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Alexander T, Asadi S, Meyer M, Harding JE, Jiang Y, Alsweiler JM, Muelbert M, Bloomfield FH. Nutritional Support for Moderate-to-Late-Preterm Infants - A Randomized Trial. N Engl J Med 2024; 390:1493-1504. [PMID: 38657245 DOI: 10.1056/nejmoa2313942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Most moderate-to-late-preterm infants need nutritional support until they are feeding exclusively on their mother's breast milk. Evidence to guide nutrition strategies for these infants is lacking. METHODS We conducted a multicenter, factorial, randomized trial involving infants born at 32 weeks 0 days' to 35 weeks 6 days' gestation who had intravenous access and whose mothers intended to breast-feed. Each infant was assigned to three interventions or their comparators: intravenous amino acid solution (parenteral nutrition) or dextrose solution until full feeding with milk was established; milk supplement given when maternal milk was insufficient or mother's breast milk exclusively with no supplementation; and taste and smell exposure before gastric-tube feeding or no taste and smell exposure. The primary outcome for the parenteral nutrition and the milk supplement interventions was the body-fat percentage at 4 months of corrected gestational age, and the primary outcome for the taste and smell intervention was the time to full enteral feeding (150 ml per kilogram of body weight per day or exclusive breast-feeding). RESULTS A total of 532 infants (291 boys [55%]) were included in the trial. The mean (±SD) body-fat percentage at 4 months was similar among the infants who received parenteral nutrition and those who received dextrose solution (26.0±5.4% vs. 26.2±5.2%; adjusted mean difference, -0.20; 95% confidence interval [CI], -1.32 to 0.92; P = 0.72) and among the infants who received milk supplement and those who received mother's breast milk exclusively (26.3±5.3% vs. 25.8±5.4%; adjusted mean difference, 0.65; 95% CI, -0.45 to 1.74; P = 0.25). The time to full enteral feeding was similar among the infants who were exposed to taste and smell and those who were not (5.8±1.5 vs. 5.7±1.9 days; P = 0.59). Secondary outcomes were similar across interventions. Serious adverse events occurred in one infant. CONCLUSIONS This trial of routine nutrition interventions to support moderate-to-late-preterm infants until full nutrition with mother's breast milk was possible did not show any effects on the time to full enteral feeding or on body composition at 4 months of corrected gestational age. (Funded by the Health Research Council of New Zealand and others; DIAMOND Australian New Zealand Clinical Trials Registry number, ACTRN12616001199404.).
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Affiliation(s)
- Tanith Alexander
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Sharin Asadi
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Michael Meyer
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Jane E Harding
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Yannan Jiang
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Jane M Alsweiler
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Mariana Muelbert
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
| | - Frank H Bloomfield
- From Liggins Institute (T.A., S.A., J.E.H., M. Muelbert, F.H.B.), the Department of Statistics, Faculty of Science (Y.J.), and the Department of Paediatrics, Child and Youth Health (J.M.A.), University of Auckland, and the Neonatal Unit, Kidz First, Middlemore Hospital, Te Whatu Ora Counties Manukau (T.A., M. Meyer), Auckland, and Newborn Services, Starship Child Health, Te Toka Tumai Auckland, Te Whatu Ora (J.M.A.) - all in New Zealand
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Harding JE, Alsweiler JM, Edwards TE, McKinlay CJD. Neonatal hypoglycaemia. BMJ Med 2024; 3:e000544. [PMID: 38618170 PMCID: PMC11015200 DOI: 10.1136/bmjmed-2023-000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Taygen E Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Chris JD McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Counties Manukau, Auckland, New Zealand
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3
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Kulmaganbetov M, Leung M, Alsweiler JM, Black J, Bloomfield FH, Gamble GD, Harding JE, Jiang Y, Poppe T, Tottman AC, Wouldes TA, Thompson B. Associations between neonatal nutrition and visual outcomes in 7-year-old children born very preterm. Ophthalmic Physiol Opt 2024; 44:347-355. [PMID: 38069619 DOI: 10.1111/opo.13260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/10/2023] [Accepted: 11/25/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE There is uncertainty about the effect of increased neonatal protein intake on neurodevelopmental outcomes following preterm birth. The aim of this study was to assess the effect of a change in neonatal nutrition protocol at a major tertiary neonatal intensive care unit intended to increase protein intake on ophthalmic and visual development in school-age children born very preterm. METHODS The study cohort comprised children (n = 128) with birthweight <1500 g or gestational age < 30 weeks born at Auckland City Hospital before (OldPro group, n = 55) and after (NewPro group, n = 73) a reformulation of parenteral nutrition that resulted in increased total protein intake during the first postnatal week and decreased carbohydrate, total parenteral fluid and sodium intake. Clinical and psychophysical vision assessments were completed at 7 years' corrected age, including visual acuity, global motion perception (a measure of dorsal stream function), stereoacuity, ocular motility and ocular health. Composite measures of favourable overall visual, binocular and functional visual outcomes along with individual vision measures were compared between the groups using logistic and linear regression models. RESULTS Favourable overall visual outcome did not differ between the two groups. However, global motion perception was better in the NewPro group (p = 0.04), whereas the OldPro group were more likely to have favourable binocular visual outcomes (60% vs. 36%, p = 0.02) and passing stereoacuity (p = 0.02). CONCLUSIONS These results indicate subtle but complex associations between early neonatal nutrition after very preterm birth and visual development at school age.
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Affiliation(s)
- Mukhit Kulmaganbetov
- Centre for Eye and Vision Research (CEVR), 17W Hong Kong Science Park, Hong Kong, Hong Kong
- Kazakh Eye Research Institute, Almaty, Kazakhstan
| | - Myra Leung
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
- Discipline of Optometry and Vision Science, University of Canberra, Canberra, Australian Capital Territory, Australia
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Joanna Black
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | | | - Greg D Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Tanya Poppe
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Anna C Tottman
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- Centre for Eye and Vision Research (CEVR), 17W Hong Kong Science Park, Hong Kong, Hong Kong
- Liggins Institute, University of Auckland, Auckland, New Zealand
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
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4
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Wei X, Franke N, Alsweiler JM, Brown GTL, Gamble GD, McNeill A, Rogers J, Thompson B, Turuwhenua J, Wouldes TA, Harding JE, McKinlay CJD. Dextrose gel prophylaxis for neonatal hypoglycaemia and neurocognitive function at early school age: a randomised dosage trial. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326452. [PMID: 38307710 DOI: 10.1136/archdischild-2023-326452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/07/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To investigate the effect of different doses of prophylactic dextrose gel on neurocognitive function and health at 6-7 years. DESIGN Early school-age follow-up of the pre-hPOD (hypoglycaemia Prevention with Oral Dextrose) study. SETTING Schools and communities. PATIENTS Children born at ≥35 weeks with ≥1 risk factor for neonatal hypoglycaemia: maternal diabetes, small or large for gestational age, or late preterm. INTERVENTIONS Four interventions commencing at 1 hour of age: dextrose gel (40%) 200 mg/kg; 400 mg/kg; 200 mg/kg and 200 mg/kg repeated before three feeds (800 mg/kg); 400 mg/kg and 200 mg/kg before three feeds (1000 mg/kg); compared with equivolume placebo (combined for analysis). MAIN OUTCOMES MEASURES Toolbox cognitive and motor batteries, as well as tests of motion perception, numeracy and cardiometabolic health, were used. The primary outcome was neurocognitive impairment, defined as a standard score of more than 1 SD below the age-corrected mean on one or more Toolbox tests. FINDINGS Of 392 eligible children, 309 were assessed for the primary outcome. There were no significant differences in the rate of neurocognitive impairment between those randomised to placebo (56%) and dextrose gel (200 mg/kg 46%: adjusted risk difference (aRD)=-14%, 95% CI -35%, 7%; 400 mg/kg 48%: aRD=-7%, 95% CI -27%, 12%; 800 mg/kg 45%: aRD=-14%, 95% CI -36%, 9%; 1000 mg/kg 50%: aRD=-8%, 95% CI -29%, 13%). Children exposed to any dose of dextrose gel (combined), compared with placebo, had a lower risk of motor impairment (3% vs 14%, aRD=-11%, 95% CI -19%, -3%) and higher mean (SD) cognitive scores (106.0 (15.3) vs 101.1 (15.7), adjusted mean difference=5.4, 95% CI 1.8, 8.9). CONCLUSIONS Prophylactic neonatal dextrose gel did not alter neurocognitive impairment at early school age but may have motor and cognitive benefits. Further school-age follow-up studies are needed.
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Affiliation(s)
- Xingyu Wei
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Nike Franke
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Jane M Alsweiler
- Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Gavin T L Brown
- Learning, Development and Professional Practice, The University of Auckland, Auckland, New Zealand
| | - Gregory D Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Alicia McNeill
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Benjamin Thompson
- Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
- Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Jason Turuwhenua
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand, Auckland, New Zealand
| | - Christopher J D McKinlay
- Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
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5
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Sadler LC, Thompson JMD, Alsweiler JM, McKinlay CJD, Cronin R, Browne E, Baillie-Bellew T, Harvey AD, Hill MG. Maternal and neonatal morbidity associated with Fetal Pillow® use at full dilatation caesarean: A retrospective cohort. BJOG 2024. [PMID: 38287196 DOI: 10.1111/1471-0528.17772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVE To investigate associations of the Fetal Pillow® with maternal and neonatal morbidity. DESIGN Retrospective cohort. SETTING Two tertiary maternity units, New Zealand. POPULATION OR SAMPLE Full dilatation singleton, term, cephalic caesarean section, with three comparisons: at Unit A (1) before versus after introduction of the Fetal Pillow® (1 Jaunary 2016-31 October 2021); (2) with versus without the Fetal Pillow® after introduction (27 July 2017-31 October 2021); and (3) between Unit A and Unit B during the same time period (1 January 2019-31 October 2021). The Fetal Pillow® is unavailable at Unit B. METHODS Cases were ascertained and clinical data were extracted from electronic clinical databases and records. Outcome data were adjusted and presented as adjusted odds ratios (aOR) with 95% CI. MAIN OUTCOME MEASURES Primary outcome "any" uterine incision extension; secondary outcomes included major extension (into adjacent structures), and a composite neonatal outcome. RESULTS In all, 1703 caesareans were included; 375 with the device and 1328 without. Uterine incision extension rates were: at Unit A before versus after introduction: 26.8% versus 24.8% (aOR 0.88, 95% CI 0.65-1.19); at Unit A with the Fetal Pillow® versus without: 26.1% versus 23.8% (aOR 1.14, 95% CI 0.83-1.57); and at Unit A versus Unit B: 24.2% versus 29.2% (aOR 0.73, 95% CI 0.54-0.99). No differences were found in major extensions, or neonatal composite outcome. CONCLUSIONS Despite the relatively large size of this study, it could not rule out either a positive or a negative association between use of the Fetal Pillow® and uterine extensions, major uterine incision extensions, and neonatal morbidity. Randomised controlled trial evidence is required to assess efficacy.
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Affiliation(s)
- Lynn C Sadler
- Women's Health, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - John M D Thompson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, University of Auckland, Te Whatu Ora, Auckland, New Zealand
| | - Christopher J D McKinlay
- Department of Paediatrics, University of Auckland, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Robin Cronin
- Department of Women's Health, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | | | | | - Amanda D Harvey
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Meghan G Hill
- Women's Health, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Manerkar K, Crowther CA, Harding JE, Meyer MP, Conlon CA, Rush EC, Alsweiler JM, McCowan LME, Rowan JA, Edlin R, Amitrano F, McKinlay CJD. Impact of Gestational Diabetes Detection Thresholds on Infant Growth and Body Composition: A Prospective Cohort Study Within a Randomized Trial. Diabetes Care 2024; 47:56-65. [PMID: 37643291 DOI: 10.2337/dc23-0464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Gestational diabetes mellitus (GDM) is associated with offspring metabolic disease, including childhood obesity, but causal mediators remain to be established. We assessed the impact of lower versus higher thresholds for detection and treatment of GDM on infant risk factors for obesity, including body composition, growth, nutrition, and appetite. RESEARCH DESIGN AND METHODS In this prospective cohort study within the Gestational Diabetes Mellitus Trial of Diagnostic Detection Thresholds (GEMS), pregnant women were randomly allocated to detection of GDM using the lower criteria of the International Association of Diabetes and Pregnancy Study Groups or higher New Zealand criteria (ACTRN12615000290594). Randomly selected control infants of women without GDM were compared with infants exposed to A) GDM by lower but not higher criteria, with usual treatment for diabetes in pregnancy; B) GDM by lower but not higher criteria, untreated; or C) GDM by higher criteria, treated. The primary outcome was whole-body fat mass at 5-6 months. RESULTS There were 760 infants enrolled, and 432 were assessed for the primary outcome. Fat mass was not significantly different between control infants (2.05 kg) and exposure groups: A) GDM by lower but not higher criteria, treated (1.96 kg), adjusted mean difference (aMD) -0.09 (95% CI -0.29, 0.10); B) GDM by lower but not higher criteria, untreated (1.94 kg), aMD -0.15 (95% CI -0.35, 0.06); and C) GDM detected and treated using higher thresholds (1.87 kg), aMD -0.17 (95% CI -0.37, 0.03). CONCLUSIONS GDM detected using lower but not higher criteria, was not associated with increased infant fat mass at 5-6 months, regardless of maternal treatment. GDM detected and treated using higher thresholds was also not associated with increased fat mass at 5-6 months.
