Neonatal hypoglycemia: continuous glucose monitoring

Neonatal Hypoglycemia and Neurodevelopmental Outcomes-An Updated Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

The effects of neonatal hypoglycemia on the developing brain are well known, resulting in poor neurological outcomes. We aimed to perform an updated meta-analysis on neonatal hypoglycemia, the severity of hypoglycemia, and the associated neurodevelopmental outcomes from infancy to adulthood.

METHODS

A systematic literature search was conducted from inception until March 2024, using the PubMed, CINAHL, Embase, and the CENTRAL databases. Randomized/quasi-randomized trials and observational studies that evaluated at least one of the pre-specified outcomes were included. A random-effects model meta-analysis was performed to yield the pooled OR and its 95% CI for each outcome due to the expected heterogeneity in the studies. The study findings were reported as per the PRISMA guidelines. Neurodevelopmental impairment (NDI), cognitive impairment, and visual-motor or visual impairment were the primary outcomes.

RESULTS

A total of 17 studies (19 publications) were included in the final analysis. NDI, as defined by authors, was significantly higher in early- (OR = 1.16; 95% CI = 1.11-1.43) and mid-childhood (OR = 3.67; 95%CI = 1.07-12.2) in infants with neonatal hypoglycemia. 'Any cognitive impairment' was significantly more common in infants with neonatal hypoglycemia (OR = 2.12; 95%CI = 1.79-2.52). Visual-motor impairment (OR = 3.33; 95%CI = 1.14-9.72) and executive dysfunction (OR = 1.99; 95%CI = 1.36-2.91) were also more common in the hypoglycemic group. No difference in the incidence of epilepsy, motor impairment, emotional-behavioral problems, or hearing impairment were noted. Certainty of evidence was adjudged as 'low' to 'very low' for most outcomes. The severity of hypoglycemia was studied at different intervals, with NDI more common with a blood glucose interval between 20 and 34 mg/dL (1.1-1.9 mmol/L).

CONCLUSIONS

Low-quality evidence from large observational studies finds a significant association with hypoglycemia in the early neonatal period and long-term neurodevelopmental problems. Additional studies with long enough follow-up are paramount to determine the cut-off concentration and to quantify the impact beyond the infancy period.

Expanding the horizon of continuous glucose monitoring into the future of pediatric medicine

Glucose monitoring has rapidly evolved with the development of minimally invasive continuous glucose monitoring (CGM) using interstitial fluid. It is recommended as standard of care in the ambulatory setting, nearly replacing capillary glucose testing in those with access to CGM. The newest CGM devices continue to be smaller and more accurate, and integration with automated insulin delivery systems has further revolutionized the management of diabetes, leading to successful improvements in care and quality of life. Many studies confirm accuracy and application of CGM in various adult inpatient settings. Studies in adult patients increased during the COVID 19 Pandemic, but despite reassuring results, inpatient CGM use is not yet approved by the FDA. There is a lack of studies in inpatient pediatric settings, although data from the NICU and PICU have started to emerge. Given the exponential increase in the use of CGM, it is imperative that hospitals develop protocols for CGM use, with a need for ongoing implementation research. In this review we describe how CGM systems work, discuss benefits and barriers, summarize research in inpatient pediatric CGM use, explore gaps in research design along with emerging recommendations for inpatient use, and discuss overall CGM utility beyond outpatient diabetes management. IMPACT: Current CGM systems allow for uninterrupted monitoring of interstitial glucose excursions, and have triggered multiple innovations including automated insulin delivery. CGM technology has become part of standard of care for outpatient diabetes management, endorsed by many international medical societies, now with significant uptake, replacing capillary glucose testing for daily management in patients with access to CGM technology. Although CGM is not approved by the FDA for inpatient hospital use, studies in adult settings support its use in hospitals. More studies are needed for pediatrics. Implementation research is paramount to expand the role of CGM in the inpatient setting and beyond.

Relationship between EEG spectral power and dysglycemia with neurodevelopmental outcomes after neonatal encephalopathy

OBJECTIVE

We investigated how electroencephalography (EEG) quantitative measures and dysglycemia relate to neurodevelopmental outcomes following neonatal encephalopathy (NE).

