss the cerebral glucose homeostasis, the mechanisms of brain injury following neonatal hypoglycemia and the possible treatment strategies to reduce its occurrence.

Feasibility of neonatal haemoglobin A1C as a biomarker for retinopathy of prematurity

INTRODUCTION

Retinopathy of prematurity (ROP) is a potentially serious eye disorder affecting very preterm infants. Non-proliferative ROP (NP-ROP), also known as Early Stage ROP, is characterized by deficient retinal angiogenesis. Proliferative ROP (P-ROP), also known as Late Stage ROP, is characterized by pathologic angiogenesis. The use of neonatal haemoglobin A1C as a biomarker for ROP has not yet been evaluated.

MATERIALS AND METHODS

We modified the Haemoglobin A1C assay for use with neonatal dried blood spots (DBS) and then assessed A1C levels via Elisa immunoassay on DBS from 43 preterm infants (with gestational ages 26-28 weeks). We measured A1C on DBS collected at <1 week and 4 weeks of chronological age.

RESULTS

Compared to matched counterparts without ROP, there is significantly lower HbA1c in infants who develop NP-ROP, this occurs at Week 4 (p=0.004), but is not seen at Week 1; there is significantly higher HbA1c in infants with P-ROP, this occurs both at Week 1 (p<0.05) and Week 4 (p=0.005).

CONCLUSIONS

The A1C test, modified for use with DBS, is a feasible biomarker for ROP; low A1C is a potential biomarker for non-proliferative ROP and high A1C is for proliferative ROP.