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Affiliation(s)
- Komal Manerkar
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Michael P Meyer
- Te Whatu Ora, Counties Manukau, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Cathryn A Conlon
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Elaine C Rush
- School of Sport and Recreation, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Lesley M E McCowan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Janet A Rowan
- Te Whatu Ora, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Richard Edlin
- Health Systems, University of Auckland, Auckland, New Zealand
| | | | - Christopher J D McKinlay
- Te Whatu Ora, Counties Manukau, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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7
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O'Brien M, Gilchrist C, Sadler L, Hegarty JE, Alsweiler JM. Infants Eligible for Neonatal Hypoglycemia Screening: A Systematic Review. JAMA Pediatr 2023; 177:1187-1196. [PMID: 37782488 PMCID: PMC10546298 DOI: 10.1001/jamapediatrics.2023.3957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/02/2023] [Indexed: 10/03/2023]
Abstract
Importance Neonatal hypoglycemia is common, occurring in up to 50% of infants at risk for hypoglycemia (infant of diabetic mother [IDM], small for gestational age [SGA], large for gestational age [LGA], and preterm) and is associated with long-term neurodevelopmental impairment. Guidelines recommend screening infants at risk of hypoglycemia. The proportion of infants who require screening for neonatal hypoglycemia is unknown. Objective To determine the proportion of infants eligible for neonatal hypoglycemia screening using criteria from the highest-scoring critically appraised clinical guideline. Design, Setting, and Participants This systematic review of the literature was conducted to identify clinical practice guidelines for neonatal hypoglycemia and took place at a tertiary maternity hospital in Auckland, New Zealand. Eligible guidelines were critically appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Using screening criteria extracted from the highest-scoring guideline, the proportion of infants eligible for neonatal hypoglycemia screening was determined in a retrospective observational cohort study of infants born January 1, 2004, to December 31, 2018. Data were analyzed by logistic regression. Infant participants were included if gestational age was 35 weeks or more, birth weight was 2000 g or more, and they were not admitted to a neonatal intensive care unit less than 1 hour after birth. The data were analyzed from November 2022 through February 2023. A total of 101 372 infants met the inclusion criteria. Exposure Risk factors for neonatal hypoglycemia. Main Outcome Proportion of infants eligible for neonatal hypoglycemia screening. Results The study team screened 2366 abstracts and 18 guidelines met inclusion criteria for appraisal. There was variability in the assessed quality of guidelines and a lack of consensus between screening criteria. The highest-scoring guideline defined screening criteria as: IDM, preterm (less than 37 weeks' gestation), SGA (less than 10th percentile), birth weight of less than 2500 g or more than 4500 g, LGA (more than 90th percentile), or gestational age more than 42 weeks. A total of 101 372 infants met criteria for inclusion in the cohort study; median (IQR) gestational age was 39 (38-40) weeks and 51% were male. The overall proportion of infants eligible for screening was 26.3%. There was an increase in the proportion of eligible infants from 25.6% to 28.5% over 15 years, which was not statistically significant after adjustment for maternal age, body mass index, ethnicity, and multiple pregnancy (odds ratio, 0.99; 95% CI, 0.93-1.03; change in proportion per year). Conclusion A systematic review found that practice guidelines providing recommendations for clinical care of neonatal hypoglycemia were of variable quality with is a lack of consensus regarding definitions for infants at risk for hypoglycemia. In the cohort study, one-quarter of infants were eligible for hypoglycemia screening. Further research is required to identify which infants may benefit from neonatal hypoglycemia screening.
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Affiliation(s)
- Michelle O'Brien
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Catherine Gilchrist
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- Obstetrics and Gynaecology, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, New Zealand
- Women's Health, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Joanne E Hegarty
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, Child and Youth Health, Waipapa Taumata Rau - The University of Auckland, Auckland, New Zealand
- Newborn Services, Te Whatu Ora - Health New Zealand, Te Toka Tumai, Auckland, New Zealand
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Alsweiler JM, Crowther CA, Harding JE. Midwife or doctor leader to implement a national guideline in babies on postnatal wards (DesIGN): A cluster-randomised, controlled, trial. PLoS One 2023; 18:e0291784. [PMID: 37768901 PMCID: PMC10538667 DOI: 10.1371/journal.pone.0291784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 09/05/2023] [Indexed: 09/30/2023] Open
Abstract
The aim of this trial was to determine if midwives or doctor leaders are more effective at implementing a clinical practice guideline for oral dextrose gel to treat neonatal hypoglycaemia. This was a cluster-randomised, controlled, trial. New Zealand maternity hospitals were randomised to guideline implementation by a midwife or doctor implementation leader. The primary outcome was the change in the proportion of hypoglycaemic babies (blood glucose concentration <2.6 mmol/L in the first 48 hours after birth), treated with dextrose gel from before, to three months after, implementation. Twenty-one maternity hospitals that cared for babies at risk of hypoglycaemia consented to participate, of which 15 treated babies with hypoglycaemia at both time points (7 randomised to midwifery led, 8 randomised to doctor led implementation). The primary outcome included 463 hypoglycaemic babies (292 midwifery led, 171 doctor led implementation). There was no difference in the primary outcome between hospitals randomised to midwifery or doctor led implementation (proportion treated with gel, mean(SD); midwifery led: before 71 (38)%, 3 months after 87 (12)%; doctor led: before 63 (43)%, 3 months after 86 (16)%; adjusted mean change in proportion (95%CI); 19.3% (-4.5-43.1), p = 0.11). There was an increase in the proportion of eligible babies treated with oral dextrose gel from before to 3 months after implementation of the guideline (122/153 (80%) v 144/163 (88%), OR (95%CI); 3.42 (1.67-6.98), p<0.001). Implementation of a clinical practice guideline improved uptake of oral dextrose gel. There was no evidence of a difference between midwife and doctor implementation leaders for implementing this guideline for treatment of hypoglycaemic babies. The trial was prospectively registered on the ISRCTN registry on the 20/05/2015 (ISRCTN61154098).
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Affiliation(s)
- Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | | | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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9
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Purohit TJ, Laing D, McKinlay CJD, Alsweiler JM, Hanning SM. Development and clinical application of a stability-indicating chromatography technique for the quantification of diazoxide. Heliyon 2023; 9:e20101. [PMID: 37810084 PMCID: PMC10559840 DOI: 10.1016/j.heliyon.2023.e20101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/21/2023] [Accepted: 09/12/2023] [Indexed: 10/10/2023] Open
Abstract
Diazoxide is a potential candidate for the treatment of transitional hypoglycaemia in infants. A clinical trial is currently underway to investigate whether low-dose oral diazoxide is beneficial for severe or recurrent transitional neonatal hypoglycaemia (the NeoGluCO Study, registration ANZCTR12620000129987). The present study aimed to develop and validate the parameters for quantifying diazoxide from neonatal plasma samples, and to assess the stability of extemporaneously prepared diazoxide suspensions to support the NeoGluCO Study. To determine the plasma concentration of diazoxide, a protein precipitation mediated extraction protocol was developed, which demonstrated >94% diazoxide extraction recoveries from all samples. The method was linear over the range of 0.2-40 μg/mL (R2 > 0.9994) with a limit of quantification of 0.2 μg/mL. Accuracy of the method was within 97-106% with relative standard deviation < 6% for all samples. Diazoxide-plasma samples were stable for up to three months at -20 °C and up to 48 h when stored in the auto-sampler. Samples were stable for up to two freeze-thaw cycles, with further cycles compromising stability of diazoxide in plasma. The developed method was applied to determine chemical stability of the extemporaneously prepared diazoxide suspensions. These were stable at both 2-8 °C and 25 °C/60% RH, with 98% of diazoxide remaining after 35 days in both storage conditions. Diazoxide was successfully quantified from plasma collected from six neonates enrolled in the NeoGluCO Study, using the developed protocol. Overall, an efficient and reproducible extraction protocol was developed and validated for the estimation of diazoxide from human plasma.
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Affiliation(s)
- Trusha J. Purohit
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Don Laing
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Christopher JD. McKinlay
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Neonatal Care, Starship Hospital, Auckland, New Zealand
| | - Sara M. Hanning
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
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10
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Oliphant EA, McKinlay CJ, McNamara D, Cavadino A, Alsweiler JM. Caffeine to prevent intermittent hypoxaemia in late preterm infants: randomised controlled dosage trial. Arch Dis Child Fetal Neonatal Ed 2023; 108:106-113. [PMID: 36038256 PMCID: PMC9985705 DOI: 10.1136/archdischild-2022-324010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To establish the most effective and best tolerated dose of caffeine citrate for the prevention of intermittent hypoxaemia (IH) in late preterm infants. DESIGN Phase IIB, double-blind, five-arm, parallel, randomised controlled trial. SETTING Neonatal units and postnatal wards of two tertiary maternity hospitals in New Zealand. PARTICIPANTS Late preterm infants born at 34+0-36+6 weeks' gestation, recruited within 72 hours of birth. INTERVENTION Infants were randomly assigned to receive a loading dose (10, 20, 30 or 40 mg/kg) followed by 5, 10, 15 or 20 mg/kg/day equivolume enteral caffeine citrate or placebo daily until term corrected age. PRIMARY OUTCOME IH (events/hour with oxygen saturation concentration ≥10% below baseline for ≤2 min), 2 weeks postrandomisation. RESULTS 132 infants with mean (SD) birth weight 2561 (481) g and gestational age 35.7 (0.8) weeks were randomised (24-28 per group). Caffeine reduced the rate of IH at 2 weeks postrandomisation (geometric mean (GM): 4.6, 4.6, 2.0, 3.8 and 1.7 events/hour for placebo, 5, 10, 15 and 20 mg/kg/day, respectively), with differences statistically significant for 10 mg/kg/day (GM ratio (95% CI] 0.39 (0.20 to 0.76]; p=0.006) and 20 mg/kg/day (GM ratio (95% CI] 0.33 (0.17 to 0.68]; p=0.003) compared with placebo. The 20 mg/kg/day dose increased mean (SD) pulse oximetry oxygen saturation (SpO2) (97.2 (1.0) vs placebo 96.0 (0.8); p<0.001), and reduced median (IQR) percentage of time SpO2 <90% (0.5 (0.2-0.8) vs 1.1 (0.6-2.4); p<0.001) at 2 weeks, without significant adverse effects on growth velocity or sleeping. CONCLUSION Caffeine reduces IH in late preterm infants at 2 weeks of age, with 20 mg/kg/day being the most effective dose. TRIAL REGISTRATION NUMBER ACTRN12618001745235.
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Affiliation(s)
- Elizabeth Anne Oliphant
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Starship Child Health, Auckland District Health Board, Auckland, New Zealand
| | - Christopher Jd McKinlay
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau District Health Board, Auckland, New Zealand
| | - David McNamara
- Starship Child Health, Auckland District Health Board, Auckland, New Zealand
| | - Alana Cavadino
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand .,Starship Child Health, Auckland District Health Board, Auckland, New Zealand
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11
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Kremer LJ, Medlicott N, Sime MJ, Broadbent R, Edmonds L, Berry MJ, Austin NC, Alsweiler JM, Reith DM. Low dose or very low dose phenylephrine and cyclopentolate microdrops for retinopathy of prematurity eye examinations (The Little Eye Drop Study): a randomised controlled non-inferiority trial. Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-324929. [PMID: 36593111 DOI: 10.1136/archdischild-2022-324929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine if very low dose (VLD, 0.5% phenylephrine, 0.1% cyclopentolate) mydriatic microdrop (approximately 7 μL) administration (up to three doses) is non-inferior to low dose (LD, 1% phenylephrine, 0.2% cyclopentolate) mydriatic microdrop administration for ophthalmologist-determined successful retinopathy of prematurity eye examination (ROPEE). DESIGN Multicentre, prospective, randomised controlled, non-inferiority clinical trial. SETTING Four neonatal intensive care units in Aotearoa, New Zealand from October 2019 to September 2021. PATIENTS Infants with a birth weight less than 1250 g or gestational age less than 30+6 weeks and who required a ROPEE. INTERVENTIONS The intervention: microdrop (approximately 7 μL) of VLD (0.5% phenylephrine and 0.1% cyclopentolate) to both eyes, or the comparison: microdrop of LD (1% phenylephrine and 0.2% cyclopentolate) to both eyes. Up to three doses could be administered. MAIN OUTCOME MEASURES The primary outcome measure was an ophthalmologist-determined successful ROPEE. RESULTS One hundred and fifty preterm infants (LD mean GA=27.4±1.8 weeks, mean birth weight=1011±290 g, VLD mean GA=27.5±1.9 weeks, mean birth weight=1049±281 g,) were randomised. Non-inferiority for successful ROPEE was demonstrated for the VLD group compared with the LD group (VLD successful ROPEE=100%, LD successful ROPEE=100%, 95% CI no continuity correction -0.05 to 0.05) and for Māori (95% CI no continuity correction -0.02 to 0.19). CONCLUSION VLD microdrops enable safe and effective screening for ROPEE in both Māori and non-Māori preterm infants. TRIAL REGISTRATION NUMBER ACTRN12619000795190.
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Affiliation(s)
- Lisa Jean Kremer
- He Rau Kawakawa (School of Pharmacy), University of Otago Division of Health Sciences, Dunedin, New Zealand .,Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Natalie Medlicott
- He Rau Kawakawa (School of Pharmacy), University of Otago Division of Health Sciences, Dunedin, New Zealand
| | - Mary Jane Sime
- Ophthalmology, Te Whatu Ora (Health New Zealand), Southern, Dunedin, New Zealand
| | - Roland Broadbent
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | - Liza Edmonds
- Division of Health Sciences, Kōhatu Centre for Hauora Māori, University of Otago, Dunedin, New Zealand
| | - Mary Judith Berry
- Department of Paediatrics and Child Health, University of Otago Wellington, Wellington, New Zealand
| | - Nicola C Austin
- Neonatal Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, The University of Auckland School of Medicine, Auckland, New Zealand.,Newborn Services, Auckland Hospital, Te Whatu Ora Health New Zealand, Auckland, New Zealand
| | - David M Reith
- Deans Department, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
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12
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Edwards T, Alsweiler JM, Gamble GD, Griffith R, Lin L, McKinlay CJD, Rogers JA, Thompson B, Wouldes TA, Harding JE. Neurocognitive Outcomes at Age 2 Years After Neonatal Hypoglycemia in a Cohort of Participants From the hPOD Randomized Trial. JAMA Netw Open 2022; 5:e2235989. [PMID: 36219444 PMCID: PMC9554702 DOI: 10.1001/jamanetworkopen.2022.35989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Neonatal hypoglycemia is common, but its association with later neurodevelopment is uncertain. OBJECTIVE To examine associations between neonatal hypoglycemia and neurocognitive outcomes at corrected age 2 years. DESIGN, SETTING, AND PARTICIPANTS Exploratory cohort analysis of the Hypoglycaemia Prevention With Oral Dextrose (hPOD) randomized clinical trial was conducted. The trial recruited participants from January 9, 2015, to May 5, 2019, with follow-up between January 26, 2017, and July 31, 2021. Infants were recruited from 9 maternity hospitals in New Zealand and assessed at home or in a research clinic. Children born late preterm and at term at risk of neonatal hypoglycemia but without evidence of acute or imminent illness in the first hour after birth were screened and treated to maintain blood glucose concentrations greater than or equal to 47 mg/dL. EXPOSURES Hypoglycemia was defined as any blood glucose concentration less than 47 mg/dL, recurrent as 3 or more episodes, and severe as less than 36 mg/dL. MAIN OUTCOMES AND MEASURES Neurologic examination and tests of development (Bayley III) and executive function. The primary outcome was neurosensory impairment (any of the following: blindness, deafness, cerebral palsy, developmental delay, or executive function total score worse than 1.5 SD below the mean). RESULTS A total of 1197 of 1321 (91%) eligible children were assessed at a mean of corrected age 24 months; 616 (52%) were male. Compared with the normoglycemia group, children who experienced hypoglycemia were more likely to have neurosensory impairment (111 [23%] vs 125 [18%]; adjusted risk ratio [aRR], 1.28; 95% CI, 1.01-1.60), particularly if they experienced severe episodes (30 [28%] vs 125 [18%]; aRR, 1.68; 95% CI, 1.20-2.36), but not recurrent episodes (12 [19%] vs 125 [18%]; aRR, 1.06; 95% CI, 0.63-1.80). The risk of cognitive, language, or motor delay was similar between groups, but children who experienced hypoglycemia had lower Bayley-III composite cognitive (adjusted mean difference [aMD], -1.48; 95% CI, -2.79 to -0.18) and motor scores (aMD, -2.05; 95% CI, -3.30 to -0.79). CONCLUSIONS AND RELEVANCE In children born at risk of hypoglycemia but otherwise well, those who experienced neonatal hypoglycemia were more likely to have neurosensory impairment at corrected age 2 years, with higher risks after severe episodes. Further research is required to determine causality.
