Clinically stable very low birthweight infants are at risk for recurrent tissue glucose fluctuations even after fully established enteral nutrition

Insulin resistance prior to term age in very low birthweight infants: a prospective study

OBJECTIVE

To explore the glucose-related hormone profile of very low birthweight (VLBW) infants and assess the association between neonatal hyperglycaemia and insulin resistance during the admission period.

DESIGN

A prospective observational study-the Very Low Birth Weight Infants, Glucose and Hormonal Profiles over Time study.

SETTING

A tertiary neonatal intensive care unit and four neonatal units in county hospitals in Sweden.

PATIENTS

48 infants born <1500 g (VLBW) during 2016-2019.

OUTCOME MEASURES

Plasma concentrations of glucose-related hormones and proteins (C-peptide, insulin, ghrelin, glucagon-like peptide 1 (GLP-1), glucagon, leptin, resistin and proinsulin), insulin:C-peptide and proinsulin:insulin ratios, Homoeostatic Model Assessment 2 (HOMA2) and Quantitative Insulin Sensitivity Check (QUICKI) indices, measured on day of life (DOL) 7 and at postmenstrual age 36 weeks.

RESULTS

Lower gestational age was significantly associated with higher glucose, C-peptide, insulin, proinsulin, leptin, ghrelin, resistin and GLP-1 concentrations, increased HOMA2 index, and decreased QUICKI index and proinsulin:insulin ratio. Hyperglycaemic infants had significantly higher glucose, C-peptide, insulin, leptin and proinsulin concentrations, and lower QUICKI index, than normoglycaemic infants. Higher glucose and proinsulin concentrations and insulin:C-peptide ratio, and lower QUICKI index on DOL 7 were significantly associated with longer duration of hyperglycaemia during the admission period.

CONCLUSIONS

VLBW infants seem to have a hormone profile consistent with insulin resistance. Lower gestational age and hyperglycaemia are associated with higher concentrations of insulin resistance markers.

Hyperglycemia and prematurity: a narrative review

Hyperglycemia is commonly encountered in extremely preterm newborns and physiologically can be attributed to immaturity in several biochemical pathways related to glucose metabolism. Although hyperglycemia is associated with a variety of adverse outcomes frequently described in this population, evidence for causality is lacking. Variations in definitions and treatment approaches have further complicated the understanding and implications of hyperglycemia on the immediate and long-term effects in preterm newborns. In this review, we describe the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research. IMPACT: Hyperglycemia is common and less well described than hypoglycemia in extremely preterm newborns. Hyperglycemia can be attributed to immaturity in several cellular pathways involved in glucose metabolism in this age group. Hyperglycemia has been shown to be associated with a variety of adverse outcomes frequently described in this population; however, evidence for causality is lacking. Variations in definitions and treatment approaches have complicated the understanding and the implications of hyperglycemia on the immediate and long-term effects outcomes. This review describes the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research.

Should continuous glucose monitoring be used to manage neonates at risk of hypoglycaemia?

The National Institute for Clinical Excellence (NICE) now recommends that continuous glucose monitoring (CGM) be offered to adults and children with diabetes who are at risk from hypoglycaemia. Hypoglycaemia is common in the neonatal period, and is a preventable cause of poor neurodevelopmental outcome, but is CGM helpful in the management of neonates at risk of hypoglycaemia? Neonatal studies have shown that CGM can detect clinically silent hypoglycaemia, which has been associated with reduced executive and visual function in early childhood. Intervention trials have further shown CGM can support the targeting of glucose levels in high-risk extremely preterm neonates. In spite of significant advances in technology, including smaller sensors, better accuracy and factory calibration, further progress and adoption into clinical practice has been limited as current devices are not designed nor have regulatory approval for the specific needs of the newborn. The use of CGM has the potential to support clinical management, and prevention of hypoglycaemia but must be set within its current limitations. The data CGM provides however also provides an important opportunity to improve our understanding of potential risks of hypoglycaemia and the impact of clinical interventions to prevent it.

