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Zamir I, Stoltz Sjöström E, van den Berg J, Berhan Y, Naumburg E, Domellöf M. Glucose disturbances in very low-birthweight infants-Results from the prospective LIGHT study. Acta Paediatr 2024. [PMID: 39087626 DOI: 10.1111/apa.17370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/20/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
AIM To describe glucose homeostasis disturbances (dysglycaemia) in very low-birthweight infants (<1500 g) during the admission period and explore associated risk factors. METHODS The LIGHT (very low-birthweight infants - glucose and hormonal profile over time) study was a prospective observational cohort study that included 49 very low-birthweight infants admitted to the tertiary neonatal intensive care unit in Umeå, Sweden, during 2016-2019. All glucose concentrations (n = 3515) sampled during the admission period were registered. RESULTS Hyperglycaemia >10 mmol/L and hypoglycaemia <2.6 mmol/L were registered in 63% and 55% of the infants, respectively. Onset of dysglycaemia occurred almost exclusively in the first postnatal week. Hyperglycaemia followed 15% of corticosteroid doses given; all were preceded by pre-existing hyperglycaemia. Pre-existing hyperglycaemia was found in 66.7% of hyperglycaemic infants who received inotrope treatment. Upon commencement, 72.5% of antimicrobial treatments given were neither preceded nor followed by hyperglycaemia. CONCLUSION Dysglycaemia was common in very low-birthweight infants. Daily means of glucose concentrations seemed to follow a postmenstrual age-dependent pattern, decreasing towards term age suggesting a postmenstrual age-dependent developmental mechanism. The primary mechanism causing hyperglycaemia was independent of sepsis, and corticosteroid and inotrope treatments. No hypoglycaemia was registered during ongoing insulin treatment.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | | | | | - Yonas Berhan
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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2
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Lagacé M, Tam EWY. Neonatal dysglycemia: a review of dysglycemia in relation to brain health and neurodevelopmental outcomes. Pediatr Res 2024:10.1038/s41390-024-03411-0. [PMID: 38972961 DOI: 10.1038/s41390-024-03411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/09/2024]
Abstract
Neonatal dysglycemia has been a longstanding interest of research in neonatology. Adverse outcomes from hypoglycemia were recognized early but are still being characterized. Premature infants additionally introduced and led the reflection on the importance of neonatal hyperglycemia. Cohorts of infants following neonatal encephalopathy provided further information about the impacts of hypoglycemia and, more recently, highlighted hyperglycemia as a central concern for this population. Innovative studies exposed the challenges of management of neonatal glycemic levels with a "u-shape" relationship between dysglycemia and adverse neurological outcomes. Lately, glycemic lability has been recognized as a key factor in adverse neurodevelopmental outcomes. Research and new technologies, such as MRI and continuous glucose monitoring, offered novel insight into neonatal dysglycemia. Combining clinical, physiological, and epidemiological data allowed the foundation of safe operational definitions, including initiation of treatment, to delineate neonatal hypoglycemia as ≤47 mg/dL, and >150-180 mg/dL for neonatal hyperglycemia. However, questions remain about the appropriate management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to continue to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes. IMPACT STATEMENT: Safe operational definitions guide the initiation of treatment of neonatal hypoglycemia and hyperglycemia. Innovative studies exposed the challenges of neonatal glycemia management with a "u-shaped" relationship between dysglycemia and adverse neurological outcomes. The importance of glycemic lability is also being recognized. However, questions remain about the optimal management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes.