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Affiliation(s)
- Taygen Edwards
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Greg D. Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Rebecca Griffith
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Luling Lin
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher J. D. McKinlay
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Jenny A. Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, Waterloo, Canada
- Center for Eye and Vision Research, Hong Kong
| | - Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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13
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Kuo J, Petrie KJ, Alsweiler JM. Prioritising long-term outcomes for preterm babies: A survey of consumers and clinicians. J Paediatr Child Health 2022; 58:1778-1785. [PMID: 35770605 PMCID: PMC9796048 DOI: 10.1111/jpc.16093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
AIM To determine if consumers and clinicians believe intelligence or health outcomes are more important long-term outcomes for babies born preterm. METHODS Prospective, online survey of six outcomes ranked using a hierarchy ladder, Likert scale and a hypothetical scenario: education (complete secondary school); longevity (70 years of age or more); money (sufficient for rent and food); normal weight; good health and intelligence. Participants were clinicians taking care of preterm babies, parents of preterm babies, ex-preterm adults and adult controls. RESULTS The survey was completed by 145 participants (35 controls, 36 clinicians, 39 parents and 35 ex-preterm adults). Health was the most frequently top-ranked variable on the hierarchy ladder (health; 99/145 (68.3%), money; 17/145 (11.7%), longevity; 10/145 (6.9%), education; 8/145 (5.5%), normal weight; 6/145 (4.1%), intelligence; 5/145 (3.4%), P < 0.0001), with no statistical difference between the groups. On a 5-point Likert scale, participants were most likely to agree that sufficient money, health and finishing secondary school were important for preterm babies to have a good life (mean (SD): money 4.43 (0.81); health 4.39 (0.72); education 4.37 (0.81); normal weight 4.10 (0.81); intelligence 4.03 (0.94); longevity 4.01 (1.07), P < 0.0001). In the scenario, the option of an ex-preterm adult having a healthy life with low socio-economic status (SES), was preferred over high SES with an unhealthy life (p < 0.0001). CONCLUSIONS Health was perceived as the most important long-term outcome for preterm babies. Future research should prioritise good health outcomes for babies born preterm.
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Affiliation(s)
- Jex Kuo
- Department of Paediatrics: Child and Youth HealthThe University of AucklandAucklandNew Zealand
| | - Keith J Petrie
- Department of Psychological MedicineThe University of AucklandAucklandNew Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth HealthThe University of AucklandAucklandNew Zealand,Starship Child HealthAuckland District Health BoardAucklandNew Zealand
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14
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Crowther CA, Samuel D, Hughes R, Tran T, Brown J, Alsweiler JM. Tighter or less tight glycaemic targets for women with gestational diabetes mellitus for reducing maternal and perinatal morbidity: A stepped-wedge, cluster-randomised trial. PLoS Med 2022; 19:e1004087. [PMID: 36074760 PMCID: PMC9455881 DOI: 10.1371/journal.pmed.1004087] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Treatment for gestational diabetes mellitus (GDM) aims to reduce maternal hyperglycaemia. The TARGET Trial assessed whether tighter compared with less tight glycaemic control reduced maternal and perinatal morbidity. METHODS AND FINDINGS In this stepped-wedge, cluster-randomised trial, identification number ACTRN12615000282583, 10 hospitals in New Zealand were randomised to 1 of 5 implementation dates. The trial was registered before the first participant was enrolled. All hospitals initially used less tight targets (fasting plasma glucose (FPG) <5.5 mmol/L (<99 mg/dL), 1-hour <8.0 mmol/L (<144 mg/dL), 2 hour postprandial <7.0 mmol/L (<126 mg/dL)) and every 4 months, 2 hospitals moved to use tighter targets (FPG ≤5.0 mmol/L (≤90 mg/dL), 1-hour ≤7.4 mmol/L (≤133 mg/dL), 2 hour postprandial ≤6.7 mmol/L) (≤121 mg/dL). Women with GDM, blinded to the targets in use, were eligible. The primary outcome was large for gestational age. Secondary outcomes assessed maternal and infant health. Analyses were by intention to treat. Between May 2015 and November 2017, data were collected from 1,100 women with GDM (1,108 infants); 598 women (602 infants) used the tighter targets and 502 women (506 infants) used the less tight targets. The rate of large for gestational age was similar between the treatment target groups (88/599, 14.7% versus 76/502, 15.1%; adjusted relative risk [adjRR] 0.96, 95% confidence interval [CI] 0.66 to 1.40, P = 0.839). The composite serious health outcome for the infant of perinatal death, birth trauma, or shoulder dystocia was apparently reduced in the tighter group when adjusted for gestational age at diagnosis of GDM, BMI, ethnicity, and history of GDM compared with the less tight group (8/599, 1.3% versus 13/505, 2.6%, adjRR 0.23, 95% CI 0.06 to 0.88, P = 0.032). No differences were seen for the other infant secondary outcomes apart from a shorter stay in intensive care (P = 0.041). Secondary outcomes for the woman showed an apparent increase for the composite serious health outcome that included major haemorrhage, coagulopathy, embolism, and obstetric complications in the tighter group (35/595, 5.9% versus 15/501, 3.0%, adjRR 2.29, 95% CI 1.14 to 4.59, P = 0.020). There were no differences between the target groups in the risk for pre-eclampsia, induction of labour, or cesarean birth, but more women using tighter targets required pharmacological treatment (404/595, 67.9% versus 293/501, 58.5%, adjRR 1.20, 95% CI 1.00 to 1.44, P = 0.047). The main study limitation is that the treatment targets used may vary to those in use in some countries. CONCLUSIONS Tighter glycaemic targets in women with GDM compared to less tight targets did not reduce the risk of a large for gestational age infant, but did reduce serious infant morbidity, although serious maternal morbidity was increased. These findings can be used to aid decisions on the glycaemic targets women with GDM should use. TRIAL REGISTRATION The Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12615000282583.
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Affiliation(s)
| | - Deborah Samuel
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, Christchurch Women’s Hospital, University of Otago, Christchurch, New Zealand
| | - Thach Tran
- Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, Australia
| | - Julie Brown
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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15
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St Clair SL, Harding JE, O'Sullivan JM, Gamble GD, Alsweiler JM, Vatanen T. Effect of prophylactic dextrose gel on the neonatal gut microbiome. Arch Dis Child Fetal Neonatal Ed 2022; 107:501-507. [PMID: 34857640 PMCID: PMC9160211 DOI: 10.1136/archdischild-2021-322757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/05/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the effect of prophylactic dextrose gel on the infant gut microbiome. DESIGN Observational cohort study nested in a randomised trial. SETTING Three maternity hospitals in New Zealand. PATIENTS Infants at risk of neonatal hypoglycaemia whose parents consented to participation in the hypoglycaemia Prevention in newborns with Oral Dextrose trial (hPOD). Infants were randomised to receive prophylactic dextrose gel or placebo gel, or were not randomised and received no gel (controls). Stool samples were collected on days 1, 7 and 28. MAIN OUTCOME MEASURES The primary outcome was microbiome beta-diversity at 4 weeks. Secondary outcomes were beta-diversity, alpha-diversity, bacterial DNA concentration, microbial community stability and relative abundance of individual bacterial taxa at each time point. RESULTS We analysed 434 stool samples from 165 infants using 16S rRNA gene amplicon sequencing. There were no differences between groups in beta-diversity at 4 weeks (p=0.49). There were also no differences between groups in any other microbiome measures including beta-diversity (p=0.53 at day 7), alpha-diversity (p=0.46 for day 7 and week 4), bacterial DNA concentration (p=0.91), microbial community stability (p=0.52) and microbial relative abundance at genus level. There was no evidence that exposure to any dextrose gel (prophylaxis or treatment) had any effect on the microbiome. Mode of birth, type of milk fed, hospital of birth and ethnicity were all associated with differences in the neonatal microbiome. CONCLUSIONS Clinicians and consumers can be reassured that dextrose gel used for prophylaxis or treatment of neonatal hypoglycaemia does not alter the neonatal gut microbiome. TRIAL REGISTRATION NUMBER 12614001263684.
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Affiliation(s)
- Sophie L St Clair
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | - Gregory D Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Tommi Vatanen
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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16
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Laing D, Walsh E, Alsweiler JM, Hanning SM, Meyer MP, Ardern J, Cutfield WS, Rogers J, Gamble GD, Chase JG, Harding JE, McKinlay CJ. Oral diazoxide versus placebo for severe or recurrent neonatal hypoglycaemia: Neonatal Glucose Care Optimisation (NeoGluCO) study - a randomised controlled trial. BMJ Open 2022; 12:e059452. [PMID: 35977769 PMCID: PMC9389093 DOI: 10.1136/bmjopen-2021-059452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Infants with severe or recurrent transitional hypoglycaemia continue to have high rates of adverse neurological outcomes and new treatment approaches are needed that target the underlying pathophysiology. Diazoxide is one such treatment that acts on the pancreatic β-cell in a dose-dependent manner to decrease insulin secretion. METHODS AND ANALYSIS Phase IIB, double-blind, two-arm, parallel, randomised trial of diazoxide versus placebo in neonates ≥35 weeks' gestation for treatment of severe (blood glucose concentration (BGC)<1.2 mmol/L or BGC 1.2 to <2.0 mmol/L despite two doses of buccal dextrose gel and feeding in a single episode) or recurrent (≥3 episodes <2.6 mmol/L in 48 hours) transitional hypoglycaemia. Infants are loaded with diazoxide 5 mg/kg orally and then commenced on a maintenance dose of 1.5 mg/kg every 12 hours, or an equal volume of placebo. The intervention is titrated from the third maintenance dose by protocol to target BGC in the range of 2.6-5.4 mmol/L. The primary outcome is time to resolution of hypoglycaemia, defined as the first point at which the following criteria are met concurrently for ≥24 hours: no intravenous fluids, enteral bolus feeding and normoglycaemia. Groups will be compared for the primary outcome using Cox's proportional hazard regression analysis, expressed as adjusted HR with a 95% CI. ETHICS AND DISSEMINATION This trial has been approved by the Health and Disability Ethics Committees of New Zealand (19CEN189). Findings will be disseminated in peer-reviewed journals, to clinicians and researchers at local and international conferences and to the public. TRIAL REGISTRATION NUMBER ACTRN12620000129987.