Cerebral Effects of Neonatal Dysglycemia

This article summarizes the available evidence reporting the relationship between perinatal dysglycemia and long-term neurodevelopment. We review the physiology of perinatal glucose metabolism and discuss the controversies surrounding definitions of perinatal dysglycemia. We briefly review the epidemiology of hypoglycemia and hyperglycemia in fetal, preterm, and term infants. We discuss potential pathophysiologic mechanisms contributing to dysglycemia and its effect on neurodevelopment. We highlight current strategies to prevent and treat dysglycemia in the context of neurodevelopmental outcomes. Finally, we discuss areas of future research and the potential role of continuous glucose monitoring.

Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study

BACKGROUND

There is a lack of evidence of the effect of cue-based feeding compared with scheduled feeding on important outcomes for preterm infants.

OBJECTIVES

The objectives were as follows: (1) to describe the characteristics, components, theoretical basis and outcomes of approaches to feeding preterm infants transitioning from tube to oral feeding; (2) to identify operational policies, barriers and facilitators, and staff and parents' educational needs in neonatal units implementing cue-based feeding; (3) to co-produce an intervention for feeding preterm infants in response to feeding cues; (4) to appraise the willingness of parents and staff to implement and sustain the intervention; (5) to assess associated costs of implementing cue-based feeding; (6) to determine the feasibility and acceptability of a future trial; (7) to scope existing data-recording systems and potential outcome measures; and (8) to determine stakeholders' views of whether or not a randomised controlled trial of this approach is feasible.

DESIGN

This was a mixed-methods intervention development and feasibility study comprising (1) a systematic review, case studies, qualitative research and stakeholder consensus; (2) the co-production of the intervention; (3) a mixed-methods feasibility study; and (4) an assessment of stakeholder preferences for a future evaluation.

SETTING

Three neonatal units in the UK (two level 3 units and one level 2 unit).

PARTICIPANTS

Developmentally normal, clinically stable preterm infants receiving enteral feeds (n = 50), parents (n = 15 pre intervention development; n = 14 in the feasibility study) and health-care practitioners (n = 54 pre intervention development; n = 16 in the feasibility study).

INTERVENTION

An evidence-informed multicomponent intervention comprising training, a feeding protocol, feeding assessment tools, supplementary training materials [including posters, a film and a narrated PowerPoint (Microsoft Corporation, Redmond, WA, USA) presentation] and the 'Our Feeding Journey' document.

MAIN OUTCOME MEASURES

The main outcome measures were recruitment and screening rates, infant weight gain, duration of the intervention, feeding outcomes, implementation outcomes (contextual facilitators and barriers, acceptability, adoption, appropriateness and fidelity) and stakeholder preferences for a future evaluation.

RESULTS

The systematic review of 25 studies concluded that evidence in favour of cue-based feeding should be treated cautiously. The case studies and qualitative research highlighted contextual barriers to and facilitators of the implementation of cue-based feeding. The telephone survey found that many neonatal units are considering implementing cue-based feeding. We recruited 37% of eligible infants, and there was good retention in the study until discharge but a high loss to follow-up at 2 weeks post discharge. The mean number of days from intervention to transition to full oral feeding was 10.8, and the mean daily change in weight gain was 25 g. The intervention was acceptable to parents and staff, although there was dissatisfaction with the study documentation. Intervention training did not reach all staff. A cluster-randomised design with a composite outcome was suggested by stakeholders for a future study.

LIMITATIONS

The intervention was available only in English. Intervention training did not reach all staff. There was low recruitment to qualitative interviews and observations. Only a small number of medical staff engaged in either the training or the interviews.

CONCLUSIONS

It is feasible to implement a cue-based feeding intervention with improved training and documentation. Further work is needed to assess the feasibility of a future trial, noting evidence of existing lack of equipoise.

