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Stanley CA, De Leon DD. Etiology of the Neonatal Hypoglycemias. Adv Pediatr 2024; 71:119-134. [PMID: 38944478 DOI: 10.1016/j.yapd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
To provide a more appropriate foundation for dealing with the problem of hypoglycemia in newborn infants, this article focuses on the mechanisms which underlie the various forms of neonatal hypoglycemia and discusses their implications for newborn care. Evidence indicates that all of the major forms of neonatal hypoglycemia are the result of hyperinsulinism due to dysregulation of pancreatic islet insulin secretion. Based on these observations, the authors propose that routine measurement of B-hydroxybutyrate should be considered an essential part of glucose monitoring in newborn infants.
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Affiliation(s)
- Charles A Stanley
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diva D De Leon
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Zamir I, Stoltz Sjöström E, van den Berg J, Berhan Y, Naumburg E, Domellöf M. Glucose disturbances in very low-birthweight infants-Results from the prospective LIGHT study. Acta Paediatr 2024. [PMID: 39087626 DOI: 10.1111/apa.17370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/20/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
AIM To describe glucose homeostasis disturbances (dysglycaemia) in very low-birthweight infants (<1500 g) during the admission period and explore associated risk factors. METHODS The LIGHT (very low-birthweight infants - glucose and hormonal profile over time) study was a prospective observational cohort study that included 49 very low-birthweight infants admitted to the tertiary neonatal intensive care unit in Umeå, Sweden, during 2016-2019. All glucose concentrations (n = 3515) sampled during the admission period were registered. RESULTS Hyperglycaemia >10 mmol/L and hypoglycaemia <2.6 mmol/L were registered in 63% and 55% of the infants, respectively. Onset of dysglycaemia occurred almost exclusively in the first postnatal week. Hyperglycaemia followed 15% of corticosteroid doses given; all were preceded by pre-existing hyperglycaemia. Pre-existing hyperglycaemia was found in 66.7% of hyperglycaemic infants who received inotrope treatment. Upon commencement, 72.5% of antimicrobial treatments given were neither preceded nor followed by hyperglycaemia. CONCLUSION Dysglycaemia was common in very low-birthweight infants. Daily means of glucose concentrations seemed to follow a postmenstrual age-dependent pattern, decreasing towards term age suggesting a postmenstrual age-dependent developmental mechanism. The primary mechanism causing hyperglycaemia was independent of sepsis, and corticosteroid and inotrope treatments. No hypoglycaemia was registered during ongoing insulin treatment.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | | | | | - Yonas Berhan
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Thornton PS, Hawkes CP. Approach to the Patient: Investigation of Pediatric Hypoglycemia in the Emergency Department-A Practical Algorithm. J Clin Endocrinol Metab 2024; 109:e1513-e1521. [PMID: 38320208 DOI: 10.1210/clinem/dgae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Abstract
Hypoglycemia in the pediatric population tends to present in the newborn period or during metabolic crisis triggered by prolonged fasting and intercurrent illness. Current recommendations to investigate all children presenting with hypoglycemia for the first time are cumbersome and costly but necessary to identify those with serious conditions who predispose to hypoglycemia. We describe a practical and cost-effective method of evaluating children who present to the emergency department with previously undiagnosed hypoglycemia. Glucose and point-of-care (POC) beta-hydroxybutyrate levels should be measured on all children with a low screening POC glucose level, and a full history and physical examination will identify those requiring further investigation. This approach is suggested to identify patients with serious and life-threatening disease with the same fidelity as the currently recommended approach of performing a critical sample on all children with hypoglycemia. Our streamlined approach will reduce the cost to approximately 10% of the current approach per patient diagnosed with a serious underlying disease. Further, children without underlying hypoglycemia-predisposing disorders will be identified and discharged without unnecessary intervention.
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Affiliation(s)
- Paul S Thornton
- Congential Hyperinsulinism Center, Cook Children's Medical Center, Fort Worth, TX 76104, USA
- Burnett School of Medicine, TCU, Fort Worth, TX 76109, USA
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Paediatrics and Child Health, University College Cork, Cork T12K8AF, Ireland
- INFANT Research Centre, University College Cork, Cork T12K8AF, Ireland
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Kaiser JR, Amatya S, Burke RJ, Corr TE, Darwish N, Gandhi CK, Gasda A, Glass KM, Kresch MJ, Mahdally SM, McGarvey MT, Mola SJ, Murray YL, Nissly K, Santiago-Aponte NM, Valencia JC, Palmer TW. Proposed Screening for Congenital Hyperinsulinism in Newborns: Perspective from a Neonatal-Perinatal Medicine Group. J Clin Med 2024; 13:2953. [PMID: 38792494 PMCID: PMC11122587 DOI: 10.3390/jcm13102953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
This perspective work by academic neonatal providers is written specifically for the audience of newborn care providers and neonatologists involved in neonatal hypoglycemia screening. Herein, we propose adding a screen for congenital hyperinsulinism (CHI) by measuring glucose and ketone (i.e., β-hydroxybutyrate (BOHB)) concentrations just prior to newborn hospital discharge and as close to 48 h after birth as possible, at the same time that the mandated state Newborn Dried Blood Spot Screen is obtained. In the proposed protocol, we do not recommend specific metabolite cutoffs, as our primary objective is to simply highlight the concept of screening for CHI in newborns to newborn caregivers. The premise for our proposed screen is based on the known effect of hyperinsulinism in suppressing ketogenesis, thereby limiting ketone production. We will briefly discuss genetic CHI, other forms of neonatal hypoglycemia, and their shared mechanisms; the mechanism of insulin regulation by functional pancreatic islet cell membrane KATP channels; adverse neurodevelopmental sequelae and brain injury due to missing or delaying the CHI diagnosis; the principles of a good screening test; how current neonatal hypoglycemia screening programs do not fulfill the criteria for being effective screening tests; and our proposed algorithm for screening for CHI in newborns.
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Affiliation(s)
- Jeffrey R. Kaiser
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Shaili Amatya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Rebecca J. Burke
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Tammy E. Corr
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Nada Darwish
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Chintan K. Gandhi
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Adrienne Gasda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Kristen M. Glass
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Mitchell J. Kresch
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Sarah M. Mahdally
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Maria T. McGarvey
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Sara J. Mola
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Yuanyi L. Murray
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Katie Nissly
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Nanyaly M. Santiago-Aponte
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Jazmine C. Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Timothy W. Palmer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
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Rattanasakol T, Kitsommart R. Factors associated with neonatal hyperinsulinemic hypoglycemia, a case-control study. J Pediatr Endocrinol Metab 2024; 37:243-249. [PMID: 38235510 DOI: 10.1515/jpem-2023-0526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/04/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVES We aimed to identify perinatal risk factors associated with hyperinsulinemic hypoglycemia in neonates. Secondary objectives included an examination of clinical and biochemical characteristics at the time of diagnosis and an exploration of the duration of diazoxide therapy. METHODS A case-control study was conducted, involving individual chart reviews of inborn infants diagnosed with hyperinsulinemic hypoglycemia (the HH group) between 2014 and 2021. These cases were paired with controls (the non-HH group) belonging to the same gestational age (GA) strata who did not exhibit HH or only had transient postnatal hypoglycemia. RESULTS A total of 52 infants with HH were matched with corresponding controls. The mean GA in the HH group was 34.4 ± 3.1 weeks. Notably, the HH group exhibited lower mean minimum plasma glucose (PG) levels and required higher glucose infusion rates in comparison to the non-HH group (26.5 ± 15.6 vs. 49.1 ± 37.7 mg/dL and 12.9 ± 3.8 vs. 5.7 ± 2.1 mg/kg/min, respectively; p<0.001 for both). After adjusting for potential confounding factors, only two variables, fetal growth restriction (FGR) and neonatal sepsis, demonstrated significant associations with HH (adjusted odds ratio [95 % confidence interval]: 8.1 [2.1-31.0], p=0.002 and 6.3 [1.9-21.4], p=0.003, respectively). The median duration of diazoxide therapy for the HH group was 4 months. CONCLUSIONS FGR and neonatal sepsis emerged as notable risk factors for HH. These infants exhibited lower PG levels and necessitated higher glucose infusion rates compared to their non-HH counterparts. Importantly, a substantial proportion of the HH group received diazoxide therapy, with a median treatment duration of 4 months.
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Affiliation(s)
- Thanaporn Rattanasakol
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Li Q, Wang H, Yang Q, Zhang L, Dai F, Yu L, Wu L, Ge J, Zhu P. Association of gestational cardiovascular health with infant neurodevelopment: A prospective study in Hefei of Anhui, China. Prev Med Rep 2024; 38:102586. [PMID: 38283966 PMCID: PMC10818252 DOI: 10.1016/j.pmedr.2024.102586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024] Open
Abstract
We investigate the prospective the association of gestational cardiovascular health (CVH) with infant neurodevelopment, and whether such relation was mediated by cord blood metabolites. The data come from the prospective birth cohort study in Hefei of Anhui, China. A total of 1714 mother-infant pairs are included from March 2018 and June 2021. CVH was evaluated at 24 to 28 gestational weeks by the combination of five metrics: body mass index, blood pressure, total cholesterol, glucose, and smoking. Cord blood samples were collected at delivery for the detection of related indicators. Infant neurodevelopment at 12 months was assessed by the Ages and Stages Questionnaire Edition 3 (ASQ-3). We stratified the status of CVH into three levels, ideal, intermediate, and poor. Compared with the ideal CVH, poor CVH was associated with infant communication domain failure (RR = 2.06; 95 %CI, 1.24-3.42) and cord blood C-peptide levels (β = 0.09; 95 %CI, 0.06-0.13) were higher. Cord blood C-peptide level with infant communication domain failure risk increased (RR = 3.43, 95 %CI: 2.11-5.58). Mediation analysis showed that cord blood C-peptide mediated 13.9 % of the effect. Key findings indicated that maternal poor CVH at 24 to 28 weeks gestation was associated with an increased risk of infant neurodevelopment at ASQ-3 failure in the communication domain, and cord blood C-peptide might mediate this association. The findings, if confirmed by replications, specific nursing cares among pregnant women with poor CVH, might have implications for the offspring neurodevelopment prevention strategies targeting.
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Affiliation(s)
- Qiong Li
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Haixia Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Qiaolan Yang
- Department of Urology, Institute of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lei Zhang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Feicai Dai
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Lijun Yu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Lin Wu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
| | - Jinfang Ge
- School of Pharmacy, Anhui Medical University, Hefei, China
| | - Peng Zhu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
- MOE Key Laboratory of Population Health Across Life Cycle, Hefei, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, Anhui Medical University, Hefei, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China
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Bezirganoglu H, Okur N, Celik K, Tas FF, Ozbek MN. Evaluation and management of neonatal onset hyperinsulinemic hypoglycemia: a single neonatal center experience. J Matern Fetal Neonatal Med 2023; 36:2272014. [PMID: 37860935 DOI: 10.1080/14767058.2023.2272014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVES To evaluate the clinical characteristics and treatment options of neonates requiring prolonged hospitalization due to persistent hyperinsulinemic hypoglycemia (HH). METHODS This retrospective cohort study included infants >34 weeks of gestation at birth who were born in our hospital between 2018 and 2021, diagnosed with HH, and required diazoxide within the first 28 days of life. The baseline clinical characteristics, age at the time of diagnosis and treatment options in diazoxide resistance cases were recorded. Genetic mutation analysis, if performed, was also included. RESULTS A total of 32 infants diagnosed with neonatal HH were followed up. Among the cohort, 25 infants were classified as having transient form of HH and seven infants were classified as having congenital hyperinsulinemic hypoglycemia (CHI). Thirty-one percent of the infants had no risk factors. The median birth weight was significantly higher in the CHI group, whereas no differences were found in other baseline characteristics. Patients diagnosed with CHI required higher glucose infusion rate, higher doses, and longer duration of diazoxide treatment than those in the transient HH group. Eight patients were resistant to diazoxide, and six of them required treatment with octreotide and finally sirolimus. Sirolimus prevented the need of pancreatectomy in five of six patients without causing major side effects. Homozygous mutations in the ABCC8 gene were found in four patients with CHI. CONCLUSIONS The risk of persistent neonatal hyperinsulinism should be considered in hypoglycemic neonates particularly located in regions with high rates of consanguinity. Our study demonstrated sirolimus as an effective treatment option in avoiding pancreatectomy in severe cases.
