Defining neonatal hypoglycaemia: a continuing debate

Development and internal validation of a clinical score to predict neonatal hypoglycaemia in women with gestational diabetes

INTRODUCTION

Gestational diabetes (GD) is a risk factor for neonatal hypoglycaemia (NH), but other factors can increase this risk.

OBJECTIVES

To create a score to predict NH in women with GD.

METHODS

Retrospective study of women with GD with a live singleton birth between 2012 and 2017 from the Portuguese GD registry. Pregnancies with and without NH were compared. A logistic regression was used to study NH predictors. Variables independently associated with NH were used to score derivation. The model's internal validation was performed by a bootstrapping. The association between the score and NH was assessed by logistic regression.

RESULTS

We studied 10216 pregnancies, 410 (4.0%) with NH. The model's AUC was 0.628 (95%CI: 0.599-0.657). Optimism-corrected c-index: 0.626. Points were assigned to variables associated with NH in proportion to the model's lowest regression coefficient: insulin-treatment 1, preeclampsia 3, preterm delivery 2, male sex 1, and small-for-gestational-age 2, or large-for-gestational-age 3. NH prevalence by score category 0-1, 2, 3, 4, and ≥5 was 2.3%, 3.0%, 4.5%, 6.0%, 7.4%, and 11.5%, respectively. Per point, the OR for NH was 1.35 (95% CI: 1.27-1.42). A score of 2, 3, 4, 5 or ≥6 (versus ≤1) had a OR for NH of 1.67 (1.29-2.15), 2.24 (1.65-3.04), 2.83 (2.02-3.98), 3.08 (1.83-5.16), and 6.84 (4.34-10.77), respectively.

CONCLUSION

Per each score point, women with GD had 35% higher risk of NH. Those with ≥6 points had 6.8-fold higher risk of NH compared to a score ≤1. Our score may be useful for identifying women at a higher risk of NH.

Systematic review of guidelines on neonatal hypoglycemia

OBJECTIVE

In recent years, a series of clinical guidelines on neonatal hypoglycemia have been developed in different countries and regions. This systematic review was aimed at providing evidence for clinical decision-making and providing ideas for future research by comparatively analyzing the contents of various guidelines.

METHODS

A multilateral approach was used, including comprehensive literature searches and online research. The retrieved studies were screened by two independent reviewers according to our inclusion criteria. The two reviewers independently extracted the descriptive data. Four appraisers assessed the guidelines using the AGREE-II instrument.

RESULTS

Ten clinical guidelines on neonatal hypoglycemia were included, with a mean score of 45.28%-83.45% in six domains. The guidelines are relatively consistent in their recommendations on clinical symptoms of neonatal hypoglycemia, but different in risk factors, preventive measures, thresholds for clinical management of hypoglycemia, target glucose ranges for its control, and pharmacotherapy.

CONCLUSION

By summarising the recommendations in the guidelines on neonatal hypoglycemia, we found that blood glucose values were not the only observational indicator, and other indicators (e.g., ketone bodies, lactate) related to glucose metabolism should also be considered for a comprehensive assessment. There is still a lack of consensus on thresholds for the clinical management of hypoglycemia and target glucose ranges for its control, and the recommendations on its pharmacotherapy are rather simple and sketchy. In the future, more high-quality studies are required to further improve the early identification of neonatal hypoglycemia and intervention strategies against it.

Maximizing the detection rate of hypoglycemia among preterm neonates admitted in Neonatal intensive care unit in Ethiopia, 2021

The burden of hypoglycemia is high in resource limited countries, such as Ethiopia. However, there are no sufficient studies conducted in Ethiopia in general and in the study setting in particular in the previous era. Hence, this study aims to assess the proportion of hypoglycemia and associated factors among preterm neonates admitted to the neonatal intensive care unit at Debre Tabor Comprehensive Specialized Hospital, Ethiopia, in 2021. A hospital-based cross-sectional study was conducted from October 1 to December 30, 2021, at Debre Tabor Comprehensive Specialized Hospital in the neonatal intensive care unit ward. The data was entered in Epi-info 7 and exported to STATA version 14. A binary and multivariable logistic regression was computed at 95% confidence interval (CI). During bivariable analysis, variables having a p-value of less than 0.25 were chosen for multivariable logistic regression analysis, and variables having a p-value of less than 0.05 in multivariable analysis, were significant associations with the dependent variable. The study included 267 preterm neonates, and 23.59% (95% CI 18.9-29.1) were develop hypoglycemia. Moreover, 49 (18.35%) preterm neonates died during the study period. In this study, preterm neonates with hypothermia [Adjusted Odds Ratio (AOR = 4.5; 95 CI 3.4, 7.2)], birth asphyxia (AOR = 5.1; 95 CI 3.9, 27.1), seizure (AOR = 4.7; 95 CI 2.8, 17.8), and also preterm neonates born from diabetic mothers (AOR = 6.7; 95 CI 3.3, 27.2) were significantly associated with the occurrence of hypoglycemia in the neonatal intensive care. The proportion of hypoglycemia and associated factors among preterm neonates admitted to the neonatal intensive care unit at Debre Tabor Comprehensive Specialized Hospital was found to be high. The associated factors for the occurrence of hypoglycemia were discovered to be neonates with hypothermia, birth asphyxia, seizure, and neonates born with a diabetes mother. Thus, recognizing and treating the above associated factors is essential to preventing, and controlling hypoglycemia.

Dynamic magnetic resonance imaging findings in the early stages of neonatal hypoglycemic brain injury

Hypoglycemia is common among neonates and can cause neurological dysfunction. This study aimed to identify the specific time window to perform diffusion-weighted imaging (DWI) for detecting early brain injury in neonatal hypoglycemia and assess the clinical characteristics and neurological outcomes of different patterns of brain injury in neonatal hypoglycemia. We conducted a retrospective analysis of the changes in conventional magnetic resonance imaging (MRI) and DWI at different time points and clinical characteristics in 86 neonates with hypoglycemic brain injury. Among 139 DWI scans, 84 showed injury site hyperintensities within 7 days after hypoglycemia. Thirty-nine scans revealed low DWI and abnormal T1-/T2-weighted imaging signals within 11-23 days after onset, of which 21 showed DWI hyperintensities in the corpus callosum. Abnormal signals were undetected in the second scans of 13 infants within 9-20 days after onset. Vulnerable sites comprised the occipital lobe (98%), splenium of the corpus callosum (60%), and parietal lobe (30%). Compared with focal injury (n = 66), extensive injury (n = 20) had higher involvement of the internal capsule, basal ganglia, and thalamus (P < 0.05); higher incidence of recurrent convulsions, respiratory failure, and coma (P < 0.01); and a higher proportion of death and severe neurodevelopmental impairment (P < 0.05).