METHODS

This retrospective study included 90 neonates with encephalopathy who received therapeutic hypothermia. EEG absolute spectral power was calculated during post-rewarming and 2-month follow-up. Measures of dysglycemia (hypoglycemia, hyperglycemia, and glycemic lability) and glucose variability were computed for the first 48 h of life. We evaluated the ability of EEG and glucose measures to predict neurodevelopmental outcomes at ≥ 18 months, using logistic regressions (with area under the receiver operating characteristic [AUROC] curves).

RESULTS

The post-rewarming global delta power (average all electrodes), hyperglycemia and glycemic lability predicted moderate/severe neurodevelopmental outcome separately (AUROC = 0.8, 95%CI [0.7,0.9], p < .001) and even more so when combined (AUROC = 0.9, 95%CI [0.8,0.9], p < .001). After adjusting for NE severity and magnetic resonance imaging (MRI) brain injury, only global delta power remained significantly associated with moderate/severe neurodevelopmental outcome (odds ratio [OR] = 0.9, 95%CI [0.8,1.0], p = .04), gross motor delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), global developmental delay (OR = 0.9, 95%CI [0.8,1.0], p = .04), and auditory deficits (OR = 0.9, 95%CI [0.8,1.0], p = .03).

CONCLUSIONS

In NE, global delta power post-rewarming was predictive of outcomes at ≥ 18 months.

SIGNIFICANCE

EEG markers post-rewarming can aid prediction of neurodevelopmental outcomes following NE.

Infants Eligible for Neonatal Hypoglycemia Screening: A Systematic Review

Importance

Neonatal hypoglycemia is common, occurring in up to 50% of infants at risk for hypoglycemia (infant of diabetic mother [IDM], small for gestational age [SGA], large for gestational age [LGA], and preterm) and is associated with long-term neurodevelopmental impairment. Guidelines recommend screening infants at risk of hypoglycemia. The proportion of infants who require screening for neonatal hypoglycemia is unknown.

Objective

To determine the proportion of infants eligible for neonatal hypoglycemia screening using criteria from the highest-scoring critically appraised clinical guideline.

Design, Setting, and Participants

This systematic review of the literature was conducted to identify clinical practice guidelines for neonatal hypoglycemia and took place at a tertiary maternity hospital in Auckland, New Zealand. Eligible guidelines were critically appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Using screening criteria extracted from the highest-scoring guideline, the proportion of infants eligible for neonatal hypoglycemia screening was determined in a retrospective observational cohort study of infants born January 1, 2004, to December 31, 2018. Data were analyzed by logistic regression. Infant participants were included if gestational age was 35 weeks or more, birth weight was 2000 g or more, and they were not admitted to a neonatal intensive care unit less than 1 hour after birth. The data were analyzed from November 2022 through February 2023. A total of 101 372 infants met the inclusion criteria.

Exposure

Risk factors for neonatal hypoglycemia.

Main Outcome

Proportion of infants eligible for neonatal hypoglycemia screening.

Results

The study team screened 2366 abstracts and 18 guidelines met inclusion criteria for appraisal. There was variability in the assessed quality of guidelines and a lack of consensus between screening criteria. The highest-scoring guideline defined screening criteria as: IDM, preterm (less than 37 weeks' gestation), SGA (less than 10th percentile), birth weight of less than 2500 g or more than 4500 g, LGA (more than 90th percentile), or gestational age more than 42 weeks. A total of 101 372 infants met criteria for inclusion in the cohort study; median (IQR) gestational age was 39 (38-40) weeks and 51% were male. The overall proportion of infants eligible for screening was 26.3%. There was an increase in the proportion of eligible infants from 25.6% to 28.5% over 15 years, which was not statistically significant after adjustment for maternal age, body mass index, ethnicity, and multiple pregnancy (odds ratio, 0.99; 95% CI, 0.93-1.03; change in proportion per year).

Conclusion

A systematic review found that practice guidelines providing recommendations for clinical care of neonatal hypoglycemia were of variable quality with is a lack of consensus regarding definitions for infants at risk for hypoglycemia. In the cohort study, one-quarter of infants were eligible for hypoglycemia screening. Further research is required to identify which infants may benefit from neonatal hypoglycemia screening.

