Hyperglycaemia in the Newborn Infant. Physiology Verses Pathology

Adverse events in the neonatal intensive care unit identified by triggers

Objective

The main aim of this study was to identify adverse events (AEs) in neonates admitted to a Neonatal Intensive Care Unit (NICU) using a trigger-based approach.

Methods

A retrospective observational study was conducted at Hospital Estadual Sumaré -Dr. Leandro Franceschini, Sumaré, SP, Brazil, over 6 months in 2021. Data from 120 electronic medical records of neonates hospitalized for ≥48 h and prescribed at least one medication were analyzed. Seventeen triggers, such as healthcare-associated infections (HAIs), antimicrobial use, accidental extubation, electrolyte disorders, and others, were employed to identify AEs, including those specific to adverse drug reaction (ADRs). AE severity was assessed using the Neonatal Adverse Event Severity Scale (NAESS) and the World Health Organization (WHO) classification, while ADR causality was evaluated using the WHO criteria and the algorithm proposed by Du et at. Risk factors such as gestational age, birth weight, and length of hospital stay were also analyzed.

Results

A total of 249 triggers identified 168 confirmed AEs, resulting in a Positive Predictive Value (PPV) of 67.5%. At least one AE was observed in 50.0% of neonates and 40.8% experienced ADRs. The most frequent triggers that identified AEs included HAIs and antimicrobial use (30.8/100 records, each), followed by hyperglycemia (22.5/100 records), increased frequency of bowel movements (16.7/100 records), and hyponatremia (10.8/100 records). Severe complications such as necrotizing enterocolitis (2.5/100 records) and accidental extubation (5.0/100 records) were also recorded. Triggers with a PPV of 100% included necrotizing enterocolitis, accidental extubation, hypocalcemia, HAIs, and antimicrobial use. According to the NAESS, most AEs were classified as grade 2 - moderate, (44.0%) or grade 3 - severe (51.2%). Critical events, such as life-threatening conditions (grade 4) and death (grade 5), were less common, totaling 4.8%. Regarding ADRs, the majority were classified as possible or unlikely by both methods. The distribution of AEs varied by neonatal subgroups, with extremely preterm showing higher rates of AEs, including hyponatremia (53.8%) and accidental extubation (66.7%). Among all events, elevated serum creatinine (75.0%), necrotizing enterocolitis (66.7%), and hypercalcemia (100.0%) predominantly occurred in neonates with extremely low birth weight (ELBW). In contrast, neonates with appropriate birth weight experienced fewer AEs and lower AE severity. This association was not assessed for gestational age.

Conclusion

The findings suggest that prematurity, low birth weight, and prolonged hospitalization are relevant risk factors for AEs in NICUs. Nonetheless, trigger tools proved effective in identifying severe events and enhancing patient safety in this high-risk setting. Prevention strategies based on these findings can help mitigate risks and optimize neonatal care.

Risk factors for neonatal hypoglycemia: a meta-analysis

OBJECTIVE

This Study aims to investigate the risk factors of hypoglycemia in neonates through meta-analysis.

METHOD

PubMed, Embase, Cochrane library, and Web of science databases were searched for case-control studies on risk factors for neonatal hypoglycemia. The search was done up to 1st October 2023 and Stata 15.0 was used for data analysis.

RESULTS

A total of 12 published studies were included, including 991 neonates in the hypoglycemic group and 4388 neonates in the non-hypoglycemic group. Meta-analysis results suggested caesarean section [OR = 1.90 95%CI (1.23, 2.92)], small gestational age[OR = 2.88, 95%CI (1.59, 5.20)], gestational diabetes [OR = 1.65, 95%CI (1.11, 2.46)], gestational hypertension[OR = 2,79, 95%CI (1.78, 4.35)] and respiratory distress syndrome[OR = 5.33, 95%CI (2.22, 12.84)] were risk factors for neonatal hypoglycemia.

CONCLUSION

Based on the current study, we found that caesarean section, small gestational age, gestational diabetes, gestational hypertension, respiratory distress syndrome are risk factors for neonatal hypoglycemia.

PROSPERO REGISTRATION NUMBER

CRD42023472974.

Insulin for Treatment of Neonatal Hyperglycemia in Premature Infants: Prevalence over Time and Association with Outcomes

OBJECTIVE

Our objective was to determine the prevalence of insulin treatment in premature infants with hyperglycemia and evaluate the association of length of treatment with outcomes.

STUDY DESIGN

The study included cohort of 29,974 infants 22 to 32 weeks gestational age (GA) admitted to over 300 neonatal intensive care unit (NICU) from 1997 to 2018 and diagnosed with hyperglycemia.