CONCLUSIONS

Neonatal hypoglycemic brain injury was most common in the occipital lobes. Severe clinical symptoms were significantly associated with extensive brain injury involving the internal capsule, basal ganglia, and thalamus, which could be attributed to hypoxia-ischemia and lead to a poor prognosis.

WHAT IS KNOWN

• There is no clear neurological safe threshold for hypoglycemia in neonates. Studies suggest that symptomatic hypoglycemia can be related to brain injury.

WHAT IS NEW

• Severe clinical symptoms are significantly associated with extensive brain injury on MRI scans. Extensive brain injuries involving the internal capsule, basal ganglia, and thalamus, which could be due to associated hypoxia-ischemia and lead to a poor prognosis.

Identifying additional risk factors for early asymptomatic neonatal hypoglycemia in term and late preterm babies

BACKGROUND

Neonatal hypoglycemia is a common metabolic disorder in newborns, which may present with non-specific symptoms or even be asymptomatic. Current guidelines recommend screening for hypoglycemia in at-risk babies (late preterm, small for gestational age, large for gestational age, and infants of diabetic mothers). Past studies have suggested other potential risk factors, such as maternal obesity, gestational hypertension, cesarean section, etc. In this study, we aim to identify additional prenatal and perinatal maternal/fetal characteristics associated with early asymptomatic hypoglycemia in term and late preterm babies.

METHODS

We performed a retrospective review on medical charts of all newborns, born between January, 2017 and December, 2020, in the well-baby newborn nursery of a tertiary medical center. We identified newborns who had received blood glucose concentration monitor after birth. Detailed prenatal and perinatal maternal/newborn information were collected for analysis.

RESULTS

In the study period, 841 newborns had received blood glucose screening after birth. After matching by sex and indication for postnatal blood glucose screen (SGA, LGA, and GDM), 148 newborns were included in the "hypoglycemia group" and 296 newborns were included in the "euglycemia group". In the univariate analysis, parity, insulin treatment for gestational diabetes mellitus (GDM), and cesarean section were associated with an increased risk for neonatal hypoglycemia. Factors associated with decreased risk included higher gestational age, longer duration of skin-to-skin contact, neonatal hyperthermia, higher maternal labor pain score, and epidural anesthesia administration. By multivariable analysis, insulin treatment for GDM was identified as an independent factor associated with increased risk for neonatal hypoglycemia.

CONCLUSION

Our study showed insulin treatment for GDM to be independently associated with neonatal hypoglycemia. Other risk factors noted in the univariate analysis, such as decreased skin-to-skin contact duration, hypothermia, Cesarean section, and preterm delivery, would require further investigation to confirm the findings.

Imaging of Inherited Metabolic and Endocrine Disorders

"Inherited metabolic disorders represent a large group of disorders of which approximately 25% present in neonatal period with acute metabolic decompensation, rapid clinical deterioration, and often nonspecific imaging findings. Neonatal onset signifies the profound severity of the metabolic abnormality compared with cases with later presentation and necessitates rapid diagnosis and urgent therapeutic measures in an attempt to decrease the extent of brain injury and prevent grave neurologic sequela or death. Here, the authors discuss classification and clinical and imaging findings in a spectrum of metabolic and endocrine disorders with neonatal presentation."

Prise en charge périnatale du nouveau-né lors d’une naissance en milieu extrahospitalier

Les accouchements inopinés extrahospitaliers représentent environ 0,3 % des accouchements en France. La prise en charge du nouveau-né en préhospitalier par une équipe Smur fait partie de l’activité courante. L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa fréquence cardiaque (FC) et respiratoire (FR), l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). Nous faisons ici une mise au point sur les données connues et avons adapté les pratiques, si besoin, au contexte extrahospitalier, car la majeure partie des données rapportées dans la littérature concernent les prises en charge en maternité ou en milieu hospitalier. Nous abordons les points essentiels de la prise en charge des nouveau-nés, à savoir la réanimation cardiopulmonaire, le clampage tardif du cordon ombilical, la lutte contre l’hypothermie et l’hypoglycémie; ainsi que des situations particulières comme la prématurité, la conduite à tenir en cas de liquide méconial ou de certaines malformations congénitales. Nous proposons aussi quels peuvent être : le matériel nécessaire à la prise en charge des nouveau-nés en extrahospitalier, les critères d’engagement d’un renfort pédiatrique à la régulation ainsi que les méthodes de ventilation et d’abord vasculaire que l’urgentiste doit maîtriser. L’objectif de cette mise au point est de proposer des prises en charge les plus adaptées au contexte préhospitalier.

Effect of a carbohydrate-rich beverage on rate of cesarean delivery in primigravidae with epidural labor analgesia: a multicenter randomized trial

BACKGROUND

Labor represents a period of significant physical activity. Inefficient energy supply may delay labor process and even lead to cesarean delivery. Herein we investigated whether ingestion of a carbohydrate-rich beverage could reduce cesarean delivery in laboring women with epidural analgesia.

METHODS

This multicenter randomized trial was conducted in obstetrician-led maternity units of nine tertiary hospitals in China. Primigravidae with single term cephalic pregnancy who were preparing for vaginal birth under epidural analgesia were randomized to intake a carbohydrate-rich beverage or commercially available low-carbohydrate beverages during labor. The primary outcome was the rate of cesarean delivery. Secondary outcomes included maternal feeling of hunger, assessed with an 11-point scale where 0 indicated no hunger and 10 the most severe hunger, and maternal and neonatal blood glucose after childbirth.