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Affiliation(s)
- Don Laing
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Eamon Walsh
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Starship Children's Health, Auckland, New Zealand
| | - Sara M Hanning
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Michael P Meyer
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau District Health Board, Auckland, New Zealand
| | - Julena Ardern
- Kidz First Neonatal Care, Counties Manukau District Health Board, Auckland, New Zealand
| | - Wayne S Cutfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- Starship Children's Health, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Greg D Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - J Geoffrey Chase
- College of Engineering, University of Canterbury, Christchurch, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Christopher Jd McKinlay
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau District Health Board, Auckland, New Zealand
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17
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Oliphant EA, Purohit TJ, Alsweiler JM, McKinlay CJD, Hanning SM. Validation and application of a simple and rapid stability-indicating liquid chromatographic assay for the quantification of caffeine from human saliva. J LIQ CHROMATOGR R T 2022. [DOI: 10.1080/10826076.2022.2095402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Elizabeth A. Oliphant
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | | | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | | | - Sara M. Hanning
- School of Pharmacy, University of Auckland, Auckland, New Zealand
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18
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Tottman AC, Bloomfield FH, Cormack BE, Harding JE, Taylor J, Alsweiler JM. Correction: Sex-specific relationships between early nutrition and neurodevelopment in preterm infants. Pediatr Res 2022; 91:1627. [PMID: 34040163 DOI: 10.1038/s41390-021-01582-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Anna C Tottman
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Frank H Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Newborn Services, Starship Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Barbara E Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Newborn Services, Starship Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Janice Taylor
- Child Development Unit, National Women's Health, Auckland, New Zealand
| | - Jane M Alsweiler
- Newborn Services, Starship Hospital, Auckland District Health Board, Auckland, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
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19
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Shah R, Dai DWT, Alsweiler JM, Brown GTL, Chase JG, Gamble GD, Harris DL, Keegan P, Nivins S, Wouldes TA, Thompson B, Turuwhenua J, Harding JE, McKinlay CJD. Association of Neonatal Hypoglycemia With Academic Performance in Mid-Childhood. JAMA 2022; 327:1158-1170. [PMID: 35315886 PMCID: PMC8941348 DOI: 10.1001/jama.2022.0992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Neonatal hypoglycemia is associated with increased risk of poor executive and visual-motor function, but implications for later learning are uncertain. OBJECTIVE To test the hypothesis that neonatal hypoglycemia is associated with educational performance at age 9 to 10 years. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of moderate to late preterm and term infants born at risk of hypoglycemia. Blood and masked interstitial sensor glucose concentrations were measured for up to 7 days. Infants with hypoglycemic episodes (blood glucose concentration <47 mg/dL [2.6 mmol/L]) were treated to maintain a blood glucose concentration of at least 47 mg/dL. Six hundred fourteen infants were recruited at Waikato Hospital, Hamilton, New Zealand, in 2006-2010; 480 were assessed at age 9 to 10 years in 2016-2020. EXPOSURES Hypoglycemia was defined as at least 1 hypoglycemic event, representing the sum of nonconcurrent hypoglycemic and interstitial episodes (sensor glucose concentration <47 mg/dL for ≥10 minutes) more than 20 minutes apart. MAIN OUTCOMES AND MEASURES The primary outcome was low educational achievement, defined as performing below or well below the normative curriculum level in standardized tests of reading comprehension or mathematics. There were 47 secondary outcomes related to executive function, visual-motor function, psychosocial adaptation, and general health. RESULTS Of 587 eligible children (230 [48%] female), 480 (82%) were assessed at a mean age of 9.4 (SD, 0.3) years. Children who were and were not exposed to neonatal hypoglycemia did not significantly differ on rates of low educational achievement (138/304 [47%] vs 82/176 [48%], respectively; adjusted risk difference, -2% [95% CI, -11% to 8%]; adjusted relative risk, 0.95 [95% CI, 0.78-1.15]). Children who were exposed to neonatal hypoglycemia, compared with those not exposed, were significantly less likely to be rated by teachers as being below or well below the curriculum level for reading (68/281 [24%] vs 49/157 [31%], respectively; adjusted risk difference, -9% [95% CI, -17% to -1%]; adjusted relative risk, 0.72 [95% CI, 0.53-0.99; P = .04]). Groups were not significantly different for other secondary end points. CONCLUSIONS AND RELEVANCE Among participants at risk of neonatal hypoglycemia who were screened and treated if needed, exposure to neonatal hypoglycemia compared with no such exposure was not significantly associated with lower educational achievement in mid-childhood.
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Affiliation(s)
- Rajesh Shah
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Darren W. T. Dai
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Gavin T. L. Brown
- Faculty of Education and Social Work, University of Auckland, Auckland, New Zealand
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | | | - Deborah L. Harris
- Liggins Institute, University of Auckland, Auckland, New Zealand
- School of Nursing, Midwifery, and Health Practice, Victoria University of Wellington, Wellington, New Zealand
| | - Peter Keegan
- Te Puna Wānanga, University of Auckland, Auckland, New Zealand
| | - Samson Nivins
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A. Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
- Centre for Eye and Vision Research, Hong Kong
| | - Jason Turuwhenua
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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20
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Edwards T, Alsweiler JM, Crowther CA, Edlin R, Gamble GD, Hegarty JE, Lin L, McKinlay CJD, Rogers JA, Thompson B, Wouldes TA, Harding JE. Prophylactic Oral Dextrose Gel and Neurosensory Impairment at 2-Year Follow-up of Participants in the hPOD Randomized Trial. JAMA 2022; 327:1149-1157. [PMID: 35315885 PMCID: PMC8941358 DOI: 10.1001/jama.2022.2363] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Prophylactic oral dextrose gel reduces neonatal hypoglycemia, but later benefits or harms remain unclear. OBJECTIVE To assess the effects on later development of prophylactic dextrose gel for infants born at risk of neonatal hypoglycemia. DESIGN, SETTING, AND PARTICIPANTS Prospective follow-up of a multicenter randomized clinical trial conducted in 18 Australian and New Zealand hospitals from January 2015 to May 2019. Participants were late preterm or term at-risk infants; those randomized in 9 New Zealand centers (n = 1359) were included and followed up between January 2017 and July 2021. INTERVENTIONS Infants were randomized to prophylactic 40% dextrose (n = 681) or placebo (n = 678) gel, 0.5 mL/kg, massaged into the buccal mucosa 1 hour after birth. MAIN OUTCOMES AND MEASURES The primary outcome of this follow-up study was neurosensory impairment at 2 years' corrected age. There were 44 secondary outcomes, including cognitive, language, and motor composite Bayley-III scores (mean [SD], 100 [15]; higher scores indicate better performance). RESULTS Of eligible infants, 1197 (91%) were assessed (581 females [49%]). Neurosensory impairment was not significantly different between the dextrose and placebo gel groups (20.8% vs 18.7%; unadjusted risk difference [RD], 2.09% [95% CI, -2.43% to 6.60%]; adjusted risk ratio [aRR], 1.13 [95% CI, 0.90 to 1.41]). The risk of cognitive and language delay was not significantly different between the dextrose and placebo groups (cognitive: 7.6% vs 5.3%; RD, 2.32% [95% CI, -0.46% to 5.11%]; aRR, 1.40 [95% CI, 0.91 to 2.17]; language: 17.0% vs 14.7%; RD, 2.35% [95% CI, -1.80% to 6.50%]; aRR, 1.19 [95% CI, 0.92 to 1.54]). However, the dextrose gel group had a significantly higher risk of motor delay (2.5% vs 0.7%; RD, 1.81% [95% CI, 0.40% to 3.23%]; aRR, 3.79 [95% CI, 1.27 to 11.32]) and significantly lower composite scores for cognitive (adjusted mean difference [aMD], -1.30 [95% CI, -2.55 to -0.05]), language (aMD, -2.16 [95% CI, -3.86 to -0.46]), and motor (aMD, -1.40 [95% CI, -2.60 to -0.20]) performance. There were no significant differences between groups in the other 27 secondary outcomes. CONCLUSIONS AND RELEVANCE Among late preterm and term infants born at risk of neonatal hypoglycemia, prophylactic oral 40% dextrose gel at 1 hour of age, compared with placebo, resulted in no significant difference in the risk of neurosensory impairment at 2 years' corrected age. However, the study may have been underpowered to detect a small but potentially clinically important increase in risk, and further research including longer-term follow-up is required. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12614001263684.
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Affiliation(s)
- Taygen Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Richard Edlin
- Health Systems, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Greg D. Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Luling Lin
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J. D. McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Jenny A. Rogers
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, Waterloo, Ontario, Canada
- Center for Eye and Vision Research, Hong Kong
| | - Trecia A. Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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21
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Nivins S, Kennedy E, Thompson B, Gamble GD, Alsweiler JM, Metcalfe R, McKinlay CJD, Harding JE. Associations between neonatal hypoglycaemia and brain volumes, cortical thickness and white matter microstructure in mid-childhood: An MRI study. Neuroimage Clin 2022; 33:102943. [PMID: 35063925 PMCID: PMC8856905 DOI: 10.1016/j.nicl.2022.102943] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/11/2022]
Abstract
Neonatal hypoglycaemia is associated with damage to the brain in the acute phase. In mid-childhood, neonatal hypoglycaemia is associated with smaller brain regions. Deep grey matter regions such as the caudate and thalamus are implicated. Children with neonatal hypoglycemia had smaller occipital lobe cortical thickness. Grey matter may be especially vulnerable to long-term effects of neonatal hypoglycemia.
Neonatal hypoglycaemia is a common metabolic disorder that may cause brain damage, most visible in parieto-occipital regions on MRI in the acute phase. However, the long term effects of neonatal hypoglycaemia on the brain are not well understood. We investigated the association between neonatal hypoglycaemia and brain volumes, cortical thickness and white matter microstructure at 9–10 years. Children born at risk of neonatal hypoglycaemia at ≥ 36 weeks’ gestation who took part in a prospective cohort study underwent brain MRI at 9–10 years. Neonatal hypoglycaemia was defined as at least one hypoglycaemic episode (at least one consecutive blood glucose concentration < 2.6 mmol/L) or interstitial episode (at least 10 min of interstitial glucose concentrations < 2.6 mmol/L). Brain volumes and cortical thickness were computed using Freesurfer. White matter microstructure was assessed using tract-based spatial statistics. Children who had (n = 75) and had not (n = 26) experienced neonatal hypoglycaemia had similar combined parietal and occipital lobe volumes and no differences in white matter microstructure at nine years of age. However, those who had experienced neonatal hypoglycaemia had smaller caudate volumes (mean difference: −557 mm3, 95% confidence interval (CI), −933 to −182, p = 0.004) and smaller thalamus (−0.03%, 95%CI, −0.06 to 0.00; p = 0.05) and subcortical grey matter (−0.10%, 95%CI −0.20 to 0.00, p = 0.05) volumes as percentage of total brain volume, and thinner occipital lobe cortex (−0.05 mm, 95%CI −0.10 to 0.00, p = 0.05) than those who had not. The finding of smaller caudate volumes after neonatal hypoglycaemia was consistent across analyses of pre-specified severity groups, clinically detected hypoglycaemic episodes, and severity and frequency of hypoglycaemic events. Neonatal hypoglycaemia is associated with smaller deep grey matter brain regions and thinner occipital lobe cortex but not altered white matter microstructure in mid-childhood.
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Affiliation(s)
- Samson Nivins
- Liggins Institute, University of Auckland, New Zealand
| | | | - Benjamin Thompson
- Liggins Institute, University of Auckland, New Zealand; School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada; Centre for Eye and Vision Research, 17W Science Park, Hong Kong
| | | | - Jane M Alsweiler
- Auckland District Health Board, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, University of Auckland, New Zealand
| | | | - Christopher J D McKinlay
- Liggins Institute, University of Auckland, New Zealand; Kidz First Neonatal Care, Counties Manukau Health, New Zealand
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22
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Alsweiler JM, Heather N, Harris DL, McKinlay CJD. Application of the screening test principles to screening for neonatal hypoglycemia. Front Pediatr 2022; 10:1048897. [PMID: 36568425 PMCID: PMC9768220 DOI: 10.3389/fped.2022.1048897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Severe and prolonged neonatal hypoglycemia can cause brain injury, while the long-term consequences of mild or transitional hypoglycemia are uncertain. As neonatal hypoglycemia is often asymptomatic it is routine practice to screen infants considered at risk, including infants of mothers with diabetes and those born preterm, small or large, with serial blood tests over the first 12-24 h after birth. However, to prevent brain injury, the gold standard would be to determine if an infant has neuroglycopenia, for which currently there is not a diagnostic test. Therefore, screening of infants at risk for neonatal hypoglycemia with blood glucose monitoring does not meet several screening test principles. Specifically, the long-term neurodevelopmental outcomes of transient neonatal hypoglycemia are not well understood and there is no direct evidence from randomized controlled trials that treatment of hypoglycemia improves long-term neurodevelopmental outcomes. There have been no studies that have compared the long-term neurodevelopmental outcomes of at-risk infants screened for neonatal hypoglycemia and those not screened. However, screening infants at risk of hypoglycemia and treating those with hypoglycaemic episodes to maintain the blood glucose concentrations ≥2.6 mmol/L appears to preserve cognitive function compared to those without episodes. This narrative review explores the evidence for screening for neonatal hypoglycemia, the effectiveness of blood glucose screening as a screening test and recommend future research areas to improve screening for neonatal hypoglycemia. Screening babies at-risk of neonatal hypoglycemia continues to be necessary, but as over a quarter of all infants may be screened for neonatal hypoglycemia, further research is urgently needed to determine the optimal method of screening and which infants would benefit from screening and treatment.
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Affiliation(s)
- J M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - N Heather
- Newborn Metabolic Screening Programme, LabPlus, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - D L Harris
- School of Nursing, Midwifery and Health Practice, Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - C J D McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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23
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Alexander T, Meyer M, Harding JE, Alsweiler JM, Jiang Y, Wall C, Muelbert M, Bloomfield FH. Nutritional Management of Moderate- and Late-Preterm Infants Commenced on Intravenous Fluids Pending Mother's Own Milk: Cohort Analysis From the DIAMOND Trial. Front Pediatr 2022; 10:817331. [PMID: 35433556 PMCID: PMC9008239 DOI: 10.3389/fped.2022.817331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Exclusive breastmilk is the desired enteral nutrition for babies born moderate- and late-preterm between 32+0 and 36+6 weeks' gestation; however, this goal is often difficult to achieve. METHODS A prospective cohort of babies 32+0 -35+6 weeks' gestation enrolled in the DIAMOND trial were randomized to a condition specifying that babies should receive mother's own milk (MOM) as the only enteral feed. Factors associated with the successful transition to MOM, defined as MOM being the sole enteral feeding at the time of the first cessation of intravenous (IV) fluids, were investigated by logistic regression. Time to commencement of a milk other than MOM was analyzed by Kaplan-Meier survival curves. RESULTS A total of 151 eligible babies (60% boys) were included, 93 (63%) of whom successfully transitioned from IV fluids onto MOM only. Alternative sources of milk, mostly formula, were used to transition from IV fluids onto enteral feeds more often in multiples and Māori, and was commenced earlier in Māori than other ethnicities (p = 0.007) and in late-preterm compared with moderate-preterm babies (p=0.01). Receiving exclusively breastmilk at discharge was more likely for babies who successfully transitioned from IV fluids onto MOM only [OR (95% confidence intervals) 4.9 (2.3-10.6)] and who received only MOM in the first week after birth [4.8 (2.2-10.4)], both p < 0.0001. Receiving breastmilk exclusively at discharge was less likely for Māori than Caucasian babies [0.2 (0.1-0.6), p < 0.0006]. There was no difference in the use of alternative sources of milk in babies who received parenteral nutrition or dextrose or between small-for-gestational-age and appropriate-for-gestational-age babies. CONCLUSIONS Despite an intention to provide only MOM, significant numbers of moderate- and late-preterm babies received formula to transition from IV fluids, and this differed by ethnicity. The drivers underlying these decisions require further investigation. These data highlight an urgent need for quality initiatives to support and encourage mothers of moderate- and late-preterm babies in their lactation.
