Retrospective evaluation of a national guideline to prevent neonatal hypoglycemia

Transitional Neonatal Hypoglycemia and Adverse Neurodevelopment in Midchildhood

Importance

The circumstances under which neonatal hypoglycemia leads to brain damage remain unclear due to a lack of long-term data on the neurodevelopment of affected children. As a result, diagnostic strategies and treatment recommendations are inconsistent.

Objective

To evaluate whether the occurrence of severe transitional neonatal hypoglycemia (defined as having at least 1 blood glucose measurement of 30 mg/dL or below) is associated with adverse neurodevelopment in midchildhood.

Design, Setting, and Participants

This cohort study using neurodevelopmental testing of a retrospectively recruited cohort was conducted at a single-center tertiary hospital in Germany between March 2022 and February 2023. Children with neonatal blood glucose screening data were randomly selected from all births between 2010 and 2015. Frequency matching for sex, birth weight, gestational age, socioeconomic status, and primary risk factors for neonatal hypoglycemia was performed. Children with persistent hypoglycemia diseases or any risk factor for adverse neurodevelopment except hypoglycemia were excluded. Data were analyzed between February 2023 and March 2023.

Exposure

At least 1 neonatal hypoglycemia measurement with blood glucose measuring 30 mg/dL or below vs all measured blood glucose levels above 30 mg/dL during postnatal blood glucose screening starting on the first day of life.

Main Outcomes and Measures

Cognitive function measured by full-scale IQ test. Secondary outcomes included standardized scales of motor, visual, and executive functions, and child behavior, each measured at ages 7 to 11 years.

Results

A total of 140 children (mean [SD] age 9.1 [1.3] years; 77 male [55.0%]) participated in the study. Children with severe neonatal hypoglycemia had a 4.8 points lower mean full-scale IQ than controls (107.0 [95% CI, 104.0-109.9] vs 111.8 [95% CI, 108.8-114.8]). They showed a 4.9-fold (95% CI, 1.5-15.5) increased odds of abnormal fine motor function and a 5.3-fold (95% CI, 2.1-13.3) increased odds of abnormal visual-motor integration. Significantly higher T scores for attention problems (58.2 [95% CI, 56.1-60.2] vs 54.6 [95% CI, 52.6-56.6]) and attention-deficit/hyperactivity disorder symptoms (58.2 [95% CI, 56.2-60.2] vs 54.7 [95% CI, 52.8-56.7]) were reported by parents.

Conclusions and Relevance

Neonatal hypoglycemia with blood glucose levels of 30 mg/dL or below was associated with an increased risk for suboptimal neurodevelopmental outcomes in midchildhood. These findings imply that treatment strategies should aim to prevent episodes of hypoglycemia at these severely low levels.

Risk Factors for Hypoglycemia Among Neonates: A Prospective Cohort Study Among Pregnant People With Gestational Diabetes Mellitus

OBJECTIVE

Neonatal hypoglycemia (NH) is the most frequent complication in neonates born to pregnant people with gestational diabetes mellitus (GDM) and an important cause of brain damage and death of neonates. We explored the risk factors for NH in neonates of pregnant people with GDM.

METHODS

A prospective cohort study was conducted involving 322 pregnant people with GDM at the Guangzhou Women and Children's Medical Centre. Maternal sociodemographic, clinical, and biochemical data, as well as general characteristics of neonates, were collected to analyze their associations with NH in neonates of pregnant people with GDM.

RESULTS

The incidence of NH among neonates of pregnant people with GDM was 19.57% (63/322). After adjustment for confounders, the factors significantly associated with an increased risk of NH were cesarean delivery (relative risk [RR] = 3.44; 95% confidence interval [CI], 1.83-6.45), red blood cell (RBC) count (RR = 2.19; 95% CI, 1.22-3.96), and 1-hour postprandial glucose (RR = 2.35; 95% CI, 1.23-4.46) during pregnancy, whereas later gestational age (RR = 0.58; 95% CI, 0.42-0.80) and multiparity (RR = 0.32; 95% CI, 0.16-0.66) were associated with a reduced risk of NH.

