Hypoglycemia in term newborns with a birth weight below the 10th percentile

A cost-effectiveness analysis of a South African pregnancy support grant

Poverty among expectant mothers often results in sub-optimal maternal nutrition and inadequate antenatal care, with negative consequences on child health outcomes. South Africa has a child support grant that is available from birth to those in need. This study aims to determine whether a pregnancy support grant, administered through the extension of the child support grant, would be cost-effective compared to the existing child support grant alone. A cost-utility analysis was performed using a decision-tree model to predict the incremental costs (ZAR) and disability-adjusted life years (DALYs) averted by the pregnancy support grant over a 2-year time horizon. An ingredients-based approach to costing was completed from a governmental perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed. The intervention resulted in a cost saving of R13.8 billion ($930 million, 95% CI: ZAR3.91 billion - ZAR23.2 billion/ $1.57 billion - $264 million) and averted 59,000 DALYs (95% CI: -6,400-110,000), indicating that the intervention is highly cost-effective. The primary cost driver was low birthweight requiring neonatal intensive care, with a disaggregated incremental cost of R31,800 ($2,149) per pregnancy. Mortality contributed most significantly to the DALYs accrued in the comparator (0.68 DALYs). The intervention remained the dominant strategy in the sensitivity analyses. The pregnancy support grant is a highly cost-effective solution for supporting expecting mothers and ensuring healthy pregnancies. With its positive impact on child health outcomes, there is a clear imperative for government to implement this grant. By investing in this program, cost savings could be leveraged. The implementation of this grant should be given high priority in public health and social policies.

Early neonatal hypoglycemia in term and late preterm small for gestational age newborns

BACKGROUND

Neonatal hypoglycemia is a common metabolic occurrence among small for gestational age (SGA) neonates. This study aims to determine the incidence of early neonatal hypoglycemia and confirms the potential risk factors among term and late preterm SGA neonates in a well-baby newborn nursery of a tertiary medical center in Southern Taiwan.

METHODS

We performed a retrospective medical record review of term and late preterm SGA (birth weight <10 percentile) neonates, born between January 1, 2012 and December 31, 2020, in the well-baby newborn nursery, of a tertiary medical center in Southern Taiwan. Blood glucose monitoring was routinely performed at 0.5, 1, 2, and 4 h of life. Antenatal and postnatal risk factors were recorded. Mean blood glucose level, age of occurrence, symptomatic hypoglycemia, and need for intravenous glucose treatment of early hypoglycemia in SGA neonates were documented.

RESULTS

690 SGA neonates in the nursery met the criteria and were retrospectively enrolled in the study, 358 of whom (51.80%) were male and 332 (48.10%) female. Of 690 enrolled SGA neonates, 134(19.42%) SGA neonates developed hypoglycemia during a well-baby nursery stay. Among these neonates, 97% of early hypoglycemic episodes occur during the first 2 h of life. The lowest blood glucose level was 46.78 ± 11.13 mg/dL, recorded in the first hour of life. Among the hypoglycemic 134 neonates, 26 (19.40%) neonates had to be transferred from the nursery to the neonatal ward and they required intravenous glucose treatment to achieve euglycemia. 14 (10.40%) neonates had symptomatic hypoglycemia. A multivariate logistic regression analysis revealed that cesarean delivery, small head circumference, small chest circumference, and low 1-min Apgar score were significant risk factors for early hypoglycemia in these neonates.

CONCLUSION

Periodic routine blood glucose level monitoring within the first 4 h of life in term and late preterm SGA neonates is required, especially those with cesarean delivery and low Apgar score.

Fitness of INTERGROWTH-21st birth weight standards for Chinese-ethnicity babies

OBJECTIVE

To determine the fitness of the INTERGROWTH-21st birth weight standards (INTERGROWTH21) for ethnic Chinese babies compared with a local reference (FOK2003).

DESIGN

Population-based analysis of territory-wide birth data.

SETTING

All public hospitals in Hong Kong.

PARTICIPANTS

Live births between 24 and 42 complete weeks' gestation during 2006-2017.

MAIN OUTCOME MEASURES

Babies' birth weight Z-scores were calculated using published methods. The two references were compared in three aspects: (1) the proportions of large-for-gestational-age (LGA) or small-for-gestational-age (SGA) infants, (2) the gestation-specific and sex-specific mean birth weight Z-scores and (3) the predictive power for SGA-related complications.

RESULTS

488 896 infants were included. Using INTERGROWTH21, among neonates born <33 weeks' gestation, the mean birth weight Z-scores per week were closer to zero (-0.2 to 0.05), while most of them were further from zero (0.06 to 0.34) after excluding infants with a high risk of abnormal intrauterine growth. Compared with FOK2003, INTERGROWTH21 classified smaller proportions of infants as SGA (8.3% vs 9.6%) and LGA (6.6% vs 7.9%), especially SGA among preterm infants (13.1% vs 17.0%). The area under the receiver operating characteristic curve for predicting SGA-related complications was greater with FOK2003 (0.674, 95% CI 0.670 to 0.677) than INTERGROWTH21 (0.658, 95% CI 0.655 to 0.661) (p<0.001).