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Affiliation(s)
- Tanith Alexander
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Kidz First, Middlemore Hospital, Counties Mankau Health, Auckland, New Zealand
| | - Michael Meyer
- Neonatal Unit, Kidz First, Middlemore Hospital, Counties Mankau Health, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand.,The Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Clare Wall
- Department of Nutrition, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mariana Muelbert
- Liggins Institute, University of Auckland, Auckland, New Zealand
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24
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Walsh EPG, Alsweiler JM, Ardern J, Hanning SM, Harding JE, McKinlay CJD. Glucagon for Neonatal Hypoglycaemia: Systematic Review and Meta-Analysis. Neonatology 2022; 119:285-294. [PMID: 35263748 DOI: 10.1159/000522415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/31/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Glucagon is often used in neonatal hypoglycaemia, but its effects have not been systematically assessed. We undertook a systematic review to determine the efficacy and safety of glucagon treatment for neonatal hypoglycaemia. METHODS We searched MEDLINE, CINAHL, EMBASE, and CENTRAL from inception until May 2021. We included studies that reported one or more prespecified outcomes and compared glucagon with placebo or no glucagon. Studies were excluded if the majority (>70%) of participants were >1 month of age. Two authors independently extracted data. We used ROB-2/modified ROBINS-I to assess risk of bias, GRADE for certainty of evidence, and RevMan for meta-analysis. RESULTS 100 studies were screened, 37 reviewed in full, and seven single-arm non-randomised intervention studies, involving 348 infants, were included (no trials). Data were insufficient to undertake meta-analysis of the critical outcomes (time to blood glucose normalization, recurrent hypoglycaemia, neurocognitive impairment). In 3 studies, ≥80% of neonates achieved normoglycaemia within 4 h of glucagon administration. However, recurrent hypoglycaemia was common (up to 55%). Glucagon increased blood glucose concentration at 1-2 h by 2.3 mmol/L (95% CI 2.1, 2.5) (low certainty evidence, 6 studies, N = 323). There were few data for other important clinical outcomes. CONCLUSION There is a paucity of evidence about the efficacy and safety of glucagon for treatment of neonatal hypoglycaemia. Low certainty evidence suggests that glucagon may increase blood glucose by ∼2.3 mmol/L but recurrent hypoglycaemia appears common. High-quality, randomized controlled trials are required to determine the role of glucagon in managing neonatal hypoglycaemia.
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Affiliation(s)
- Eamon P G Walsh
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Julena Ardern
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - Sara M Hanning
- School of Pharmacy, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J D McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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25
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Hegarty JE, Alsweiler JM, Gamble GG, Crowther CA, Harding JE. Effect of Prophylactic Dextrose Gel on Continuous Measures of Neonatal Glycemia: Secondary Analysis of the Pre-hPOD Trial. J Pediatr 2021; 235:107-115.e4. [PMID: 33798509 PMCID: PMC8502486 DOI: 10.1016/j.jpeds.2021.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the effects of different doses of prophylactic dextrose gel on glycemic stability assessed using continuous glucose monitoring in the first 48 hours when given to babies at risk of neonatal hypoglycemia. STUDY DESIGN Continuous glucose monitoring was undertaken for the first 48 hours in 133 infants at risk of hypoglycemia who participated in the pre-hPOD randomized dosage trial of dextrose gel prophylaxis. RESULTS Low glucose concentrations were detected in 41% of infants by blood glucose monitoring and 68% by continuous interstitial glucose monitoring. The mean ± SD duration of low interstitial glucose concentrations was 295 ± 351 minutes in the first 48 hours. Infants who received any dose of dextrose gel seemed to be less likely than those who received placebo gel to experience low glucose concentrations (<47 mg/dL [2.6 mmol/L]; P = .08), particularly if they received a single dose of 200 mg/kg (relative risk, 0.70; 95% CI, 0.50-0.10; P = .049). They also spent a greater proportion of time in the central glucose concentration range of 54-72 mg/dL (3-4 mmol/L) (any dose, mean ± SD, 58.2 ± 20.3%; placebo, 50.0 ± 21.9%; mean difference, 8.20%; 95% CI, 0.43-15.9%; P = .038). Dextrose gel did not increase recurrent or severe episodes of low glucose concentrations and did not increase the peak glucose concentration. These effects were similar for all trial dosages. CONCLUSIONS Low glucose concentrations were common in infants at risk of hypoglycemia despite blood glucose monitoring and treatment. Prophylactic dextrose gel reduced the risk of hypoglycemia without adverse effects on glucose stability.
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Affiliation(s)
- Joanne E Hegarty
- Liggins Institute, University of Auckland, New Zealand,Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Jane M Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | | | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
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26
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Alsweiler JM, Harris DL, Harding JE, McKinlay CJD. Strategies to improve neurodevelopmental outcomes in babies at risk of neonatal hypoglycaemia. Lancet Child Adolesc Health 2021; 5:513-523. [PMID: 33836151 PMCID: PMC8528170 DOI: 10.1016/s2352-4642(20)30387-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/26/2020] [Accepted: 12/04/2020] [Indexed: 10/21/2022]
Abstract
Neonatal hypoglycaemia is associated with adverse development, particularly visual-motor and executive function impairment, in childhood. As neonatal hypoglycaemia is common and frequently asymptomatic in at-risk babies-ie, those born preterm, small or large for gestational age, or to mothers with diabetes, it is recommended that these babies are screened for hypoglycaemia in the first 1-2 days after birth with frequent blood glucose measurements. Neonatal hypoglycaemia can be prevented and treated with buccal dextrose gel, and it is also common to treat babies with hypoglycaemia with infant formula and intravenous dextrose. However, it is uncertain if screening, prophylaxis, or treatment improves long-term outcomes of babies at risk of neonatal hypoglycaemia. This narrative review assesses the latest evidence for screening, prophylaxis, and treatment of neonates at risk of hypoglycaemia to improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Deborah L Harris
- School of Nursing Midwifery and Health Practice, Victoria University of Wellington, Wellington, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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McKinlay CJD, Alsweiler JM, Bailey MJ, Cutfield WS, Rout A, Harding JE. A better taxonomy for neonatal hypoglycemia is needed. J Perinatol 2021; 41:1205-1206. [PMID: 33850290 DOI: 10.1038/s41372-021-01058-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 02/26/2021] [Accepted: 03/29/2021] [Indexed: 11/09/2022]
Affiliation(s)
- C J D McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand. .,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand.
| | - J M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Care, Starship Children's Health, Auckland, New Zealand
| | - M J Bailey
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand.,Neonatal Care, Starship Children's Health, Auckland, New Zealand
| | - W S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Paediatric Endocrinology, Starship Children's Health, Auckland, New Zealand.,A Better Start Science Challenge, Auckland, New Zealand
| | - A Rout
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
| | - J E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Griffith R, Hegarty JE, Alsweiler JM, Gamble GD, May R, McKinlay CJD, Thompson B, Wouldes TA, Harding JE. Two-year outcomes after dextrose gel prophylaxis for neonatal hypoglycaemia. Arch Dis Child Fetal Neonatal Ed 2021; 106:278-285. [PMID: 33148686 PMCID: PMC8062278 DOI: 10.1136/archdischild-2020-320305] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the effect of prophylactic dextrose gel for prevention of neonatal hypoglycaemia on neurodevelopment and executive function at 2 years' corrected age. DESIGN Prospective follow-up of a randomised trial. SETTING New Zealand. PATIENTS Participants from the pre-hypoglycaemia Prevention with Oral Dextrose (pre-hPOD) trial randomised to one of four dose regimes of buccal 40% dextrose gel or equivolume placebo. MAIN OUTCOME MEASURES Coprimary outcomes were neurosensory impairment and executive function. Secondary outcomes were components of the primary outcomes, neurology, anthropometry and health measures. RESULTS We assessed 360 of 401 eligible children (90%) at 2 years' corrected age. There were no differences between dextrose gel dose groups, single or multiple dose groups, or any dextrose and any placebo groups in the risk of neurosensory impairment or low executive function (any dextrose vs any placebo neurosensory impairment: relative risk (RR) 0.77, 95% CI 0.50 to 1.19, p=0.23; low executive function: RR 0.50, 95% CI 0.24 to 1.06, p=0.07). There were also no differences between groups in any secondary outcomes. There was no difference between children who did or did not develop neonatal hypoglycaemia in the risk of neurosensory impairment (RR 1.05, 95% CI 0.68 to 1.64, p=0.81) or low executive function (RR 0.73, 95% CI 0.34 to 1.59, p=0.43). CONCLUSION Prophylactic dextrose gel did not alter neurodevelopment or executive function and had no adverse effects to 2 years' corrected age, but this study was underpowered to detect potentially clinically important effects on neurosensory outcomes.
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Affiliation(s)
- Rebecca Griffith
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | | | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Greg D Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Robyn May
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher Joel Dorman McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Kids First Neonatal Care, Counties District Health Board, Auckland, New Zealand
| | - Benjamin Thompson
- Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
- Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Bailey MJ, Rout A, Harding JE, Alsweiler JM, Cutfield WS, McKinlay CJD. Prolonged transitional neonatal hypoglycaemia: characterisation of a clinical syndrome. J Perinatol 2021; 41:1149-1157. [PMID: 33279942 DOI: 10.1038/s41372-020-00891-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND We performed a case-control study to characterise infants with "prolonged transitional hypoglycaemia". METHODS Cases were born ≥36 weeks' gestation; had ≥1 hypoglycaemic episode <72 h and ≥72 h; received ongoing treatment for hypoglycaemia ≥72 h; and were without congenital disorders or acute illness. Cases were compared to controls born ≥36 weeks' with brief transitional hypoglycaemia, resolving <72 h. RESULTS 39/471 infants screened met case definition: 71.8% were male, 61.5% were small-for-gestational-age (SGA), and most were admitted <6 h. Compared to controls (N = 75), key risk factors for prolonged transitional hypoglycaemia were SGA (OR = 6.4, 95%CI 2.7-15.1), severe/recurrent hypoglycaemia <24 h (OR = 16.7, 95%CI 4.5-16.1), intravenous glucose bolus <24 h (OR = 26.6, 95%CI 9.4-75.1) and maximum glucose delivery rate <48 h of ≥8 mg/kg/min (OR = 25.5, 95%CI 7.7-84.1). CONCLUSIONS Infants with prolonged transitional hypoglycaemia are predominantly male, SGA and have early severe/recurrent hypoglycaemia requiring glucose boluses and high glucose delivery rates in the first 24-48 h.
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Affiliation(s)
- Miranda J Bailey
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Kidz First, Counties Manukau Health, Auckland, New Zealand
| | - Allie Rout
- Kidz First, Counties Manukau Health, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Wayne S Cutfield
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start Science Challenge, Auckland, New Zealand
| | - Christopher J D McKinlay
- Kidz First, Counties Manukau Health, Auckland, New Zealand. .,Liggins Institute, University of Auckland, Auckland, New Zealand.
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Harding JE, Hegarty JE, Crowther CA, Edlin RP, Gamble GD, Alsweiler JM. Evaluation of oral dextrose gel for prevention of neonatal hypoglycemia (hPOD): A multicenter, double-blind randomized controlled trial. PLoS Med 2021; 18:e1003411. [PMID: 33507929 PMCID: PMC7842885 DOI: 10.1371/journal.pmed.1003411] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Neonatal hypoglycemia is common and can cause brain injury. Buccal dextrose gel is effective for treatment of neonatal hypoglycemia, and when used for prevention may reduce the incidence of hypoglycemia in babies at risk, but its clinical utility remains uncertain. METHODS AND FINDINGS We conducted a multicenter, double-blinded, placebo-controlled randomized trial in 18 New Zealand and Australian maternity hospitals from January 2015 to May 2019. Babies at risk of neonatal hypoglycemia (maternal diabetes, late preterm, or high or low birthweight) without indications for neonatal intensive care unit (NICU) admission were randomized to 0.5 ml/kg buccal 40% dextrose or placebo gel at 1 hour of age. Primary outcome was NICU admission, with power to detect a 4% absolute reduction. Secondary outcomes included hypoglycemia, NICU admission for hypoglycemia, hyperglycemia, breastfeeding at discharge, formula feeding at 6 weeks, and maternal satisfaction. Families and clinical and study staff were unaware of treatment allocation. A total of 2,149 babies were randomized (48.7% girls). NICU admission occurred for 111/1,070 (10.4%) randomized to dextrose gel and 100/1,063 (9.4%) randomized to placebo (adjusted relative risk [aRR] 1.10; 95% CI 0.86, 1.42; p = 0.44). Babies randomized to dextrose gel were less likely to become hypoglycemic (blood glucose < 2.6 mmol/l) (399/1,070, 37%, versus 448/1,063, 42%; aRR 0.88; 95% CI 0.80, 0.98; p = 0.02) although NICU admission for hypoglycemia was similar between groups (65/1,070, 6.1%, versus 48/1,063, 4.5%; aRR 1.35; 95% CI 0.94, 1.94; p = 0.10). There were no differences between groups in breastfeeding at discharge from hospital (aRR 1.00; 95% CI 0.99, 1.02; p = 0.67), receipt of formula before discharge (aRR 0.99; 95% CI 0.92, 1.08; p = 0.90), and formula feeding at 6 weeks (aRR 1.01; 95% CI 0.93, 1.10; p = 0.81), and there was no hyperglycemia. Most mothers (95%) would recommend the study to friends. No adverse effects, including 2 deaths in each group, were attributable to dextrose gel. Limitations of this study included that most participants (81%) were infants of mothers with diabetes, which may limit generalizability, and a less reliable analyzer was used in 16.5% of glucose measurements. CONCLUSIONS In this placebo-controlled randomized trial, prophylactic dextrose gel 200 mg/kg did not reduce NICU admission in babies at risk of hypoglycemia but did reduce hypoglycemia. Long-term follow-up is needed to determine the clinical utility of this strategy. TRIAL REGISTRATION ACTRN 12614001263684.