RESULTS

Use of insulin significantly decreased during the study period (p = 0.002) among studied NICUs. The percentage of hyperglycemic infants exposed to insulin ranged from 0 to 81%. Infants who received insulin were more likely to have lower GA, birth weight, 5-minute Apgar score, longer duration of stay, and require mechanical ventilation. After adjustment for GA, infants requiring insulin for >14 days were more likely to have treated retinopathy of prematurity (ROP) and develop chronic lung disease (CLD). Insulin treatment of 1 to 7 days had increased odds of death, death/ROP, and death/CLD compared with no exposure.

CONCLUSION

Insulin use decreased over time, and differing durations of use were associated with adverse outcomes.

KEY POINTS

· Insulin use decreased over time.. · There is a temporal relation between the duration of treatment and adverse outcomes.. · Further studies are needed to determine the efficacy and safety of insulin use..

Postnatal hyperglycemia alters amino acid profile in retinas (model of Phase I ROP)

Nutritional deprivation occurring in most preterm infants postnatally can induce hyperglycemia, a significant and independent risk factor for suppressing physiological retinal vascularization (Phase I retinopathy of prematurity (ROP)), leading to compensatory but pathological neovascularization. Amino acid supplementation reduces retinal neovascularization in mice. Little is known about amino acid contribution to Phase I ROP. In mice modeling hyperglycemia-associated Phase I ROP, we found significant changes in retinal amino acids (including most decreased L-leucine, L-isoleucine, and L-valine). Parenteral L-isoleucine suppressed physiological retinal vascularization. In premature infants, severe ROP was associated with a higher mean intake of parenteral versus enteral amino acids in the first two weeks of life after adjustment for treatment group, gestational age at birth, birth weight, and sex. The number of days with parenteral amino acids support independently predicted severe ROP. Further understanding and modulating amino acids may help improve nutritional intervention and prevent Phase I ROP.

Transient neonatal hyperglycemia induces metabolic shifts in the rat hippocampus: a 1H NMR-based metabolomics analysis

Diabetes has been reported to induce brain metabolic disturbance, but the effect of transient neonatal hyperglycemia (TNH) on brain metabolism remains unclear. Herein the rats were treated with a single intraperitoneal injection of 100 µg/g body weight of streptozotocin within 12 h after birth and displayed a typical clinical characteristic of TNH. Then we used NMR-based metabolomics to examine the metabolic changes in the hippocampus between TNH and normal control (Ctrl) rats at postnatal 7 days (P7) and 21 days (P21). The results show that TNH rats had significantly increased levels of N-acetyl aspartate, glutamine, aspartate and choline in the hippocampus relative to Ctrl rats at P7. Moreover, we found that the levels of alanine, myo-inositol and choline were significantly lower in TNH rats, although their blood glucose levels have been recovered to the normal level at P21. Therefore, our results suggest that TNH may have a long-term effect on hippocampal metabolic changes mainly involving neurotransmitter metabolism and choline metabolism.

Retinopathy of Prematurity: The Role of Nutrition

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. ROP occurs in infants who are born very preterm. In ROP, retinal blood vessel development, which is prematurely arrested in preterm infants, is altered by perinatal exposures like oxygen and inflammation. Optimizing nutritional practices for preterm infants may mitigate the risk of ROP. In this article, we review the evidence that postnatal growth, hyperglycemia, polyunsaturated fatty acids, and breast milk provision may affect ROP risk. We also outline the current management strategies for ROP and describe the vision outcomes of children affected by ROP. [Pediatr Ann. 2023;52(8):e303-e308.].

Glycemia and Neonatal Encephalopathy: Outcomes in the LyTONEPAL (Long-Term Outcome of Neonatal Hypoxic EncePhALopathy in the Era of Neuroprotective Treatment With Hypothermia) Cohort

OBJECTIVES

To assess in newborns with neonatal encephalopathy (NE), presumptively related to a peripartum hypoxic-ischemic event, the frequency of dysglycemia and its association with neonatal adverse outcomes.

STUDY DESIGN

We conducted a secondary analysis of LyTONEPAL (Long-Term Outcome of Neonatal hypoxic EncePhALopathy in the era of neuroprotective treatment with hypothermia), a population-based cohort study including 545 patients with moderate-to-severe NE. Newborns were categorized by the glycemia values assessed by routine clinical care during the first 3 days of life: normoglycemic (all glycemia measurements ranged from 2.2 to 8.3 mmol/L), hyperglycemic (at least 1 measurement >8.3 mmol/L), hypoglycemic (at least 1 measurement <2.2 mmol/L), or with glycemic lability (measurements included at least 1 episode of hypoglycemia and 1 episode of hyperglycemia). The primary adverse outcome was a composite outcome defined by death and/or brain lesions on magnetic resonance imaging, regardless of severity or location.