Dilemmas in parenteral glucose delivery and approach to glucose monitoring and interpretation in the neonate

Glucose control continues to be challenging for intensivists, in particular in high-risk neonates. Many factors play a role in glucose regulation including intrinsic and extrinsic factors. Optimal targets for euglycemia are debatable with uncertain short and long-term effects. Glucose measurement technology has continued to advance over the past decade; unfortunately, the availability of these advanced devices outside of research continues to be problematic. Treatment approaches should be individualized depending on etiology, symptoms, and neonatal conditions. Glucose infusions should be titrated based upon variations in organ glucose uptake, co-morbidities and postnatal development. In this article we summarize the most common dilemmas encountered in the NICU: ranges for euglycemia, physiological differences, approach for glucose measurements, monitoring and best strategies to control parenteral glucose delivery.

Early treatment of neonatal diabetes with oral glibenclamide in an extremely preterm infant

Early treatment of neonatal diabetes with sulfonylureas has been proven to produce marked improvements of neurodevelopment, beside the demonstrated efficacy on glycemic control. Several barriers still prevent an early treatment in preterm babies including the limited availability of suitable galenic form of glibenclamide. We adopted oral glibenclamide suspension (Amglidia) for the early treatment of neonatal diabetes due to an homozygous variant of KCNJ11 gene c.10C>T [p.Arg4Cys] in an extremely preterm infant born at 26 + 2 weeks' of gestational age. After ~6 weeks of insulin treatment with a low glucose intake (4.5 g/kg/day), the infant was switched to Amglidia 6 mg/ml diluted in maternal milk, via nasogastric tube (0.2 mg/kg/day) progressively reduced to 0.01 mg/kg/day (after ~3 months). While on glibenclamide, the patient exhibited a mean daily growth of 11 g/kg/day. The treatment was suspended at month 6 of birth (weight 4.9 kg [5th-10th centile], M3 of c.a.) for normalization of glucose profile. During the treatment, the patient exhibited a stable glucose profile within the range of 4-8 mmol/L in the absence of hypo or hyperglycemic episodes with 2-3 blood glucose tests per day. The patient was diagnosed with retinopathy of prematurity Stade II in Zone II without plus disease at 32 weeks, with progressive regression and complete retinal vascularization at 6 months of birth. Amglidia could be regarded as the specific treatment for neonatal diabetes even in preterm babies due to its beneficial effect on the metabolic and neurodevelopmental side.

Continuous glucose monitoring in an infant with panhypopituitarism having hypoglycemia on growth hormone therapy

OBJECTIVES

The usefulness of continuous glucose monitoring (CGM) in infants with panhypopituitarism (PH) having hypoglycemia is yet to be explored. The potential adverse effects of growth hormone (GH) replacement therapy, such as hyperglycemia, cannot be comprehensively evaluated using the conventional measurement.

CASE PRESENTATION

A 2-month-old infant with PH, including severe GH deficiency, had hypoglycemia despite frequent feeding. Glucose levels were monitored using CGM before and after GH replacement therapy. The proportion of time for hypoglycemia decreased from 4.9 to 0% (p<0.017). Hyperglycemia did not increase. The CGM method did not contribute to any adverse events requiring intervention. Our patient only experienced minor bleeding and no episode of cellulitis.

CONCLUSIONS

CGM is useful in controlling glucose levels in infants with hypoglycemia and PH.

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.

Congenital hyperinsulinism in clinical practice: From biochemical pathophysiology to new monitoring techniques

Congenital hyperinsulinism comprises a group of diseases characterized by a persistent hyperinsulinemic hypoglycemia, due to mutation in the genes involved in the regulation of insulin secretion. The severity and the duration of hypoglycemic episodes, primarily in the neonatal period, can lead to neurological impairment. Detecting blood sugar is relatively simple but, unfortunately, symptoms associated with hypoglycemia may be non-specific. Research in this field has led to novel insight in diagnosis, monitoring and treatment, leading to a better neurological outcome. Given the increased availability of continuous glucose monitoring systems that allow glucose level recognition in a minimally invasive way, monitoring the glycemic trend becomes easier and there are more possibilities of a better follow-up of patients. We aim to provide an overview of new available technologies and new discoveries and their potential impact on clinical practice, convinced that only with a better awareness of the disease and available tools we can have a better impact on CHI diagnosis, prevention and clinical sequelae.