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Affiliation(s)
- Micheline Lagacé
- Faculty of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, BC, Canada
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Emily W Y Tam
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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3
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Paulsen ME, Marka N, Lunos S, Nagel EM, Gonzalez Villamizar JD, Nathan B, Ramel S. Insulin-like growth factor-1 and insulin-like growth factor binding protein-3 as early predictors of growth, body composition, and neurodevelopment in preterm infants. J Perinatol 2024:10.1038/s41372-024-01933-3. [PMID: 38561392 PMCID: PMC11442679 DOI: 10.1038/s41372-024-01933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To investigate the relationship between insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 3 (IGFBP-3) and long-term growth, body composition, and neurodevelopment in preterm infants. STUDY DESIGN Prospective data were collected from ≤32 weeks gestational age infant cohort (N = 50). IGF-1 and IGFBP-3 concentrations were measured at 1 week (early) and 35 weeks (late) post-menstrual age (PMA). Growth, body composition, and neurodevelopment outcomes were measured at 4 and 12 months PMA. Relationships were measured by linear regression analysis. RESULTS Early IGFBP-3 concentration was positively associated with neurodevelopment at 12 months PMA. Early IGF-1 concentration was positively associated with weight at 4 months PMA, head circumference at 12 months PMA, and body mass index at 12 months PMA. Late IGFBP-3 concentration was positively associated with weight at 4 months PMA. CONCLUSION Further investigation of these associations may lead to novel biomarkers and/or treatments to optimize health outcomes in preterm infants.
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Affiliation(s)
- Megan E Paulsen
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA.
- Children's Minnesota, Minneapolis, MN, USA.
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN, USA.
| | - Nicholas Marka
- Biostatistical Design and Analysis Center, Clinical Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Emily M Nagel
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Juan David Gonzalez Villamizar
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
- Children's Minnesota, Minneapolis, MN, USA
| | - Brandon Nathan
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sara Ramel
- Division of Neonatology, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN, USA
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4
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Predanič Drobne I, Kornhauser Cerar L, Erčulj V, Grosek Š. A Higher Amount of Nutritional Intake as a Possible Cause of Hyperglycemia in Extremely Premature Infants in Parenteral and Enteral Nutrition at the Tertiary Neonatal Intensive Care Unit. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1651. [PMID: 37892314 PMCID: PMC10605466 DOI: 10.3390/children10101651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND This study aimed to find an association between infants who had hyperglycemia and those who did not, those treated with insulin or not and several prenatal and postnatal variables or the suboptimal prescription of parenteral nutrition. METHODS We conducted a retrospective study, which included extremely premature infants (<28 weeks of gestation) admitted to the tertiary NICU, University Medical Centre Ljubljana, between 1 January 2021 and 31 December 2021. Blood glucose measurements, insulin treatment, general characteristics, nutritional data and complications of prematurity were obtained retrospectively from hospital data. RESULTS There were 21 infants included in the study who did not receive insulin and 17 who were treated with insulin. Infants receiving insulin were younger and lighter compared to the non-insulin treatment group (mean gestational age 178 vs. 188 days; median birth weight 680 g vs. 990 g). The younger insulin group of infants received the same daily number of total macronutrients per kg per day compared to the older non-insulin group, i.e., glucose, lipids and amino acids, as recommended for the gestational age and birth weight. After adjusting for gestational age, no significant association with complications of prematurity was found. CONCLUSIONS The postulated explanation (with the prescription of a higher amount of macronutrients during the first seven days) for hyperglycemia and treatment with insulin in the less mature and lighter infants cannot be supported by the data given.