CONCLUSION

Cesarean delivery, maternal 1-hour glucose of the oral glucose tolerance test, and increased RBC count of pregnant people with GDM are independent risk factors for NH, while later gestational age and multiparity are protective factors.

Neonatal hypoglycemia: lack of evidence for a safe management

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.

The Auxological and Metabolic Consequences for Children Born Small for Gestational Age

'Small for gestational age' (SGA) is an auxological and not an etiological definition that characterizes children born small based upon low-birth-weight and/or birth-length criteria [≥ 2 standard deviations (SD) below the mean for gestational age]. Most SGA children exhibit catch-up growth into the normal range within 6 mo of age. Overall SGA children are 4 cm shorter than expected based upon midparental height and being born SGA is a common cause of adult short stature. Recombinant human growth hormone (rhGH) has been shown to improve adult height by 0.9 SDs and is a safe treatment. Surprisingly, a higher rhGH dose (67 μgm/kg/d) did not lead to a greater adult height than a conventional dose (33 μgm/kg/d). At least 85% of SGA children treated through childhood with rhGH achieve a height within the normal adult range. Other long-term consequences for children born SGA include insulin resistance, abdominal adiposity, dyslipidemia, type 2 diabetes mellitus, and metabolic syndrome. Cross-sectional studies have found reduced insulin sensitivity in the neonatal, childhood, and young adult periods. Increased abdominal fat has been shown in preschool SGA children and is more evident in young adults. Increased adiposity markedly accentuates reduction in insulin sensitivity. Many SGA children have suffered from in utero nutritional restriction that leads to long-term growth restriction and adverse metabolic sequelae.

Clinical management and knowledge of neonatal hypoglycaemia in Germany: A national survey of midwives and nurses

AIM

Despite being a common metabolic condition, the detection and care of neonatal hypoglycaemia in Germany largely depends on the infant's health-care provider, rather than a national protocol. Therefore, this study aimed to evaluate midwives' and nurses' knowledge and management of neonatal hypoglycaemia and to determine the need for national guidelines.

METHODS

An anonymous online survey was developed and completed by 127 perinatal nurses and midwives. Descriptive statistics, Mann-Whitney-U, χ² and Fisher's exact tests were used to summarise and analyse the results.

RESULTS

In total, 82% of respondents indicated using guidelines but routine blood glucose screening for neonates at risk for hypoglycaemia was rarely reported (44%). A blood glucose concentration of 2.5 mmol/L (45 mg/dL) was considered the treatment threshold by 52% of the respondents. However, the responses to clinical scenarios showed distinct differences regarding the management of neonatal hypoglycaemia. Finally, 49% of respondents reported insufficient knowledge regarding neonatal hypoglycaemia and 77% indicated that they would advocate the implication of enhanced national guidelines.

CONCLUSIONS

There is considerable variation in knowledge about the prevention, screening and management of neonatal hypoglycaemia among nurses and midwives in Germany. Enhanced guidelines and education of health-care professionals are urgently needed to provide the best possible care to all hypoglycaemic newborns.

Higher C-peptide levels and glucose requirements may identify neonates with transient hyperinsulinism hypoglycemia who will benefit from diazoxide treatment