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Affiliation(s)
- Handan Bezirganoglu
- Division of Neonatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Nilufer Okur
- Division of Neonatology, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Kiymet Celik
- Division of Neonatology, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Funda Feryal Tas
- Division of Pediatric Endocrinology, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Mehmet Nuri Ozbek
- Department of Pediatrics, Division of Pediatric Endocrinology, Mardin Artuklu University Medical School, Mardin, Turkey
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Lee CT, Tsai WH, Chang CC, Chen PC, Fann CSJ, Chang HK, Liu SY, Wu MZ, Chiu PC, Hsu WM, Yang WS, Lai LP, Tsai WY, Yang SB, Chen PL. Genotype-phenotype correlation in Taiwanese children with diazoxide-unresponsive congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1283907. [PMID: 38033998 PMCID: PMC10687152 DOI: 10.3389/fendo.2023.1283907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Congenital hyperinsulinism (CHI) is a group of clinically and genetically heterogeneous disorders characterized by dysregulated insulin secretion. The aim of the study was to elucidate genetic etiologies of Taiwanese children with the most severe diazoxide-unresponsive CHI and analyze their genotype-phenotype correlations. Methods We combined Sanger with whole exome sequencing (WES) to analyze CHI-related genes. The allele frequency of the most common variant was estimated by single-nucleotide polymorphism haplotype analysis. The functional effects of the ATP-sensitive potassium (KATP) channel variants were assessed using patch clamp recording and Western blot. Results Nine of 13 (69%) patients with ten different pathogenic variants (7 in ABCC8, 2 in KCNJ11 and 1 in GCK) were identified by the combined sequencing. The variant ABCC8 p.T1042QfsX75 identified in three probands was located in a specific haplotype. Functional study revealed the human SUR1 (hSUR1)-L366F KATP channels failed to respond to intracellular MgADP and diazoxide while hSUR1-R797Q and hSUR1-R1393C KATP channels were defective in trafficking. One patient had a de novo dominant mutation in the GCK gene (p.I211F), and WES revealed mosaicism of this variant from another patient. Conclusion Pathogenic variants in KATP channels are the most common underlying cause of diazoxide-unresponsive CHI in the Taiwanese cohort. The p.T1042QfsX75 variant in the ABCC8 gene is highly suggestive of a founder effect. The I211F mutation in the GCK gene and three rare SUR1 variants associated with defective gating (p.L366F) or traffic (p.R797Q and p.R1393C) KATP channels are also associated with the diazoxide-unresponsive phenotype.
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Affiliation(s)
- Cheng-Ting Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Hao Tsai
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | | | - Pei-Chun Chen
- Department of Physiology, National Cheng-Kung University, Tainan, Taiwan
| | | | - Hsueh-Kai Chang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mu-Zon Wu
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pao-Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Ming Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Shiung Yang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ling-Ping Lai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Yu Tsai
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shi-Bing Yang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Pei-Lung Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
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9
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Alam KA, Svalastoga P, Martinez A, Glennon JC, Haavik J. Potassium channels in behavioral brain disorders. Molecular mechanisms and therapeutic potential: A narrative review. Neurosci Biobehav Rev 2023; 152:105301. [PMID: 37414376 DOI: 10.1016/j.neubiorev.2023.105301] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
Potassium channels (K+-channels) selectively control the passive flow of potassium ions across biological membranes and thereby also regulate membrane excitability. Genetic variants affecting many of the human K+-channels are well known causes of Mendelian disorders within cardiology, neurology, and endocrinology. K+-channels are also primary targets of many natural toxins from poisonous organisms and drugs used within cardiology and metabolism. As genetic tools are improving and larger clinical samples are being investigated, the spectrum of clinical phenotypes implicated in K+-channels dysfunction is rapidly expanding, notably within immunology, neurosciences, and metabolism. K+-channels that previously were considered to be expressed in only a few organs and to have discrete physiological functions, have recently been found in multiple tissues and with new, unexpected functions. The pleiotropic functions and patterns of expression of K+-channels may provide additional therapeutic opportunities, along with new emerging challenges from off-target effects. Here we review the functions and therapeutic potential of K+-channels, with an emphasis on the nervous system, roles in neuropsychiatric disorders and their involvement in other organ systems and diseases.
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Affiliation(s)
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway; Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | | | - Jeffrey Colm Glennon
- Conway Institute for Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Norway.
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10
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De Leon DD, Arnoux JB, Banerjee I, Bergada I, Bhatti T, Conwell LS, Fu J, Flanagan SE, Gillis D, Meissner T, Mohnike K, Pasquini TL, Shah P, Stanley CA, Vella A, Yorifuji T, Thornton PS. International Guidelines for the Diagnosis and Management of Hyperinsulinism. Horm Res Paediatr 2023; 97:279-298. [PMID: 37454648 PMCID: PMC11124746 DOI: 10.1159/000531766] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/16/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Hyperinsulinism (HI) due to dysregulation of pancreatic beta-cell insulin secretion is the most common and most severe cause of persistent hypoglycemia in infants and children. In the 65 years since HI in children was first described, there has been a dramatic advancement in the diagnostic tools available, including new genetic techniques and novel radiologic imaging for focal HI; however, there have been almost no new therapeutic modalities since the development of diazoxide. SUMMARY Recent advances in neonatal research and genetics have improved our understanding of the pathophysiology of both transient and persistent forms of neonatal hyperinsulinism. Rapid turnaround of genetic test results combined with advanced radiologic imaging can permit identification and localization of surgically-curable focal lesions in a large proportion of children with congenital forms of HI, but are only available in certain centers in "developed" countries. Diazoxide, the only drug currently approved for treating HI, was recently designated as an "essential medicine" by the World Health Organization but has been approved in only 16% of Latin American countries and remains unavailable in many under-developed areas of the world. Novel treatments for HI are emerging, but they await completion of safety and efficacy trials before being considered for clinical use. KEY MESSAGES This international consensus statement on diagnosis and management of HI was developed in order to assist specialists, general pediatricians, and neonatologists in early recognition and treatment of HI with the ultimate aim of reducing the prevalence of brain injury caused by hypoglycemia. A previous statement on diagnosis and management of HI in Japan was published in 2017. The current document provides an updated guideline for management of infants and children with HI and includes potential accommodations for less-developed regions of the world where resources may be limited.
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Affiliation(s)
- Diva D. De Leon
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants Malades Hospital, AP-HP, University of Paris-Cité, Paris, France
| | - Indraneel Banerjee
- Paediatric Endocrinology, Royal Manchester Children’s Hospital, University of Manchester, Manchester, UK
| | - Ignacio Bergada
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CONICET – FEI), Division de Endrocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Tricia Bhatti
- Department of Clinical Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Louise S. Conwell
- Australia and Children’s Health Queensland Clinical Unit, Department of Endocrinology and Diabetes, Queensland Children’s Hospital, Children’s Health Queensland, Greater Brisbane Clinical School, Medical School, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Junfen Fu
- National Clinical Research Center for Child Health, Department of Endocrinology, The Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sarah E. Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - David Gillis
- Hadassah Medical Center, Department of Pediatrics, Ein-Kerem, Jerusalem and Faculty of Medicine, Hebrew-University, Jerusalem, Israel
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Klaus Mohnike
- Department of General Pediatrics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Tai L.S. Pasquini
- Research and Policy Director, Congenital Hyperinsulinism International, Glen Ridge, NJ, USA
| | - Pratik Shah
- Pediatric Endocrinology, The Royal London Children’s Hospital, Queen Mary University of London, London, UK
| | - Charles A. Stanley
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Adrian Vella
- Division of Diabetes, Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Tohru Yorifuji
- Pediatric Endocrinology and Metabolism, Children’s Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Paul S. Thornton
- Congenital Hyperinsulinism Center, Cook Children’s Medical Center and Texas Christian University Burnett School of Medicine, Fort Worth, TX, USA
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Giouleka S, Gkiouleka M, Tsakiridis I, Daniilidou A, Mamopoulos A, Athanasiadis A, Dagklis T. Diagnosis and Management of Neonatal Hypoglycemia: A Comprehensive Review of Guidelines. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1220. [PMID: 37508719 PMCID: PMC10378472 DOI: 10.3390/children10071220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
Hypoglycemia represents one of the most frequent metabolic disturbances of the neonate, associated with increased morbidity and mortality, especially if left untreated or diagnosed after the establishment of brain damage. The aim of this study was to review and compare the recommendations from the most recently published influential guidelines on the diagnosis, screening, prevention and management of this common neonatal complication. Therefore, a descriptive review of the guidelines from the American Academy of Pediatrics (AAP), the British Association of Perinatal Medicine (BAPM), the European Foundation for the Care of the Newborn Infants (EFCNI), the Queensland Clinical Guidelines-Australia (AUS), the Canadian Pediatric Society (CPS) and the Pediatric Endocrine Society (PES) on neonatal hypoglycemia was carried out. There is a consensus among the reviewed guidelines on the risk factors, the clinical signs and symptoms of NH, and the main preventive strategies. Additionally, the importance of early recognition of at-risk infants, timely identification of NH and prompt initiation of treatment in optimizing the outcomes of hypoglycemic neonates are universally highlighted. All medical societies, except PES, recommend screening for NH in asymptomatic high-risk and symptomatic newborn infants, but they do not provide consistent screening approaches. Moreover, the reviewed guidelines point out that the diagnosis of NH should be confirmed by laboratory methods of BGL measurement, although treatment should not be delayed until the results become available. The definition of NH lacks uniformity and it is generally agreed that a single BG value cannot accurately define this clinical entity. Therefore, all medical societies support the use of operational thresholds for the management of NH, although discrepancies exist regarding the recommended cut-off values, the optimal treatment and surveillance strategies of both symptomatic and asymptomatic hypoglycemic neonates as well as the treatment targets. Over the past several decades, ΝH has remained an issue of keen debate as it is a preventable cause of brain injury and neurodevelopmental impairment; however, there is no clear definition or consistent treatment policies. Thus, the establishment of specific diagnostic criteria and uniform protocols for the management of this common biochemical disorder is of paramount importance as it will hopefully allow for the early identification of infants at risk, the establishment of efficient preventive measures, the optimal treatment in the first hours of a neonate's life and, subsequently, the improvement of neonatal outcomes.