RESULTS

In total, 199 newborns were categorized as normoglycemic (36.5%), 74 hypoglycemic (13.6%), 213 hyperglycemic (39.1%), and 59 (10.8%) with glycemic lability, based on the 2593 glycemia measurements collected. The primary adverse outcome was observed in 77 (45.8%) normoglycemic newborns, 37 (59.7%) with hypoglycemia, 137 (67.5%) with hyperglycemia, and 40 (70.2%) with glycemic lability (P < .01). With the normoglycemic group as the reference, the aORs and 95% 95% CIs for the adverse outcome were significantly greater for the group with hyperglycemia (aOR 1.81; 95% CI 1.06-3.11).

CONCLUSIONS

Dysglycemia affects nearly two-thirds of newborns with NE and is independently associated with a greater risk of mortality and/or brain lesions on magnetic resonance imaging.

TRIAL REGISTRATION

NCT02676063.

Serum metabolomic characterization in pigs in relation to birth weight category and neonatal nutrition

The objective of this study was to characterize developmental differences in low birth weight (LBW) and normal birth weight (NBW) piglets with or without pre-weaning nutrient restriction using serum metabolomic profile analysis. At farrowing, 112 piglets were identified as LBW (1.22 ± 0.28 kg) or NBW (1.70 ± 0.27 kg) and were randomly assigned to receive normal nutrition (NN) or restricted nutrition (RN) (6 h/day no suckling) from days 2 to 28 post farrow (n = 8 pigs/group). On day 28, piglets were weaned onto a common diet. Fasted blood samples were obtained on days 28 and 56 (n = 8 pigs/group) and were analyzed using quantitative metabolomics via a combination of direct injection mass spectrometry with a reverse-phase LC-MS/MS custom assay. Data were normalized using logarithmic transformation and auto-scaling. Partial least squares discriminant analysis (PLS-DA) was carried out to further explore the differential metabolites among the groups (metaboanalyst.ca) with an integrated enrichment and pathway topography analysis. On day 28, LBW piglets had lower levels of essential amino acids as well as reduced metabolites associated with fatty acid oxidation, glycolysis, and the tri-carboxylic acid (TCA) cycle compared to the NBW group. The overall reduction of metabolites associated with energy production and regulation suggests that LBW vs. NBW are in an energy-survival state. On day 56, LBW pigs had increased utilization of fatty acids and resultant ketone production, evident by increased carnitines, acetoacetate, β-hydroxybutyrate, and glycerol compared to NBW pigs. In addition, compared to the NBW pigs LBW pigs had a consistent decrease in serum glucose and lactate as well as reduced TCA cycle metabolites: pyruvate, succinate, citrate, and α-ketoglutaric acid similar to day 28. Low reliance on glycolysis and the TCA cycle and higher glycerol production in the LBW pigs may indicate impairments in glucose tolerance at 56 d. In summary, LBW piglets appear to have more metabolic alterations in early life, which is not resolved with adequate nutrition or refeeding and may elucidate physiological and metabolic mechanisms of poor growth and life performance compared to NBW pigs later in life.

Continuous glucose monitoring during therapeutic hypothermia for hypoxic ischaemic encephalopathy: a feasibility study

OBJECTIVES

Glucose dysregulation is common in infants with hypoxic ischaemic encephalopathy (HIE) and is likely to exacerbate cerebral injury. Infrequent measurement of glucose concentrations makes both identification and prevention of this risk challenging. Continuous glucose monitoring (CGM) has the potential to address both these challenges, but has not been explored in these infants. We aimed to evaluate the feasibility and potential impact of real-time CGM in term infants with HIE being treated with therapeutic hypothermia (TH).

DESIGN

Feasibility study.

SETTING

Tertiary-level neonatal unit, UK.

PATIENTS

Term infants with HIE undergoing TH.

INTERVENTION

A CGM sensor was inserted within 48 hours of birth and kept in situ for the first week of life. Clinical staff were blinded to the CGM recordings and clinical decisions were based on blood glucose assays.

MAIN OUTCOME MEASURES

(1) Accuracy of CGM values during and post TH, (2) Per cent of time spent outside the clinical range (2.6-10 mmol/L), (3) Episodes of hypoglycaemia and hyperglycaemia, (4) Adverse effects.

RESULTS

The accuracy of CGM values during TH were comparable to those when infants were normothermic. There was wide variation in per cent time outside the target range (2.6-10 mmol/L) between infants (median 5%, range 0%-34%). CGM identified 44% of infants with ≥1 episode of hypoglycaemia (<2.6 mmol/L) and 50% with ≥1 episode of hyperglycaemia (>10 mmol/L). No adverse events were observed.