FUTURE WORK

The next steps are to digitalise the intervention and conduct a survey of all neonatal units in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018097317 and ISRCTN13414304.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 74. See the NIHR Journals Library website for further project information.

Hyperglycemia in Extremely Preterm Infants

Hyperglycemia after birth is common in extremely preterm infants (<28 weeks of gestation). Lower gestational age, lower birthweight, presence of severe illness, and higher parenteral glucose intake increase the risk for hyperglycemia, while provision of higher amounts of amino acids and lipids in parenteral nutrition and early initiation and faster achievement of full enteral feeding decrease the risk. Hyperglycemia is associated with increased mortality and morbidity in the neonatal period. Limited data show an association with long-term adverse effects on growth, neurodevelopment, and cardiovascular and metabolic health. Lowering the glucose infusion rate and administration of insulin are the 2 treatment options. Lowering the glucose infusion could lead to calorie deficits and long-term adverse effects on growth and neurodevelopment. Conversely, insulin use increases the risk for hypoglycemia and requires close blood glucose monitoring and frequent adjustments to glucose infusion and insulin dosage. Randomized trials of varying strategies of nutrient provision and/or insulin therapy and long-term follow-up are needed to improve clinical care and overall health of extremely preterm infants with hyperglycemia.

Hyperglycaemia in the Newborn Infant. Physiology Verses Pathology

Hyperglycemia is common in newborns requiring intensive care, particularly in preterm infants, in sepsis and following perinatal hypoxia. The clinical significance, and optimal intervention strategy varies with context, but hyperglycaemia is associated with increased mortality and morbidity. The limited evidence for optimal clinical targets mean controversy remains regarding thresholds for intervention, and management strategies. The first consideration in the management of hyperglycaemia must be to ascertain potentially treatable causes. Calculation of the glucose infusion rate (GIR) to insure this is not excessive, is critical but the use of insulin is often helpful in the extremely preterm infant, but is associated with an increased risk of hypoglycaemia. The use of continuous glucose monitoring (CGM) has recently been demonstrated to be helpful in targeting glucose control, and reducing the risk from hypoglycaemia in the preterm infant. Its use in other at risk infants remains to be explored, and further studies are needed to provide a better understanding of the optimal glucose targets for different clinical conditions. In the future the combination of CGM and advances in computer algorithms, to provide intelligent closed loop systems, could allow a safer and more personalized approached to management.

Neonatal Hypoglycaemia: A Never-Ending Story?

Neonatal hypoglycaemia is a common metabolic disorder presenting in the first days of life and one potentially preventable cause of brain injury. However, a universal approach to diagnosis and management is still lacking. The rapid decrease in blood glucose (BG) after birth triggers homeostatic mechanisms. Most episodes of hypoglycaemia are asymptomatic, and symptoms, when they occur, are nonspecific. Therefore, neonatologists are presented with the challenge of identifying infants at risk who might benefit from a rapid and effective therapy while sparing others unnecessary sampling and overtreatment. There is much controversy regarding the definition of hypoglycaemia, and one level does not fit all infants since postnatal age and clinical situations trigger different accepted thresholds for therapy. The concentration and duration of BG which cause neurological damage are unclear. Recognizing which newborn infants are at risk of hypoglycaemia and establishing protocols for treatment are essential to avoid possible deleterious effects on neurodevelopment. Early breastfeeding may reduce the risk of hypoglycaemia, but in some cases, the amount of breast milk available immediately after birth is insufficient or non-existent. In these situations, other therapeutic alternatives such as oral dextrose gel may lower the risk for NICU admissions. Current guidelines continue to be based on expert opinion and weak evidence. However, malpractice litigation related to neurodevelopmental disorders is frequent in children who suffered hypoglycaemia in the neonatal period even if they had other important factors contributing to the poor outcome. This review is aimed to help the practicing paediatricians and neonatologists to comprehend neonatal hypoglycaemia from physiology to therapy, hoping it will result in a rational decision-making process in an area not sufficiently supported by evidence.