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Affiliation(s)
- Sonia Giouleka
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Maria Gkiouleka
- University College London Hospital, University College London Medical School, 250 Euston Road, London NW1 2PG, UK
| | - Ioannis Tsakiridis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Anastasia Daniilidou
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
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12
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Al-Ameer A, Alsomali A, Habib Z. Incidence, predictors and outcomes of redo pancreatectomy in infants with congenital hyperinsulinism: a 16-year tertiary center experience. Pediatr Surg Int 2023; 39:183. [PMID: 37079145 DOI: 10.1007/s00383-023-05470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Recurrent severe hypoglycemic attacks often persist even after performing pancreatectomy for medically unresponsive congenital hyperinsulinism (CHI). In this study, we present our experience with redo pancreatectomy for CHI. METHODS We reviewed all children who underwent pancreatectomy for CHI between January 2005 and April 2021 in our center. A comparison was made between patients whose hypoglycemia was controlled after primary pancreatectomy and patients who required reoperation. RESULTS A total of 58 patients underwent pancreatectomy for CHI. Refractory hypoglycemia after pancreatectomy occurred in 10 patients (17%), who subsequently underwent redo pancreatectomy. All patients who required redo pancreatectomy had positive family history of CHI (p = 0.0031). Median extent of initial pancreatectomy was lesser in the redo group with borderline level of statistical significance (95% vs. 98%, p = 0.0561). Aggressive pancreatectomy at the initial surgery significantly (p = 0.0279) decreased the risk for the need to redo pancreatectomy; OR 0.793 (95% CI 0.645-0.975). Incidence of diabetes was significantly higher in the redo group (40% vs. 9%, p = 0.033). CONCLUSION Pancreatectomy with 98% extent of resection for diffuse CHI, especially with positive family history of CHI, is warranted to decrease the chance of reoperation for persistent severe hypoglycemia.
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Affiliation(s)
- Ali Al-Ameer
- Department of Pediatric Surgery, King Fahad Medical City, PO Box 59046, Riyadh, 11525, Kingdom of Saudi Arabia.
| | - Afrah Alsomali
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, 11211, Kingdom of Saudi Arabia
| | - Zakaria Habib
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, 11211, Kingdom of Saudi Arabia
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13
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Stanley CA, Thornton PS, De Leon DD. New approaches to screening and management of neonatal hypoglycemia based on improved understanding of the molecular mechanism of hypoglycemia. Front Pediatr 2023; 11:1071206. [PMID: 36969273 PMCID: PMC10036912 DOI: 10.3389/fped.2023.1071206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/23/2023] [Indexed: 03/29/2023] Open
Abstract
For the past 70 years, controversy about hypoglycemia in newborn infants has focused on a numerical "definition of neonatal hypoglycemia", without regard to its mechanism. This ignores the purpose of screening newborns for hypoglycemia, which is to identify those with pathological forms of hypoglycemia and to prevent hypoglycemic brain injury. Recent clinical and basic research indicates that the three major forms of neonatal hypoglycemia are caused by hyperinsulinism (recognizing also that other rare hormonal or metabolic conditions may also present during this time frame). These include transitional hypoglycemia, which affects all normal newborns in the first few days after birth; perinatal stress-induced hypoglycemia in high-risk newborns, which afflicts ∼1 in 1,200 newborns; and genetic forms of congenital hyperinsulinism which afflict ∼1 in 10,000-40,000 newborns. (1) Transitional hyperinsulinism in normal newborns reflects persistence of the low glucose threshold for insulin secretion during fetal life into the first few postnatal days. Recent data indicate that the underlying mechanism is decreased trafficking of ATP-sensitive potassium channels to the beta-cell plasma membrane, likely a result of the hypoxemic state of fetal life. (2) Perinatal stress-induced hyperinsulinism in high-risk infants appears to reflect an exaggeration of this normal low fetal glucose threshold for insulin release due to more severe and prolonged exposure to perinatal hypoxemia. (3) Genetic hyperinsulinism, in contrast, reflects permanent genetic defects in various steps controlling beta-cell insulin release, such as inactivating mutations of the K ATP-channel genes. The purpose of this report is to review our current knowledge of these three major forms of neonatal hyperinsulinism as a foundation for the diagnosis and management of hypoglycemia in newborn infants. This includes selection of appropriate interventions based on underlying disease mechanism; combined monitoring of both plasma glucose and ketone levels to improve screening for infants with persistent forms of hypoglycemia; and ultimately to ensure that infants at risk of persistent hyperinsulinemic hypoglycemia are recognized prior to discharge from the nursery.
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Affiliation(s)
- Charles A. Stanley
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Paul S. Thornton
- Congenital Hyperinsulinism Center, Division of Endocrinology, Cook Children’s Medical Center, Fort Worth, TX, United States
- Department of Pediatrics, Texas Christian University Burnett School of Medicine, Fort Worth, TX, United States
- Correspondence: Paul S. Thornton Diva D. De Leon
| | - Diva D. De Leon
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Correspondence: Paul S. Thornton Diva D. De Leon
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14
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Diazoxide for Neonatal Hyperinsulinemic Hypoglycemia and Pulmonary Hypertension. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010005. [PMID: 36670556 PMCID: PMC9856357 DOI: 10.3390/children10010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Hypoglycemia in neonates is associated with long-term neurodevelopmental effects. Hyperinsulinemic hypoglycemia (HH) is the most common cause of persistent hypoglycemia in neonatal intensive care units. Diazoxide is the only medication that is currently recommended for treatment of HH in neonates. However, the use of diazoxide in neonates is associated with pulmonary hypertension as an adverse effect. In this article, we review the literature on the mechanism of action and adverse effects with the use of diazoxide in neonatal hyperinsulinism. We then present a case series of neonates treated with diazoxide in our neonatal intensive care unit over a 5-year period. Among 23 neonates who received diazoxide, 4 developed pulmonary hypertension and 1 died. All infants who developed pulmonary hypertension were born preterm at less than 36 weeks gestation and had pre-existing risk factors for pulmonary hypertension. HH in preterm neonates, with pre-existing pulmonary hypertension or with risk factors for pulmonary hypertension requires thoughtful management.
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15
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Zhao J, Wang S, Hee Kim S, Han S, Rico-Bautista E, Sturchler E, Nguyen J, Tan H, Staley C, Karin Kusnetzow A, Betz SF, Johns M, Goulet L, Luo R, Fowler M, Athanacio J, Markison S, Scott Struthers R, Zhu Y. Discovery of 4-(3-aminopyrrolidinyl)-3-aryl-5-(benzimidazol-2-yl)-pyridines as potent and selective SST5 agonists for the treatment of congenital hyperinsulinism. Bioorg Med Chem Lett 2022; 71:128807. [PMID: 35605837 DOI: 10.1016/j.bmcl.2022.128807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/26/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Abstract
SST5 receptor activation potently inhibits insulin secretion from pancreatic β-cells, and an orally available nonpeptide selective SST5 agonist may be used to effectively manage the blood glucose levels of congenital HI patients to avoid severe hypoglycemia. Our medicinal chemistry efforts have led to the discovery of 4-(3-aminopyrrolidinyl)-3-aryl-5-(benzimidazol-2-yl)-pyridine analogs as potent SST5 agonists. This class of molecules exhibits excellent human SST5 potency and selectivity against SST1, SST2, SST3 and SST4 receptors. Leading compound 3-{4-[(3S)-3-aminopyrrolidin-1-yl]-5-(4-methyl-1H-1,3-benzodiazol-2-yl)pyridin-3-yl-5-fluorobenzonitrile (28, CRN02481) showed limited off-target activity and good pharmacokinetic profiles in both male Sprague Dawley rats and Beagle dogs to advance into further preclinical evaluations.
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Affiliation(s)
- Jian Zhao
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States.
| | - Shimiao Wang
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Sun Hee Kim
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Sangdon Han
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Elizabeth Rico-Bautista
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Emmanuel Sturchler
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Julie Nguyen
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Hannah Tan
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Christine Staley
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Ana Karin Kusnetzow
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Stephen F Betz
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Michael Johns
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Lance Goulet
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Rosa Luo
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Melissa Fowler
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Jon Athanacio
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Stacy Markison
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - R Scott Struthers
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
| | - Yunfei Zhu
- Crinetics Pharmaceuticals, Inc., 10222 Barnes Canyon Road, San Diego, CA 92121, United States
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16
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KOCA SB, ALTINTAŞ AH, DUBA B. Yenidoğan hipoglisemisine güncel yaklaşım. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.1074719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Serkan Bilge KOCA
- University of Health Sciences Kayseri City Educational and Research Hospital
| | | | - Büşra DUBA
- AFYONKARAHISAR HEALTH SCIENCES UNIVERSITY
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Saneifard H, Hajihashemi E, Fallahi M. Clinical Course and Outcome in Children with Congenital Hyperinsulinism. ARCHIVES OF IRANIAN MEDICINE 2022; 25:422-427. [DOI: 10.34172/aim.2022.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
Background: Hyperinsulinism is the most common cause of persistent or recurrent neonatal hypoglycemia that may result in neurological deficits. The treatment goal in these patients is prevention of hypoglycemia to decrease mortality and morbidity. This study was done to determine the clinical course and outcome in children with congenital hyperinsulinism (CHI) referring to Mofid Children’s Hospital from 2011 to 2017. Methods: This study was done on 22 children with CHI referring to Mofid Children’s Hospital from 2011 to 2017. The demographic, perinatal, clinical, laboratory, imaging, pharmacological, treatment and follow up data of these children were collected and analyzed. Results: Among 22 children with CHI, the mortality rate was higher among those who received hydrocortisone versus those who did not receive hydrocortisone (46% versus 40%). Conclusion: According to the results of this study, hydrocortisone had a negative impact on the outcomes of these children, which is important in the management of hypoglycemia. The clinical course and outcome of children with CHI was better with medical compared to surgical treatment.
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Affiliation(s)
| | - Elham Hajihashemi
- Pediatric Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Minoo Fallahi
- Neonatal Health Research Center, Research Institute for Children Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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18
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Elucidating the Relationship Between Maternal Diabetes and Neonatal Abstinence Syndrome: A 2017-2018 Project WATCH Study in Rural Appalachia. Adv Neonatal Care 2022; 22:239-245. [PMID: 34138790 DOI: 10.1097/anc.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous research indicated that diabetes during pregnancy results in a more permeable placenta. Based on this data, we hypothesized that women with maternal diabetes were more likely to have infants who developed neonatal abstinence syndrome (NAS). PURPOSE The purpose of the study was to examine the association between maternal diabetes and NAS in a cohort of women reporting substance use during pregnancy. METHODS This study used data from a population-based cohort of all newborns born in 2017 and 2018 (N = 36,974) in the state of West Virginia and restricted the analysis to those infants with intrauterine substance exposure (14%, n = 5188). Multiple logistic regression was performed to analyze the adjusted relationship between maternal diabetes and NAS while controlling for maternal and infant covariates. RESULTS Just over 28% of women with diabetes had an infant who developed NAS, whereas 34.8% of women without diabetes had an infant who developed NAS. The adjusted odds ratio of infants developing NAS born to women with diabetes was 0.70 (95% confidence interval: 0.51, 0.94) compared with those born to mothers without diabetes after controlling for covariates. Contrary to our hypothesis, the study suggests that maternal diabetes during pregnancy is associated with a decreased risk of an infant developing NAS. IMPLICATIONS FOR PRACTICE Future research generating from this hypothesis may lead to potential implications for practice for infants born to mothers with substance use during pregnancy and diabetes. IMPLICATIONS FOR RESEARCH More research should be conducted to investigate the relationship between glucose metabolism and NAS.
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Abstract
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.