Continuous Glucose Monitoring in the Management of Neonates With Persistent Hypoglycemia and Congenital Hyperinsulinism

BACKGROUND

Persistent hypoglycemia is common in the newborn and is associated with poor neurodevelopmental outcome. Adequate monitoring is critical in prevention, but is dependent on frequent, often hourly blood sampling. Continuous glucose monitoring (CGM) is increasingly being used in children with type 1 diabetes mellitus, but use in neonatology remains limited. We aimed to introduce real-time CGM to provide insights into patterns of dysglycemia and to support the management of persistent neonatal hypoglycemia.

METHODS

This is a single-center retrospective study of real-time CGM use over a 4-year period in babies with persistent hypoglycemia.

RESULTS

CGMs were inserted in 14 babies: 8 term and 6 preterm infants, 9 with evidence of congenital hyperinsulinism (CHI). A total of 224 days of data was collected demonstrating marked fluctuations in glucose levels in babies with CHI, with a higher sensor glucose SD (1.52 ± 0.79 mmol/L vs 0.77 ± 0.22 mmol/L) in infants with CHI compared with preterm infants. A total of 1254 paired glucose values (CGM and blood) were compared and gave a mean absolute relative difference of 11%.

CONCLUSION

CGM highlighted the challenges of preventing hypoglycemia in these babies when using intermittent blood glucose levels alone, and the potential application of CGM as an adjunct to clinical care.

Continuous glucose monitoring for the prevention of morbidity and mortality in preterm infants

BACKGROUND

Preterm infants are susceptible to hyperglycaemia and hypoglycaemia, which may lead to adverse neurodevelopment. The use of continuous glucose monitoring (CGM) devices might help in keeping glucose levels in the normal range, and reduce the need for blood sampling. However, the use of CGM might be associated with harms in the preterm infant.

OBJECTIVES

To assess the benefits and harms of CGM versus intermittent modalities to measure glycaemia in preterm infants 1. at risk of hypoglycaemia or hyperglycaemia; 2. with proven hypoglycaemia; or 3. with proven hyperglycaemia.

SEARCH METHODS

We searched CENTRAL (2021, Issue 4); PubMed; Embase; and CINAHL in April 2021. We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs comparing the use of CGM versus intermittent modalities to measure glycaemia in preterm infants at risk of hypoglycaemia or hyperglycaemia; with proven hypoglycaemia; or with proven hyperglycaemia.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) with 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included four trials enrolling 300 infants in our updated review. We included one new study and excluded another previously included study (because the inclusion criteria of the review have been narrowed). We compared the use of CGM to intermittent modalities in preterm infants at risk of hypoglycaemia or hyperglycaemia; however, one of these trials was analyzed separately because CGM was used as a standalone device, without being coupled to a control algorithm as in the other trials. We identified no studies in preterm infants with proven hypoglycaemia or hyperglycaemia.  None of the four included trials reported the neurodevelopmental outcome (i.e. the primary outcome of this review), or seizures. The effect of the use of CGM on mortality during hospitalization is uncertain (RR 0.59, 95% CI 0.16 to 2.13; RD -0.02, 95% CI -0.07 to 0.03; 230 participants; 2 studies; very low-certainty evidence). The certainty of the evidence was very low for all outcomes because of limitations in study design, and imprecision of estimates. One study is ongoing (estimated sample size 60 infants) and planned to be completed in 2022.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if CGM affects preterm infant mortality or morbidities.  We are very uncertain of the safety of CGM and the available management algorithms, and many morbidities remain unreported. Preterm infants at risk of hypoglycaemia or hyperglycaemia were enrolled in all four included studies. No studies have been conducted in preterm infants with proven hypoglycaemia or hyperglycaemia. Long-term outcomes were not reported. Events of necrotizing enterocolitis, reported in the study published in 2021, were lower in the CGM group. However, the effect of CGM on this outcome remains very uncertain. Clinical trials are required to determine the most effective CGM and glycaemic management regimens in preterm infants before larger studies can be performed to assess the efficacy of CGM for reducing mortality, morbidity, and long-term neurodevelopmental impairments.

