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Lee CD, Nelin TD, Nelin LD. Things We Do for No Reason™: Reflexively testing for hypoglycemia in jittery low-risk infants. J Hosp Med 2024. [PMID: 39092601 DOI: 10.1002/jhm.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 07/21/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Clement D Lee
- Tufts School of Medicine, Boston, Massachusetts, USA
- Division of Pediatrics, Newton-Wellesley Hospital, Boston, Massachusetts, USA
| | - Timothy D Nelin
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leif D Nelin
- Division of Neonatology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
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2
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Lagacé M, Tam EWY. Neonatal dysglycemia: a review of dysglycemia in relation to brain health and neurodevelopmental outcomes. Pediatr Res 2024:10.1038/s41390-024-03411-0. [PMID: 38972961 DOI: 10.1038/s41390-024-03411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/09/2024]
Abstract
Neonatal dysglycemia has been a longstanding interest of research in neonatology. Adverse outcomes from hypoglycemia were recognized early but are still being characterized. Premature infants additionally introduced and led the reflection on the importance of neonatal hyperglycemia. Cohorts of infants following neonatal encephalopathy provided further information about the impacts of hypoglycemia and, more recently, highlighted hyperglycemia as a central concern for this population. Innovative studies exposed the challenges of management of neonatal glycemic levels with a "u-shape" relationship between dysglycemia and adverse neurological outcomes. Lately, glycemic lability has been recognized as a key factor in adverse neurodevelopmental outcomes. Research and new technologies, such as MRI and continuous glucose monitoring, offered novel insight into neonatal dysglycemia. Combining clinical, physiological, and epidemiological data allowed the foundation of safe operational definitions, including initiation of treatment, to delineate neonatal hypoglycemia as ≤47 mg/dL, and >150-180 mg/dL for neonatal hyperglycemia. However, questions remain about the appropriate management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to continue to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes. IMPACT STATEMENT: Safe operational definitions guide the initiation of treatment of neonatal hypoglycemia and hyperglycemia. Innovative studies exposed the challenges of neonatal glycemia management with a "u-shaped" relationship between dysglycemia and adverse neurological outcomes. The importance of glycemic lability is also being recognized. However, questions remain about the optimal management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes.
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Affiliation(s)
- Micheline Lagacé
- Faculty of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, BC, Canada
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Emily W Y Tam
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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Maines E, Cardellini MC, Stringari G, Leonardi L, Piccoli G, Urru SAM, Maiorana A, Soffiati M, Franceschi R. Drug-Induced Hypoglycemia in Neonates Born to Nondiabetic Women Treated with Medications during the Pregnancy or the Labor: A Systematic Review of the Literature. Am J Perinatol 2024; 41:e2850-e2861. [PMID: 37848046 DOI: 10.1055/s-0043-1776061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
The prompt identification of at-risk newborns for drug-induced hypoglycemia can minimize the risk for adverse side effects, inappropriate investigations, and considerable unnecessary costs. Existing literature discusses drug-induced hypoglycemia, but a systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing. We reviewed the association between neonatal hypoglycemia and maternal medications. We systematically searched the literature according to the PICOS model on drug-induced hypoglycemia in neonates born to nondiabetic women treated with medications during the pregnancy or the labor. The main outcomes of the review were: (1) prevalence of hypoglycemia, (2) risk factors and potential confounders, (3) time at onset and severity of hypoglycemia, (4) dose-response gradient, (5) metabolic features of hypoglycemia, (6) modalities to treat hypoglycemia, and (7) quality of the studies. We included 69 studies in this review and we identified 11 groups of maternal drugs related to neonatal hypoglycemia. Results were classified for each outcome. Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia and in the differential diagnosis of neonatal hypoglycemia. Further studies are necessary to assess the risk of neonatal hypoglycemia associated with common maternal medications. KEY POINTS: · A systematic description of neonatal hypoglycemia induced or exacerbated by maternal medications is missing.. · In our review we identified 11 groups of maternal drugs related to neonatal hypoglycemia.. · Our review aims at supporting clinicians in the identification of the newborn at risk for hypoglycemia..