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Affiliation(s)
- Iza Predanič Drobne
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Lilijana Kornhauser Cerar
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Vanja Erčulj
- Rho Sigma Research & Statistics, 1000 Ljubljana, Slovenia;
- Faculty of Criminal Justice and Security, University of Maribor, 1000 Ljubljana, Slovenia
| | - Štefan Grosek
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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5
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Angelis D, Jaleel MA, Brion LP. Hyperglycemia and prematurity: a narrative review. Pediatr Res 2023; 94:892-903. [PMID: 37120652 DOI: 10.1038/s41390-023-02628-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/01/2023]
Abstract
Hyperglycemia is commonly encountered in extremely preterm newborns and physiologically can be attributed to immaturity in several biochemical pathways related to glucose metabolism. Although hyperglycemia is associated with a variety of adverse outcomes frequently described in this population, evidence for causality is lacking. Variations in definitions and treatment approaches have further complicated the understanding and implications of hyperglycemia on the immediate and long-term effects in preterm newborns. In this review, we describe the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research. IMPACT: Hyperglycemia is common and less well described than hypoglycemia in extremely preterm newborns. Hyperglycemia can be attributed to immaturity in several cellular pathways involved in glucose metabolism in this age group. Hyperglycemia has been shown to be associated with a variety of adverse outcomes frequently described in this population; however, evidence for causality is lacking. Variations in definitions and treatment approaches have complicated the understanding and the implications of hyperglycemia on the immediate and long-term effects outcomes. This review describes the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research.
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Affiliation(s)
- Dimitrios Angelis
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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6
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Schoephoerster J, Roston S, Lunos S, Ramel SE, Anderson J, Georgieff MK, Ingolfsland EC. Identification of clinical factors associated with timing and duration of spontaneous regression of retinopathy of prematurity not requiring treatment. J Perinatol 2023; 43:702-708. [PMID: 36973383 DOI: 10.1038/s41372-023-01649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Identify clinical factors that delay or prolong spontaneous regression of retinopathy of prematurity (ROP). STUDY DESIGN Secondary analysis of three prospective studies with 76 infants with ROP not requiring treatment, born ≤30 weeks postmenstrual age (PMA) and ≤1500 grams. Outcomes were PMA at greatest severity of ROP (PMA MSROP), at which regression began, at time of complete vascularization (PMA CV), and regression duration. Pearson's correlation coefficients, t-tests, or analyses of variance were calculated. RESULTS Increased positive bacterial cultures, hyperglycemia, transfusion volume of platelets and red blood cells and severity of ROP were associated with later PMA MSROP. Positive bacterial cultures, maternal chorioamnionitis, and less iron deficiency were associated with later PMA CV and prolonged regression duration. Slower length gain was associated with later PMA CV. P < 0.05 for all. CONCLUSIONS Preterm infants with inflammatory exposures or linear growth impairment may require longer surveillance for ROP resolution and complete vascularization.
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Affiliation(s)
| | - Sydney Roston
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Sara E Ramel
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Jill Anderson
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Michael K Georgieff
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Ellen C Ingolfsland
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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7
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Abstract
This article summarizes the available evidence reporting the relationship between perinatal dysglycemia and long-term neurodevelopment. We review the physiology of perinatal glucose metabolism and discuss the controversies surrounding definitions of perinatal dysglycemia. We briefly review the epidemiology of hypoglycemia and hyperglycemia in fetal, preterm, and term infants. We discuss potential pathophysiologic mechanisms contributing to dysglycemia and its effect on neurodevelopment. We highlight current strategies to prevent and treat dysglycemia in the context of neurodevelopmental outcomes. Finally, we discuss areas of future research and the potential role of continuous glucose monitoring.
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Affiliation(s)
- Megan E Paulsen
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414.