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Affiliation(s)
- Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
- * E-mail:
| | - Joanne E. Hegarty
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Richard P. Edlin
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Jane M. Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Dai DWT, Wouldes TA, Brown GTL, Tottman AC, Alsweiler JM, Gamble GD, Harding JE. Relationships between intelligence, executive function and academic achievement in children born very preterm. Early Hum Dev 2020; 148:105122. [PMID: 32679472 DOI: 10.1016/j.earlhumdev.2020.105122] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children born very preterm are at higher risk of adverse neurocognitive and educational outcomes. However, how low intelligence (IQ) and low executive function may each contribute to poorer academic outcomes at school age requires clarification. AIM To examine the associations between intelligence, executive function and academic achievement in children born very preterm. DESIGN/METHODS This cohort study assessed children born <30 weeks' gestation or <1500 g at age 7 years using the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV) for IQ, and the Test of Everyday Attention for Children (TEA-Ch) and Behavior Rating Inventory of Executive Function (BRIEF) for executive function. Academic achievement was rated by teachers against curriculum standards. RESULTS Of the 76 children (35 girls, 41 boys, mean age = 7.2 year), 22 (28%) were rated below expected level for reading, 32 (42%) for writing and 38 (50%) for mathematics. After adjustment for sex and socioeconomic status, low IQ (OR's 9.0-12.3) and most low executive function measures (OR's 4.1-9.3) were associated with below-expected achievement. After further adjustment for IQ, low cognitive flexibility (OR = 9.3, 95% CI = 1.2-71.5) and teacher ratings of executive function (OR = 5.3, 95% CI = 1.4-20.2) were associated with below-expected achievement. Mediation analysis showed IQ had indirect effects on writing (b = 1.5, 95% CI = 0.6-3.1) via attentional control; and on reading (b = 1.0, 95% CI = 0.2-3.2) and writing (b = 0.8, 95% CI = 0.1-2.5) via cognitive flexibility. CONCLUSIONS Both low IQ and low executive function are associated with below-expected teacher-rated academic achievement in children born very preterm. IQ may influence academic achievement in part through executive function.
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Affiliation(s)
- Darren W T Dai
- Liggins Institute, University of Auckland, Private Bag 92019, Auckland 1023, New Zealand.
| | - Trecia A Wouldes
- Department of Psychological Medicine, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Gavin T L Brown
- Faculty of Education & Social Work, University of Auckland, Private Bag 92601, Symonds Street, Auckland 1150, New Zealand.
| | - Anna C Tottman
- Liggins Institute, University of Auckland, Private Bag 92019, Auckland 1023, New Zealand; Neonatal Services, Royal Women's Hospital, Melbourne, Locked Bag 300, Grattan St & Flemington Rd, Parkville, VIC 3052, Australia.
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Level 12, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.
| | - Greg D Gamble
- Liggins Institute, University of Auckland, Private Bag 92019, Auckland 1023, New Zealand.
| | - Jane E Harding
- Liggins Institute, University of Auckland, Private Bag 92019, Auckland 1023, New Zealand.
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Leung M, Black J, Bloomfield FH, Gamble GD, Harding JE, Jiang Y, Poppe T, Thompson B, Tottman AC, Wouldes TA, Alsweiler JM. Effects of Neonatal Hyperglycemia on Retinopathy of Prematurity and Visual Outcomes at 7 Years of Age: A Matched Cohort Study. J Pediatr 2020; 223:42-50.e2. [PMID: 32711750 DOI: 10.1016/j.jpeds.2020.04.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/06/2020] [Accepted: 04/23/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine whether neonatal hyperglycemia is associated with retinopathy of prematurity (ROP), visual outcomes, and ocular growth at 7 years of age. STUDY DESIGN Children born preterm (<30 weeks of gestational age) at a tertiary hospital in Auckland, New Zealand, who developed neonatal hyperglycemia (2 blood glucose concentrations ≥153 mg/dL [8.5 mmol/L] 4 hours apart) were matched with children who were not hyperglycemic (matching criteria: sex, gestational age, birth weight, age, socioeconomic status, and multiple birth) and assessed at 7 years of corrected age. The primary outcome, favorable overall visual outcome (visual acuity ≤0.3 logarithm of the minimum angle of resolution, no strabismus, stereoacuity ≤240 arcsec, not requiring spectacles) was compared between groups using generalized matching criteria-adjusted linear regression models. RESULTS Assessments were performed on 57 children with neonatal hyperglycemia (hyperglycemia group) and 54 matched children without hyperglycemia (control group). There were no differences in overall favorable visual outcome (OR 0.95, 95% CI 0.42-2.13, P = .90) or severe ROP incidence (OR 2.20, 95% CI 0.63-7.63, P = .21) between groups. Children with hyperglycemia had poorer binocular distance visual acuity (mean difference 0.08, 95% CI 0.03-0.14 logarithm of the minimum angle of resolution, P < .01), more strabismus (OR 6.22, 95% CI 1.31-29.45, P = .02), and thicker crystalline lens (mean difference 0.14, 95% CI 0.04-0.24 mm, P < .01). Maximum blood glucose concentration was greater in the ROP-treated group compared with the ROP-not treated and no ROP groups after adjusting for sex, gestational age, and birth weight z score (P = .02). CONCLUSIONS Neonatal hyperglycemia was not associated with overall visual outcomes at 7 years of age. However, there were between-group differences for specific outcome measures relating to interocular lens growth and binocular vision. Further follow-up is required to determine implications on long-term visual outcome.
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Affiliation(s)
- Myra Leung
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; Department of Optometry and Vision Science, University of Canberra, Canberra, Australia
| | - Joanna Black
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | | | - Greg D Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tanya Poppe
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, University of Auckland, Auckland, New Zealand; School of Optometry and Vision Science, University of Waterloo, Ontario, Canada
| | - Anna C Tottman
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
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Alsweiler JM, Gomes L, Nagy T, Gilchrist CA, Hegarty JE. Adherence to neonatal hypoglycaemia guidelines: A retrospective cohort study. J Paediatr Child Health 2020; 56:148-154. [PMID: 31228228 DOI: 10.1111/jpc.14544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/31/2019] [Indexed: 11/25/2022]
Abstract
AIM To determine if the routine use of automatically calculated birthweight centiles prior to discharge from the delivery unit is associated with improved adherence to the neonatal hypoglycaemia guideline. METHODS We conducted retrospective audits of adherence to the neonatal hypoglycaemia guideline in a tertiary maternity hospital in Auckland, New Zealand in a randomly selected cohort of newborn infants at risk of neonatal hypoglycaemia before (2011) and after (2015) the introduction of routine use of calculated birthweight centiles for all infants. The primary outcome was adherence to the guideline, defined as (i) blood glucose concentration screening in the first 48 h after birth; (ii) the initial measurement taken 1-2 h after birth; and (iii) at least three consecutive blood glucose concentrations ≥2.6 mmol/L, over 12 h, prior to cessation of screening. RESULTS The audits examined the records of 400 infants (200 each in 2011 and 2015) to determine guideline adherence. Adherence improved from 2011 to 2015 (59/200 (30%) vs. 95/200 (48%), P < 0.001), with the largest improvement in large-for-gestational age infants (7/50 (14%) vs. 25/50 (50%), P = <0.001). Screened infants whose care was adherent to the guideline had a higher incidence of hypoglycaemia detection (adherent, 64/154 (42%) vs. non-adherent, 34/246 (14%), P < 0.001). CONCLUSIONS The routine use of calculated birthweight centiles was associated with improved adherence to the neonatal hypoglycaemia guideline and increased detection of neonatal hypoglycaemia in at-risk infants. Thus, identifying practices that improve guideline adherence may improve the detection of hypoglycaemia in asymptomatic at-risk infants.
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Affiliation(s)
- Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Leanora Gomes
- Neonatal Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Tess Nagy
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Catherine A Gilchrist
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Joanne E Hegarty
- Neonatal Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
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Cloete E, Gentles TL, Webster DR, Davidkova S, Dixon LA, Alsweiler JM, Bloomfield FH. Pulse oximetry screening in a midwifery-led maternity setting with high antenatal detection of congenital heart disease. Acta Paediatr 2020; 109:100-108. [PMID: 31298757 PMCID: PMC6972617 DOI: 10.1111/apa.14934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/14/2019] [Accepted: 07/09/2019] [Indexed: 01/29/2023]
Abstract
Aim To assess local and individual factors that should be considered in the design of a pulse oximetry screening strategy in New Zealand's midwifery‐led maternity setting. Methods An intervention study was conducted over 2 years. Three hospitals and four primary maternity units participated in the study. Post‐ductal saturation levels were measured on well infants with a gestation of ≥35 weeks. Infant activity and age (hours) at the time of the test were recorded. Results Screening was performed on 16 644 of 27 172 (61%) eligible infants. The age at which the screening algorithm was initiated varied significantly among centres. The probability of achieving a pass result (saturations ≥95%) in the context of no underlying pathology ranged from .94 for an unsettled infant screened <4 hours of age to .99 (P < .001) when the test was performed after 24 hours on a settled infant. Forty‐eight (0.3%) infants failed to reach saturation targets: 37 had significant pathology of which three had cardiac disease. Conclusion Screening practices were influenced by the setting in which it was undertaken. Infant activity and age at the time of testing can influence saturation levels. Screening is associated with the identification of significant non‐cardiac pathology.
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Affiliation(s)
- Elza Cloete
- Liggins Institute University of Auckland Auckland New Zealand
| | - Thomas L. Gentles
- Paediatric and Congenital Cardiac Services Starship Children's Hospital Auckland New Zealand
| | - Dianne R. Webster
- Newborn Metabolic Screening Unit Auckland City Hospital Auckland New Zealand
| | - Sarka Davidkova
- Department of Paediatrics Rotorua Hospital Rotorua New Zealand
| | | | - Jane M. Alsweiler
- Department of Paediatrics, Child and Youth Health University of Auckland Auckland New Zealand
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Cloete E, Gentles TL, Dixon LA, Webster DR, Agnew JD, Davidkova S, Alsweiler JM, Rogers J, Bloomfield FH. Feasibility study assessing equitable delivery of newborn pulse oximetry screening in New Zealand's midwifery-led maternity setting. BMJ Open 2019; 9:e030506. [PMID: 31427341 PMCID: PMC6701602 DOI: 10.1136/bmjopen-2019-030506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/16/2019] [Accepted: 07/18/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aim of this study was to conduct New Zealand-specific research to inform the design of a pulse oximetry screening strategy that ensures equity of access for the New Zealand maternity population. Equity is an important consideration as the test has the potential to benefit some populations and socioeconomic groups more than others. SETTING New Zealand has an ethnically diverse population and a midwifery-led maternity service. One quaternary hospital and urban primary birthing unit (Region A), two regional hospitals (Region B) and three regional primary birthing units (Region C) from three Health Boards in New Zealand's North Island participated in a feasibility study of pulse oximetry screening. Home births in these regions were also included. PARTICIPANTS There were 27 172 infants that satisfied the inclusion criteria; 16 644 (61%) were screened. The following data were collected for all well newborn infants with a gestation age ≥35 weeks: date of birth, ethnicity, type of maternity care provider, deprivation index and screening status (yes/no). The study was conducted over a 2-year period from May 2016 to April 2018. RESULTS Screening rates improved over time. Infants born in Region B (adjusted OR=0.75; 95% CI 0.67 to 0.83) and C (adjusted OR=0.29; 95% CI 0.27 to 0.32) were less likely to receive screening compared with those born in Region A. There were significant associations between screening rates and deprivation, ethnicity and maternity care provider. Lack of human and material resources prohibited universal access to screening. CONCLUSION A pulse oximetry screening programme that is sector-led is likely to perpetuate inequity. Screening programmes need to be designed so that resources are distributed in the way most likely to optimise health outcomes for infants born with cardiac anomalies. ETHICS APPROVAL This study was approved by the Health and Disability Ethics Committees of New Zealand (15/NTA/168).
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Affiliation(s)
- Elza Cloete
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Thomas L Gentles
- Paediatric and Congenital Cardiac Service, Starship Children's Health, Auckland, New Zealand
| | - Lesley A Dixon
- New Zealand College of Midwives Inc, Christchurch, New Zealand
| | - Dianne R Webster
- Newborn Metabolic Screening Unit, Auckland District Health Board, Auckland, New Zealand
| | - Joshua D Agnew
- Department of Paediatrics, Tauranga Hospital, Tauranga, New Zealand
| | - Sarka Davidkova
- Department of Paediatrics, Rotorua Hospital, Rotorua, New Zealand
| | - Jane M Alsweiler
- Paediatrics: Child and Youth Health, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Jenny Rogers
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Alsweiler JM, Woodall SM, Crowther CA, Harding JE. Oral dextrose gel to treat neonatal hypoglycaemia: Clinician survey. J Paediatr Child Health 2019; 55:844-850. [PMID: 30565771 DOI: 10.1111/jpc.14306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/16/2018] [Accepted: 10/21/2018] [Indexed: 11/30/2022]
Abstract
AIMS To determine the use of oral dextrose gel to treat neonatal hypoglycaemia in New Zealand (NZ), to identify barriers and enablers to the implementation of the guideline and to determine if there is variation in management between clinical disciplines caring for at-risk babies. METHODS An online survey was distributed to clinicians (including doctors, midwives and nurses) caring for babies with neonatal hypoglycaemia via stakeholders and maternity hospitals. RESULTS A total of 251 clinicians from all 20 District Health Boards (DHBs) completed the survey. Of the responding clinicians, 148 (59%) from 15 (75%) DHBs reported oral dextrose gel use in their hospital, and of these, 129 (87%) reported a local guideline. In 12 of 15 (80%) DHBs, oral dextrose gel could be prescribed by midwives. For a clinical scenario of a baby with neonatal hypoglycaemia, doctors were more likely to prescribe oral dextrose gel than midwives (odds ratio (95% confidence interval), 2.9 (2.2-3.8), P < 0.0001). Of 32 possible combinations of treatment options for this scenario, 31 were selected by one or more clinicians. A guideline was perceived to be the most useful enabler, and availability of oral dextrose gel was seen as the most important barrier. CONCLUSIONS Oral dextrose gel is widely used to treat neonatal hypoglycaemia in NZ. Increasing availability of dextrose gel and the clinical practice guideline are likely to further increase the use of oral dextrose gel.