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Affiliation(s)
- Megan E Paulsen
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414.
| | - Raghavendra B Rao
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414
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20
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Giri D, Hawton K, Senniappan S. Congenital hyperinsulinism: recent updates on molecular mechanisms, diagnosis and management. J Pediatr Endocrinol Metab 2022; 35:279-296. [PMID: 34547194 DOI: 10.1515/jpem-2021-0369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 12/20/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare disease characterized by an unregulated insulin release, leading to hypoglycaemia. It is the most frequent cause of persistent and severe hypoglycaemia in the neonatal period and early childhood. Mutations in 16 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, KCNQ1, CACNA1D, FOXA2, EIF2S3, PGM1 and PMM2) that are involved in regulating the insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms of CHI. CHI can also be associated with specific syndromes and can be secondary to intrauterine growth restriction (IUGR), maternal diabetes, birth asphyxia, etc. It is important to diagnose and promptly initiate appropriate management as untreated hypoglycaemia can be associated with significant neurodisability. CHI can be histopathologically classified into diffuse, focal and atypical forms. Advances in molecular genetics, imaging techniques (18F-fluoro-l-dihydroxyphenylalanine positron emission tomography/computed tomography scanning), novel medical therapies and surgical advances (laparoscopic pancreatectomy) have changed the management and improved the outcome of patients with CHI. This review article provides an overview of the background, clinical presentation, diagnosis, molecular genetics and therapy for children with different forms of CHI.
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Affiliation(s)
- Dinesh Giri
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Katherine Hawton
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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21
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Hyperinsulinism. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital or monogenic hyperinsulinism (HI) is a group of rare genetic disorders characterized by dysregulated insulin secretion and is the most common cause of persistent hypoglycemia in children. Knowledge of normal glucose homeostasis allows for a better understanding of the underlying pathophysiology of hyperinsulinemic hypoglycemia, facilitating timely diagnosis and management. The goal of management is to prevent cerebral insults secondary to hypoglycemia, which can result in poor neurologic outcomes and intellectual disability. Responsiveness to diazoxide, the first-line pharmacologic therapy for persistent hypoglycemia, is also the first step to distinguishing the different genotypic causes of monogenic hyperinsulinism. Early genetic testing becomes necessary when monogenic HI is strongly considered. Knowledge of specific gene mutations allows the determination of a clinical prognosis and definite therapeutic options, such as identifying those with focal forms of hyperinsulinism, who may attain a complete cure through surgical removal of specific affected parts of the pancreas. However, the lack of identifiable cause in a considerable number of patients identified with HI suggests there may be other genetic loci that are yet to be discovered. Furthermore, continued research is needed to explore new forms of therapy, particularly in severe, diazoxide-nonresponsive cases.
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22
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Güemes M, Kostopoulou E, AlYahyaei M, Gilbert C, Shah P. When is it best to discontinue diazoxide in children with persistent hyperinsulinaemic hypoglycaemia and negative genetics for K ATP channel gene variants? Clin Endocrinol (Oxf) 2022; 96:107-113. [PMID: 34370339 DOI: 10.1111/cen.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/26/2021] [Accepted: 07/27/2021] [Indexed: 11/29/2022]
Abstract
Diazoxide is the first-line treatment in children with hyperinsulinaemic hypoglycaemia (HH); however, limited information is available on the duration of diazoxide treatment in children who require over 2 years of it. Hence, we retrospectively reviewed the clinical and biochemical aspects, as well as the duration of therapy and neurodevelopmental assessment, in genetically uncharacterised diazoxide-responsive HH patients admitted to a tertiary hospital over the last 16 years, who had successfully discontinued diazoxide and remained euglycaemic. To exclude transient HH forms, only patients that required diazoxide for over 2 years were studied. We identified a total of 17 patients (70% males), in whom HH was diagnosed between 1 day and 18 months of age, and 88% were born at term with a median birth weight of 3.79 kg. All children responded to diazoxide at a median dose of 11.5 mg/kg/day, and it was stopped at a median age of 8.5 years, with a median duration of therapy of 7.25 years. The cases that required diazoxide the longest manifested no specific biochemical or clinical characteristics. Fasting tests performed after diazoxide discontinuation showed no longer requirement of diazoxide in all the cases. A total of 64.7% of the children showed mild to moderate developmental delay. Therefore, it seems that long-term resolution of HH in children with negative genetics for KATP channel genes who required diazoxide for over 2 years will ensue, and thus regular evaluation is crucial. The possible molecular mechanisms involved are unclear.
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Affiliation(s)
- Maria Güemes
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London, UK
- Department of Paediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Eirini Kostopoulou
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, School of Medicine, University of Patras, Patras, Greece
| | - Mouza AlYahyaei
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Paediatric Endocrinology, Royal Hospital, Muscat, Oman
| | - Clare Gilbert
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Pratik Shah
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London, UK
- Department of Paediatric Endocrine, Centre for Endocrinology, The Royal London Children's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK
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23
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Sigal WM, Alzahrani O, Guadalupe GM, Guzman H, Radcliffe J, Thomas NH, Jawad AF, De Leon DD. Natural history and neurodevelopmental outcomes in perinatal stress induced hyperinsulinism. Front Pediatr 2022; 10:999274. [PMID: 36389353 PMCID: PMC9659894 DOI: 10.3389/fped.2022.999274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To describe perinatal stress induced hyperinsulinism (PSIHI), determine the prevalence of neurodevelopmental differences, and identify risk factors for poor developmental prognosis. METHODS Subjects with a history of hyperinsulinism (HI) and perinatal stress and in whom resolution of the HI was demonstrated were included. Medical record review, caregiver interview, and three validated developmental assessments were completed. RESULTS Of the 107 subjects (75% male), 36% were born between 32 and 37 weeks. Median age of hypoglycemia presentation was 0 days. Median age at HI diagnosis was 12 days (IQR 13.5). Median length of time for initiation of definitive treatment was 14 days (IQR 14).Caregiver interviews were completed for 53 of 79 eligible subjects. Developmental concerns were reported by 51%. Neurodevelopmental assessments were completed by caregivers of 37 of the 53 enrolled subjects. The proportion of subjects scoring >1 SD and >2 SD away from the mean in the direction of concern on the major composite scores was significantly greater than in the general population (40.5% vs. 15.8%, P ≤ 0.0001 and 18.9% vs. 2.2%, P ≤ 0.0001, respectively).Male sex, small for gestational age status (SGA), and treatment with continuous feeds were associated with assessment scores >1 SD from the mean (P < 0.05). SGA and preeclampsia were associated with assessment scores >2 SD from the mean (P < 0.05). CONCLUSION While the majority of infants presented with hypoglycemia in the first day of life, diagnosis and treatment occurred 12-14 days later. Children with PSIHI are at high risk of neurodevelopmental deficits and are more likely to perform below average on developmental assessment.
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Affiliation(s)
- Winnie M Sigal
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Ohoud Alzahrani
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Gabriela M Guadalupe
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Herodes Guzman
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jerilynn Radcliffe
- Behavioral Neuroscience Core, Center for Human Phenomic Science, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Developmental and Behavioral Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nina H Thomas
- Behavioral Neuroscience Core, Center for Human Phenomic Science, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Child and Adolescent Psychiatry, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Psychiatry, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abbas F Jawad
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Biostatistics Core, Center for Human Phenomic Science, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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24
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Win M, Beckett R, Thomson L, Thankamony A, Beardsall K. Continuous Glucose Monitoring in the Management of Neonates With Persistent Hypoglycemia and Congenital Hyperinsulinism. J Clin Endocrinol Metab 2022; 107:e246-e253. [PMID: 34407200 PMCID: PMC8830056 DOI: 10.1210/clinem/dgab601] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Myat Win
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Rowan Beckett
- School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Lynn Thomson
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Ajay Thankamony
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Kathryn Beardsall
- Department of Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
- Department of Paediatrics, University of Cambridge, Cambridge CB2 0QQ, UK
- Correspondence: Kathryn Beardsall, University of Cambridge, Department of Paediatrics, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
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25
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Raskin J, Pasquini TLS, Bose S, Tallis D, Schmitt J. Congenital Hyperinsulinism International: A Community Focused on Improving the Lives of People Living With Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2022; 13:886552. [PMID: 35573986 PMCID: PMC9097272 DOI: 10.3389/fendo.2022.886552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 12/03/2022] Open
Abstract
Congenital hyperinsulinism (HI) is a rare disease affecting newborns. HI causes severe hypoglycemia due to the overproduction of insulin. The signs and symptoms of hypoglycemia in HI babies is often not discovered until brain damage has already occurred. Prolonged hypoglycemia from HI can even lead to death. Disease management is often complex with a high burden on caregivers. Treatment options are extremely limited and often require long hospital stays to devise. Cascading from suboptimal treatments and diagnostic practices are a host of other problems and challenges that many with HI and their families experience including continued fear of hypoglycemia and feeding problems. The aim of this paper is (1) to describe the current challenges of living with HI including diagnosis and disease management told from the perspective of people who live with the condition (2), to provide family stories of life with HI, and (3) to share how a rare disease patient organization, Congenital Hyperinsulinism International (CHI) is working to improve the lives of HI patients and their families. CHI is a United States based nonprofit organization with a global focus. The paper communicates the programs the patient advocacy organization has put into place to support HI families through its virtual and in-person gatherings. The organization also helps individuals access diagnostics, medical experts, and treatments. CHI also raises awareness of HI to improve patient outcomes with information about HI and prolonged hypoglycemia in twenty-three languages. CHI drives innovation for new and better treatments by funding research pilot grants, conducting research through the HI Global Registry, and providing patient experience expertise to researchers developing new treatments. The organization is also the sponsor of the CHI Collaborative Research Network which brings medical and scientific experts together for the development of a patient-focused prioritized research agenda.
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Vijayanand S, Stevenson PG, Grant M, Choong CS, Davis EA, Abraham MB. The utility of continuous glucose monitoring systems in the management of children with persistent hypoglycaemia. J Pediatr Endocrinol Metab 2021; 34:1567-1572. [PMID: 34520640 DOI: 10.1515/jpem-2021-0414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/02/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Glucose monitoring is vital in children with persistent hypoglycaemia to reduce the risk of adverse neuro-behavioural outcomes; especially in children with hyperinsulinism. The role of continuous glucose monitoring (CGM) systems in monitoring glucose levels in this cohort is limited. The objective of this study was to ascertain the effectiveness of CGM and to evaluate parents' experience of using CGM for monitoring glucose levels in children with hypoglycaemia. METHODS Retrospective analysis of sensor glucose (SG) values from Dexcom G4 CGM with paired finger-prick blood glucose (BG) values was performed to determine the accuracy of CGM. The parent experience of CGM was assessed using a questionnaire administered to families of children with congenital hyperinsulinism currently attending the clinic. RESULTS SG data from 40 children (median age 6 months) with persistent hypoglycaemia (60% Hyperinsulinism) were analysed. The mean difference between 5,650 paired BG and SG values was 0.28 mmol/L. The sensitivity and specificity of CGM to identify severe hypoglycaemia (BG < 3.0 mmol/L) were 54.3% (95% CI: 39.0%, 69.1%) and 97.4% (95% CI: 96.9%, 97.8%) respectively. Parents (n=11) reported less anxiety (n=9), better sleep at night (n=7) and preferred to use CGM for monitoring (n=9). CONCLUSIONS Although the high number of false-positive readings precludes the routine use of CGM in the evaluation of hypoglycaemia, it avoids unnecessary BG testing during normoglycaemia. It is an acceptable tool for parents for monitoring their children who are at risk of hypoglycaemia. Newer CGM systems with improved accuracy at lower glucose levels have the potential to further improve monitoring.