| | - Raghavendra B Rao
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414
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8
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Rath CP, Shivamallappa M, Muthusamy S, Rao SC, Patole S. Outcomes of very preterm infants with neonatal hyperglycaemia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:269-280. [PMID: 34330757 DOI: 10.1136/archdischild-2020-321449] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/15/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore the association between hyperglycaemia and adverse outcomes in very preterm infants. DESIGN Systematic review and meta-analysis. Data were pooled separately for adjusted and unadjusted odds ratios (ORs) using random-effects model. Subgroup analysis was conducted based on study design (cohort and case control). MAIN OUTCOME MEASURES Association between hyperglycaemia in preterm neonates (<32 weeks or <1500 g) and mortality and morbidities. FINDINGS Forty-six studies (30 cohort and 16 case control) with data from 34 527 infants were included. Meta-analysis of unadjusted ORs from cohort studies found hyperglycaemia to be significantly associated with mortality, any-grade intraventricular haemorrhage (IVH), severe IVH, any-stage retinopathy of prematurity (ROP), severe ROP, sepsis, chronic lung disease and disability. However, pooling of adjusted ORs found significant associations only for mortality (adjusted OR (CI): 2.37 (1.40 to 4.01); I2: 36%; 6 studies), 'Any grade IVH' (adjusted OR (CI): 2.60 (1.09 to 6.20); I2: 0%; 2 studies) and 'Any stage ROP' (adjusted OR (CI): 3.70 (1.55 to 8.84); I2: 0%; 2 studies). Meta-regression analysis found glucose levels >10 mmol/L to be associated with increased odds of mortality compared with <10 mmol/L. Pooled analysis from case-control studies were similar to cohort studies for most outcomes but limited by small sample size. Longer duration of hyperglycaemia was associated with adverse outcomes. GRADE of evidence was 'Low' or 'Very low'. CONCLUSION Hyperglycaemia in very preterm infants is associated with higher odds of mortality, any-grade IVH and any-stage ROP. A limitation was lack of availability of adjusted ORs from many of the included studies. PROSPERO REGISTRATION NUMBER CRD42020193016.
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Affiliation(s)
- Chandra Prakash Rath
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Madhusudhan Shivamallappa
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Saravanan Muthusamy
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Shripada C Rao
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia .,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,School of Medicine, University of Western Australia, Crawley, Western Australia
| | - Sanjay Patole
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,School of Medicine, University of Western Australia, Crawley, Western Australia
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9
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Paulsen ME, Brown SJ, Satrom KM, Scheurer JM, Ramel SE, Rao RB. Long-Term Outcomes after Early Neonatal Hyperglycemia in VLBW Infants: A Systematic Review. Neonatology 2021; 118:509-521. [PMID: 34412051 PMCID: PMC8530871 DOI: 10.1159/000517951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Long-term effects of early hyperglycemia in VLBW infants are poorly characterized. The objective of this study was to systematically review the effect of early hyperglycemia on growth, metabolic health, and neurodevelopment after neonatal intensive care unit discharge in VLBW infants. METHODS The systematic review was conducted in accordance with the PRISMA guidelines. A study protocol was registered in PROSPERO (CRD42019123335). Data sources included Ovid MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus. Selected studies included infants with a blood glucose concentration >150 mg/dL (8.3 mmol/L) during the first 28 days of life, a gestational age (GA) <32 weeks, and/or a birth weight <1,500 g and longitudinal data on growth, metabolic health, or neurodevelopment outcomes. The GRADE system was used to assess quality of evidence. RESULTS Eight studies (n = 987 infants) reported long-term outcomes from 4-month corrected GA to 7 years old. Most studies compared long-term outcomes of preterm infants with and without hyperglycemia. Two studies addressed outcomes related to interventions following early hyperglycemia. Some studies found differences in growth, metabolic health, and neurodevelopment outcomes between VLBW preterm infants with hyperglycemia and without hyperglycemia, while other studies found no differences between groups. The overall graded quality of evidence was low. CONCLUSIONS Well-designed randomized controlled and prospective studies are necessary to determine the effect of early hyperglycemia and its treatment on later metabolic and neurodevelopmental outcomes in VLBW infants. Authors propose a potential study design for standardizing the assessment of long-term metabolic and neurodevelopmental outcomes following early hyperglycemia in preterm infants.