RESULTS

Between 17 January 2018 and 20 July 2018, 2008 women were enrolled and randomized, 1953 were included in the intention-to-treat analysis. The rate of cesarean delivery did not differ between the two groups (11.3% [111/982] with carbohydrate-rich beverage vs. 10.9% [106/971] with low-carbohydrate beverages; relative risk 1.04, 95% CI 0.81 to 1.33; p = 0.79). Women in the carbohydrate-rich beverage group had lower subjective hunger score (median 3 [interquartile range 2 to 5] vs. 4 [2 to 6]; median difference - 1; 95% CI - 1 to 0; p < 0.01); their neonates had less hypoglycemia (1.0% [10/968] vs. 2.3% [22/956]; relative risk 0.45; 95% CI 0.21 to 0.94; p = 0.03) when compared with those in the low-carbohydrate beverage group. They also had higher rates of maternal hyperglycemia (6.9% [67/965] vs. 1.9% [18/953]; p < 0.01) and neonatal hyperglycemia (9.2% [89/968] vs. 5.8% [55/956]; p < 0.01), but none required special treatment.

CONCLUSIONS

For laboring primigravidae with epidural analgesia, ingestion of a carbohydrate-rich beverage compared with low-carbohydrate beverages did not reduce cesarean delivery, but relieved maternal hunger and reduced neonatal hypoglycemia at the expense of increased hyperglycemia of both mothers and neonates. Optimal rate of carbohydrate supplementation remains to be determined.

TRIAL REGISTRATION

www.chictr.org.cn ; identifier: ChiCTR-IOR-17011994 ; registered on 14 July 2017.

Effect of Antenatal Dexamethasone in Late Preterm Period on Neonatal Hypoglycemia: A Prospective Cohort Study from a Developing Country

OBJECTIVES

This study compared the risk of hypoglycemia within 72 h of life in infants with and without exposure to antenatal dexamethasone in the late preterm period (34-366/7 week's gestational age).

METHODS

This prospective cohort study was conducted in a tertiary care neonatal unit of Eastern India from May 2021 to November 2021. Babies in the exposed group received at least one dose of antenatal dexamethasone in the late preterm period between 7 days before delivery and birth. 'Complete course' of antenatal steroid was defined as four doses of injection dexamethasone at 12 h intervals and <4 doses were considered as 'Partial course'. Primary outcome was incidence of hypoglycemia within 72 h of life, defined as whole blood glucose <45 mg/dl.

RESULTS

Total 298 infants (98 in control, 134 in partial and 66 in complete group) were assessed for final outcome. No significant difference in outcomes were seen in the exposed group compared to unexposed group. However, incidence of hypoglycemia within 72 h (complete vs. partial p= 0.008, complete vs. control p=0.005) and 12 h of life (complete vs. partial p=0.013, complete vs. control p=0.013) was significantly less in complete steroid group. Logistic regression analysis revealed complete course of antenatal corticosteroid significantly decreased the risk of hypoglycemia [adjusted odds ratio, 95% confidence interval (CI) 0.15 (0.03-0.69), p=0.015]. Number needed to be exposed for one additional benefit was 7 (95% CI, 6.35-22.14).

CONCLUSION

Complete course of dexamethasone administered to mothers at risk of late preterm delivery reduces risk of neonatal hypoglycemia within 72 h of life.

Diagnostic utility of impedance-pH monitoring in infants of diabetic mothers with oral feeding difficulties

OBJECTIVE

To determine the diagnostic utility of impedance-pH monitoring in infants of diabetic mothers (IDM) with oral feeding difficulties.

STUDY DESIGN

Retrospective review of a consecutive sample of 50 IDM who had impedance-pH monitoring for objective gastroesophageal reflux disease (GERD) diagnosis. Acid reflux index (ARI) ≥ 7 was considered pathological (ARI+).

RESULTS

Impedance-pH monitoring was performed at 42.1-week postmenstrual age. Twenty infants (40%) with ARI+ compared to 30 with ARI < 7 (ARI-). ARI+ had lower weight at study vs. ARI- (p < 0.05). ARI+ had significantly higher reflux parameters but had similar symptom burden and symptom-association scores vs. ARI-. All ARI+ received proton-pump inhibitors (PPI) vs. 7 (23.3%) in ARI- (p < 0.05), but oral feeding outcomes, gastrostomy rate, growth, and hospital length of stay were similar in both groups.

CONCLUSIONS

The diagnostic yield of impedance-pH monitoring in IDM is about 40%. However, GERD diagnosis or treatment with PPI did not modify short-term clinical outcomes.

Practice Variations in Diagnosis and Treatment of Hypoglycemia in Asymptomatic Newborns

OBJECTIVES

To describe variations in the practice of hypoglycemia screening and treatment in asymptomatic infants in the United States.

METHODS

During the time period from February 2018 to June 2018, we surveyed representatives of hospitals participating in the Better Outcomes through Research for Newborns Network, a national research network of clinicians providing hospital care to term and late-preterm newborns. The survey included 22 questions evaluating practices related to hypoglycemia screening and management of asymptomatic infants.

RESULTS

Of 108 network sites, 84 (78%) responded to the survey; 100% had a hypoglycemia protocol for screening at-risk infants in the well-baby nursery. There were wide variations between sites regarding the definition of hypoglycemia (mg/dL) (<45 [24%]; <40 [23%]; <40 [0-4 hours] and <45 [4-24 hours] [27%]; <25 [0-4 hours] and <35 [4-24 hours] [8%]), timing of first glucose check (<1 hour [18%], 1-2 hours [30%], 30 minutes post feed [48%]), and threshold glucose level for treatment (<45 [19%]; <40 [18%]; <40 [0-4 hours] and <45 [4-24 hours] [20%]; <25 [0-4 hours] and <35 [4-24 hours] [15%]). All respondents used breast milk as a component of initial therapy. Criteria for admission to the NICU for hypoglycemia included the need for dextrose containing intravenous fluids (52%), persistent hypoglycemia despite treatment (49%), and hypoglycemia below a certain value (37%).

CONCLUSIONS

There is a significant practice variation in hypoglycemia screening and management across the United States.

ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical conditions that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Clinical Aspects of Neonatal Hypoglycemia: A Mini Review

Introduction: Neonatal hypoglycemia is common and a preventable cause of brain damage. The goal of management is to prevent or minimize brain injury. The purpose of this mini review is to summarize recent advances and current thinking around clinical aspects of transient neonatal hypoglycemia. Results: The groups of babies at highest risk of hypoglycemia are well defined. However, the optimal frequency and duration of screening for hypoglycemia, as well as the threshold at which treatment would prevent brain injury, remains uncertain. Continuous interstitial glucose monitoring in a research setting provides useful information about glycemic control, including the duration, frequency, and severity of hypoglycemia. However, it remains unknown whether continuous monitoring is associated with clinical benefits or harms. Oral dextrose gel is increasingly being recommended as a first-line treatment for neonatal hypoglycemia. There is some evidence that even transient and clinically undetected episodes of neonatal hypoglycemia are associated with adverse sequelae, suggesting that prophylaxis should also be considered. Mild transient hypoglycemia is not associated with neurodevelopmental impairment at preschool ages, but is associated with low visual motor and executive function, and with neurodevelopmental impairment and poor literacy and mathematics achievement in later childhood. Conclusion: Our current management of neonatal hypoglycemia lacks a reliable evidence base. Randomized trials are required to assess the effects of different prophylactic and treatment strategies, but need to be adequately powered to assess outcomes at least to school age.

Glucose concentrations in enterally fed preterm infants

OBJECTIVES

Determine the prevalence of glucose concentrations below the Pediatric Endocrine Society (PES) term and late preterm-focused guideline target for mean glucose concentrations (≥70 mg/dL) among preterm NICU infants on full enteral nutrition and assess the impact on monitoring practices.

STUDY DESIGN

Retrospective cohort study.

RESULTS

We analyzed 1717 infants who were at least 2 days old and 48 hours after parenteral fluids were discontinued. Glucose concentrations were ≥70, 60-69, 50-59, and <50 mg/dL in 76.6, 16.2, 5.9, and 1.3% of measurements, respectively. In multivariate models, concentrations <60 mg/dL were common among male infants at lower postnatal age, small-for-gestational age, and born to women with hypertension (p < 0.05). After PES guideline, infants were more likely to have >3 glucose measurements (p < 0.05).

CONCLUSIONS

Glucose concentrations <70 mg/dL are not uncommon among preterm infants receiving full enteral nutrition. Monitoring increased after guideline publication. Applying PES threshold to well-appearing preterm infants may promote increased monitoring and intervention without clear long-term benefit.

The association between novel glucose indices in parturients with type 1 diabetes mellitus and clinically significant neonatal hypoglycemia

The aim of this study was to determine the association between glucose control indices of parturient with type 1 diabetes (T1DM), treated with an insulin pump and utilizing continuous glucose monitoring (CGM), and clinically significant neonatal hypoglycemia. This was a retrospective cohort study which included 37 pregnant women with T1DM. All women were followed at a single tertiary center and had available CGM data. The association between maternal glucose indices before delivery and the risk for neonatal hypoglycemia requiring IV glucose (clinically significant hypoglycemia) was assessed using logistic regression. Mothers to neonates that experienced clinically significant hypoglycemia had a higher glucose standard deviation (SD) before delivery than did mothers to neonates who did not (25.5 ± 13 mg/dL vs. 14.7 ± 6.7 mg/dl respectively; p = .008). This association persisted after adjustment for maternal age, maternal pregestational body mass index (BMI), gestational age at delivery, neonatal birth weight, large for gestational age (LGA) and gender. This study demonstrates an association between high maternal glucose standard deviation before delivery and the risk for clinically significant neonatal hypoglycemia. Larger studies are needed to confirm these results and further explore the role of intrapartum glucose variability in the prediction and prevention of significant neonatal hypoglycemia.

Identifying risk effectors involved in neonatal hypoglycemia occurrence

Hypoglycemia is a common metabolic condition in neonatal period, but severe and persistent hypoglycemia can cause neurological damage and brain injury. The aim of the present study was to analyze the risk factors of neonatal hypoglycemia in clinic. A total of 135 neonatal hypoglycemia infants and 135 healthy infants were included in the present study. The differences in birth weight between neonatal hypoglycemia group and healthy control group were analyzed via t test. The associations between neonatal blood sugar level and relevant characteristic factors were explored using χ2 test. Binary logistic regression analysis was used to analyze risk factors related to the incidence of neonatal hypoglycemia. The results showed that the average birth weight was matched in neonatal hypoglycemia group and healthy control group. Neonatal blood sugar level of the infants was significantly associated with born term, birth weight, feed, gestational diabetes mellitus (GDM) and hypothermia (all P<0.05). Besides, logistic regression analysis showed that babies' born term (odds ratio (OR) = 2.715, 95% confidence interval (95% CI): 1.311-5.625), birth weight (OR = 1.910, 95% CI: 1.234-2.955), improper feeding (OR = 3.165, 95% CI: 1.295-7.736) and mother's GDM (OR = 2.184, 95% CI: 1.153-4.134) were high risk factors for neonatal hypoglycemia. The incidence of hypoglycemia in infants was significantly associated with various clinical factors. And monitoring these risk factors is one of important measures to reduce long-term neurological damage caused by neonatal hypoglycemia.

Congenital hyperinsulinsim: case report and review of literature

Neonatal hypoglycemia (NH) is one of the most common abnormalities encountered in the newborn. Hypoglycemia continues to be an important cause of morbidity in neonates and children. Prompt diagnosis and management of the underlying hypoglycemia disorder is critical for preventing brain damage and improving outcomes. Congenital hyperinsulinism (CHI) is the most common and severe cause of persistent hypoglycemia in neonates and children, it represents a group of clinically, genetically and morphologically heterogeneous disorders characterised by dysregulation of insulin secretion from pancreatic β-cells. It is extremely important to recognize this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, CHI is divided mainly into two types focal and diffuse disease. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localized to a small region of the pancreas. Recent discoveries of the genetic causes of CHI have improved our understanding of the pathophysiology, but its management is complex and requires the integration of clinical, biochemical, molecular, and imaging findings to establish the appropriate treatment according to the subtype. Here we present a case of sever congenital hyperinsulinism in a girl admitted for lethargy, irritability and general seizures accompanied with profound hypoglycemia, in spite of aggressive medical treatment, she died because of sever congenital hyperinsulinism diazoxide unresponsive.

Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia

BACKGROUND

Worldwide, many newborns who are preterm, small or large for gestational age, or born to mothers with diabetes are screened for hypoglycemia, with a goal of preventing brain injury. However, there is no consensus on a treatment threshold that is safe but also avoids overtreatment.