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Affiliation(s)
- Sathyakala Vijayanand
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Paul G Stevenson
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Maree Grant
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Catherine S Choong
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- The University of Western Australia, Perth, Western Australia, Australia
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Maiorana A, Caviglia S, Greco B, Alfieri P, Cumbo F, Campana C, Bernabei SM, Cusmai R, Mosca A, Dionisi-Vici C. Ketogenic diet as elective treatment in patients with drug-unresponsive hyperinsulinemic hypoglycemia caused by glucokinase mutations. Orphanet J Rare Dis 2021; 16:424. [PMID: 34635134 PMCID: PMC8507241 DOI: 10.1186/s13023-021-02045-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hyperinsulinemic hypoglycemia (HI) is the most frequent cause of recurrent hypoglycemia in children. Despite diagnostic and therapeutic advances, it remains an important cause of morbidity, leading to neurological complications, such as psychomotor retardation and epilepsy. Patients with diffuse drug-unresponsive HI manifest neurological impairment and neurobehavioral problems, even though surgically treated with a near-total pancreatectomy. Based on the analogies between HI and GLUT1 deficiency, both presenting with neuroglycopenia and lack of alternative cerebral energy sources, we administered a ketogenic diet (KD) in three drug-unresponsive GCK-HI patients with the aim of preserving neurodevelopment and avoiding the need of a near-total pancreatectomy. They presented recurrent symptomatic hypoglycemia, intellectual disability and refractory epilepsy. Patients were treated with classical KD for 79, 27 and 18 months, respectively. Results All patients became asymptomatic in a few days and showed an important improvement of the alert state. Epilepsy disappeared and no appearance of novel hypoglycemic lesions was detected with a brain MRI. Cognitive and adaptive abilities rapidly improved and normalized. IQ rose significantly from 81 to 111 (p = 0.04) in patient 1, from 82 vs 95 (p = 0.04) in patient 2, from 60 to 90 (p = 0.04) in patient 3. Conclusions We demonstrated the safety and efficacy of KD in the treatment of drug-unresponsive GCK-HI at a short and long-term. The neuroprotective effects of KD determined the recovery from epilepsy and intellectual disabilities and averted the need of a near-total pancreatectomy. All patients and their families reported an improvement of physical and psychosocial well-being, with a substantial improvement of their quality of life. These results might change the course and the quality of life of these patients and their families, having a relevant impact on human lives. Therefore, KD might be considered the elective treatment in unresponsive forms of GCK-HI. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02045-3.
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Affiliation(s)
- Arianna Maiorana
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCSS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Stefania Caviglia
- Psychology Clinic Unit, Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Benedetta Greco
- Psychology Clinic Unit, Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Paolo Alfieri
- Child and Adolescent Psychiatric Unit, Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesca Cumbo
- Child and Adolescent Psychiatric Unit, Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Carmen Campana
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCSS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Silvia Maria Bernabei
- Division of Artificial Nutrition, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Raffaella Cusmai
- Neurology Unit, Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Antonella Mosca
- Department of Hepatology, Gastroenterology and Nutrition, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCSS, Piazza S. Onofrio 4, 00165, Rome, Italy
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Falzone N, Harrington J. Clinical Predictors of Transient versus Persistent Neonatal Hyperinsulinism. Horm Res Paediatr 2021; 93:297-303. [PMID: 33197914 DOI: 10.1159/000511139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hyperinsulinism (HI), the most common neonatal cause of persistent hypoglycemia, can be associated with prolonged hospitalizations and risk for long-term neurological sequelae. Rapid identification of transient versus persistent forms of HI is crucial to optimize management. OBJECTIVES The aims of the study were to assess the ability of clinical and biochemical features at presentation to predict transient versus persistent HI, and to evaluate differences in hospital outcomes. METHODS This study is a retrospective review of 79 infants with HI admitted to the Hospital for Sick Children, Toronto, from 2012 to 2017. Patients were classified into 3 groups: transient and the 2 persistent forms, diazoxide responsive and diazoxide unresponsive (DU). RESULTS Infants with birth weight >90th percentile had an 8-fold increased risk of having a persistent form of HI (OR 8.8, 95% CI 2.5-30) and a 21-fold increased risk of having a DU form of HI (OR 21.1, 95% CI 4.9-91.8). The majority of children with transient HI and a birth weight >90th percentile were born to mothers with gestational diabetes. There were no other useful clinical or biochemical presenting features that differentiated the groups. There were significant differences in outcome measures, with the DU children more likely to require gastrostomy tube insertion and have an extended length of hospital admission. CONCLUSION A higher birth weight in the absence of maternal gestational diabetes is highly associated with a persistent form of HI. Given the marked difference in clinical outcomes between groups, expedited genetic testing should be considered in infants with this presentation to inform clinical management.
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Affiliation(s)
- Nicole Falzone
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Harrington
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, .,Department of Pediatrics, Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada,
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Fuchs S, Regev R, Harrington J. Transient neonatal hyperinsulinism: early predictors of duration. J Pediatr Endocrinol Metab 2021; 34:1041-1044. [PMID: 33866697 DOI: 10.1515/jpem-2020-0594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/22/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Hyperinsulinism is the most common cause of recurrent hypoglycemia in infants, with transient and permanent forms. Currently, there are no effective tools to predict severity and time to resolution in infants with transient hyperinsulinism (tHI). Therefore, our objective was to assess whether early glucose trends predict disease duration in tHI. METHODS A retrospective, pilot cohort of infants admitted with tHI was phenotyped for clinical and laboratory parameters. Blood glucose (BG) values were collected from the first documented hypoglycemia for 120 h (five days). RESULTS In 27 neonates with tHI, the presence of fetal distress (p=0.001) and higher mean daily BG (p=0.035) were associated with shorter time to resolution of hypoglycemia. In a further sensitivity analysis that grouped the cohort by the presence or absence of fetal distress, we found that in neonates without fetal distress, lower mean daily glucose was associated with longer disease duration (R2=0.53, p=0.01). CONCLUSIONS Our pilot data suggests that predictors for disease duration of tHI may be elicited in the first week of life, and that tHI associated with fetal distress may represent a distinct clinical entity with a shorter time course.
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Affiliation(s)
- Shai Fuchs
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ravit Regev
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jennifer Harrington
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Abstract
This review provides an update on neonatal hypoglycemia in the term infant, including discussion of glucose metabolism, definitions of hypoglycemia, identification of infants commonly at risk, and the screening, treatment, and potential neurologic outcomes of postnatal hypoglycemia. Neonatal hypoglycemia is a common metabolic condition that continues to plague clinicians because there is no clear relationship between low glucose concentrations or their duration that determines adverse neurologic outcomes. However, severely low, prolonged, recurrent low glucose concentrations in infants who also have marked symptoms such as seizures, flaccid hypotonia with apnea, and coma clearly are associated with permanent brain damage. Early identification of at-risk infants, early and continued breastfeeding augmented with oral dextrose gel, monitoring prefeed glucose concentrations, treating symptomatic infants who have very low and recurrent low glucose concentrations, and identifying and aggressively managing infants with persistent hyperinsulinemia and metabolic defects may help prevent neuronal injury.
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Laimon W, Aboelenin HM, El Tantawi NT. Clinical characteristics, outcome, and predictors of neurological sequelae of persistent congenital hyperinsulinism: A single tertiary center experience. Pediatr Diabetes 2021; 22:388-399. [PMID: 33528087 DOI: 10.1111/pedi.13186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/09/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022] Open
Abstract
AIM Congenital hyperinsulinism (CHI) is a heterogeneous disease with variable genetic etiology, histopathology, and clinical phenotype. This study aims to describe the clinical characteristics of persistent CHI and evaluate long-term neurological outcome and its risk factors in a cohort of Egyptian children. METHODS Clinical, genetic, and biochemical data of 42 patients with CHI were collected. Patients were invited for neurological assessment, electroencephalogram, and magnetic resonance imaging of the brain. RESULTS ABCC8 mutation was found in (61%) of cases who underwent genetic testing (17/28). Five cases with homozygous biparental ABCC8 mutation responded to combined diazoxide and octreotide without needing surgery. Seven out of twenty-one patients who had pancreatectomy (33%) developed diabetes after a median period of 4.8 (range:1-10) years following surgery. Fifty-five percent of our patients had neurodevelopmental impairment at follow-up. Logistic regression analysis has shown that delayed referral to tertiary centre for more than 8 days, delayed diagnosis of CHI for more than 14 days and hospital admission for more than 30 days, are significant predictors of unfavorable neurological sequelae in CHI; (OR = 12.7 [2.56], p = 0.001), (OR = 12.7 [2.9-56], p = 0.001), and (OR = 3.8 [0.14.5], p = 0.043), respectively. CONCLUSIONS ABCC8 mutation was the commonest genetic mutation underlying CHI in this study group. CHI cases with biparental homozygous ABCC8 mutation may show response to combined octreotide and diazoxide therapy. More than half of our patients had neurodevelopmental impairment at follow-up. Delayed referral to expert centre, delayed diagnosis and longer hospital stay are significant predictors of neurological disability in CHI cases.
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Affiliation(s)
- Wafaa Laimon
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Hadil Mohamed Aboelenin
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Noha T El Tantawi
- Pediatric Neurology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
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Drachmann D, Hoffmann E, Carrigg A, Davis-Yates B, Weaver V, Thornton P, Weinstein DA, Petersen JS, Shah P, Christesen HT. Towards enhanced understanding of idiopathic ketotic hypoglycemia: a literature review and introduction of the patient organization, Ketotic Hypoglycemia International. Orphanet J Rare Dis 2021; 16:173. [PMID: 33849624 PMCID: PMC8045369 DOI: 10.1186/s13023-021-01797-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic Ketotic hypoglycemia (IKH) is a diagnosis of exclusion. Although considered as the most frequent cause of hypoglycemia in childhood, little progress has been made to advance the understanding of IKH since the medical term was coined in 1964. We aimed to review the literature on ketotic hypoglycemia (KH) and introduce a novel patient organization, Ketotic Hypoglycemia International (KHI). RESULTS IKH may be diagnosed after the exclusion of various metabolic and hormonal diseases with KH. Although often mild and self-limiting, more severe and long-lasting IKH occurs. We therefore divide IKH in physiological KH and pathological KH, the latter defined as recurrent symptomatic, or occasionally symptomatic, episodes with beta-hydroxybutyrate ≥ 1.0 mmol/L and blood glucose < 70 mg/dL (3.9 mol/L), in the absence of prolonged fasting, acute infections and chronic diseases known to cause KH. Pathological KH may represent undiscovered diseases, e.g. glycogen storage disease IXa, Silver-Russel syndrome, and ketone transporter defects, or suggested novel disease entities identified by exome sequencing. The management of KH aims to prevent hypoglycemia, fatty acid oxidation and protein deficiency by supplying adequate amounts of carbohydrates and protein, including nutritional therapy, uncooked cornstarch, and sometimes continuous tube feeding by night. Still, intravenous dextrose may be needed in acute KH episodes. Failure to acknowledge that IKH can be more than normal variation may lead to under-treatment. KHI is a non-profit, patient-centric, global organization established in 2020. The organization was created by adult IKH patients, patient family members, and volunteers. The mission of KHI is to enhance the understanding of IKH while advocating for patients, their families and the continued research into KH. CONCLUSION IKH is a heterogeneous disorder including physiological KH and pathological KH. IKH may represent missed diagnoses or novel disease entities, but shares common management principles to prevent fatty acid oxygenation. KHI, a novel patient organization, aims to enhance the understanding of IKH by supporting IKH families and research into IKH.
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Affiliation(s)
| | - Erica Hoffmann
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Austin Carrigg
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Beccie Davis-Yates
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark.,School of Social Science, Nottingham Institute of Education, Nottingham, UK
| | - Valerie Weaver
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | | | - David A Weinstein
- Glycogen Storage Disease Program, University of Connecticut, Farmington, CT, USA
| | | | - Pratik Shah
- Endocrinology Department, The Royal London Children's Hospital, Barts Health NHS Trust and Queen Mary University London, London, UK
| | - Henrik Thybo Christesen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Hans Christian Andersen Children's Hospital and Steno Diabetes Centre Odense, Odense University Hospital, JB Windsloews Vej 4, 5000, Odense C, Denmark.