CONCLUSIONS

INTERGROWTH21 performed less well than FOK2003, a local reference for ethnic Chinese babies, especially in infants born <33 weeks' gestation. Although the differences are clinically small, both these references performed poorly for extremely preterm infants, and thus a more robust chart based on a larger sample of appropriately selected infants is needed.

Birth anthropometry among three Asian racial groups in Singapore: proposed new growth charts

OBJECTIVE

We analysed birth anthropometry of babies of Chinese, Malay and Indian ancestry living in Singapore with an aim to develop gestational age (GA) and gender-specific birth anthropometry charts and compare these with the widely used Fenton charts.

DESIGN

Retrospective observational study.

SETTING

Department of Neonatology, National University Hospital, Singapore.

POPULATION

We report data from 52 220 infants, born between 1991-1997 and 2010-2017 in Singapore.

METHODS

Anthropometry charts were built using smoothened centile curves and compared with Fenton's using binomial test. Birth weight (BW), crown-heel length and head circumference (HC) were each modelled with maternal exposures using general additive model.

MAIN OUTCOME MEASURES

BW, crown-heel length and HC.

RESULTS

There were 22 248 Chinese (43%), 16 006 Malay (31%) and 8543 Indian (16%) babies. Mean BW was 3103 g (95% CI 3096 to 3109), 3075 g (95% CI 3067 to 3083) and 3052 g (95% CI 3041 to 3062) for Chinese, Malays and Indians, respectively. When exposed to a uniform socioeconomic environment, intrauterine growth and birth anthropometry of studied races were almost identical. From our GA-specific anthropometric charts until about late prematurity, Asian growth curves mirrored that of Fenton's; thereafter, Asian babies showed a reduction in growth velocity.

CONCLUSIONS

These findings suggest that Asian babies living in relatively uniform socioeconomic strata exhibit similar growth patterns. There is a slowing of growth among Asian babies towards term, prompting review of existing birth anthropometry charts. The proposed charts will increase accuracy of identification of true fetal growth restriction as well as true postnatal growth failure in preterm infants when applied to the appropriate population.

The Role of Early Pregnancy Maternal pGCD59 Levels in Predicting Neonatal Hypoglycemia-Subanalysis of the DALI Study

CONTEXT

Neonatal hypoglycaemia (NH) is the most common metabolic problem in infants born of mothers with gestational diabetes. Plasma glycated CD59 (pGCD59) is an emerging biomarker that has shown potential in identifying women at risk of developing gestational diabetes. The aim of this study was to assess the association between early maternal levels of pGCD59 and NH.

OBJECTIVE

The aim of this study was to assess the association between early pregnancy maternal levels of plasma glycated CD59 (pGCD59) and neonatal hypoglycemia (NH).

METHODS

This is an observational study of pregnant women with a prepregnancy body mass index (BMI) greater than or equal to 29 screened for eligibility to participate in the Vitamin D and Lifestyle Intervention for Gestational Diabetes (DALI) trial. This analysis included 399 pregnancies. Levels of pGCD59 were measured in fasting maternal samples taken at the time of a 75-g, 2-hour oral glucose tolerance test performed in early pregnancy (< 20 weeks). NH, the study outcome, was defined as a heel-prick capillary glucose level of less than 2.6 mmol/L within 48 hours of delivery.

RESULTS

We identified 30 infants with NH. Maternal levels of pGCD59 in early pregnancy were positively associated with the prevalence of NH (one-way analysis of variance, P < .001). The odds of NH were higher in infants from mothers in tertile 3 of pGCD59 levels compared to those from mothers in tertile 1 (odds ratio [OR]: 2.41; 95% CI, 1.03-5.63). However, this was attenuated when adjusted for maternal BMI (OR: 2.28; 95% CI, 0.96-5.43). The cross-validated area under the curve (AUC) was 0.64 (95% CI, 0.54-0.74), and adjusted for maternal BMI, age, and ethnicity, the AUC was 0.70 (95% CI, 0.56-0.78).

CONCLUSION

Although pGCD59 levels in early pregnancy in women with BMI greater than or equal to 29 are associated with NH, our results indicate that this biomarker by itself is only a fair predictor of NH.

Cord Blood from SGA Preterm Infants Exhibits Increased GLUT4 mRNA Expression

Background

Insulin and insulin-like growth factor (IGF) signaling plays an important role in prenatal and postnatal growth and glucose metabolism. Both small-for-gestational age (SGA) and preterm infants have abnormal growth and glucose metabolism. However, the underlying mechanism remains unknown. Recently, we showed that term SGA infants have abnormal insulin/IGF signaling in cord blood. In this study, we examined whether preterm infants show similar aberrations in cord blood insulin/IGF signaling.