METHODS

In a multicenter, randomized, noninferiority trial involving 689 otherwise healthy newborns born at 35 weeks of gestation or later and identified as being at risk for hypoglycemia, we compared two threshold values for treatment of asymptomatic moderate hypoglycemia. We sought to determine whether a management strategy that used a lower threshold (treatment administered at a glucose concentration of <36 mg per deciliter [2.0 mmol per liter]) would be noninferior to a traditional threshold (treatment at a glucose concentration of <47 mg per deciliter [2.6 mmol per liter]) with respect to psychomotor development at 18 months, assessed with the Bayley Scales of Infant and Toddler Development, third edition, Dutch version (Bayley-III-NL; scores range from 50 to 150 [mean {±SD}, 100±15]), with higher scores indicating more advanced development and 7.5 points (one half the SD) representing a clinically important difference). The lower threshold would be considered noninferior if scores were less than 7.5 points lower than scores in the traditional-threshold group.

RESULTS

Bayley-III-NL scores were assessed in 287 of the 348 children (82.5%) in the lower-threshold group and in 295 of the 341 children (86.5%) in the traditional-threshold group. Cognitive and motor outcome scores were similar in the two groups (mean scores [±SE], 102.9±0.7 [cognitive] and 104.6±0.7 [motor] in the lower-threshold group and 102.2±0.7 [cognitive] and 104.9±0.7 [motor] in the traditional-threshold group). The prespecified inferiority limit was not crossed. The mean glucose concentration was 57±0.4 mg per deciliter (3.2±0.02 mmol per liter) in the lower-threshold group and 61±0.5 mg per deciliter (3.4±0.03 mmol per liter) in the traditional-threshold group. Fewer and less severe hypoglycemic episodes occurred in the traditional-threshold group, but that group had more invasive diagnostic and treatment interventions. Serious adverse events in the lower-threshold group included convulsions (during normoglycemia) in one newborn and one death.

CONCLUSIONS

In otherwise healthy newborns with asymptomatic moderate hypoglycemia, a lower glucose treatment threshold (36 mg per deciliter) was noninferior to a traditional threshold (47 mg per deciliter) with regard to psychomotor development at 18 months. (Funded by the Netherlands Organization for Health Research and Development; HypoEXIT Current Controlled Trials number, ISRCTN79705768.).

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

Incidence and Risk Factors for Hypoglycemia During Fetal-to-Neonatal Transition in Premature Infants

Objective: To determine the incidence and risk factors associated with neonatal hypoglycemia in the premature population <33 weeks' gestation. Methods: This was a secondary retrospective analysis from previous infants enrolled in randomized controlled trials. A total of 255 infants <33 weeks' gestation were born during the study period. Eight infants were excluded due to missing glucose or maternal data and 175 infants were analyzed. Main outcome measures: Primary outcome was hypoglycemia (blood glucose <2.6mmol/L) determined via glucose oxidase method on arterial or venous blood gas. Birth weight subgroups: small for gestational age (SGA, birth weight <10%ile for gestational age) and large for gestational age (LGA, birth weight >90%ile for gestational age). Maternal hypertension was systolic blood pressure >140mmHg. Results: 175 infants <33 weeks' gestational age (89 male, 84 female) were analyzed. Hypoglycemia occurred in 59 infants (33.7%). Maternal hypertension (OR 3.07, 95% CI 1.51-6.30, p = 0.002) was the sole risk factor for neonatal hypoglycemia. Protective factors for hypoglycemia included labor at time of delivery (OR 4.51, 95% CI 2.29-9.18, p <0.0001) and antenatal magnesium sulfate (OR 2.53, 95% CI 1.23-5.50, p = 0.01). There were no significant differences between hypoglycemic and euglycemic infants in sex, gestational age, LGA infants, antenatal steroids, vaginal birth, or maternal diabetes. SGA infants were excluded from analysis due to sample size. Conclusions: Premature infants <33 weeks' gestation have increased risk of hypoglycemia. Maternal hypertension increases hypoglycemia risk. Antenatal magnesium sulfate administration or labor at time of delivery decrease hypoglycemia risk.

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

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

Follow-up study of neurodevelopment in 2-year-old infants who had suffered from neonatal hypoglycemia

BACKGROUND

Neonatal hypoglycemia is tightly related to adverse neurodevelopmental and brain injury outcomes.

METHODS

A total of 195 infants who were born from diabetic mothers with a low blood glucose level (< 2.6 mM) within 0.5 h after birth were enrolled in this prospective cohort study. Of these, 157 infants who had neonatal hypoglycemia (group A) were followed up, and this group was further divided into A1 [blood glucose concentration (BGC) < 2.6 mM at < 2 h after birth], A2 (BGC < 2.6 mM at 2-24 h after birth), and A3 (BGC < 2.6 mM at > 24 h after birth). A total of 144 infants whose mothers had no high risk for gestational diabetes mellitus were followed up as the control group during the same period. The neurodevelopment of the infants was evaluated by the Gesell scoring method.

RESULTS

The adaptability in the A2 and A3 subgroups was significantly lower than that in the control group (73.9 ± 6.6 vs. 87.9 ± 11.2; 71.5 ± 8.9 vs. 87.9 ± 11.2, respectively). There were significantly more mothers who used insulin during the perinatal period in A3 than in A1 and A2 (31% vs. 2%; 31% vs. 7.9%, respectively). The mothers of babies in subgroups A2 and A3 gained more weight than those of the control group (15.3 ± 1.9 kg vs. 11.1 ± 2.2 kg; 14.8 ± 2.6 kg vs. 11.1 ± 2.2 kg, respectively).

CONCLUSIONS

Long and repeated neonatal hypoglycemia caused poor adaptability. The babies of mothers who used insulin or had a high weight gain during pregnancy were associated with severe or persistent neonatal hypoglycemia.

Innovations and Challenges of Implementing a Glucose Gel Toolkit for Neonatal Hypoglycemia

BACKGROUND

Transient neonatal hypoglycemia occurs most commonly in newborns who are small for gestational age, large for gestational age, infants of diabetic mothers, and late preterm infants. An exact blood glucose value has not been determined for neonatal hypoglycemia, and it is important to note that poor neurologic outcomes can occur if hypoglycemia is left untreated. Interventions that separate mothers and newborns, as well as use of formula to treat hypoglycemia, have the potential to disrupt exclusive breastfeeding.