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33
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Sims K. Congenital Hyperinsulinism. Neoreviews 2021; 22:e230-e240. [PMID: 33795398 DOI: 10.1542/neo.22-4-e230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is fairly common in neonates, particularly those born to diabetic mothers and those who are either large or small for gestational age. Immediate management of the disease focuses on achieving normoglycemia through frequent high-calorie feedings and/or intravenous glucose administration. Glucagon may be used for unstable infants in whom intravenous access cannot be obtained and enteral feedings cannot be administered. HH that persists despite these interventions should raise concern for congenital hyperinsulinism (CHI), prompting clinicians to perform a thorough evaluation. CHI consists of a group of genetic disorders in which inappropriate insulin secretion results in persistent hypoglycemia. Defects can occur in the various genes that regulate the pathway for insulin secretion in the pancreatic β-cells. Pharmacologic therapies are used for long-term management of the disease coupled with either curative or therapeutic surgical intervention. Because of the developing brain's high demand for glucose, these infants are at increased risk for hypoglycemic brain injury. This review will describe the pathogenesis of CHI, outlining the more common genetic mutations and associated syndromes. We will also discuss the clinical presentation, diagnosis, and management of CHI while providing insight into the overall prognosis.
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Männistö JME, Jääskeläinen J, Otonkoski T, Huopio H. Long-Term Outcome and Treatment in Persistent and Transient Congenital Hyperinsulinism: A Finnish Population-Based Study. J Clin Endocrinol Metab 2021; 106:e1542-e1551. [PMID: 33475139 PMCID: PMC7993590 DOI: 10.1210/clinem/dgab024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT The management of congenital hyperinsulinism (CHI) has improved. OBJECTIVE To examine the treatment and long-term outcome of Finnish patients with persistent and transient CHI (P-CHI and T-CHI). DESIGN A population-based retrospective study of CHI patients treated from 1972 to 2015. PATIENTS 106 patients with P-CHI and 132 patients with T-CHI (in total, 42 diagnosed before and 196 after year 2000) with median follow-up durations of 12.5 and 6.2 years, respectively. MAIN OUTCOME MEASURES Recovery, diabetes, pancreatic exocrine dysfunction, neurodevelopment. RESULTS The overall incidence of CHI (n = 238) was 1:11 300 live births (1972-2015). From 2000 to 2015, the incidence of P-CHI (n = 69) was 1:13 500 and of T-CHI (n = 127) 1:7400 live births. In the 21st century P-CHI group, hyperinsulinemic medication was initiated and normoglycemia achieved faster relative to earlier. Of the 74 medically treated P-CHI patients, 68% had discontinued medication. Thirteen (12%) P-CHI patients had partial pancreatic resection and 19 (18%) underwent near-total pancreatectomy. Of these, 0% and 84% developed diabetes and 23% and 58% had clinical pancreatic exocrine dysfunction, respectively. Mild neurological difficulties (21% vs 16%, respectively) and intellectual disability (9% vs 5%, respectively) were as common in the P-CHI and T-CHI groups. However, the 21st century P-CHI patients had significantly more frequent normal neurodevelopment and significantly more infrequent diabetes and pancreatic exocrine dysfunction compared with those diagnosed earlier. CONCLUSIONS Our results demonstrated improved treatment and long-term outcome in the 21st century P-CHI patients relative to earlier.
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Affiliation(s)
- Jonna M E Männistö
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
- Correspondence: Jonna Männistö, MD, Department of Pediatrics, Kuopio University Hospital, P.O. Box 100, FI-70029 KYS, Kuopio, Finland.
| | - Jarmo Jääskeläinen
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Timo Otonkoski
- Children’s Hospital and Stem Cells and Metabolism Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Huopio
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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35
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Worth C, Dunne M, Ghosh A, Harper S, Banerjee I. Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020. Pediatr Diabetes 2020; 21:697-706. [PMID: 32315515 DOI: 10.1111/pedi.13029] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Arunabha Ghosh
- Department of Inherited Metabolic Disease, St Mary's Hospital, Manchester, UK
| | - Simon Harper
- Faculty of Computer Engineering, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
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36
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The Incidence and Etiology of Previously Undiagnosed Hypoglycemic Disorders in the Emergency Department. Pediatr Emerg Care 2020; 36:322-326. [PMID: 30365409 DOI: 10.1097/pec.0000000000001634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine the incidence and etiology of previously undiagnosed hypoglycemia in children (<18 years of age) seen in a hospital emergency department (ED). METHODS A retrospective review of all emergency room visits over a 2-year period was conducted to identify patients younger than 18 years who had hypoglycemia (<50 mg/dL) not associated with a previously known cause. Evaluation of hypoglycemia was conducted during a spontaneous hypoglycemic event or during hypoglycemia induced by a fasting study. Insulin and counter-regulatory hormones were measured simultaneously when the blood glucose was less than 50 mg/dL. RESULTS Of 224,125 children seen in the ED during the study, 160 (1:1400) were documented to have hypoglycemia not caused by a previously known condition. Eighty-five (53%) of the 160 hypoglycemic subjects underwent a diagnostic evaluation. Seventeen (20%) of the 85 were classified as having a high-risk disorder causing hypoglycemia, whereas 63 (74%) had a low-risk disorder. Seventy-five patients (47%) did not undergo a diagnostic evaluation during the ED visit or hospital admission. CONCLUSIONS Hypoglycemia of unknown etiology occurs in 1:1400 (0.07%) children who attended the ED during the study. Assuming that none of the children who failed to undergo a diagnostic evaluation had a high-risk disorder, 10.6% of the subjects with hypoglycemia were found to have a high-risk disorder. Because of the increased incidence of high-risk disorders causing hypoglycemia and the long-term health risk associated with hypoglycemia, we recommend that all children with hypoglycemia of unknown etiology have a critical blood sample drawn at the time of hypoglycemia (blood glucose <50 mg/dL) or be admitted for a diagnostic evaluation.
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37
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Worth C, Hashmi LA, Yau D, Salomon-Estebanez M, Ruiz DP, Hall C, O'Shea E, Stokes H, Foster P, Flanagan SE, Cosgrove KE, Dunne MJ, Banerjee I. Longitudinal Auxological recovery in a cohort of children with Hyperinsulinaemic Hypoglycaemia. Orphanet J Rare Dis 2020; 15:162. [PMID: 32580746 PMCID: PMC7313198 DOI: 10.1186/s13023-020-01438-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background Hypoglycaemia due to hyperinsulinism (HI) is the commonest cause of severe, recurrent hypoglycaemia in childhood. Cohort outcomes of HI remain to be described and whilst previous follow up studies have focused on neurodevelopmental outcomes, there is no information available on feeding and auxology. Aim We aimed to describe HI outcomes for auxology, medications, feeding and neurodevelopmental in a cohort up to age 5 years. Method We reviewed medical records for all patients with confirmed HI over a three-year period in a single centre to derive a longitudinal dataset. Results Seventy patients were recruited to the study. Mean weight at birth was − 1.0 standard deviation scores (SDS) for age and sex, while mean height at 3 months was − 1.5 SDS. Both weight and height trended to the population median over the follow up period. Feeding difficulties were noted in 17% of patients at 3 months and this reduced to 3% by 5 years. At age 5 years, 11 patients (15%) had neurodevelopmental delay and of these only one was severe. Resolution of disease was predicted by lower maximum early diazoxide dose (p = 0.007) and being born SGA (p = 0.009). Conclusion In a three-year cohort of HI patients followed up for 5 years, in spite of feeding difficulties and carbohydrate loading in early life, auxology parameters are normal in follow up. A lower than expected rate of neurodevelopmental delay could be attributed to prompt early treatment.
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Affiliation(s)
- Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - Laila Al Hashmi
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Department of Paediatrics, Nizwa Hospital, Nizwa, Sultanate of Oman
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Department of Pediatrics, Division of Endocrinology, Jim Pattison Children's Hospital, Saskatoon, Canada
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | | | - Caroline Hall
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Helen Stokes
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Peter Foster
- Dept of Mathematics, University of Manchester, Manchester, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Karen E Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Congenital hyperinsulinism: management and outcome, a single tertiary centre experience. Eur J Pediatr 2020; 179:947-952. [PMID: 32002613 DOI: 10.1007/s00431-020-03581-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
Abstract
Hyperinsulinemic hypoglycaemia (HH) is the most frequent cause of persistent hypoglycaemia in neonates and infants. The most severe forms of HH are inherited and referred to as congenital hyperinsulinism (CHI). Diazoxide is the mainstay of treatment, with surgery being an option in appropriate cases. To describe the management and outcome of patients with CHI within our service. Children referred to or attending HH clinic between 2009 and 2017 were identified. Clinical course, genetics and interventions were documented. A total of 39 children were identified, and seven patients with secondary and syndromic HH were excluded. Most were born with an appropriate weight for gestational age (62.5%). Diazoxide was started in all patients; however, 7 did not respond and required octreotide/continuous feeding, with 6/7 requiring surgery. Genetic mutations were detected in 12/32 (37.5%). Hyperinsulinism resolved in conservatively treated patients within 12 months in 11/32 (34.3%) compared to 14/32 (43.7%) requiring more than 12 months of medication. A total of 7 patients underwent pancreatectomy.Conclusion: Although LGA and SGA are risk factors, most babies in our cohort are born AGA. A genetic mutation does not exclude medical remission; long-term conservative treatment of CHI is feasible as surgery does not guarantee complete remission.What is Known:•Congenital hyperinsulinism (CHI) is a clinically and genetically heterogeneous disorder that is the most common cause of permanent hypoglycaemia in infants and children.•Identification of genetic mutations and the use of 18F-DOPA PET scan when feasible lead to better outcomes.What is New:•The study describes clinical criteria, management and outcome of large number of patients with CHI in single tertiary centre.•Conservative treatment is feasible without the need for surgery, with HH resolving in over 30% within 12 months, irrespective of genetic mutation.
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Worth C, Yau D, Salomon Estebanez M, O'Shea E, Cosgrove K, Dunne M, Banerjee I. Complexities in the medical management of hypoglycaemia due to congenital hyperinsulinism. Clin Endocrinol (Oxf) 2020; 92:387-395. [PMID: 31917867 DOI: 10.1111/cen.14152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
Congenital Hyperinsulinism (CHI) is a rare disease of hypoglycaemia but is the most common form of recurrent and severe hypoglycaemia causing brain injury and neurodisability in children. The management of CHI is complex due to the limited choice of medications, all with a limited therapeutic window, often lacking efficacy and associated with serious side effects. The therapeutic strategy in CHI is to recognize and treat hypoglycaemia promptly, thereby optimizing long-term neurological outcomes; this should be achieved through individualized treatment plans that deliver glycaemic stability while minimizing side effects. Further, such a strategy should consider the likelihood of reduction in disease severity over time, with dose adjustments and medication withdrawal as indicated to optimize both safety and tolerability. The option for pancreatic surgery should also be considered in specific circumstances as appropriate for the patient's best long-term interests.