The aim of the study was to characterize factors that may serve as clinical tools to identify neonates with transient neonatal hyperinsulinism hypoglycemia (HH) who may benefit from diazoxide treatment. This retrospective study included 141 neonates with transient HH (93 males) of whom 34 (24%) were treated with diazoxide. Diazoxide treatment was started at median age of 13 days (range 5-35) and discontinued at median age of 42 days (range 14-224). The maximal dose was 7.1 ± 2.3 mg/kg/day. Diazoxide-treated neonates required a higher glucose infusion rate (GIR) compared with non-treated neonates (16.6 ± 3.4 vs. 10.4 ± 4.0 mg/kg/min, respectively, P < .01), had a longer duration of intravenous fluids (15.9 ± 9.3 vs. 7.8 ± 6.5 days, P < .01), a longer hospitalization (32.8 ± 22.7 vs. 20.4 ± 13.4 days, P < .01), a longer duration of carbohydrate supplementation (38.9 ± 40.4 vs. 17.8 ± 21.4 days, P < .01), and higher mean C-peptide levels on "critical sample" (1.4 ± 0.9 vs. 0.8 ± 0.5 ng/ml, P < .01). Their insulin levels also tended to be higher (3.5 ± 2.9 vs. 2.2 ± 3.8 μU/ml, P = .07). A stepwise logistic regression model revealed that significant predictors of prolonged HH were maximal GIRs (odds ratio (OR) 1.56, 95%; confidence interval (CI) 1.3-1.88, P < .001) and C-peptide levels (OR 3.57, 95%; CI 1.3-12.1, P = .005).Conclusion: Higher C-peptide levels and higher GIR requirements may serve as clinical tools to identify neonates with transient HH who may benefit from diazoxide treatment.What is Known:• Neonates with transient hyperinsulinism usually do not require treatment beyond glucose supplementation due to its self-limited clinical course, but some may benefit from diazoxide treatment.What is New:• Higher C-peptide levels and higher GIR requirements may serve as clinical tools to identify neonates with transient HH who may benefit from diazoxide treatment.• The incidence of prolonged neonatal HH is higher than the currently accepted figures.

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

Severe, persistent neonatal hypoglycemia as a presenting feature in patients with congenital hypopituitarism: a review of our case series

Background Persistent hypoglycemia (PH) beyond 3 days of life warrants investigation which includes a critical sample. We report our case series of five neonates who presented with PH as the first sign of congenital hypopituitarism. Design This is a case series. Methods/Results This is a case series of five neonates evaluated at our academic institution in a 3-year period (2013-2016), who presented with persistent severe hypoglycemia and were subsequently diagnosed with congenital hypopituitarism. All neonates were full term (mean gestational age 39.8 ± 1.4 weeks) born by caesarian section with a mean weight of 3.5 ± 0.16 kg and a mean length of 51.2 ± 1.2 cm at birth. All five neonates had PH beyond 3 days with an average blood glucose (BG) <35 mg/dL at presentation, requiring a mean glucose infusion rate (GIR) of 7.22 ± 1.98 mg/kg/min. The average BG during the critical sample was 42 ± 0.16 mg/dL (three patients). The mean duration of requirement of the glucose infusion was 6.2 ± 3 days during the immediate neonatal period. Diagnosis of the hypopituitarism took 2-52 days from the initial presentation of hypoglycemia. Besides growth hormone (GH) deficiency, cortisol deficiency was diagnosed in all the five neonates. Neuroimaging findings in all the neonates were consistent with pituitary stalk interruption syndrome (hypoplastic anterior pituitary, ectopic posterior pituitary [EPP] and interrupted pituitary stalk). Conclusions Hypoglycemia is a common metabolic complication affecting an infant in the immediate neonatal period. Delay in the diagnosis of hypopituitarism presenting as hypoglycemia is the result of the lack of awareness among neonatologists and/or pediatricians. We propose that providers be cognizant that PH can be the only presentation of hypopituitarism in the neonatal period. Therefore, having a high index of suspicion about this condition can avoid a delay in the evaluation, diagnosis and treatment of hypopituitarism.

Breastfeeding and skin-to-skin contact as non-pharmacological prevention of neonatal hypoglycemia in infants born to women with gestational diabetes; a Danish quasi-experimental study

OBJECTIVE

To investigate the effect on infant blood glucose levels of an intervention consisting of early, frequent breastfeeding and two hours of immediate uninterrupted skin-to-skin contact following birth of term infants born to mothers with diet-treated gestational diabetes (GDM).

STUDY DESIGN

Quasi-experimental study design with a historical control group (n = 132) and an intervention group (n = 401) testing a procedure to prevent neonatal hypoglycemia.

MAIN OUTCOME MEASURES

Data collection on blood glucose levels, hypoglycemia incidence with a cut-off of <2.5 mmol/l, breastfeeding within the first two hours after birth, breastfeeding frequency within the first six hours, and amount of formula given to hypoglycemic infants.