Influence of innate immune activation on endocrine and metabolic pathways in infancy

Prematurity is the leading cause of neonatal morbidity and mortality worldwide. Premature infants often require extended hospital stays, with increased risk of developing infection compared with term infants. A picture is emerging of wide-ranging deleterious consequences resulting from innate immune system activation in the newborn infant. Those who survive infection have been exposed to a stimulus that can impose long-lasting alterations into later life. In this review, we discuss sepsis-driven alterations in integrated neuroendocrine and metabolic pathways and highlight current knowledge gaps in respect of neonatal sepsis. We review established biomarkers for sepsis and extend the discussion to examine emerging findings from human and animal models of neonatal sepsis that propose novel biomarkers for early identification of sepsis. Future research in this area is required to establish a greater understanding of the distinct neonatal signature of early and late-stage infection, to improve diagnosis, curtail inappropriate antibiotic use, and promote precision medicine through a biomarker-guided empirical and adjunctive treatment approach for neonatal sepsis. There is an unmet clinical need to decrease sepsis-induced morbidity in neonates, to limit and prevent adverse consequences in later life and decrease mortality.

Case Report: Neonatal Diabetes Mellitus Caused by a Novel GLIS3 Mutation in Twins

Background

Mutations in GLIS3 cause a rare syndrome characterized by neonatal diabetes mellitus (NDM), congenital hypothyroidism, congenital glaucoma and cystic kidneys. To date, 14 mutations in GLIS3 have been reported, inherited in an autosomal recessive manner. GLIS3 is a key transcription factor involved in β-cell development, insulin expression, and development of the thyroid, eyes, liver and kidneys.

Cases

We describe non-identical twins born to consanguineous parents presenting with NDM, congenital hypothyroidism, congenital glaucoma, hepatic cholestasis, cystic kidney and delayed psychomotor development. Sequence analysis of GLIS3 identified a novel homozygous nonsense mutation, c.2392C>T, p.Gln798Ter (p.Q798*), which results in an early stop codon. The diabetes was treated with a continuous subcutaneous insulin infusion pump and continuous glucose monitoring. Fluctuating blood glucose and intermittent hypoglycemia were observed on follow-up.

Conclusions

This report highlights the importance of early molecular diagnosis for appropriate management of NDM. We describe a novel nonsense mutation of GLIS3 causing NDM, extend the phenotype, and discuss the challenges in clinical management. Our findings provide new areas for further investigation into the roles of GLIS3 in the pathophysiology of diabetes mellitus.

Intermittent Use of Continuous Glucose Monitoring: Expanding the Clinical Value of CGM

In addition to the continuous use, the intermittent use of continuous glucose monitoring (CGM) is an application of CGM, expanding the typical medical use cases. There are a variety of reasons and occasions that speak in favor of using CGM only for a limited time. To date, these circumstances have not been sufficiently discussed. In this article, we define discontinuous or intermittent CGM use, provide reasons for using it, and expand on the benefits and possibilities of using CGM on a temporary basis. We aim to draw attention to this important topic in the discussion of CGM use and give examples for a different method of CGM use. As well, we would like to foster the allocation of CGM to the right patient groups and indications, especially in cases of limited resources. From a global point of view, intermittent CGM use is more likely to occur than continuous use, primarily for economic reasons.

ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical conditions that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Clinical Aspects of Neonatal Hypoglycemia: A Mini Review

Introduction: Neonatal hypoglycemia is common and a preventable cause of brain damage. The goal of management is to prevent or minimize brain injury. The purpose of this mini review is to summarize recent advances and current thinking around clinical aspects of transient neonatal hypoglycemia. Results: The groups of babies at highest risk of hypoglycemia are well defined. However, the optimal frequency and duration of screening for hypoglycemia, as well as the threshold at which treatment would prevent brain injury, remains uncertain. Continuous interstitial glucose monitoring in a research setting provides useful information about glycemic control, including the duration, frequency, and severity of hypoglycemia. However, it remains unknown whether continuous monitoring is associated with clinical benefits or harms. Oral dextrose gel is increasingly being recommended as a first-line treatment for neonatal hypoglycemia. There is some evidence that even transient and clinically undetected episodes of neonatal hypoglycemia are associated with adverse sequelae, suggesting that prophylaxis should also be considered. Mild transient hypoglycemia is not associated with neurodevelopmental impairment at preschool ages, but is associated with low visual motor and executive function, and with neurodevelopmental impairment and poor literacy and mathematics achievement in later childhood. Conclusion: Our current management of neonatal hypoglycemia lacks a reliable evidence base. Randomized trials are required to assess the effects of different prophylactic and treatment strategies, but need to be adequately powered to assess outcomes at least to school age.