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Affiliation(s)
- Christopher Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Department of Pediatrics, Division of Endocrinology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Karen Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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40
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Yamada Y, Kitayama K, Oyachi M, Higuchi S, Kawakita R, Kanamori Y, Yorifuji T. Nationwide survey of endogenous hyperinsulinemic hypoglycemia in Japan (2017-2018): Congenital hyperinsulinism, insulinoma, non-insulinoma pancreatogenous hypoglycemia syndrome and insulin autoimmune syndrome (Hirata's disease). J Diabetes Investig 2020; 11:554-563. [PMID: 31742894 PMCID: PMC7232294 DOI: 10.1111/jdi.13180] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/02/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
AIMS/INTRODUCTION We aimed to investigate the nationwide incidence, treatment details and outcomes of patients with endogenous hyperinsulinemic hypoglycemia (EHH), including those with transient/persistent congenital hyperinsulinism (CHI), insulinoma, non-insulinoma pancreatogenous hypoglycemia syndrome and insulin autoimmune syndrome (Hirata's disease) in Japan. MATERIALS AND METHODS A nationwide, questionnaire-based survey was carried out to determine the number of patients with EHH who were treated for hypoglycemia or hypoglycemia-related complications in 2017-2018. The questionnaires were sent to all hospitals in Japan with >300 beds, and with pediatric and/or adult clinics likely managing EHH patients. The secondary questionnaires were sent to obtain the patients' date of birth, sex, age at onset, treatment details and post-treatment outcomes. RESULTS A total of 447 patients with CHI (197 transient CHI, 225 persistent CHI and 25, unknown histology), 205 with insulinoma (118 benign, 18 malignant and 69 unknown subtype), 111 with non-insulinoma pancreatogenous hypoglycemia syndrome (33 post-gastric surgery HH, 57 postprandial HH, 10 nesidioblastosis and 11 unknown subtype) and 22 with insulin autoimmune syndrome were identified. Novel findings included: (i) marked improvement in the prognosis of persistent CHI over the past 10 years; (ii) male dominance in the incidence of transient CHI; (iii) non-insulinoma pancreatogenous hypoglycemia syndrome emerging as the second most common form of EHH in adults; (iv) frequent association of diabetes mellitus with insulin autoimmune syndrome; and (v) frequent post-treatment residual hypoglycemia and impaired quality of life. CONCLUSIONS The first nationwide, all age group survey of EHH showed the current status of each type of EHH disorder and the unmet needs of the patients.
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Affiliation(s)
- Yuki Yamada
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Kana Kitayama
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Maki Oyachi
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Shinji Higuchi
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Rie Kawakita
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
| | - Yutaka Kanamori
- Division of SurgeryNational Center for Child Health and DevelopmentTokyoJapan
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and MetabolismChildren’s Medical CenterOsaka City General HospitalOsakaJapan
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Davidov AS, Elkon-Tamir E, Haham A, Shefer G, Weintrob N, Oren A, Lebenthal Y, Mandel D, Eyal O. Higher C-peptide levels and glucose requirements may identify neonates with transient hyperinsulinism hypoglycemia who will benefit from diazoxide treatment. Eur J Pediatr 2020; 179:597-602. [PMID: 31863303 DOI: 10.1007/s00431-019-03544-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Anita Schachter Davidov
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erella Elkon-Tamir
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Haham
- Department of Neonatology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabi Shefer
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, , Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naomi Weintrob
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Oren
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Mandel
- Department of Neonatology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Eyal
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Roeper M, Salimi Dafsari R, Hoermann H, Mayatepek E, Kummer S, Meissner T. Risk Factors for Adverse Neurodevelopment in Transient or Persistent Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:580642. [PMID: 33424766 PMCID: PMC7793856 DOI: 10.3389/fendo.2020.580642] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/29/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Aim was to identify hypotheses why adverse neurodevelopment still occurs in children with transient or persistent hyperinsulinism despite improvements in long-term treatment options during the last decades. MATERIAL AND METHODS A retrospective review of 87 children with transient (n=37) or persistent congenital hyperinsulinism (CHI) (n=50) was conducted at the University Children's Hospital Duesseldorf, Germany. Possible risk factors for neurodevelopmental sequelae due to hypoglycemia were analyzed with a focus on the first days after onset of disease. RESULTS Median age at follow-up was 7 years (IQR 8). Adverse neurodevelopmental outcome was seen in 34.5% (n=30) of all CHI patients. Fifteen had mildly abnormal neurodevelopment and 15 had a severe hypoglycemic brain injury. In univariate analysis, mildly abnormal neurodevelopment was associated with the diagnosis of persistent CHI (odds ratio (OR) 8.3; p=0.004) and higher birth weight (mean difference 1049 g; p<0.001). Severe hypoglycemic brain injury was associated with the diagnosis of persistent CHI (OR 5.1; p=0.013), being born abroad (OR 18.3; p<0.001) or in a lower-level maternity hospital (OR 4.8; p=0.039), and of note history of hypoglycemic seizures (OR 13.0; p=<0.001), and a delay between first symptoms of hypoglycemia and first blood glucose measurement/initiation of treatment (OR 10.7; p<0.001). Children with severe hypoglycemic brain injury had lower recorded blood glucose (mean difference -8.34 mg/dl; p=0.022) and higher birth weight than children with normal development (mean difference 829 g; p=0.012). In multivariate binary logistic regression models, lowest blood glucose <20 mg/dl (OR 134.3; p=0.004), a delay between initial symptoms and first blood glucose measurement/initiation of treatment (OR 71.7; p=0.017) and hypoglycemic seizures (OR 12.9; p=0.008) were positively correlated with severe brain injury. Analysis showed that the odds for brain injury decreased by 15% (OR 0.85; p=0.035) if the blood glucose increased by one unit. CONCLUSION While some risk factors for adverse outcome in CHI are not influenceable, others like lowest recorded blood glucose values <20 mg/dl, hypoglycemic seizures, and insufficiently-or even untreated hypoglycemia can be avoided. Future guidelines for management of neonatal hypoglycemia should address this by ensuring early identification and immediate treatment with appropriate escalation steps.
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Siersbæk J, Larsen AR, Nybo M, Christesen HT. A Sensitive Plasma Insulin Immunoassay to Establish the Diagnosis of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:614993. [PMID: 33679602 PMCID: PMC7935514 DOI: 10.3389/fendo.2020.614993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The diagnosis of congenital hyperinsulinism (CHI) may be hampered by a plasma (p-) insulin detection limit of 12-18 pmol/L (2-3 mU/L). OBJECTIVE To evaluate the diagnostic performance of a sensitive insulin immunoassay and to find the optimal p-insulin cut-off for the diagnosis of CHI. METHODS Diagnostic fasting tests, performed without medication or i.v.-glucose, were investigated in children with a clinical diagnosis of CHI, or idiopathic ketotic hypoglycemia (IKH). The CHI diagnosis was either clinical or by the alternative, p-insulin-free criteria; hypoglycemia plus disease-causing genetic mutations and/or CHI-compatible pancreatic histopathology. We included diagnostic p-insulin samples with simultaneous p-glucose <3.2 mmol/L and used a sensitive insulin assay (Cobas e411 immunoassay analyzer; lower detection limit 1.2 pmol/L; normal range 15.1-147.1 pmol/L). Receiver operating characteristics area under the curve (ROC AUC) values and optimal cut-offs were analyzed for the performance of p-insulin to diagnose CHI. RESULTS In 61 CHI patients, the median (range) p-insulin was 76.5 (17-644) pmol/L compared to 1.5 (1.5-7.7) pmol/L in IKH patients (n=15). The ROC AUC was 1.0 for the diagnosis of CHI defined both by the clinical diagnosis (n=61) and by alternative criteria (n=57). The optimal p-insulin cut-offs were 12.3 pmol/L, and 10.6 pmol/L, at p-glucose <3.2 mmol/L (n=61), and <3.0 mmol/L (n=49), respectively. CONCLUSIONS The sensitive insulin assay performed excellent in diagnosing CHI with optimal p-insulin cut-offs at 12.3 pmol/L (2.0 mU/L), and 10.6 pmol/L (1.8 mU/L), at p-glucose <3.2 mmol/L, and <3.0 mmol/L, respectively. A sensitive insulin assay may serve to simplify the diagnosis of CHI.
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Affiliation(s)
- Julie Siersbæk
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Annette Rønholt Larsen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik Thybo Christesen,
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Chen SC, Dastamani A, Pintus D, Yau D, Aftab S, Bath L, Swinburne C, Hunter L, Giardini A, Christov G, Senniappan S, Banerjee I, Shaikh MG, Shah P. Diazoxide-induced pulmonary hypertension in hyperinsulinaemic hypoglycaemia: Recommendations from a multicentre study in the United Kingdom. Clin Endocrinol (Oxf) 2019; 91:770-775. [PMID: 31520536 DOI: 10.1111/cen.14096] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Diazoxide is first-line treatment for hyperinsulinaemic hypoglycaemia (HH) but diazoxide-induced pulmonary hypertension (PH) can occur. We aim to characterize the incidence and risk factors of diazoxide-induced PH in a large HH cohort to provide recommendations for anticipating and preventing PH in diazoxide-treated patients with HH. DESIGN AND PATIENTS Retrospective cohort study involving four UK regional HH centres; review of case notes of HH patients on diazoxide. MEASUREMENTS The diagnosis of PH was based on clinical and echocardiography evidence. Patient and treatment-related risk factors were analysed for association. RESULTS Thirteen (6 men) of 177 HH diazoxide-treated patients developed PH, an incidence of 7%. In the PH group, HH was diagnosed at median (range) of 9 (1,180) days, with diazoxide commenced 4 (0,76) days from diagnosis and reaching a maximum dose of 7 (2.5,20) mg/kg/d. The majority (8 of 13 patients) developed PH within 2 weeks of diazoxide. Complete diazoxide withdrawal, but not dose reduction, led to PH resolution at 41 (3,959) days. In three patients, PH continued beyond 12 months. Risk factors for the development of PH included the presence of congenital heart disease (CHD) (P = .008), and total fluid volume exceeding 130 mL/kg/d in the immediate 24 hours preceding diazoxide (P = .019). CONCLUSION Pulmonary hypertension can occur in 7% of diazoxide-treated HH patients. Risk factors include the presence of congenital heart disease and fluid overload. Recommendations include echocardiography and fluid restriction to 130 mL/kg/d prior to diazoxide treatment and immediate discontinuation of diazoxide if PH develops.
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Affiliation(s)
- Suet Ching Chen
- Paediatric Endocrinology, Royal Hospital for Children, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Antonia Dastamani
- Paediatric Endocrinology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Donatella Pintus
- Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Daphne Yau
- Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sommayya Aftab
- Paediatric Endocrinology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Louise Bath
- Paediatric Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Craig Swinburne
- Paediatric Cardiology, Royal Hospital for Children, NHS Greater Glasgow and Clyde Glasgow, Glasgow, UK
| | - Lindsey Hunter
- Paediatric Cardiology, Royal Hospital for Children, NHS Greater Glasgow and Clyde Glasgow, Glasgow, UK
| | - Alessandro Giardini
- Paediatric Cardiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Georgi Christov
- Paediatric Cardiology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | | - Indraneel Banerjee
- Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Mohamad Guftar Shaikh
- Paediatric Endocrinology, Royal Hospital for Children, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Pratik Shah
- Paediatric Endocrinology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London, UK
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45
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Thornton P, Truong L, Reynolds C, Hamby T, Nedrelow J. Rate of Serious Adverse Events Associated with Diazoxide Treatment of Patients with Hyperinsulinism. Horm Res Paediatr 2019; 91:25-32. [PMID: 30889588 DOI: 10.1159/000497458] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/03/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Diazoxide is the first line and only Federal Drug Agency approved pharmacological agent for the treatment of hyperinsulinism. Its use has increased over the years to include patients with various genetic forms of hyperinsulinism, perinatal stress hyperinsulinism and infants of diabetic mothers with more babies than ever being exposed to this therapy. METHODS We performed a retrospective analysis of 194 patients with hyperinsulinism in our clinic and looked for those who had experienced serious adverse events (SAE) including pulmonary hypertension and neutropenia. We compared the rates of SAE in the different types of hyperinsulinism. RESULTS Out of 194 patients with hyperinsulinism, 165 (85.1%) were treated with diazoxide. There were 17 SAEs in 16 patients including 8 cases of pulmonary hypertension and 8 of neutropenia. These data show that overall the frequency of SAE associated with diazoxide use is 9.7%, but that those with perinatal stress hyperinsulinism have a much higher rate than those with genetic forms of hyperinsulinism (16.7 vs. 3.6%; p = 0.01). We also found diazoxide is associated with pulmonary hypertension (4.8% of patients treated). Although more patients with perinatal stress hyperinsulinism (7.6%) were affected than genetic hyperinsulinism (1.2%), the difference was not significant (p = 0.088). CONCLUSION The rate of SAEs associated with (not necessarily caused by) diazoxide has been demonstrated. The rate of SAE in newborns with perinatal stress hyperinsulinism is significantly higher than that of otherwise healthy babies with genetic forms of hyperinsulinism, suggesting that caution should be used when prescribing diazoxide to this population. This information should help balance the risk benefit of treatment and provide guidance on screening for these complications in the population of treated patients.