Open-Source Technology for Real-Time Continuous Glucose Monitoring in the Neonatal Intensive Care Unit: Case Study in a Neonate With Transient Congenital Hyperinsulinism

BACKGROUND

Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited.

OBJECTIVE

This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period.

METHODS

The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age.

RESULTS

Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time.

CONCLUSIONS

While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient's individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed.

Prematurity at less than 24 weeks of gestation is a risk for prolonged hyperglycemia in extremely low-birth weight infants

Hyperglycemia in extremely low-birth weight infants (ELBWIs) is frequently observed during the acute perinatal phase, (i.e., first 1-2 weeks postnatal period); however it can occasionally persists for >2 weeks, extending to the post-acute phase. Since such prolonged hyperglycemia (PH) is not typical for ELBWIs, the aim of the present study was to further understand the clinical details of PH. Twenty-five hyperglycemic ELBWIs born before 28 weeks of gestation from 2015 to 2018 were included in the study. Based on the duration of hyperglycemia, we separated the subjects into two groups: non-prolonged hyperglycemia (NPH) who achieved remission within ≤2 weeks [n = 18, median 3.0 (range, 2.0-4.0) days], and PH, whose hyperglycemia persisted for >2 weeks [n = 7, median 50.0 (range, 33.5-66.0) days]. Compared to the NPH group, glucose metabolism of the PH group was more deteriorate. The peak blood glucose level was significantly higher in the PH group [PH: median 472 mg/dL, NPH: median 275 mg/dL, p < 0.001], and a higher proportion of subjects in the PH group required insulin therapy [PH: 100% (7/7) vs. NPH: 22% (4/22)]. Multivariate analysis revealed that among perinatal factors, prematurity was the only independent risk factor for PH (glucocorticoid therapy: p = 0.884, gestational age: p = 0.006), with a cutoff of 23W4D determined by receiver operating characteristic analysis. Our data revealed distinctive clinical features of PH, suggesting a type different from the previously reported hyperglycemia in ELBWIs. Specifically, extreme prematurity, less than 24 weeks of gestation, is a risk for PH, and aggressive interventions, such as insulin would be required.

Management of a case of transient neonatal diabetes mellitus using continuous glucose monitoring

Neonatal diabetes mellitus (NDM) is a very rare disorder and its diagnosis can be challenging especially in mild and transient cases. Herein, we describe a 2.4-kg female infant born at 38 wk of gestation who showed hyperglycemia (388 mg/dL) on Day 1. Intermittent blood sampling showed glucose concentrations of 100–150 mg/dL on Day 2–5. However, continuous glucose monitoring (CGM) from Day 7 revealed hyperglycemia (> 200 mg/dL) after every feeding. The patient required low-dose (0.1–0.2 U/kg/d) insulin therapy for a short period (7 d). During the treatment, hypoglycemic (< 50 mg/dL) events were not detected by real- time CGM. Follow-up CGM from Day 32 showed normoglycemia for 3 full days; therefore, we ascertained that the diabetes had been transient. Later genetic analysis revealed an abnormal methylation pattern on chromosome 6q24, which is the most frequent cause of transient NDM. Most cases of 6q24-related NDM relapse after puberty, implying that long term follow up is required. We speculate that the NDM in this case might not have been diagnosed without CGM. This report highlights the usefulness of CGM for the initial diagnosis, monitoring during insulin therapy, and confirmation of improvement in patients with transient NDM.