Continuous glucose monitoring for the prevention of morbidity and mortality in preterm infants

BACKGROUND

Preterm infants are susceptible to hyperglycemia and hypoglycemia, conditions which may lead to adverse neurodevelopment. The use of continuous glucose monitoring devices (CGM) might help keeping glucose levels in the normal range, and reduce the need for blood sampling. However, the use of CGM might be associated with harms in the preterm infant.

OBJECTIVES

Objective one: to assess the benefits and harms of CGM alone versus standard method of glycemic measure in preterm infants. Objective two: to assess the benefits and harms of CGM with automated algorithm versus standard method of glycemic measure in preterm infants. Objective three: to assess the benefits and harms of CGM with automated algorithm versus CGM without automated algorithm in preterm infants.

SEARCH METHODS

We adopted the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 9), in the Cochrane Library; MEDLINE via PubMed (1966 to 25 September 2020); Embase (1980 to 25 September 2020); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 25 September 2020). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs in preterm infants comparing: 1) the use of CGM versus intermittent modalities to measure glycemia (comparison 1); or CGM associated with prespecified interventions to correct hypoglycemia or hyperglycemia versus CGM without such prespecified interventions (comparison 2).

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

Four trials enrolling 138 infants met our inclusion criteria. Investigators in three trials (118 infants) compared the use of CGM to intermittent modalities (comparison one); however one of these trials was analyzed separately because CGM was used as a standalone device, without being coupled to a control algorithm like in the other trials. A fourth trial (20 infants) assessed CGM with an automated algorithm versus CGM with a manual algorithm. None of the four included trials reported the neurodevelopmental outcome, i.e. the primary outcome of this review. Within comparison one, the certainty of the evidence on the use of CGM on mortality during hospitalization is very uncertain (typical RR 3.00, 95% CI 0.13 to 70.30; typical RD 0.04, 95% CI -0.06 to 0.14; 50 participants; 1  study; very low certainty). The number of hypoglycemic episodes was reported in two studies with conflicting data. The number of hyperglycemic episodes was reported in one study (typical MD -1.40, 95% CI -2.84 to 0.04; 50 participants; 1 study). The certainty of the evidence was very low for all outcomes because of limitations in study design, and imprecision of estimates.  Three studies are ongoing.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if CGM improves preterm infant mortality or morbidities. Long-term outcomes were not reported. Clinical trials are required to determine the most effective CGM and glycemic management regimens in preterm infants before larger studies can be performed to assess the efficacy of CGM  for reducing mortality, morbidity and long-term neurodevelopmental impairments. The absence of CGM labelled for neonatal use is still a major limit in its use as well as the absence of dedicated neonatal devices.

Continuous glucose monitoring profile during therapeutic hypothermia in encephalopathic infants with unfavorable outcome

BACKGROUND

The relation between glucose homeostasis and outcome in hypoxic-ischemic encephalopathy (HIE) is unclear. To investigate whether glucose abnormalities assessed by using continuous interstitial glucose monitoring (CGM) correlate with later neurological outcomes in HIE.

METHODS

Prospective cohort study recruiting full-term neonates who received therapeutic hypothermia for HIE. CGM devices were placed soon after birth and recorded glucose profile for 3 days. The association between hypoglycemia (≤50 mg/dL), hyperglycemia (>144 mg/dL) and primary outcome defined as death or moderate or severe disability was examined with generalized estimating equations adjusted for Apgar scores, umbilical artery pH and base deficit. Neurodevelopmental outcome was assessed between 18 and 24 months.

RESULTS

Fifty-four neonates had outcome data available for the analysis; 19 of them (35%) had adverse outcome. Longer duration of hypoglycemia (OR 7.1, 95% CI 1.8-20.3, P < 0.001) and hyperglycemia (OR 5.4, 95% CI 1.6-15.7, P < 0.001), a greater area under the hypoglycemic (OR 2.6, 95% CI 1.4-4.6, P = 0.04) and hyperglycemic (OR 6.4, 95% CI 1.9-16.3, P < 0.001) curve were significantly associated with adverse outcomes.