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Affiliation(s)
- Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Sonja M Woodall
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Griffith RJ, Harding JE, McKinlay CJ, Wouldes TA, Harris D, Alsweiler JM. Maternal glycemic control in diabetic pregnancies and neurodevelopmental outcomes in preschool aged children. A prospective cohort study. Early Hum Dev 2019; 130:101-108. [PMID: 30716594 PMCID: PMC6402955 DOI: 10.1016/j.earlhumdev.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 01/03/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Affiliation(s)
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Christopher J.D. McKinlay
- Department of Paediatrics, University of Auckland, Auckland, New Zealand,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Trecia A. Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Deborah Harris
- Liggins Institute, University of Auckland, Auckland, New Zealand,Newborn Intensive Care Unit Waikato District Health Board, Hamilton, New Zealand
| | - Jane M. Alsweiler
- Department of Paediatrics, University of Auckland, Auckland, New Zealand,Liggins Institute, University of Auckland, Auckland, New Zealand
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Crowther CA, Alsweiler JM, Hughes R, Brown J. Tight or less tight glycaemic targets for women with gestational diabetes mellitus for reducing maternal and perinatal morbidity? (TARGET): study protocol for a stepped wedge randomised trial. BMC Pregnancy Childbirth 2018; 18:425. [PMID: 30373539 PMCID: PMC6206938 DOI: 10.1186/s12884-018-2060-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/16/2018] [Indexed: 01/04/2023] Open
Abstract
Background Gestational diabetes mellitus (GDM) is strongly associated with significant adverse maternal and perinatal health outcomes that have lifelong consequences. Treatment for women with GDM aims to normalise maternal blood glucose concentrations to reduce these adverse health risks. Target recommendations for glycaemic control in women with GDM vary amongst international organisations. All their recommendations rely on consensus, as there have been no published randomised trials that compare different intensities of glucose control in women with GDM. The TARGET Trial aims to determine whether tighter targets for glycaemic control in women with GDM compared with less tight targets, reduce maternal and perinatal morbidity without adverse health consequences. Methods/design Using a stepped wedge, cluster randomised trial the 10 participating hospitals will be randomised to the timing of the change from the less tight to the tighter glycaemic target period. During the less tight target period, all health professionals at the hospital will aim to use the less tight glycaemic targets for treatment of women with GDM (fasting plasma glucose < 5.5 mmol/L; 1 h postprandial < 8.0 mmol/L; 2 h postprandial < 7.0 mmol/L). During the tighter target period all health professionals at the hospital will aim to use the tighter glycaemic targets for treatment of women with GDM (fasting plasma glucose ≤5.0 mmol/L, 1 h postprandial ≤7.4 mmol/L; 2 h postprandial ≤6.7 mmol/L). The primary study outcome is large for gestational age infant (birth weight > 90th centile). A sample size of 1080 participants will detect a treatment difference of 6% in the proportion of large for gestational age babies from 13% with less tight glycaemic targets to 7% with tighter targets, assuming an intra-cluster correlation coefficient of 0.05. Discussion The TARGET Trial will provide high-level evidence of direct relevance for clinical practice. If tighter treatment targets for women with GDM clearly result in significantly fewer large for gestational age infants and less adverse maternal and perinatal outcomes then they should be recommended for women with GDM. This would be of great importance to these women, their children, health services and communities. Trial registration Australian New Zealand Clinical Trials Registry - ACTRN 12615000282583.
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Affiliation(s)
- Caroline A Crowther
- Liggins Institute, The University of Auckland, Building 503, Level 2, 85 Park Road, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Jane M Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, Christchurch Women's Hospital, University of Otago, Christchurch, New Zealand
| | - Julie Brown
- Liggins Institute, The University of Auckland, Building 503, Level 2, 85 Park Road, Private Bag 92019, Auckland, 1142, New Zealand
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Bloomfield FH, Harding JE, Meyer MP, Alsweiler JM, Jiang Y, Wall CR, Alexander T. The DIAMOND trial - DIfferent Approaches to MOderate & late preterm Nutrition: Determinants of feed tolerance, body composition and development: protocol of a randomised trial. BMC Pediatr 2018; 18:220. [PMID: 29981569 PMCID: PMC6035796 DOI: 10.1186/s12887-018-1195-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Babies born at moderate-late preterm gestations account for > 80% of all preterm births. Although survival is excellent, these babies are at increased risk of adverse neurodevelopmental outcomes. They also are at increased risk of adverse long-term health outcomes, such as cardiovascular disease, obesity and diabetes. There is little evidence guiding optimal nutritional practices in these babies; practice, therefore, varies widely. This factorial design clinical trial will address the role of parenteral nutrition, milk supplementation and exposure of the preterm infant to taste and smell with each feed on time to tolerance of full feeds, adiposity, and neurodevelopment at 2 years. METHODS/DESIGN The DIAMOND trial is a multi-centre, factorial, randomised, controlled clinical trial. A total of 528 babies born between 32+ 0 and 35+ 6 weeks' gestation receiving intravenous fluids and whose mothers intend to breastfeed will be randomised to one of eight treatment conditions that include a combination of each of the three interventions: (i) intravenous amino acid solution vs. intravenous dextrose solution until full milk feeds established; (ii) milk supplement vs. exclusive breastmilk, and (iii) taste/smell given or not given before gastric tube feeds. Babies will be excluded if a particular mode of nutrition is clinically indicated or there is a congenital abnormality. Primary study outcome: For parenteral nutrition and milk supplement interventions, body composition at 4 months' corrected age. For taste/smell intervention, time to full enteral feeds defined as 150 ml.kg- 1.day- 1 or exclusive breastfeeding. SECONDARY OUTCOMES Days to full sucking feeds; days in hospital; body composition at discharge; growth to 2 years' corrected age; development at 2 years' corrected age; breastfeeding rates. DISCUSSION This trial will provide the first direct evidence to inform feeding practices in moderate- to late-preterm infants that will optimise their growth, metabolic and developmental outcomes. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry - ACTRN12616001199404 . This trial is endorsed by the IMPACT clinical trials network ( https://impact.psanz.com.au ).
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Affiliation(s)
- Frank H. Bloomfield
- Liggins Institute, University of Auckland, Private Bag, Auckland, 92019 New Zealand
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Private Bag, Auckland, 92019 New Zealand
| | - Michael P. Meyer
- The Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Neonatal Unit, Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Jane M. Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
- The Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Clare R. Wall
- Department of Nutrition, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tanith Alexander
- Liggins Institute, University of Auckland, Private Bag, Auckland, 92019 New Zealand
- Neonatal Unit, Kidz First, Middlemore Hospital, Auckland, New Zealand
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McKinlay CJ, Chase JG, Dickson J, Harris DL, Alsweiler JM, Harding JE. Continuous glucose monitoring in neonates: a review. Matern Health Neonatol Perinatol 2017; 3:18. [PMID: 29051825 PMCID: PMC5644070 DOI: 10.1186/s40748-017-0055-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/24/2017] [Indexed: 12/17/2022] Open
Abstract
Continuous glucose monitoring (CGM) is well established in the management of diabetes mellitus, but its role in neonatal glycaemic control is less clear. CGM has provided important insights about neonatal glucose metabolism, and there is increasing interest in its clinical use, particularly in preterm neonates and in those in whom glucose control is difficult. Neonatal glucose instability, including hypoglycaemia and hyperglycaemia, has been associated with poorer neurodevelopment, and CGM offers the possibility of adjusting treatment in real time to account for individual metabolic requirements while reducing the number of blood tests required, potentially improving long-term outcomes. However, current devices are optimised for use at relatively high glucose concentrations, and several technical issues need to be resolved before real-time CGM can be recommended for routine neonatal care. These include: 1) limited point accuracy, especially at low or rapidly changing glucose concentrations; 2) calibration methods that are designed for higher glucose concentrations of children and adults, and not for neonates; 3) sensor drift, which is under-recognised; and 4) the need for dynamic and integrated metrics that can be related to long-term neurodevelopmental outcomes. CGM remains an important tool for retrospective investigation of neonatal glycaemia and the effect of different treatments on glucose metabolism. However, at present CGM should be limited to research studies, and should only be introduced into routine clinical care once benefit is demonstrated in randomised trials.
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Affiliation(s)
- Christopher J.D. McKinlay
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - J. Geoffrey Chase
- Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Dickson
- Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Deborah L. Harris
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Neonatal Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand
| | - Jane M. Alsweiler
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
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McKinlay CJD, Alsweiler JM, Anstice NS, Burakevych N, Chakraborty A, Chase JG, Gamble GD, Harris DL, Jacobs RJ, Jiang Y, Paudel N, San Diego RJ, Thompson B, Wouldes TA, Harding JE. Association of Neonatal Glycemia With Neurodevelopmental Outcomes at 4.5 Years. JAMA Pediatr 2017; 171:972-983. [PMID: 28783802 PMCID: PMC5710616 DOI: 10.1001/jamapediatrics.2017.1579] [Citation(s) in RCA: 229] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Hypoglycemia is common during neonatal transition and may cause permanent neurological impairment, but optimal intervention thresholds are unknown. OBJECTIVE To test the hypothesis that neurodevelopment at 4.5 years is related to the severity and frequency of neonatal hypoglycemia. DESIGN, SETTING, AND PARTICIPANTS The Children With Hypoglycemia and Their Later Development (CHYLD) Study is a prospective cohort investigation of moderate to late preterm and term infants born at risk of hypoglycemia. Clinicians were masked to neonatal interstitial glucose concentrations; outcome assessors were masked to neonatal glycemic status. The setting was a regional perinatal center in Hamilton, New Zealand. The study was conducted from December 2006 to November 2010. The dates of the follow-up were September 2011 to June 2015. Participants were 614 neonates born from 32 weeks' gestation with at least 1 risk factor for hypoglycemia, including diabetic mother, preterm, small, large, or acute illness. Blood and masked interstitial glucose concentrations were measured for up to 7 days after birth. Infants with hypoglycemia (whole-blood glucose concentration <47 mg/dL) were treated to maintain blood glucose concentration of at least 47 mg/dL. EXPOSURES Neonatal hypoglycemic episode, defined as at least 1 consecutive blood glucose concentration less than 47 mg/dL, a severe episode (<36 mg/dL), or recurrent (≥3 episodes). An interstitial episode was defined as an interstitial glucose concentration less than 47 mg/dL for at least 10 minutes. MAIN OUTCOMES AND MEASURES Cognitive function, executive function, visual function, and motor function were assessed at 4.5 years. The primary outcome was neurosensory impairment, defined as poor performance in one or more domains. RESULTS In total, 477 of 604 eligible children (79.0%) were assessed. Their mean (SD) age at the time of assessment was 4.5 (0.1) years, and 228 (47.8%) were female. Those exposed to neonatal hypoglycemia (280 [58.7%]) did not have increased risk of neurosensory impairment (risk difference [RD], 0.01; 95% CI, -0.07 to 0.10 and risk ratio [RR], 0.96; 95% CI, 0.77 to 1.21). However, hypoglycemia was associated with increased risk of low executive function (RD, 0.05; 95% CI, 0.01 to 0.10 and RR, 2.32; 95% CI, 1.17 to 4.59) and visual motor function (RD, 0.03; 95% CI, 0.01 to 0.06 and RR, 3.67; 95% CI, 1.15 to 11.69), with highest risk in children exposed to severe, recurrent, or clinically undetected (interstitial episodes only) hypoglycemia. CONCLUSIONS AND RELEVANCE Neonatal hypoglycemia was not associated with increased risk of combined neurosensory impairment at 4.5 years but was associated with a dose-dependent increased risk of poor executive function and visual motor function, even if not detected clinically, and may thus influence later learning. Randomized trials are needed to determine optimal screening and intervention thresholds based on assessment of neurodevelopment at least to school age.
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Affiliation(s)
- Christopher J. D. McKinlay
- Liggins Institute, The University of Auckland, Auckland, New Zealand,Department of Paediatrics, The University of Auckland, Auckland, New Zealand
| | - Jane M. Alsweiler
- Liggins Institute, The University of Auckland, Auckland, New Zealand,Department of Paediatrics, The University of Auckland, Auckland, New Zealand
| | - Nicola S. Anstice
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | | | - Arijit Chakraborty
- Liggins Institute, The University of Auckland, Auckland, New Zealand,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - J. Geoffrey Chase
- Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Gregory D. Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Deborah L. Harris
- Liggins Institute, The University of Auckland, Auckland, New Zealand,Neonatal Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand
| | - Robert J. Jacobs
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Nabin Paudel
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Ryan J. San Diego
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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Leung MP, Thompson B, Black J, Dai S, Alsweiler JM. The effects of preterm birth on visual development. Clin Exp Optom 2017; 101:4-12. [PMID: 28868651 DOI: 10.1111/cxo.12578] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/30/2017] [Accepted: 05/07/2017] [Indexed: 12/18/2022] Open
Abstract
Children born very preterm are at a greater risk of abnormal visual and neurological development when compared to children born at full term. Preterm birth is associated with retinopathy of prematurity (a proliferative retinal vascular disease) and can also affect the development of brain structures associated with post-retinal processing of visual information. Visual deficits common in children born preterm, such as reduced visual acuity, strabismus, abnormal stereopsis and refractive error, are likely to be detected through childhood vision screening programs, ophthalmological follow-up or optometric care. However, routine screening may not detect other vision problems, such as reduced visual fields, impaired contrast sensitivity and deficits in cortical visual processing, that may occur in children born preterm. For example, visual functions associated with the dorsal visual processing stream, such as global motion perception and visuomotor integration, may be impaired by preterm birth. These impairments can continue into adolescence and adulthood and may contribute to the difficulties in learning (particularly reading and mathematics), attention, behaviour and cognition that some children born preterm experience. Improvements in understanding the mechanisms by which preterm birth affects vision will inform future screening and interventions for children born preterm.
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Affiliation(s)
- Myra Ps Leung
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand.,School of Optometry and Vision Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanna Black
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - Shuan Dai
- Department of Ophthalmology, The University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, The University of Auckland, Auckland, New Zealand
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Tottman AC, Alsweiler JM, Bloomfield FH, Harding JE. Presence and pattern of scarring in children born very preterm. Arch Dis Child Fetal Neonatal Ed 2017; 103:fetalneonatal-2016-311999. [PMID: 28794133 DOI: 10.1136/archdischild-2016-311999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 06/29/2017] [Accepted: 07/19/2017] [Indexed: 11/04/2022]
Abstract
The long-term scarring burden of preterm infants undergoing modern neonatal intensive care is not known. This observational cohort study aimed to document the presence and pattern of scarring in children born <30 weeks' gestation or <1500 g birth weight and cared for at the National Women's Health neonatal intensive care unit, Auckland, New Zealand. Children were examined at 7 years' corrected age and the presence, size, number and distribution of scars documented. Scarring was seen in 90% of 129 children assessed, with 81% having multiple scars, 60% having large scars (85% of whom had no history of major neonatal surgery) and 75% having more than one body area scarred. Scarring was more common in boys and in children of non-European ethnicity. Despite modern neonatal intensive care practices, children born very preterm are frequently and extensively scarred at school age.