Real time continuous glucose monitoring in neonatal intensive care

Hypoglycaemia and hyperglycaemia are common in infants requiring intensive care and are associated with worse clinical outcomes. However, glucose levels are taken infrequently, and there remains controversy regarding optimal management. In adults and children continuous glucose monitoring (CGM) is now established as an important adjunct to caring for patients at risk from dysglycaemia. This technology is also increasingly providing insights into glucose regulation in the newborn, demonstrating significant periods of clinically silent hypoglycaemia and hyperglycaemia. This baseline data will be important to allow the significance of glucose dysregulation on long-term outcomes to be assessed. Small studies have also shown the potential for CGM to safely support targeting of glucose control in preterm infants, and a large multicentre trial is ongoing. Current technology is not specifically designed for use in NICU, but with rapid technological developments, CGM holds promise for the future care of babies in NICU.

Delivery room interventions to improve the stabilization of extremely-low-birth-weight infants

OBJECTIVE

To retrospectively verify whether the positioning of the umbilical venous catheter (UVC) in the delivery room (DR) and the early start of the preheated infusion of 10% glucose solution conditioned temperature and glycemia values of ELBW neonates in the first hours of life.

METHODS

Neonates (N = 137) were divided into two groups on the basis of timing of positioning of the UVC. In Group I the UVC was placed in DR, while in Group II after Neonatal Intensive Care Unit (NICU) admission. Data were assessed in different times: body temperature at neonatal admission to NICU (T₁); after 2 hours (T₂); then, every 2 hours until normothermia; glycemia value at NICU admission, every 1-2 hours in the first 12 hours, every 4 hours from 12 to 24 hours, and every 6-12 hours until normalization. Time slot childbirth was also detected since only in the morning shift there was a dedicated resuscitation team always present in DR, while during the afternoon and night it was available on-call. Preventive measures to limit heat dispersion were adopted in both Groups.

RESULTS

In Group I respect to Group II, both at T₁ and T₂: (a) the rate of normothermic neonates was higher and (b) the rate of neonates with moderate hypothermia was lower. The hourly temperature increase was similar between the groups and the time needed to reach normothermia was significantly lower in Group I than in Group II. Glycemic values at T₁ were lower in Group II. In Group II, after UVC positioning and glucose solution administration, the 42.2% of infants immediately brought glycemia back to normal, while the 57.8% needed specific treatment. The majority of newborns of Group I was born during the morning shift.

CONCLUSIONS

The early UVC placement by a dedicated interdisciplinary team is a relevant intervention to carry out during the "Golden minutes" to improve the ELBW stabilization soon after birth.

Factors influencing glycaemic stability after neonatal hypoglycaemia and relationship to neurodevelopmental outcome

Higher and unstable glucose concentrations in the first 48 hours in neonates at risk of hypoglycaemia have been associated with neurosensory impairment. It is unclear what defines and contributes to instability. This was a prospective study of term and late preterm babies (N = 139) born at risk of neonatal hypoglycaemia who had interstitial glucose (IG) monitoring and ≥1 hypoglycaemic episode <48 hours after birth (blood glucose concentration <2.6 mmol/l [<47 mg/dl]). For 6-hour epochs after each hypoglycaemic episode, masked IG parameters (time to reach maximum IG concentration [hours]; range, average, maximum and minimum IG concentrations; proportion of IG measurements outside the central band of 3–4 mmol/l [54–72 md/dl]; and total duration [hours] of IG concentrations <2.6 mmol/l) were analysed in tertiles and related to: (i) glycaemic instability in the first 48 hours (defined as the proportion of blood glucose concentrations outside the central band in the first 48 hours); (ii) risk factors and treatment for each episode; and (iii) risk of neurosensory impairment at 4.5 years, or at 2 years if a child was not seen at 4.5 years. Glycaemic instability in the first 48 hours was related to IG instability after hypoglycaemia. Risk factors for hypoglycaemia were not related to IG parameters. Treatment with intravenous dextrose was associated with higher IG maximum and range, and lower minimum compared to treatment with dextrose gel plus breast milk, breast milk alone or formula alone. The risk of neurosensory impairment was increased with both shorter and longer time to reach maximum epoch IG (P = 0.04; lower tertile [0.4–2.2 hours] vs middle [2.3–4.2 hours] OR 3.10 [95% CI 1.03; 9.38]; higher tertile [4.3–6.0 hours] vs middle OR 3.07; [95% CI 1.01; 9.24]). Glycaemic response to hypoglycaemia contributes to overall glycaemic instability in newborns and is influenced by treatment. Slow or rapid recovery of hypoglycaemia appears to be associated with neurosensory impairment.