CONCLUSION

Both hyper and hypoglycemia may be associated with adverse outcome in neonates with HIE. Future studies are needed to assess their prognostic association with neurological outcome.

IMPACT

Glucose abnormalities during therapeutic hypothermia are associated with later neurological outcomes.Increased glucose variability correlates to the neurological outcome between 18 and 24 months.This study provides the first data on the continuous glucose profile in a group of HIE infants followed up to 2 years of age.Glucose homeostasis represents a key point in the management of HIE patients.Further research is needed to find the appropriate glycemic target in this population.

Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

Hypoglycaemia in children is a major risk factor for adverse neurodevelopment with rates as high as 50% in hyperinsulinaemic hypoglycaemia (HH). A key part of management relies upon timely identification and treatment of hypoglycaemia. The current standard of care for glucose monitoring is by infrequent fingerprick plasma glucose testing but this carries a high risk of missed hypoglycaemia identification. High-frequency Continuous Glucose Monitoring (CGM) offers an attractive alternative for glucose trend monitoring and glycaemic phenotyping but its utility remains largely unestablished in disorders of hypoglycaemia. Attempts to determine accuracy through correlation with plasma glucose measurements using conventional methods such as Mean Absolute Relative Difference (MARD) overestimate accuracy at hypoglycaemia. The inaccuracy of CGM in true hypoglycaemia is amplified by calibration algorithms that prioritize hyperglycaemia over hypoglycaemia with minimal objective evidence of efficacy in HH. Conversely, alternative algorithm design has significant potential for predicting hypoglycaemia to prevent neuroglycopaenia and consequent brain dysfunction in childhood disorders. Delays in the detection of hypoglycaemia, alarm fatigue, device calibration and current high cost are all barriers to the wider adoption of CGM in disorders of hypoglycaemia. However, machine learning, artificial intelligence and other computer-generated algorithms now offer significant potential for further improvement in CGM device technology and widespread application in childhood hypoglycaemia.

Primum non nocere: earlier cessation of glucose monitoring is possible

Newborns are at relatively high risk for developing hypoglycaemia in the first 24 h after birth. Well-known risk factors are prematurity, small for gestational age (SGA) or large for gestational age (LGA), and maternal pre-existent or gestational diabetes mellitus. Prolonged hypoglycaemia is associated with poor neurodevelopmental outcomes; hence, prevention through proper monitoring and treatment is important. Given the ongoing debate concerning frequency and duration of screening for neonatal hypoglycaemia, therefore, we investigated the frequency and duration of glucose monitoring safe to discover neonatal hypoglycaemia in different risk groups. Data of newborns at risk for hypoglycaemia were retrospectively collected and analysed. Blood glucose concentrations were measured 1, 3, 6, 12, and 24 h after birth. Moderate hypoglycaemia was defined as a blood glucose concentration of < 2.2 mM and severe hypoglycaemia as a concentration of < 1.5 mM. Of 1570 newborns, 762 (48.5%) had at least one episode of hypoglycaemia in the first 24 h after birth; 30.6% of them had severe hypoglycaemia (all in the first 9 h after birth). Only three SGA and two LGA newborns had a first moderate asymptomatic hypoglycaemic episode beyond 12 h after birth. The incidence of hypoglycaemia increased with accumulation of multiple risk factors.

CONCLUSION

Safety of limiting the monitoring to 12 h still has to be carefully evaluated in the presence of SGA or LGA newborns; however, our results suggest that 12 h is enough for late preterm newborns (> 34 weeks) and maternal diabetes. What is Known: • Newborns are at relatively high risk for developing hypoglycaemia and such hypoglycaemia is associated with adverse neurodevelopmental outcomes. • Proper glucose monitoring and prompt treatment in case of neonatal hypoglycaemia are necessary. What is New: • Glucose monitoring 12 h after birth is proficient for most newborns at risk. • Maternal diabetes leads to the highest risk of early neonatal hypoglycaemia and newborns with more than one risk factor are at increased risk of hypoglycaemia.