PURPOSE

To determine whether implementation of a toolkit designed to support staff in the adaptation of the practice change for management of newborns at risk for hypoglycemia, that includes 40% glucose gel in an obstetric unit with a level 2 nursery will decrease admissions to the Intermediate Care Nursery, and increase exclusive breastfeeding.

METHOD

This descriptive study used a retrospective chart review for pre/postimplementation of the Management of Newborns at Risk for Hypoglycemia Toolkit (Toolkit) using a convenience sample of at-risk newborns in the first 2 days of life to evaluate the proposed outcomes.

RESULTS

Following implementation of the Toolkit, at-risk newborns had a clinically but not statistically significant 6.5% increase in exclusive breastfeeding and a clinically but not statistically significant 5% decrease in admissions to the Intermediate Care Nursery.

IMPLICATIONS FOR PRACTICE

The Toolkit was designed for ease of staff use and to improve outcomes for the at-risk newborn.

IMPLICATIONS FOR RESEARCH

Future research includes replication at other level 2 and level 1 obstetric centers and investigation into the number of 40% glucose gel doses that can safely be administered.

Moderate neonatal hypoglycemia and adverse neurological development at 2-6 years of age

To determine whether moderate neonatal hypoglycemia in otherwise healthy infants is associated with adverse neurodevelopmental outcome in pre-school children. Population-based cohort study with prospectively collected register data from Sweden. All singletons born July 1st 2008 through December 31st 2012 (n = 101,060) in the region were included. Infants with congenital malformations, infants treated in neonatal intensive care unit, infants with inborn errors of metabolism and infants to mothers with diabetes were excluded. Infants were followed-up until 2014, at 2–6 years of age. Exposure was neonatal moderate hypoglycemia. Main outcomes were a compiled neurological or neurodevelopmental outcome; any developmental delay; motor developmental delay; and cognitive developmental delay. In adjusted regression analyses, the odds ratio (OR) of any neurological or neurodevelopmental outcome was 1.48 (95% confidence interval: 1.17–1.88) in hypoglycemic compared to normoglycemic infants. The adjusted risk of any developmental delay was more than doubled (OR 2.53 [1.71–3.73]), the adjusted risk of motor developmental delay was almost doubled (OR: 1.91 [1.06–3.44]) and the adjusted risk of cognitive developmental delay was almost tripled (OR 2.85 [1.70–4.76]). Infants with early neonatal hypoglycemia (< 6 h) had a double risk (OR 1.94 [1.30–2.89]) of any neurological or neurodevelopmental outcome and a tripled risk of cognitive developmental delay (OR 3.17 [1.35–7.43]), compared to normoglycemic infants. In the first population-based study on this topic, we show that moderate neonatal hypoglycemia is associated with increased risks of impaired neurodevelopment. Current treatment routines for uncomplicated hypoglycemia should be followed.

Pregnant sheep develop hypoxaemia during short-term anaesthesia for caesarean delivery

Short-term anaesthesia of the pregnant ewe may be required for caesarean delivery of a preterm foetus within a research protocol. The aim of this study was to evaluate and compare the acid-base and haematological status of the ewe and foetus at the time of surgical delivery by collecting maternal and foetal arterial blood samples. Fifteen date-mated singleton-pregnant merino cross ewes at 122.0 (±0.5) days of gestation were anaesthetised with a combination of midazolam (0.5 mg/kg) and ketamine (10 mg/kg) by intravenous injection. A subarachnoid injection of lidocaine (60 mg) was given to desensitise the caudal abdomen. Supplemental oxygen was not provided, and an endotracheal tube was not placed in the ewe's trachea. The development of maternal respiratory acidosis (hypercapnia) and hypoxaemia was anticipated. Samples of arterial blood for blood gas analyses were collected simultaneously from the radial artery of the ewe and the umbilical artery of the foetus immediately after delivery. The results from the maternal blood samples were within the normal range for pH, partial pressure of carbon dioxide in arterial blood (PaCO₂), base excess, glucose, lactate, haematocrit and haemoglobin concentration. The maternal partial pressure of oxygen in arterial blood (PaO₂) revealed hypoxaemia: 45.2 (41.1-53.4) mmHg. Foetal arterial blood gas analysis revealed hypoxaemia (15.0 ± 3.1 mmHg) and hypoglycaemia (0.1 (0.1-1.1) mmol/L). The benefit of providing supplemental oxygen and/or placing an endotracheal tube must be carefully weighed against the benefit of saving time when prompt delivery of the foetus is planned. In this study the pregnant ewe developed severe hypoxaemia, and this abnormality may have contributed to a low foetal PaO₂.

Glucose Gel as a Treatment Strategy for Transient Neonatal Hypoglycemia

BACKGROUND

Transient asymptomatic neonatal hypoglycemia (TANH) is common as infants transition from their mother's energy stores to their own. There is little evidence supporting the blood glucose threshold that indicates a need for treatment although sustained hypoglycemia has been correlated with negative neurodevelopmental consequences. Treatment of TANH includes a stepwise approach from supplemental enteral feedings, buccal glucose gel, intravenous dextrose infusion, and/or transfer to special care units including neonatal intensive care units.

PURPOSE

The purpose of this evidence-based practice brief is to review current evidence on 40% buccal glucose gel administration as a treatment strategy for TANH.

METHODS/SEARCH STRATEGY

CINAHL, Cochrane, Google Scholar, and PubMed were searched using the key words and restricted to English language over the last 7 years.

FINDINGS/RESULTS

The use of buccal dextrose gel for TANH may reduce neonatal intensive care unit admissions, reduce hospital length of stay and cost, support the mother-infant dyad through reduced separation, support exclusive breastfeeding, and improve parental satisfaction without adverse neurodevelopmental consequences.

IMPLICATIONS FOR PRACTICE

Timely collection of blood glucose levels following intervention is critical to support clinical decisions. Clinicians should offer family education regarding the rationale for serial glucose monitoring and treatment indications including buccal glucose administration. Clinical protocols can be revised to include use of buccal dextrose gel.

IMPLICATIONS FOR RESEARCH

There is a need for rigorous long-term studies comparing treatment thresholds and neurodevelopmental outcomes among various treatment strategies for TANH.