Impact of Feeding Interval on Time to Achieve Full Oral Feeding in Preterm Infants: A Randomized Trial

BACKGROUND

Preterm infants are scheduled to receive total feeding amount in either 3-hour or 2-hour intervals. A gavage feeding may be required if the scheduled amount is not completed orally. Feedings every 2 hours are one-third smaller than feedings every 3 hours. Thus, if the volume of each feed is reduced by decreasing the feeding interval from 3 to 2 hours, the likelihood that the infant completes each volume orally increases, and the probability of requiring gavage feeding decreases. The impact of feeding with 2-hour or 3-hour intervals on time to achieve full oral feeding in preterm infants was investigated.

METHODS

Infants on full enteral gavage feedings were randomized into 2 groups to receive feedings in either 3-hour or 2-hour intervals. The time to achieve full oral feeding and the duration of feeding transition from gavage to oral feedings were investigated. Data were presented as median (interquartile range).

RESULTS

The study included 100 infants (gestational age: 29 [28-31] weeks, birth weight: 1205 [1040-1380] g) with 50 in each group. The postmenstrual age to achieve full oral feeding was 35 (35-37) weeks in the 3-hour-interval group and 35 (34-36) weeks in the 2-hour-interval group; P = 0.131. The duration of feeding transition was similar between groups.

CONCLUSIONS

Feeding every 2 hours caused no improvement in the time to achieve full oral feeding. The 3-hour-interval feeding is appropriate for the neonatal units, where less handling of preterms and decreased workload of nurses are valuable.

Hyperglycemia in Extremely Preterm Infants-Insulin Treatment, Mortality and Nutrient Intakes

OBJECTIVE

To explore the prevalence of hyperglycemia and the associations between nutritional intakes, hyperglycemia, insulin treatment, and mortality in extremely preterm infants.

STUDY DESIGN

Prospectively collected data from the Extremely Preterm Infants in Sweden Study (EXPRESS) was used in this study and included 580 infants born <27 gestational weeks during 2004-2007. Available glucose measurements (n = 9850) as well as insulin treatment and nutritional data were obtained retrospectively from hospital records for the first 28 postnatal days as well as 28- and 70-day mortality data.

RESULTS

Daily prevalence of hyperglycemia >180 mg/dL (10 mmol/L) of up to 30% was observed during the first 2 postnatal weeks, followed by a slow decrease in its occurrence thereafter. Generalized additive model analysis showed that increasing parenteral carbohydrate supply with 1 g/kg/day was associated with a 1.6% increase in glucose concentration (P < .001). Hyperglycemia was associated with more than double the 28-day mortality risk (P < .01). In a logistic regression model, insulin treatment was associated with lower 28- and 70-day mortality when given to infants with hyperglycemia irrespective of the duration of the hyperglycemic episode (P < .05).

CONCLUSIONS

Hyperglycemia is common in extremely preterm infants throughout the first postnatal month. Glucose infusions seem to have only a minimal impact on glucose concentrations. In the EXPRESS cohort, insulin treatment was associated with lower mortality in infants with hyperglycemia. Current practices of hyperglycemia treatment in extremely preterm infants should be reevaluated and assessed in randomized controlled clinical trials.

Neonatal hypoglycemia: continuous glucose monitoring

PURPOSE OF REVIEW

Continuous glucose monitoring (CGM) is increasingly used in the management of diabetes in children and adults, but there are few data regarding its use in neonates. The purpose of this article is to discuss the potential benefits and limitations of CGM in neonates.