CONCLUSIONS

This study demonstrates that CGM could be a useful adjunct for glucose monitoring in babies undergoing TH who are at risk of both hypoglycaemia and hyperglycaemia.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.

Neonatal Hyperglycemia and Neurodevelopmental Outcomes in Preterm Infants: A Review

Glucose impairment is common in preterm infants but the impact of early neonatal hyperglycemia on long term neurodevelopment is still highly controversial. This review reports current evidence of the effect of hyperglycemia on neurodevelopmental outcome. It was conducted according to the PRISMA guidelines. We searched MEDLINE via PubMed; EMBASE via Ovid; the Cochrane Central Register of Controlled Trials; the Cochrane Library; ClinicalTrials.gov; and the World Health Organization's International Trials Registry and Platform. We included studies that investigated the association between hyperglycemia, defined as at least one episode of glycemia ≥8 mmol/L, and neurodevelopment outcome evaluated either through the Griffiths Mental Developmental Scales (GMDS) or the Bayley Scales of Infant Development (BSID) for the first 5 years of life, and the Wechsler Intelligence Scale for Children (WISC) and the Movement Assessment Battery for Children (MABC) for the following age category. We selected six studies, comprising 2226 infants in total and which included 1059 (48%) infants for whom neurodevelopment assessment was available. We found an association between hyperglycemia and neurological delay in the first two years of life, especially for motor functions; this result was confirmed in later childhood. The quality of evidence was poor; therefore, the negative influence of neonatal hyperglycemia on the neurological development of preterm infants must be investigated in further studies.

Continuous Glucose Monitoring in Preterm Infants: The Role of Nutritional Management in Minimizing Glycemic Variability

Glycemic variability (GV) is common in preterm infants. In the premature population, GV is a risk factor for morbidity and mortality. Both hypo- and hyperglycemia can impair neurodevelopment. We investigated the impact of continuous versus intermittent tube enteral feeding on GV. In our prospective observational study, 20 preterm infants with a gestational age ≤ 34 weeks at either continuous or intermittent bolus full enteral feeding. For five days, continuous glucose monitoring (CGM) was utilized, which was achieved through the subcutaneous insertion of a sensor. A total of 27,532 measurements of blood glucose were taken. The mean amplitude of glycemic excursions did not differ between the two cohorts statistically. Continuous feeding resulted in higher positive values, increasing the risk of hypo- and hyperglycemia. Subjects who were small for their gestational age had a higher standard deviation during continuous feeding (p = 0.001). Data suggest that intermittent bolus nutrition is better for glycemic control than continuous nutrition. Nutritional management optimization of preterm infants appears to be critical for long-term health. In the future, CGM may provide a better understanding of the optimal glucose targets for various clinical conditions, allowing for a more personalized approach to management.

Incidence and Risk Factors for Glucose Disturbances in Premature Infants

Background and Objectives: There are limited data regarding the incidence and risk factors for hypoglycemia, hyperglycemia, and unstable glycemia in preterm infants. The aim of the present study was to determine the incidence and risk factors associated with neonatal hypoglycemia, hyperglycemia, and unstable glycemia in preterm infants during the first seven days of life. Materials and Methods: This prospective study included preterm infants <37 weeks of gestation, admitted to the Neonatal Intensive Care Unit between January 2018 and December 2020. Based on blood glucose levels in the first week of life, infants were divided into the following four groups: normoglycemic, hypoglycemic, hyperglycemic, and unstable. Blood glucose levels were measured from capillary blood at the 1st, 3rd, 6th, and 12th hour of life during the first 24 h, and at least once a day from days 2 to 7, prefeed. Results: Of 445 enrolled infants, 20.7% (92/445) were categorized as hypoglycemic, 9.9% (44/445) as hyperglycemic, and 2.9% (13/445) as unstable, respectively. Hypoglycemia was most commonly observed among infants ≥34 weeks (27.9%), and hyperglycemia was most common among preterm infants <28 weeks (50%). Female gender increased the chances of developing hypoglycemia by three times. The decrease in gestational age by one week increased the chance of developing hyperglycemia by 1.9 times. Sepsis increased the chance of developing hyperglycemia seven times, respiratory distress syndrome five times, and mechanical ventilation three times, respectively. Conclusions: Glucose disturbances in the early neonatal period in preterm infants are common and mostly asymptomatic. Therefore, careful blood glucose level monitoring is required in those infants, especially in late preterm infants, in order to prevent possible neurological complications.