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Affiliation(s)
- Evelina Maines
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
| | | | - Giovanna Stringari
- Division of Neonatology, S. Chiara General Hospital, APSS, Trento, Italy
| | - Letizia Leonardi
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Department of Cellular, Computational and Integrative Biology, Università degli Studi di Trento, Trento, Italy
| | | | - Arianna Maiorana
- Division of Metabolism and Research Unit of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Massimo Soffiati
- Division of Pediatrics, S. Chiara General Hospital, APSS, Trento, Italy
- Division of Neonatology, S. Chiara General Hospital, APSS, Trento, Italy
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Harding JE, Alsweiler JM, Edwards TE, McKinlay CJD. Neonatal hypoglycaemia. BMJ MEDICINE 2024; 3:e000544. [PMID: 38618170 PMCID: PMC11015200 DOI: 10.1136/bmjmed-2023-000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Taygen E Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Chris JD McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Counties Manukau, Auckland, New Zealand
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Luo K, Tang J, Zhang M, He Y. Systematic review of guidelines on neonatal hypoglycemia. Clin Endocrinol (Oxf) 2024; 100:36-49. [PMID: 37997458 DOI: 10.1111/cen.14995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/24/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE In recent years, a series of clinical guidelines on neonatal hypoglycemia have been developed in different countries and regions. This systematic review was aimed at providing evidence for clinical decision-making and providing ideas for future research by comparatively analyzing the contents of various guidelines. METHODS A multilateral approach was used, including comprehensive literature searches and online research. The retrieved studies were screened by two independent reviewers according to our inclusion criteria. The two reviewers independently extracted the descriptive data. Four appraisers assessed the guidelines using the AGREE-II instrument. RESULTS Ten clinical guidelines on neonatal hypoglycemia were included, with a mean score of 45.28%-83.45% in six domains. The guidelines are relatively consistent in their recommendations on clinical symptoms of neonatal hypoglycemia, but different in risk factors, preventive measures, thresholds for clinical management of hypoglycemia, target glucose ranges for its control, and pharmacotherapy. CONCLUSION By summarising the recommendations in the guidelines on neonatal hypoglycemia, we found that blood glucose values were not the only observational indicator, and other indicators (e.g., ketone bodies, lactate) related to glucose metabolism should also be considered for a comprehensive assessment. There is still a lack of consensus on thresholds for the clinical management of hypoglycemia and target glucose ranges for its control, and the recommendations on its pharmacotherapy are rather simple and sketchy. In the future, more high-quality studies are required to further improve the early identification of neonatal hypoglycemia and intervention strategies against it.
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Affiliation(s)
- Keren Luo
- Department of Neonatology, West China Second Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Jun Tang
- Department of Neonatology, West China Second Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Meng Zhang
- Department of Neonatology, West China Second Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yang He
- Department of Neonatology, West China Second Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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King G, Tabery K, Hall M, Kelleher J. Delivery room glucose to reduce the risk of admission hypoglycemia in preterm infants: a systematic literature review. J Matern Fetal Neonatal Med 2023; 36:2183466. [PMID: 36863705 DOI: 10.1080/14767058.2023.2183466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
AIMS In order to mitigate early hypoglycemia in preterm infants, some clinicians have recently explored interventions such as delivery room commencement of dextrose infusions or delivery room administration of buccal dextrose gel. This review aimed to systematically investigate the literature regarding the provision of delivery room (prior to admission) parenteral glucose as a method to reduce the risk of initial hypoglycemia (measured at the time of NICU admission blood testing) in preterm infants. MATERIALS AND METHODS Using PRISMA guidelines a literature search (May 2022) was conducted using PubMed, Embase, Scopus, Cochrane Library, OpenGrey, and Prospero databases. The clinicaltrials.gov database was searched for possible completed/ongoing clinical trials. Studies that included moderate preterm (≤33+6 weeks) or younger birth gestations or very low birth weight (or smaller) infants, and that administered parenteral glucose in the delivery room were included. The literature was appraised via data extraction, narrative synthesis, and critical review of the study data. RESULTS A total of five studies (published 2014-2022) were eligible for inclusion (three before-after "quasi-experimental" studies, one retrospective cohort study, and one case-control study). Most included studies used intravenous dextrose as the intervention. Individual study effects (odds ratios) favored the intervention in all included studies. It was felt that the low number of studies, the variability in study design, and the nonadjustment for confounding co-interventions (co-exposures) precluded a meta-analysis. Quality assessment of the studies revealed a spectrum of bias from low to high risk, however, most studies had moderate to high risk of bias, and their direction of bias favored the intervention. CONCLUSIONS This extensive search and systematic appraisal of the literature indicates that there exists few studies (these are low grade and at moderate to high risk of bias) for the interventions of either intravenous or buccal dextrose given in the delivery room. It is not clear if these interventions impact on rates of early (NICU admission) hypoglycemia in these preterm infants. Obtaining intravenous access in the delivery room is not guaranteed and can be difficult in these small infants. Future research should consider various routes for commencing delivery room glucose in these preterm infants and should take the form of randomized controlled trials.