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Affiliation(s)
- Megan E Paulsen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sarah Jane Brown
- Health Sciences Library, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katherine M Satrom
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Johannah M Scheurer
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sara E Ramel
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Raghavendra B Rao
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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10
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Abstract
Hyperglycemia after birth is common in extremely preterm infants (<28 weeks of gestation). Lower gestational age, lower birthweight, presence of severe illness, and higher parenteral glucose intake increase the risk for hyperglycemia, while provision of higher amounts of amino acids and lipids in parenteral nutrition and early initiation and faster achievement of full enteral feeding decrease the risk. Hyperglycemia is associated with increased mortality and morbidity in the neonatal period. Limited data show an association with long-term adverse effects on growth, neurodevelopment, and cardiovascular and metabolic health. Lowering the glucose infusion rate and administration of insulin are the 2 treatment options. Lowering the glucose infusion could lead to calorie deficits and long-term adverse effects on growth and neurodevelopment. Conversely, insulin use increases the risk for hypoglycemia and requires close blood glucose monitoring and frequent adjustments to glucose infusion and insulin dosage. Randomized trials of varying strategies of nutrient provision and/or insulin therapy and long-term follow-up are needed to improve clinical care and overall health of extremely preterm infants with hyperglycemia.
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Affiliation(s)
- Sara Ramel
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN
| | - Raghavendra Rao
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN.,Center for Neurobehavioral Development, University of Minnesota, Minneapolis, MN
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11
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Beardsall K. Hyperglycaemia in the Newborn Infant. Physiology Verses Pathology. Front Pediatr 2021; 9:641306. [PMID: 34368024 PMCID: PMC8333866 DOI: 10.3389/fped.2021.641306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/18/2021] [Indexed: 12/25/2022] Open
Abstract
Hyperglycemia is common in newborns requiring intensive care, particularly in preterm infants, in sepsis and following perinatal hypoxia. The clinical significance, and optimal intervention strategy varies with context, but hyperglycaemia is associated with increased mortality and morbidity. The limited evidence for optimal clinical targets mean controversy remains regarding thresholds for intervention, and management strategies. The first consideration in the management of hyperglycaemia must be to ascertain potentially treatable causes. Calculation of the glucose infusion rate (GIR) to insure this is not excessive, is critical but the use of insulin is often helpful in the extremely preterm infant, but is associated with an increased risk of hypoglycaemia. The use of continuous glucose monitoring (CGM) has recently been demonstrated to be helpful in targeting glucose control, and reducing the risk from hypoglycaemia in the preterm infant. Its use in other at risk infants remains to be explored, and further studies are needed to provide a better understanding of the optimal glucose targets for different clinical conditions. In the future the combination of CGM and advances in computer algorithms, to provide intelligent closed loop systems, could allow a safer and more personalized approached to management.
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Affiliation(s)
- Kathryn Beardsall
- Department of Paediatrics, University of Cambridge, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom.,Neonatal Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
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12
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Motte-Signoret E, Shankar-Aguilera S, Brailly-Tabard S, Soreze Y, Dell Orto V, Ben Ammar R, De Luca D, Boileau P. Small for Gestational Age Preterm Neonates Exhibit Defective GH/IGF1 Signaling Pathway. Front Pediatr 2021; 9:711400. [PMID: 34447729 PMCID: PMC8382944 DOI: 10.3389/fped.2021.711400] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the impact of fetal growth restriction (FGR) on hormonal regulation of post-natal growth and glucose metabolism [via insulin and growth hormone (GH)/Insulin-like Growth factor 1 (IGF1) axis pathways] in small for gestational age (SGA) neonates. Methods: We conducted a monocentric observational prospective comparative study on 73 singleton babies born with a weight inferior to 2,000 g. We analyzed auxological (weight, height and head circumference), and hormonal (GH, IGF1, and insulin plasma concentrations) data comparing SGA and appropriate for gestational age (AGA) neonates, between day 1 and 60. Results: One third (23/73) of the neonates were SGA. Twenty-five percent (18/73) required insulin for idiopathic hyperglycemia of prematurity and were smaller in weight and head circumference at discharge. In the SGA group compared with the AGA group, GH plasma concentrations were higher at day 3 (70.1 vs. 38.0 mIU/L) and IGF1 plasma concentrations were higher at day 10 (29.0 vs. 18.7 ng/ml). Conclusions: SGA neonates displayed resistance to GH and IGF1, concomitant to insulin resistance. This could partially explain the initial defective catch-up growth and, later in life, the higher prevalence of metabolic syndrome in this population.