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Affiliation(s)
- Paul Thornton
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA
| | - Lisa Truong
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA
| | - Courtney Reynolds
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA, .,Research Administration, Fort Worth, Texas, USA,
| | - Tyler Hamby
- Research Administration, Fort Worth, Texas, USA
| | - Jonathan Nedrelow
- Division of Neonatology, Cook Children's Medical Center, Fort Worth, Texas, USA
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46
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Raisingani M, Brar PC. Characterization of the duration of treatment with diazoxide in infants with prolonged hyperinsulinism (PHI). J Pediatr Endocrinol Metab 2019; 32:1241-1245. [PMID: 31465295 DOI: 10.1515/jpem-2019-0066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/05/2019] [Indexed: 01/13/2023]
Abstract
Background Prolonged neonatal hyperinsulinism (PHI) causes hypoglycemia in the neonatal period and is associated with perinatal stress. Even though diazoxide is an effective treatment option for PHI, it has serious adverse effects making an argument for safe yet expeditious wean off of diazoxide while ensuring normoglycemia. The objective of this study was to characterize clinical course, dose requirement and duration of treatment with diazoxide in our cohort of infants diagnosed with PHI. Methods A retrospective chart review of infants diagnosed with PHI during a 6-year period was done documenting the diagnostic workup and the duration of treatment with diazoxide. Results PHI was diagnosed (n = 20; mean ± standard deviation [SD]) at 14.3 ± 22.4 days. Elevated insulin (8.3 ± 8.4 mIU/L), normal cortisol (15.5 ± 6.6 μg/dL [6-21]), normal growth hormone (18.8 ± 15.7 ng/mL [0.1-6.2]) and inappropriate low serum free fatty acids (0.3 ± 0.2 mmol/L [>1.5]) levels were measured during hypoglycemia (plasma glucose <50 mg/dL). Detectable insulin at the time of hypoglycemia was measured in 17 of 20 infants while the same number (17/20) of infants had a positive glucagon stimulation test (GST). The dose of diazoxide was 10 ± 3.7 mg/kg/day and duration of treatment was 44.9 ± 27.9 days. Conclusions This study illustrates that the duration of treatment with diazoxide in infants with PHI can be shorter than previously reported in the literature. We speculate that active tapering of diazoxide started within a week after discharge from hospital as well an outpatient tapering of diazoxide based on glucose monitoring were possible reasons for this outcome.
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Affiliation(s)
- Manish Raisingani
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-6, Little Rock, AR 72202, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, New York University School of Medicine, New York, NY, USA
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Gu MH, Amanda F, Yuan TM. Brain Injury in Neonatal Hypoglycemia: A Hospital-Based Cohort Study. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2019; 13:1179556519867953. [PMID: 31447599 PMCID: PMC6688136 DOI: 10.1177/1179556519867953] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/15/2019] [Indexed: 11/16/2022]
Abstract
Background Neonatal hypoglycemia is more prevalent and can cause severe neurological sequelae. The objective of this study was to assess the patterns of neuroradiologic changes in neonatal hypoglycemia. Methods A retrospective cohort study was conducted on 66 neonatal hypoglycemia patients, and the magnetic resonance imaging (MRI) and clinical records were reviewed. Results Magnetic resonance imaging showed evidences of abnormality in 54.54% (36 of 66) of hypoglycemic infants. The most common abnormal findings were located on the parietal and occipital lobes of the brains. The number of days with hypoglycemia was significantly higher for abnormal MRI infants (P < .001), and prolonged/recurrent hypoglycemia was remarkably distinguished for abnormal MRI infants (P < .001). Patients with abnormal MRI findings did not have a lower blood glucose than infants without abnormal MRI findings (P > .05), but the lowest blood glucose was significantly lower for the patients with seizures (P < .01). Conclusions The pattern of bilateral occipital cortical injury is the most common abnormality for neonatal hypoglycemia. The number of days with hypoglycemia, not the lower blood glucose, was significantly related to abnormal MRI infants.
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Affiliation(s)
- Mei-Hong Gu
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Fanny Amanda
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Tian-Ming Yuan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
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48
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Stomnaroska O, Petkovska E, Jancevska S, Danilovski D. Neonatal Hypoglycemia: Risk Factors and Outcomes. ACTA ACUST UNITED AC 2019; 38:97-101. [PMID: 28593892 DOI: 10.1515/prilozi-2017-0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Severe neonatal hypoglycemia (HG) leads to neurologic damage, mental retardation, epilepsy, personality disorders, impaired cardiac performance and muscle weakness. We aimed to assess the clinical characteristics of children with hypoglycemia in a random population of newborns. PATIENTS, METHODS AND RESULTS We investigated 84 patients (M:F=35:48) born at the University Clinic for Gynecology and Obstetrics in Skopje (hospitalized in the NICU) who were found to have hypoglycemia. In total 89.25% of the babies were premature. The mean birth weight was 1795.95 +/596.08 grams, the mean birth length was 41.92+/- 4.62 cm, while the mean gestational age was 33.05±3.19 weeks. 32 children (38.08%) were very low birth weight (<1500g), 38 (45.22%) were low birth weight (1500-2500g), while there were 8 children (9.52%) appropriate for age BW and no high BW for age patients (>4000 g). HG duration was 2.42+/-2.41 hours. In the group as a whole, hypoxic-ischemic encephalopathy (HIE) was found in 3 children (3.57%), infections in 22 (26.18%), respiratory distress syndrome (RDS) in 9 patients (10.62%), intracranial haemorrhage in 2 patients (2.38%). There were no inborn errors of metabolism. There were two deaths (2.38%). CONCLUSION Neonatal HG is a significant factor in the overall neonatal mortality. HG can also cause severe invalidity. We found that infections, LBW and low gestational age were most commonly associated with neonatal HG. However the Spearman test showed weak direct correlation, without statistical significance. Neonatal HG requires complex and team interaction of prenatal and postnatal approaches to reduce the incidence of seizures, their consequences and the overall mortality. Special consideration is to be taken in measures that avoid neonatal infections, HIE, LBW and low gestational age. Further studies on a larger population are needed to fully understand and prevent the phenomenon of HG in newborns.
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Affiliation(s)
- Orhideja Stomnaroska
- University Clinic for Gynecology and Obstetrics, Medical Faculty Skopje, Vodnjanska BB, 1000 Skopje
| | | | - Snezana Jancevska
- University Clinic for Gynecology and Obstetrics, Medical Faculty Skopje
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49
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Muukkonen L, Männistö J, Jääskeläinen J, Hannonen R, Huopio H. The effect of hypoglycaemia on neurocognitive outcome in children and adolescents with transient or persistent congenital hyperinsulinism. Dev Med Child Neurol 2019; 61:451-457. [PMID: 30246438 DOI: 10.1111/dmcn.14039] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2018] [Indexed: 02/06/2023]
Abstract
AIM To examine the hypoglycaemic effect on neurodevelopmental outcome in patients with transient and persistent congenital hyperinsulinism (CHI) born in the 21st century. METHOD A cohort of 117 patients (66 males, 51 females) with CHI aged 5 to 16 years (mean age 8y 11mo, SD 2y 7mo) were selected from a Finnish nationwide registry to examine all the patients with similar methods. Neurodevelopment was first evaluated retrospectively. The 83 patients with no risk factors for neurological impairment other than hypoglycaemia were recruited and 44 participated (24 males, 20 females; mean age 9y 7mo, SD 3y 1mo) in neuropsychological assessment with the Wechsler Intelligence Scale for Children, Fourth Edition and the Finnish version of the Developmental Neuropsychological Assessment, Second Edition domains of attention, language, memory, sensorimotor, and visual functioning. RESULTS In retrospective analysis, transient and persistent CHI groups had similar prevalences of mild (22% and 18% respectively) or severe (5% and 7% respectively) neurodevelopmental difficulties. In clinical assessment, the neurocognitive profile was within the average range in both groups, but children with persistent CHI showed significant but restricted deficits in attention, memory, visual, and sensorimotor functions compared with the general population. The transient CHI group did not differ from the standardization samples. INTERPRETATION Besides the more apparent broader neurological deficits, children with persistent CHI have an increased risk for milder specific neurocognitive problems, which should be considered in the follow-up. WHAT THIS PAPER ADDS Children with persistent congenital hyperinsulinism showed deficits in attention, memory, visual, and sensorimotor functions. The deficits were potentially of hypoglycaemic origin. Children with transient hyperinsulinism did not differ from the general population.
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Affiliation(s)
- Liisa Muukkonen
- Department of Child Neurology, Siun sote North Karelia Central Hospital, Joensuu, Finland.,Coronaria Tietotaito, Joensuu, Finland
| | - Jonna Männistö
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland.,Department of Paediatrics, University of Eastern Finland, Kuopio, Finland
| | - Jarmo Jääskeläinen
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland.,Department of Paediatrics, University of Eastern Finland, Kuopio, Finland
| | - Riitta Hannonen
- Department of Psychology, Carea - Kymenlaakso Social and Health Services, Kotka, Finland.,Department of Psychology, University of Jyväskylä, Jyväskylä, Finland
| | - Hanna Huopio
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
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50
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Puchalski ML, Russell TL, Karlsen KA. Neonatal Hypoglycemia: Is There a Sweet Spot? Crit Care Nurs Clin North Am 2019; 30:467-480. [PMID: 30447807 DOI: 10.1016/j.cnc.2018.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Hypoglycemia is one of the most common neonatal problems. Despite increasing evidence that hypoglycemia is linked to neurologic impairment, knowledge regarding the specific value or duration of hypoglycemia that results in injury to the brain remains unclear. Current published statements/guidelines focused on preventing clinically significant hypoglycemia are conflicting and continue to be based on low evidence. This article reviews transitional events leading to extrauterine euglycemia, risk factors contributing to transient or persistent hypoglycemia, and common treatment approaches. Current information related to neurodevelopmental outcomes and screening strategies to prevent significant hypoglycemia with early treatment is described.
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Affiliation(s)
- Mary L Puchalski
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Neonatology, 25 East Chicago Avenue, Chicago, IL 60611, USA; Department of Women, Children, and Family Health Science, University of Illinois at Chicago, 845 South Damen Avenue, M/C 802, Chicago, IL 60612, USA.
| | - Terri L Russell
- Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Neonatology, 25 East Chicago Avenue, Chicago, IL 60611, USA; Department of Women, Children, and Family Health Science, University of Illinois at Chicago, 845 South Damen Avenue, M/C 802, Chicago, IL 60612, USA
| | - Kristine A Karlsen
- The S.T.A.B.L.E. Program, 3070 Rasmussen Road, Suite 120, Park City, UT 84098, USA; Primary Children's Hospital, Neonatal Intensive Care Unit, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA
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