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Affiliation(s)
- Graham King
- Trinity College Institute of Neuroscience, The University of Dublin Trinity College, Dublin, Ireland.,Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Krystof Tabery
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Michael Hall
- University Hospital Southampton (Visiting Professor in Neonatology), University of Southampton, Southampton, United Kingdom
| | - John Kelleher
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.,Paediatrics, School of Medicine, The University of Dublin Trinity College, Dublin, Ireland
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Hoermann H, Roeper M, Welters A, Baertling F, Mayatepek E, Meissner T, Kummer S. Delayed-Onset Transient Hyperinsulinism in Infants with Very Low and Extremely Low Birth Weights: A Cohort Study. J Pediatr 2023; 258:113399. [PMID: 37019330 DOI: 10.1016/j.jpeds.2023.113399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/23/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023]
Abstract
We describe 16 infants born preterm with birth weights <1500 g and transient hyperinsulinism. The onset of hyperinsulinism was delayed and often coincident with clinical stabilization. We hypothesize that postnatal stress caused by prematurity and associated problems may contribute to development of delayed-onset transient hyperinsulinism.
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Affiliation(s)
- Henrike Hoermann
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Marcia Roeper
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alena Welters
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Fabian Baertling
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Roeper M, Hoermann H, Kummer S, Meissner T. Neonatal hypoglycemia: lack of evidence for a safe management. Front Endocrinol (Lausanne) 2023; 14:1179102. [PMID: 37361517 PMCID: PMC10285477 DOI: 10.3389/fendo.2023.1179102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Neonatal hypoglycemia affects up to 15% of all newborns. Despite the high prevalence there is no uniform definition of neonatal hypoglycemia, and existing guidelines differ significantly in terms of when and whom to screen for hypoglycemia, and where to set interventional thresholds and treatment goals. In this review, we discuss the difficulties to define hypoglycemia in neonates. Existing knowledge on different strategies to approach this problem will be reviewed with a focus on long-term neurodevelopmental outcome studies and results of interventional trials. Furthermore, we compare existing guidelines on the screening and management of neonatal hypoglycemia. We summarize that evidence-based knowledge about whom to screen, how to screen, and how to manage neonatal hypoglycemia is limited - particularly regarding operational thresholds (single values at which to intervene) and treatment goals (what blood glucose to aim for) to reliably prevent neurodevelopmental sequelae. These research gaps need to be addressed in future studies, systematically comparing different management strategies to progressively optimize the balance between prevention of neurodevelopmental sequelae and the burden of diagnostic or therapeutic procedures. Unfortunately, such studies are exceptionally challenging because they require large numbers of participants to be followed for years, as mild but relevant neurological consequences may not become apparent until mid-childhood or even later. Until there is clear, reproducible evidence on what blood glucose levels may be tolerated without negative impact, the operational threshold needs to include some safety margin to prevent potential long-term neurocognitive impairment from outweighing the short-term burden of hypoglycemia prevention during neonatal period.
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Hay WW. Symptomatic or Asymptomatic Neonatal Hypoglycemia-Can One Tell the Difference? J Pediatr 2022; 245:7-9. [PMID: 35351532 DOI: 10.1016/j.jpeds.2022.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- William W Hay
- Retired Professor, University of Colorado, Denver, Colorado.
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