Physiological and phased approach to newborns at-risk of hyperinsulinemic hypoglycemia: A neonatal perspective

Abdominal distension resulting from hematocolpos in children: A case report

INTRODUCTION

Hymeneal imperforation is a rare genital malformation often discovered during abdominopelvic emergencies. Hematocolpos typically presents with pelvic pain, a palpable mass, and primary amenorrhoea. The diagnosis is confirmed by clinical evaluation and imaging studies such as ultrasound.

CASE PRESENTATION

A 13-year-old girl presented a four-week history of abdominal distension and pain, which worsened over time, along with constipation, but without vomiting or fever. Examination revealed stable vital signs and abdominal guarding. A gynecological exam showed an imperforate hymen. Ultrasound identified a hypoechoic fluid collection in the retrovesical area. Hematocolpos was diagnosed and surgical intervention involved opening the hymen and releasing 800 cc of blood. The patient remained stable after the operation and was discharged painless after two days.

DISCUSSION

Imperforate hymen, resulting from incomplete resorption of the hymeneal membrane during embryonic development, is a common cause of hematocolpos. Symptoms often manifest in menarche, with cyclical pelvic pain and primary amenorrhoea. The diagnosis is based on physical examination and imaging, while early intervention prevents complications such as endometriosis and infertility. Surgical treatment varies from hymenotomy to more complex reconstructive procedures based on the underlying cause.

CONCLUSIONS

Although rare, imperforate hymen is the most prevalent congenital anomaly of the vagina, often remaining asymptomatic until menarche. Accurate diagnosis and timely surgical intervention are essential to avoid severe complications. This case highlights the importance of comprehensive clinical evaluation and appropriate imaging in the management of hematocolpos.

Safety and efficacy of low-dose diazoxide in small-for-gestational-age infants with hyperinsulinaemic hypoglycaemia

OBJECTIVES

Diazoxide (DZX) is the drug of choice for treating hyperinsulinaemic hypoglycaemia (HH), and it has potentially serious adverse effects. We studied the safety and efficacy of low-dose DZX in small-for-gestational-age (SGA) infants with HH.

DESIGN

An observational cohort study from 1 September 2014 to 31 September 2020.

SETTING

A tertiary Women's and Children's Hospital in Singapore.

PATIENTS

All SGA infants with HH.

INTERVENTION

Diazoxide, at 3-5 mg/kg/day.

MAIN OUTCOME MEASURES

Short-term outcomes; adverse drug events and fasting studies to determine 'safe to go home' and 'resolution' of HH.

RESULTS

Among 71 836 live births, 11 493 (16%) were SGA. Fifty-six (0.5%) SGA infants with HH were identified, of which 27 (47%) with a mean gestational age of 36.4±2 weeks and birth weight of 1942±356 g required DZX treatment. Diazoxide was initiated at 3 mg/kg/day at a median age of 10 days. The mean effective dose was 4.6±2.2 mg/kg/day, with 24/27 (89%) receiving 3-5 mg/kg/day. Generalised hypertrichosis occurred in 2 (7.4%) and fluid retention in 1 (3.7%) infant. A fasting study was performed before home while on DZX in 26/27 (96%) cases. Diazoxide was discontinued at a median age of 63 days (9-198 days), and resolution of HH was confirmed in 26/27 (96%) infants on passing a fasting study.

CONCLUSION

Our study demonstrates that low-dose DZX effectively treats SGA infants with HH as measured by fasting studies. Although the safety profile was excellent, minimal adverse events were still observed with DZX, even at low doses.

A feed-centric hypoglycaemia pathway ensures appropriate care escalation in at-risk infants

Background

There is a lack of clarity of what constitutes the starting point of a clinical pathway for infants at-risk of hypoglycaemia. Glucose-centric pathways (GCP) identify low glucose in the first 2 hours of life that may not represent clinical hypoglycaemia and can lead to inappropriate glucose management with infusions and medications.

Objective

To study the impact of a feed-centric pathway (FCP) on the number of admissions for hypoglycaemia to level 2 special care nursery (SCN) and the need for parenteral glucose/medications, compared to GCP.

Methods

This project was conducted over 2 years, before and after switching from a GCP to FCP in our institution. FCP involves skin-to-skin care, early breast feeding, checking glucose at 2 hours and use of buccal glucose. The primary outcome was the number of SCN admissions for hypoglycaemia. Secondary outcomes include the number of infants needing intravenous glucose, medications and length of SCN stay.

Results

Of 23 786 live births, 4438 newborns were screened. We screened more infants at-risk for hypoglycaemia using the FCP (GCP:1462/11969, 12.2% vs FCP:2976/11817, 25.1%) but significantly reduced SCN admissions (GCP:246/1462, 16.8% vs FCP:102/2976, 3.4%; p<0.0001). Fewer but proportionally more FCP newborns required intravenous glucose (GCP: 136/246, 55% vs FCP: 88/102, 86%; p=0.000). Compared with GCP, FCP reduced the total duration of stay in SCN by 104 days per annum, reducing the cost of care. However, the mean length of SCN stay for FCP was higher (GCP:2.43 days vs FCP:3.49 days; p=0.001). There were no readmissions for neonatal hypoglycaemia to our institution.

Conclusion

The use of FCP safely reduced SCN admissions, averted avoidable escalation of care and helped identify infants who genuinely required intravenous glucose and SCN care, allowing more efficient utilisation of healthcare resources.