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Affiliation(s)
- Emmanuelle Motte-Signoret
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France.,Poissy St Germain Hospital, Neonatal Intensive Care Unit, Poissy, France.,Paris-Saclay University, Université Versailles Saint Quentin, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, BREED, Jouy-en-Josas, France
| | - Shivani Shankar-Aguilera
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France
| | - Sylvie Brailly-Tabard
- Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Molecular genetics Pharmacogenetics and Hormonology, Le Kremlin-Bicêtre, France
| | - Yohan Soreze
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France
| | - Valentina Dell Orto
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France
| | - Rafik Ben Ammar
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France
| | - Daniele De Luca
- Assistance Publique-Hôpitaux de Paris, Béclere Hospital, GH Paris Sud, Neonatal Intensive Care Unit, Clamart, France
| | - Pascal Boileau
- Poissy St Germain Hospital, Neonatal Intensive Care Unit, Poissy, France.,Institut National de la Santé et de la Recherche Médicale U1185, Le Kremlin-Bicêtre, France
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13
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Gonzalez Villamizar JD, Haapala JL, Scheurer JM, Rao R, Ramel SE. Relationships between Early Nutrition, Illness, and Later Outcomes among Infants Born Preterm with Hyperglycemia. J Pediatr 2020; 223:29-33.e2. [PMID: 32532652 DOI: 10.1016/j.jpeds.2020.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/12/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the effects of hyperglycemia on body composition and neurodevelopment, and how early nutrition and illness modify these relationships in infants born preterm. STUDY DESIGN Prospective data were collected from infants born <32 weeks of gestational age (N = 97), including inpatient days of hyperglycemia (blood glucose >150 mg/dL) and nutrient intake. Body composition was measured at discharge and 4 months' postmenstrual age (PMA). Bayley Scales of Infant Development III (BSID-III) were administered at 12 months' PMA. Linear regression analysis was performed, adjusting for birth gestational age. Associations between hyperglycemia, body composition, and BSID-III were analyzed in models accounting for first-week nutrition and early illness severity via Score for Neonatal Acute Physiology-II. RESULTS Mean birth gestational age was 27.8 (SD 2.4) weeks. Hyperglycemia occurred in 48.5% of infants. Hyperglycemia for ≥5 days was negatively associated with fat mass and fat free mass z scores at discharge, and fat free mass z score at 4 months' PMA (P < .05 all). Hyperglycemia for ≥5 days was negatively associated with cognition, language, and motor scores on the BSDI at 12 months (P ≤ .01 all). Associations with body composition and BSID-III were diminished when models included first week nutrition yet remained unchanged when illness severity was included. CONCLUSIONS In infants <32 weeks, ≥5 days of hyperglycemia is associated with decreased lean mass at 4 months' PMA and poorer neurodevelopmental outcome at 12 months' PMA. These associations may be mediated by decreased first week nutrition, potentially related to reduced glucose infusion rate for management of hyperglycemia.