RECENT FINDINGS

Smaller electrodes in new sensors and real-time monitoring have made CGM devices more approachable for neonatal care. CGM is well tolerated in infants including very low birth weight babies, and few if any local complications have been reported. Use of CGM in newborns may reduce the frequency of blood sampling and improve glycemic stability, with more time spent in the euglycemic range. However, CGM may also lead to more intervention, with potential adverse effects on outcomes. More information is also needed about reliability, calibration and interpretation of CGM in the neonate.

SUMMARY

Although the use of CGM in neonates appears to be well tolerated, feasible and has been associated with better glycemic status, there is not yet any evidence of improved clinical outcomes. Clinical utility of CGM should be demonstrated in randomized trials prior to its introduction into regular neonatal care.

Fluctuation of blood glucose levels in an infant with an ileostomy on continuous glucose monitoring: A case report

Infants with an ileostomy can be at high risk of hypoglycemia because of inadequate nutritional intake; however, there are no reports investigating blood glucose (BG) in infants with ileostomy. We experienced a case of an extremely low birth weight infant who was born at 24 wk of gestation and weighted 623 g. He received an ileostomy because of an intestinal perforation. After the ileostomy, he had recurrent hypoglycemia. Continuous glucose monitoring showed fluctuation of BG levels (postprandial BG elevations and subsequent declines) and non-fasting hypoglycemia, which were undetectable with intermittent fasting BG measurement. The fluctuation of BG levels and non-fasting hypoglycemia improved after closure of the ileostomy. Patients with ileostomy may present with hypoglycemia that is undetectable with intermittent fasting BG measurement. In this case, continuous glucose monitoring was very useful for detecting fluctuation of BG levels and hypoglycemic episodes. Therefore, we recommend that continuous glucose monitoring be performed in infants with an ileostomy to confirm whether they have hypoglycemia or a fluctuation in BG levels. Further studies on the postprandial dynamics of various hormones in infants with ileostomy are required.

Continuous glucose monitoring in neonates: a review

Continuous glucose monitoring (CGM) is well established in the management of diabetes mellitus, but its role in neonatal glycaemic control is less clear. CGM has provided important insights about neonatal glucose metabolism, and there is increasing interest in its clinical use, particularly in preterm neonates and in those in whom glucose control is difficult. Neonatal glucose instability, including hypoglycaemia and hyperglycaemia, has been associated with poorer neurodevelopment, and CGM offers the possibility of adjusting treatment in real time to account for individual metabolic requirements while reducing the number of blood tests required, potentially improving long-term outcomes. However, current devices are optimised for use at relatively high glucose concentrations, and several technical issues need to be resolved before real-time CGM can be recommended for routine neonatal care. These include: 1) limited point accuracy, especially at low or rapidly changing glucose concentrations; 2) calibration methods that are designed for higher glucose concentrations of children and adults, and not for neonates; 3) sensor drift, which is under-recognised; and 4) the need for dynamic and integrated metrics that can be related to long-term neurodevelopmental outcomes. CGM remains an important tool for retrospective investigation of neonatal glycaemia and the effect of different treatments on glucose metabolism. However, at present CGM should be limited to research studies, and should only be introduced into routine clinical care once benefit is demonstrated in randomised trials.

Advances in nutrition of the newborn infant

Nutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. New developments include recommendations to increase protein supply, improve formulations of parenteral lipids, and provide mineral supplements while encouraging human milk feeding. However, high quality evidence of the risks and benefits of these developments is lacking. Clinical trials are also needed to assess the effect on preterm infants of experiencing the smell and taste of milk, to determine whether boys and girls should be fed differently, and to test effects of insulin and IGF-1 supplements on growth and developmental outcomes. Moderate-to-late preterm infants have neonatal nutritional challenges that are similar to those infants born at earlier gestations, but even less high quality evidence exists upon which to base clinical decisions. The focus of research in nutrition of infants born at term is largely directed at new formula products that will improve cognitive and metabolic outcomes. Providing the most effective nutrition to preterm infants should be prioritised as an important focus of neonatal care research to improve long-term metabolic and developmental outcomes.