RESULTS

Mean blood glucose levels in the intervention group at two and four hours were within safe limits: 3.37 mmol/l (95% CI: [3.30, 3.44]) and 3.40 mmol/l (95% CI: [3.34, 3.46]), respectively. Infants suffering a hypoglycemic event within four hours after birth decreased from 22.7% (n = 30/132) in the control group to 10.2% (n = 41/401) in the intervention group. The mean number of breastfeeds in the intervention group (six hours) was 2.41 compared to 1.34 in the control group (seven hours), an increase of 80%. Only 41 of 401 infants in the intervention group were interrupted in immediate interaction with their mother because of hypoglycemia. We failed to obtain sufficient data on skin-to-skin contact.

CONCLUSION

Maintaining skin-to-skin contact for infants of mothers with diet-treated GDM, monitoring blood glucose levels until obtaining two values >2.4 mmol/l and encouraging early frequent breastfeeding is a safe strategy to prevent hypoglycemia.

Neonatal Hypoglycemia Following Diet-Controlled and Insulin-Treated Gestational Diabetes Mellitus

OBJECTIVE

To assess the risk of neonatal hypoglycemia following diet-controlled and insulin-treated gestational diabetes mellitus (GDM) and how it relates to birth weight.

RESEARCH DESIGN AND METHODS

Prospective cohort study included term neonates born after GDM from January 2013 through December 2015 at the University Medical Center Utrecht (Utrecht, the Netherlands). Routine screening of neonatal blood glucose levels was performed at 1, 3, 6, 12, and 24 h after birth. Main outcome measures were neonatal hypoglycemia defined as blood glucose ≤36 mg/dL (severe) and ≤47 mg/dL (mild).

RESULTS

A total of 506 neonates were included, born after pregnancies complicated by GDM treated either with insulin (22.5%) or without insulin (77.5%). The incidence of mild and severe hypoglycemia was similar in the insulin-treated and diet-controlled groups (33 vs. 35%, P = 0.66; and 20 vs. 21%, P = 0.79). A birth weight >90th centile was seen in 17.2% of all infants. Although children with a birth weight >90th centile had the highest risk for hypoglycemia, the vast majority of hypoglycemia (78.6%) was detected in those with a birth weight <90th centile. Over 95% of all hypoglycemia occurred within 12 h after birth.

CONCLUSIONS

Routine screening for neonatal hypoglycemia following pregnancies complicated by GDM reveals high incidence of both mild and severe hypoglycemia for both diet-controlled and insulin-treated GDM and across the full range of birth weight centiles. We propose routine blood glucose screening for neonatal hypoglycemia within the first 12 h of life in all neonates after GDM, irrespective of maternal insulin use or birth weight.

Do probiotics effectively ameliorate glycemic control during gestational diabetes? A systematic review

BACKGROUND

Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The aim of this work was to systematically review all studies in which probiotic supplements were used during pregnancy and analyse the effects on GDM.

METHODS

The data were collected using the medical subheading (MeSH) terms: ("diabetes, gestational"[MeSH Terms] OR ("diabetes"[All Fields] AND "gestational"[All Fields]) OR "gestational diabetes"[All Fields] OR ("gestational"[All Fields] AND "diabetes"[All Fields])) AND ("probiotics"[MeSH Terms] OR "probiotics"[All Fields]). The search included original articles written in English/Portuguese and published between 2012 and 2017.

RESULTS

Of the 31 articles identified, seven met the inclusion criteria and were included in this review. In these studies, the sample size ranged from 60 to 373 women with GDM, which was between 24 and 40 weeks of pregnancy (second and third trimesters). Results demonstrated that probiotics used during pregnancy in women with GDM may improve glycaemic control and reduce VDL cholesterol, triglycerides, and inflammatory markers.

CONCLUSIONS

The present systematic review highlights the importance of probiotics for glycemic control and decrease of inflammatory markers in GDM. Further long-term studies should be conducted to elucidate this interaction.