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Affiliation(s)
- Anna C Tottman
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Frank H Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Harding JE, Cormack BE, Alexander T, Alsweiler JM, Bloomfield FH. Advances in nutrition of the newborn infant. Lancet 2017; 389:1660-1668. [PMID: 28443560 DOI: 10.1016/s0140-6736(17)30552-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 01/07/2023]
Abstract
Nutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. New developments include recommendations to increase protein supply, improve formulations of parenteral lipids, and provide mineral supplements while encouraging human milk feeding. However, high quality evidence of the risks and benefits of these developments is lacking. Clinical trials are also needed to assess the effect on preterm infants of experiencing the smell and taste of milk, to determine whether boys and girls should be fed differently, and to test effects of insulin and IGF-1 supplements on growth and developmental outcomes. Moderate-to-late preterm infants have neonatal nutritional challenges that are similar to those infants born at earlier gestations, but even less high quality evidence exists upon which to base clinical decisions. The focus of research in nutrition of infants born at term is largely directed at new formula products that will improve cognitive and metabolic outcomes. Providing the most effective nutrition to preterm infants should be prioritised as an important focus of neonatal care research to improve long-term metabolic and developmental outcomes.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Barbara E Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand; Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Tanith Alexander
- Liggins Institute, University of Auckland, Auckland, New Zealand; Neonatal Unit, Middlemore Hospital, Auckland, New Zealand
| | - Jane M Alsweiler
- Liggins Institute, University of Auckland, Auckland, New Zealand; Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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Cloete E, Gentles TL, Alsweiler JM, Dixon LA, Webster DR, Rowe DL, Bloomfield FH. Should New Zealand introduce nationwide pulse oximetry screening for the detection of critical congenital heart disease in newborn infants? N Z Med J 2017; 130:64-69. [PMID: 28081558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Elza Cloete
- Neonatologist and Research Fellow, Liggins Institute, University of Auckland, Auckland
| | - Thomas L Gentles
- Paediatric Cardiologist and Service Clinical Director, Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Health, Auckland
| | - Jane M Alsweiler
- Neonatologist and Senior Lecturer, Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland
| | - Lesley A Dixon
- Midwifery Advisor, New Zealand College of Midwives, Christchurch
| | - Dianne R Webster
- Director Newborn Metabolic Screening Programme and Lead Clinical Scientist Antenatal Screening for Down Syndrome and Other Conditions, LabPlus, Auckland City Hospital, Auckland
| | - Deborah L Rowe
- Senior Lecturer, School of Nursing, University of Auckland, Auckland
| | - Frank H Bloomfield
- Professor of Neonatology and Director, Liggins Institute, University of Auckland, Auckland
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Abstract
Neonatal hypoglycaemia is common, and screening and treatment of babies considered at risk is widespread, despite there being little reliable evidence upon which to base management decisions. Although there is now evidence about which babies are at greatest risk, the threshold for diagnosis, best approach to treatment and later outcomes all remain uncertain. Recent studies suggest that treatment with dextrose gel is safe and effective and may help support breast feeding. Thresholds for intervention require a wide margin of safety in light of information that babies with glycaemic instability and with low glucose concentrations may be associated with a higher risk of later higher order cognitive and learning problems. Randomised trials are urgently needed to inform optimal thresholds for intervention and appropriate treatment strategies.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland 1023, New Zealand.
| | - Deborah L Harris
- Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland 1023, New Zealand; Waikato Hospital, Selwyn Street and Pembroke Street, Hamilton 3204, New Zealand.
| | - Joanne E Hegarty
- Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland 1023, New Zealand; National Women's Health, Auckland City Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand.
| | - Jane M Alsweiler
- Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland 1023, New Zealand; National Women's Health, Auckland City Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand; Department of Paediatrics: Child and Youth Health, University of Auckland, 2 Park Rd, Grafton, Auckland 1023, New Zealand.
| | - Christopher JD McKinlay
- Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland 1023, New Zealand,Department of Paediatrics: Child and Youth Health, University of Auckland, 2 Park Rd, Grafton, Auckland 1023, New Zealand,Kidz First Neonatal Care, Counties Manukau Health, Private Bag 93311, Otahuhu, Auckland, New Zealand
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Harris DL, Alsweiler JM, Ansell JM, Gamble GD, Thompson B, Wouldes TA, Yu TY, Harding JE. Outcome at 2 Years after Dextrose Gel Treatment for Neonatal Hypoglycemia: Follow-Up of a Randomized Trial. J Pediatr 2016; 170:54-9.e1-2. [PMID: 26613985 PMCID: PMC4769950 DOI: 10.1016/j.jpeds.2015.10.066] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/23/2015] [Accepted: 10/21/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine neurodevelopmental outcome at 2 years' corrected age in children randomized to treatment with dextrose gel or placebo for hypoglycemia soon after birth (The Sugar Babies Study). STUDY DESIGN This was a follow-up study of 184 children with hypoglycemia (<2.6 mM [47 mg/dL]) in the first 48 hours and randomized to either dextrose (90/118, 76%) or placebo gel (94/119, 79%). Assessments were performed at Kahikatea House, Hamilton, New Zealand, and included neurologic function and general health (pediatrician assessed), cognitive, language, behavior, and motor skills (Bayley Scales of Infant and Toddler Development, Third Edition), executive function (clinical assessment and Behaviour Rating Inventory of Executive Function-Preschool Edition), and vision (clinical examination and global motion perception). Coprimary outcomes were neurosensory impairment (cognitive, language or motor score below -1 SD or cerebral palsy or blind or deaf) and processing difficulty (executive function or global motion perception worse than 1.5 SD from the mean). Statistical tests were two sided with 5% significance level. RESULTS Mean (± SD) birth weight was 3093 ± 803 g and mean gestation was 37.7 ± 1.6 weeks. Sixty-six children (36%) had neurosensory impairment (1 severe, 6 moderate, 59 mild) with similar rates in both groups (dextrose 38% vs placebo 34%, relative risk 1.11, 95% CI 0.75-1.63). Processing difficulty also was similar between groups (dextrose 10% vs placebo 18%, relative risk 0.52, 95% CI 0.23-1.15). CONCLUSIONS Dextrose gel is safe for the treatment of neonatal hypoglycemia, but neurosensory impairment is common among these children. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN 12608000623392.
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Affiliation(s)
- Deborah L Harris
- Newborn Intensive Care Unit Waikato District Health Board, Hamilton, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Judith M Ansell
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gregory D Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Thompson
- Department of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Trecia A Wouldes
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Tzu-Ying Yu
- Department of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
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McKinlay CJD, Alsweiler JM, Ansell JM, Anstice NS, Chase JG, Gamble GD, Harris DL, Jacobs RJ, Jiang Y, Paudel N, Signal M, Thompson B, Wouldes TA, Yu TY, Harding JE. Neonatal Glycemia and Neurodevelopmental Outcomes at 2 Years. N Engl J Med 2015; 373:1507-18. [PMID: 26465984 PMCID: PMC4646166 DOI: 10.1056/nejmoa1504909] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neonatal hypoglycemia is common and can cause neurologic impairment, but evidence supporting thresholds for intervention is limited. METHODS We performed a prospective cohort study involving 528 neonates with a gestational age of at least 35 weeks who were considered to be at risk for hypoglycemia; all were treated to maintain a blood glucose concentration of at least 47 mg per deciliter (2.6 mmol per liter). We intermittently measured blood glucose for up to 7 days. We continuously monitored interstitial glucose concentrations, which were masked to clinical staff. Assessment at 2 years included Bayley Scales of Infant Development III and tests of executive and visual function. RESULTS Of 614 children, 528 were eligible, and 404 (77% of eligible children) were assessed; 216 children (53%) had neonatal hypoglycemia (blood glucose concentration, <47 mg per deciliter). Hypoglycemia, when treated to maintain a blood glucose concentration of at least 47 mg per deciliter, was not associated with an increased risk of the primary outcomes of neurosensory impairment (risk ratio, 0.95; 95% confidence interval [CI], 0.75 to 1.20; P=0.67) and processing difficulty, defined as an executive-function score or motion coherence threshold that was more than 1.5 SD from the mean (risk ratio, 0.92; 95% CI, 0.56 to 1.51; P=0.74). Risks were not increased among children with unrecognized hypoglycemia (a low interstitial glucose concentration only). The lowest blood glucose concentration, number of hypoglycemic episodes and events, and negative interstitial increment (area above the interstitial glucose concentration curve and below 47 mg per deciliter) also did not predict the outcome. CONCLUSIONS In this cohort, neonatal hypoglycemia was not associated with an adverse neurologic outcome when treatment was provided to maintain a blood glucose concentration of at least 47 mg per deciliter. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others.).
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Affiliation(s)
- Christopher J D McKinlay
- From the Liggins Institute (C.J.D.M., J.M. Alsweiler, J.M. Ansell, G.D.G., D.L.H., Y.J., J.E.H.), the Department of Paediatrics (J.M. Alsweiler), the School of Optometry and Vision Science (N.S.A., R.J.J., N.P., B.T., T.-Y.Y.), and the Department of Psychological Medicine (T.A.W.), University of Auckland, Auckland, the Department of Mechanical Engineering, University of Canterbury, Christchurch (J.G.C., M.S.), and the Neonatal Intensive Care Unit, Waikato District Health Board, Hamilton (D.L.H.) - all in New Zealand; and the School of Optometry and Vision Science, University of Waterloo, Waterloo, ON, Canada (B.T.)
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Bansal A, Bloomfield FH, Connor KL, Dragunow M, Thorstensen EB, Oliver MH, Sloboda DM, Harding JE, Alsweiler JM. Glucocorticoid-Induced Preterm Birth and Neonatal Hyperglycemia Alter Ovine β-Cell Development. Endocrinology 2015. [PMID: 26204462 DOI: 10.1210/en.2015-1095] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Adults born preterm are at increased risk of impaired glucose tolerance and diabetes. Late gestation fetuses exposed to high blood glucose concentration also are at increased risk of impaired glucose tolerance as adults. Preterm babies commonly become hyperglycemic and are thus exposed to high blood glucose concentration at an equivalent stage of pancreatic maturation. It is not known whether preterm birth itself, or complications of prematurity, such as hyperglycemia, alter later pancreatic function. To distinguish these, we made singleton preterm lambs hyperglycemic (HYPER) for 12 days after birth with a dextrose infusion and compared them with vehicle-treated preterm and term controls and with HYPER lambs made normoglycemic with an insulin infusion. Preterm birth reduced β-cell mass, apparent by 4 weeks after term and persisting to adulthood (12 mo), and was associated with reduced insulin secretion at 4 months (juvenile) and reduced insulin mRNA expression in adulthood. Hyperglycemia in preterm lambs further down-regulated key pancreatic gene expression in adulthood. These findings indicate that reduced β-cell mass after preterm birth may be an important factor in increased risk of diabetes after preterm birth and may be exacerbated by postnatal hyperglycemia.
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Affiliation(s)
- Amita Bansal
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Frank H Bloomfield
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Kristin L Connor
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Mike Dragunow
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Eric B Thorstensen
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Mark H Oliver
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Deborah M Sloboda
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Jane E Harding
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Jane M Alsweiler
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
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Harding JE, Hegarty JE, Crowther CA, Edlin R, Gamble G, Alsweiler JM. Randomised trial of neonatal hypoglycaemia prevention with oral dextrose gel (hPOD): study protocol. BMC Pediatr 2015; 15:120. [PMID: 26377909 PMCID: PMC4572621 DOI: 10.1186/s12887-015-0440-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 09/01/2015] [Indexed: 11/10/2022] Open
Abstract
Background Neonatal hypoglycaemia is common, affecting up to 15 % of newborn babies and 50 % of those with risk factors (preterm, infant of a diabetic, high or low birthweight). Hypoglycaemia can cause brain damage and death, and babies born at risk have an increased risk of developmental delay in later life. Treatment of hypoglycaemia usually involves additional feeding, often with infant formula, and admission to Neonatal Intensive Care for intravenous dextrose. This can be costly and inhibit the establishment of breast feeding. Prevention of neonatal hypoglycaemia would be desirable, but there are currently no strategies, beyond early feeding, for prevention of neonatal hypoglycaemia. Buccal dextrose gel is safe and effective in treatment of hypoglycaemia. The aim of this trial is to determine whether 40 % dextrose gel given to babies at risk prevents neonatal hypoglycaemia and hence reduces admission to Neonatal Intensive Care. Methods/design Design: Randomised, multicentre, placebo controlled trial. Inclusion criteria: Babies at risk of hypoglycaemia (preterm, infant of a diabetic, small or large), less than 1 h old, with no apparent indication for Neonatal Intensive Care Unit admission and mother intends to breastfeed. Trial entry & randomisation: Eligible babies of consenting parents will be allocated by online randomisation to the dextrose gel group or placebo group, using a study number and corresponding trial intervention pack. Study groups: Babies will receive a single dose of 0.5 ml/kg study gel at 1 h after birth; either 40 % dextrose gel (200 mg/kg) or 2 % hydroxymethylcellulose placebo. Gel will be massaged into the buccal mucosal and followed by a breast feed. Primary study outcome: Admission to Neonatal Intensive Care. Sample size: 2,129 babies are required to detect a decrease in admission to Neonatal Intensive Care from 10–6 % (two-sided alpha 0.05, 90 % power, 5 % drop-out rate). Discussion This study will investigate whether admission to Neonatal Intensive Care can be prevented by prophylactic oral dextrose gel; a simple, cheap and painless intervention that requires no special expertise or equipment and hence is applicable in almost any birth setting. Trial registration Australian New Zealand Clinical Trials Registry - ACTRN 12614001263684.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Joanne E Hegarty
- Liggins Institute, University of Auckland, Auckland, New Zealand. .,Newborn Services, Auckland City Hospital, Auckland, New Zealand.
| | | | - Richard Edlin
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Greg Gamble
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Jane M Alsweiler
- Newborn Services, Auckland City Hospital, Auckland, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
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