[Hospital discharge criteria for very low birth weight newborns]

Hospital discharge criteria for the pre-term newborn are mainly based on physiological competences (thermoregulation, respiratory stability, and feeding skills), although family support and ability to care for the baby, as well as a well-planned discharge are also cornerstones to ensure a successful discharge. In this article, the Committee of Standards of the Spanish Society of Neonatology reviews the current hospital discharge criteria in order for it to be useful as a clinical guide in Spanish neonatal units.

Serial investigation of continuous glucose monitoring in a very low birth weight infant with transient late-onset hyperglycemia

Transient late-onset hyperglycemia was detected in a very low birth weight (VLBW) infant (gestational age 28 weeks, birth weight 1,082 g) by routine point-of-care glucose monitoring.　The infant had no clinical symptom.　Serial continuous glucose monitoring (CGM) was conducted for 3 days at 31, 35, and 39 weeks' post conceptual age.　The difference values between the maximum and minimum blood glucose levels during the interval from one enteral feeding to the next enteral feeding were 32.3±14.3 mg/dL, 47.5±22.9 mg/dL, and 27.5±12.9 mg/dL for the 1^st, 2^nd, and 3^rd CGM, respectively.　The serial change in the values was statistically significant (p<0.01).CGM is widely used as a routine clinical practice, which is true even in VLBW infants.　Hyperglycemic events detected by only once of CGM in otherwise healthy preterm infants have already been reported on larger numbers of patients.　To our knowledge, this is the first report that the change of glucose intolerance in a VLBW infant with transient late-onset hyperglycemia was investigated by serial CGM.

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of a policy of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth rates, levels of parent satisfaction, and time to hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 17 February 2016), Embase (1980 to 17 February 2016), and CINAHL (1982 to 17 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.36, 95% CI -2.44 to -0.29 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.53, 95% CI -6.80 to -4.25 days). GRADE assessments indicated low quality of evidence. The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some (low quality) evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.

Intraday glucose fluctuation is common in preterm infants receiving intermittent tube feeding

BACKGROUND

We previously reported on three preterm infants with blood glucose abnormalities after reaching full enteral feeding. Recently, it has been shown that clinically stable preterm infants may have large fluctuations in blood glucose after the establishment of enteral nutrition. We hypothesized that intraday glucose fluctuation is a common finding in preterm infants, but improves at term post-conceptual age. This report describes a case series.

METHODS

From June 2010 to July 2012, 13 preterm infants (29.5 ± 2.1 post-conceptual weeks, 1144 ± 319 g) were enrolled in this study. Continuous glucose monitoring (CGM) was conducted on average at 33.5 ± 1.4 post-conceptual weeks, when they received gastric tube feeding every 3 h in the absence of i.v. glucose supply.

RESULTS

Eight infants (62%) had large intraday glucose fluctuation with repeated hyperglycemic (>150 mg/dL) and hypoglycemic (<50 mg/dL) events. In five infants, follow-up CGM at 36-38 weeks post-conceptual age showed more stable glycemic changes without any abnormal glucose levels.

CONCLUSIONS

On CGM, in some preterm infants intermittent tube feeding resulted in large intraday glucose fluctuation at 31-35 post-conceptual weeks, but the pattern disappeared before discharge (36-38 post-conceptual weeks).

Responsive versus scheduled feeding for preterm infants

BACKGROUND

Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge.

OBJECTIVES

To assess the effect of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth, duration of hospital stay, and parental satisfaction.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2015), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), and CINAHL (1982 to September 2015), conference proceedings, previous reviews, and trial registries.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.4, 95% CI -2.4 to -0.3 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.5, 95% CI -6.8 to -4.2 days). The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views.

AUTHORS' CONCLUSIONS

Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. However, this finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.