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Affiliation(s)
| | - Jacob L Haapala
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Johannah M Scheurer
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
| | - Raghavendra Rao
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
| | - Sara E Ramel
- Department of Pediatrics, Division of Neonatology, School of Medicine, University of Minnesota, Minneapolis, MN
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14
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Zamir I, Tornevi A, Abrahamsson T, Ahlsson F, Engström E, Hallberg B, Hansen-Pupp I, Sjöström ES, Domellöf M. Hyperglycemia in Extremely Preterm Infants-Insulin Treatment, Mortality and Nutrient Intakes. J Pediatr 2018; 200:104-110.e1. [PMID: 29731360 DOI: 10.1016/j.jpeds.2018.03.049] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/05/2018] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the prevalence of hyperglycemia and the associations between nutritional intakes, hyperglycemia, insulin treatment, and mortality in extremely preterm infants. STUDY DESIGN Prospectively collected data from the Extremely Preterm Infants in Sweden Study (EXPRESS) was used in this study and included 580 infants born <27 gestational weeks during 2004-2007. Available glucose measurements (n = 9850) as well as insulin treatment and nutritional data were obtained retrospectively from hospital records for the first 28 postnatal days as well as 28- and 70-day mortality data. RESULTS Daily prevalence of hyperglycemia >180 mg/dL (10 mmol/L) of up to 30% was observed during the first 2 postnatal weeks, followed by a slow decrease in its occurrence thereafter. Generalized additive model analysis showed that increasing parenteral carbohydrate supply with 1 g/kg/day was associated with a 1.6% increase in glucose concentration (P < .001). Hyperglycemia was associated with more than double the 28-day mortality risk (P < .01). In a logistic regression model, insulin treatment was associated with lower 28- and 70-day mortality when given to infants with hyperglycemia irrespective of the duration of the hyperglycemic episode (P < .05). CONCLUSIONS Hyperglycemia is common in extremely preterm infants throughout the first postnatal month. Glucose infusions seem to have only a minimal impact on glucose concentrations. In the EXPRESS cohort, insulin treatment was associated with lower mortality in infants with hyperglycemia. Current practices of hyperglycemia treatment in extremely preterm infants should be reevaluated and assessed in randomized controlled clinical trials.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden.
| | - Andreas Tornevi
- Department of Public Health and Clinical Medicine, Division of Occupational and Environmental Medicine, Umeå University, Umeå, Sweden
| | - Thomas Abrahamsson
- Department of Clinical and Experimental Medicine, Division of Pediatrics, Linköping University, Linköping, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Eva Engström
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Boubou Hallberg
- CLINTEC Department of Neonatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ingrid Hansen-Pupp
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
| | | | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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15
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William W. Optimizing nutrition of the preterm infant. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017. [PMID: 28100316 PMCID: PMC7390124 DOI: 10.7499/j.issn.1008-8830.2017.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
The goal of nutrition of the preterm infant is to meet the growth rate of the healthy fetus of the same gestational age and to produce the same body composition of the healthy fetus in terms of organ growth, tissue components, and cell number and structure. Nutritional quantity and quality are fundamental for normal growth and development of preterm infants, including neurodevelopmental outcomes. Failure to provide the necessary amounts of all of the essential nutrients has produced not only growth failure, but also increased morbidity and less than optimal neurodevelopment. Growth velocities during the NICU hospitalization period for preterm infants exert a significant effect on neurodevelopmental and anthropometric outcomes. Despite the obvious need for optimal nutrition, growth failure is almost universal among preterm infants. There is every reason, therefore, to optimize nutrition of the preterm infant, in terms of total energy and protein, but also in terms of individual components such as amino acids, specific carbohydrates and lipids, and even oxygen. This review presents scientific rationale for nutrient requirements and practical guidelines and approaches to intravenous and enteral feeding for preterm infants. Intravenous feeding, including amino acids, should be started right after birth at rates that are appropriate for the gestational age of the infant. Enteral feeding should be started as soon as possible after birth, using mother's colostrum and milk as first choices. Enteral feeding should begin with trophic amounts and advanced as rapidly as tolerated, decreasing IV nutrition accordingly, while maintaining nutrient intakes at recommended rates. Feeding protocols are valuable for improving nutrition and related outcomes. Further research is needed to determine the optimal nutrition and rate of growth in preterm infants that will achieve optimal neurocognitive benefits while minimizing the longer-term risk of chronic diseases.
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Affiliation(s)
- W.Hay,Jr William
- />Perinatal Research Center, Child Maternal Health Program, Colorado Clinical and Translational Sciences Institute University of Colorado School of Medicine, Aurora, Colorado, USA
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