Standards of admission capillary blood glucose levels in cesarean born neonates

BACKGROUND

Neonatal hypoglycemia (NH) and cutoffs remain undefined. Our center screens all cesarean-delivered (CD) neonates for NH. We sought to define standards of admission capillary blood glucose levels (ACBGLs) in CD neonates who were at the lowest risk for hypoglycemia.

METHODS

Of 4947 neonates, 519 met all 14 inclusion criteria. These highly-selected neonates were apparently the healthiest, least-stressed, earliest to be admitted to nursery and at lowest-risk for hypoglycemia. For each CD, cord blood gases and glucose were determined and each infant was screened for blood glucose at nursery admission.

RESULTS

Sampling age was 41.6±15.3 minutes, a mean ACBGL of 52.3±10.7 mg/dL, and percentiles as follows: 1st percentile, 29.2; 3rd, 33.6; 5th, 35.0; 10th, 39.0; 25th, 46.0; 50th, 51.0; 75th, 58.0; 90th, 67.0; 95th, 71.0; 97th, 73.0, and 99th, 84.4. ACBGL rose significantly with increasing gestational age (P=0.004), increasing cord blood glucose (P<0.001), decreasing cord blood pH (P<0.001) and decreasing sampling age (P=0.027).

CONCLUSIONS

Setting uniform ACBGL cutoffs for NH definition is unachievable due to the enormous heterogeneity among newborns. Hence, we provide group-based ACBGL standards in CD neonates. We propose setting ACBGL cutoffs for use in CD neonates: 1) hypoglycemia: ACBGL <5th percentile (<35 mg/dL); and 2) interventional hypoglycemia: ACBGL <1st percentile (<30 mg/dL).

[Revelation of the circumstances of the accident vascular arterial ischemic brain in at term or near-term and referral]

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

Neonatal Hypoglycemia

Lower blood glucose values are common in the healthy neonate immediately after birth as compared to older infants, children, and adults. These transiently lower glucose values improve and reach normal ranges within hours after birth. Such transitional hypoglycemia is common in the healthy newborn. A minority of neonates experience a more prolonged and severe hypoglycemia, usually associated with specific risk factors and possibly a congenital hypoglycemia syndrome. Despite the lack of a specific blood glucose value that defines hypoglycemia, concern for substantial neurologic morbidity in the neonatal population has led to the generation of guidelines by both the American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES). Similarities between the 2 guidelines include recognition that the transitional form of neonatal hypoglycemia likely resolves within 48 hours after birth and that hypoglycemia that persists beyond that duration may be pathologic. One major difference between the 2 sets of guidelines is the goal blood glucose value in the neonate. This article reviews transitional and pathologic hypoglycemia in the neonate and presents a framework for understanding the nuances of the AAP and PES guidelines for neonatal hypoglycemia.

Baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding

BACKGROUND

Baby-led breastfeeding is recommended as best practice in determining the frequency and duration of a breastfeed. An alternative approach is described as scheduled, where breastfeeding is timed and restricted in frequency and duration. It is necessary to review the evidence that supports current recommendations, so that women are provided with high-quality evidence to inform their feeding decisions.

OBJECTIVES

To evaluate the effects of baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding, for healthy newborns.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2016), CINAHL (1981 to 23 February 2016), EThOS, Index to Theses and ProQuest database and World Health Organization's 1998 evidence to support the 'Ten Steps' to successful breastfeeding (10 May 2016).

SELECTION CRITERIA

We planned to include randomised and quasi-randomised trials with randomisation at both the individual and cluster level. Studies presented in abstract form would have been eligible for inclusion if sufficient data were available. Studies using a cross-over design would not have been eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all potential studies we identified as a result of the search strategy. We would have resolved any disagreement through discussion or, if required, consulted a third review author, but this was not necessary.

MAIN RESULTS

No studies were identified that were eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

This review demonstrates that there is no evidence from randomised controlled trials evaluating the effect of baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding, for healthy newborns. It is recommended that no changes are made to current practice guidelines without undertaking robust research, to include many patterns of breastfeeding and not limited to baby-led and scheduled breastfeeding. Future exploratory research is needed on baby-led breastfeeding that takes the mother's perspective into consideration.

Improving the Diagnosis of Neonatal Hypoglycemia in a Well-Baby Nursery

Point of care glucose (POCG) measurements, used for detecting neonatal hypoglycemia, can have variable accuracy. The appropriate diagnosis of neonatal hypoglycemia in babies with low POCG measurements involves confirmatory serum glucose (CSG) testing. At our institution, no babies with low POCG measurements had CSG testing in their evaluation of neonatal hypoglycemia over a three year period. Our aim was to increase the percentage of CSG testing in babies with a low POCG. A secondary aim was to decrease the percentage of low-risk, asymptomatic babies who received POCG testing. Interventions included the design and implementation of an evidence-based protocol for the diagnosis and management of neonatal hypoglycemia (cycle 1), along with supportive education for multi-disciplinary providers on best practices related to neonatal hypoglycemia (cycle 2). Data were analyzed using statistical process control. During Cycle 1, the percentage of CSG testing in babies with POCG ≤40 mg/dL significantly increased from 0 to 33%, and increased further to 63% during Cycle 2. The initial gain was sustained over 2 years. The percentage of POCG testing among low-risk asymptomatic babies was 40% at baseline and did not change during the project period. 18 babies with low POCG results were spared from a diagnosis of neonatal hypoglycemia based on CSG testing. Implementation of a neonatal hypoglycemia protocol, along with supportive education, significantly improved rates of CSG testing, but not POCG overutilization, in our newborn population. Factors related to POCG overutilization should be further explored.

Hyperinsulinemic Hypoglycemia in Infancy: Current Concepts in Diagnosis and Management

PURPOSE

Molecular basis of various forms of hyperinsulinemic hypoglycemia, involving defects in key genes regulating insulin secretion, are being increasingly reported. However, the management of medically unresponsive hyperinsulinism still remains a challenge as current facilities for genetic diagnosis and appropriate imaging are limited only to very few centers in the world. We aim to provide an overview of spectrum of clinical presentation, diagnosis and management of hyperinsulinism.

METHODS

We searched the Cochrane library, MEDLINE and EMBASE databases, and reference lists of identified studies.

CONCLUSION

Analysis of blood samples, collected at the time of hypoglycemic episodes, for intermediary metabolites and hormones is critical for diagnosis and treatment. Increased awareness among clinicians about infants at-risk of hypoglycemia, and recent advances in genetic diagnosis have made remarkable contribution to the diagnosis and management of hyperinsulinism. Newer drugs like lanreotide a long acting somatostatin analogue and sirolimus (mammalian target of rapamycin (mTOR) inhibitor) appears promising as patients with diffuse disease can be treated successfully without subtotal pancreatectomy, minimizing the long-term sequelae of diabetes and pancreatic insufficiency. Newer insights in understanding the molecular and histological basis and improvements in imaging and surgical techniques will modify the approach to patients with congenital hyperinsulinism.

Neonatal Early Warning Tools for recognising and responding to clinical deterioration in neonates cared for in the maternity setting: A retrospective case-control study

BACKGROUND

All newborns are at risk of deterioration as a result of failing to make the transition to extra uterine life. Signs of deterioration can be subtle and easily missed. It has been postulated that the use of an Early Warning Tool may assist clinicians in recognising and responding to signs of deterioration earlier in neonates, thereby preventing a serious adverse event.

OBJECTIVE

To examine whether observations from a Standard Observation Tool, applied to three neonatal Early Warning Tools, would hypothetically trigger an escalation of care more frequently than actual escalation of care using the Standard Observation Tool.

DESIGN

A retrospective case-control study.

SETTING

A maternity unit in a tertiary public hospital in Australia.

METHODS

Neonates born in 2013 of greater than or equal to 34(+0) weeks gestation, admitted directly to the maternity ward from their birthing location and whose subsequent deterioration required admission to the neonatal unit, were identified as cases from databases of the study hospital. Each case was matched with three controls, inborn during the same period and who did not experience deterioration and neonatal unit admission. Clinical and physiological data recorded on a Standard Observation Tool, from time of admission to the maternity ward, for cases and controls were charted onto each of three Early Warning Tools. The primary outcome was whether the tool 'triggered an escalation of care'. Descriptive statistics (n, %, Mean and SD) were employed.

RESULTS

Cases (n=26) comprised late preterm, early term and post-term neonates and matched by gestational age group with 3 controls (n=78). Overall, the Standard Observation Tool triggered an escalation of care for 92.3% of cases compared to the Early Warning Tools; New South Wales Health 80.8%, United Kingdom Newborn Early Warning Chart 57.7% and The Australian Capital Territory Neonatal Early Warning Score 11.5%. Subgroup analysis by gestational age found differences between the tools in hypothetically triggering an escalation of care.

CONCLUSIONS

The Standard Observation Tool triggered an escalation of care more frequently than the Early Warning Tools, which may be as a result of behavioural data captured on the Standard Observation Tool and escalated, which could not be on the Early Warning Tools. Findings demonstrate that a single tool applied to all gestational age ranges may not be effective in identifying early deterioration or may over trigger an escalation of care. Further research is required into the sensitivity and specificity of Early Warning Tools in neonatal sub-populations.

Hypoglycemia, polycythemia and hyponatremia in a newborn exposed to nebivolol during pregnancy

Nebivolol is a third-generation beta blocker that exerts selective antagonistic activity on β₁ receptors. It has vasodilating properties that result from direct stimulation of endothelial nitric oxide synthase. Nebivolol is indicated for the treatment of hypertension and heart failure, and is generally well tolerated. In this article, we report a case of an infant who was admitted to the Pediatrics and Neonatology Unit of the Moscati Hospital (Aversa, Italy) about 24 hours after birth. The reason for hospitalization was persistent severe hypoglycemia (blood glucose = 30 mg/dL) and jaundice (total bilirubin = 12.5 mg/dL, indirect bilirubin 11.75 mg/dL). He was born by spontaneous delivery after a normal term pregnancy. Birth weight was 3040 g and the Apgar score was 6-9. The mother reported taking nebivolol 5 mg/day for unspecified tachycardia in the last 4 months of pregnancy. Clinical and instrumental investigations carried out during hospitalization did not reveal any congenital or perinatal abnormalities. After treatment for metabolic and electrolyte imbalance, he was discharged on the 10^th day of hospitalization, in good clinical condition and with normalization of clinical and laboratory parameters. Currently, there are no specific studies on nebivolol tolerability during pregnancy. Our data suggest that the risk profile of nebivolol during pregnancy is the same as that of other β-blockers. Therefore, further studies are required to determine the safety of β-blockers during pregnancy and the risks to the unborn child.

Baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding

BACKGROUND

Baby-led breastfeeding is recommended as best practice in determining the frequency and duration of a breastfeed. An alternative approach is described as scheduled, where breastfeeding is timed and restricted in frequency and duration. It is necessary to review the evidence that supports current recommendations, so that mothers are provided with high-quality evidence to inform their feeding decisions.

OBJECTIVES

To evaluate the effects of baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding, for healthy newborns.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2013), CINAHL (1981 to 13 November 2013), EThOS, Index to Theses and ProQuest database and World Health Organization's 1998 evidence to support the 'Ten Steps' to successful breastfeeding (6 November 2013).

SELECTION CRITERIA

Randomised and quasi-randomised trials with randomisation at both the individual and cluster level. Studies presented in abstract form were eligible for inclusion if sufficient data were available. Studies using a cross-over design were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We independently assessed for inclusion all the potential studies we identified as a result of the search strategy. We would have resolved any disagreement through discussion or, if required, consulted a third review author, but this was not necessary.

MAIN RESULTS

No studies were identified that were eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

This review demonstrates that there is no evidence from randomised controlled trials evaluating the effect of baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding, for healthy newborns, therefore no conclusions could be taken at this point. It is recommended that no changes are made to current practice guidelines without undertaking further robust research, to include many patterns of breastfeeding and not limited to baby-led and scheduled breastfeeding. Further research is needed to also evaluate the effects of baby-led compared with scheduled (or mixed) breastfeeding on successful breastfeeding, for healthy newborns. However, conducting such a study, particularly a randomised controlled trial is unlikely to receive ethical approval, as the issue of obtaining informed consent from new mothers or mothers-to-be for randomisation between baby-led and scheduled breastfeeding is a difficult one and it is likely that the Baby Friendly Hospital Initiative practices would prohibit such a study.