Methods

A total of 41 preterm cord blood samples were collected. Blood glucose, insulin, IGF-1, and C-peptide concentrations were measured, and mRNA expression of IGF1R, INSR, IRS1, IRS2, and SLC2A4 (i.e., GLUT4) was analyzed by quantitative reverse-transcription PCR.

Results

This study included 34 appropriate-for-gestational age (AGA) and 7 SGA preterm neonates. No hyperinsulinemia or any differences in IGF1R or INSR mRNA expression were detected between the two groups. However, GLUT4 mRNA levels were increased in preterm SGA. Moreover, the expression level in hypoglycemic preterm SGA was significantly higher than that in hypoglycemic preterm AGA. IRS2 mRNA expression did not show a statistically significant difference between preterm SGA and AGA neonates.

Conclusion

SGA preterm birth does not induce hyperinsulinemia; however, it modifies insulin/IGF signaling components such as GLUT4 in umbilical cord blood. Our study suggests that prematurity or adaptation to malnutrition alters the insulin/IGF signaling pathway.

Neonatal Problems and Infancy Growth of Term SGA Infants: Does "SGA" Definition Need to Be Re-evaluated?

Introduction: The exact definition of small-for-gestational-age (SGA) infant is still controversial among clinicians. In this study, we aimed to understand which definition is better in terms of establishing both early postnatal problems and growth. In this way, we compared early neonatal problems and infancy growth of term infants with birth weight (BW) < -2 SDS and with BW between 10th percentile (-1.28 SDS) and -2 SDS. Methods: A single center retrospective cohort study was conducted. Preterm infants, multiple gestations and newborns with any congenital anomalies were excluded from the study. Study group was defined as Group 1 (n = 37), infants BW < -2.00 SDS; Group 2 (n = 129), between -1.28 and -2.00 SDS; and Group 3 (n = 137), randomly selected newborns with optimal-for-gestational-age (BW between -0.67 and +0.67 SDS) as a control group. Results: The incidence of severe hypoglycemia was highest in Group 1 (%10.8) and Group 2 and 3 had similar rates of severe hypoglycemia (0.8 and 0.7%, respectively). The incidence of polycythemia was 5.4% in Group 1 and was significantly higher than Group 3 (0.0%) while it was 2.3% in Group 2. Short stature (length < -2 SDS) ratio at the age of 1 and 2 years were similar in each group. Overweight/obesity ratio at the age of 1 were 9.5, 20.8 and 16.7% in each group, respectively (p = 0.509). Conclusion: This study was planned as a pilot study to determine potential differences in the problems of hypoglycemia, polycythemia, and growth according to the differences in definition. Short term disturbances such as hypoglycemia and polycythemia are found to be higher in infants with a BW SDS below -2. From this point of view, of course, it will not be possible to change the routine applications immediately, however this study will be an initiative for discussions by making long-term studies.

Hypoglycemia in unmonitored full-term newborns-a surveillance study

Background and objectives

Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns.

Methods

With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed.

Results

All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P<0.001). Twenty-five per cent of cases had birth weight less than the 10th centile. Neurodevelopmental concern was reported in 20%. Of the 13 cases which had brain magnetic resonance imaging, 11 were abnormal.

Conclusion

Hypoglycemia in unmonitored newborns is uncommon but is associated with significant morbidity. We provide a range of clues to help identify these newborns soon after birth. Widespread adoption of norm-based standards to identify small-for-gestational age infants is supported.

Impact of transient period of metabolic adaptation on perinatal asphyxia in neonates with intrauterine growth retardation

INTRODUCTION

Temperature, glycemia and respiration make neonatal energy triangle (NET). In growth retardation (IUGR) neonates pathological metabolic adaptation exists in transient neonatal period.

AIM

The of this study was to examine the occurrence of pathological NET and check its impact on perinatal asphyxia during the transient period in IUGR neonates.

MATERIAL AND METHODS

One hundred and fifty-nine neonates with IUGR were classified into - early preterm, late preterm and term neonates. By the presence of hypothermia, hypoglycemia and hypoxia in the first hour after birth neonates were classified into: group of pathological NET, group of unstable NET and group of stable NET. We analyzed distribution per body mass, gestational age, type of IUGR, gender and the frequency of perinatal asphyxia between the groups.

RESULTS

The late preterm neonates were the most frequent in the group of pathological NET. Perinatal asphyxia was diagnosed in 52 (32.7%) neonates, with highest frequency in the group of pathological NET. Univariate binary logistic regression analysis showed that pathological NET in neonates with IUGR is significant predictor for perinatal asphyxia occurrence (OR = 8.57; CI = 4.05-18.12; p < 0.001 R² = 0.27).

CONCLUSION

Poor metabolic adaptation in neonates with IUGR in the first hour after birth is significant risk factor for the perinatal asphyxia.

Developmental regulation of key gluconeogenic molecules in nonhuman primates

Aberrant glucose regulation is common in preterm and full‐term neonates leading to short and long‐term morbidity/mortality; however, glucose metabolism in this population is understudied. The aim of this study was to investigate developmental differences in hepatic gluconeogenic pathways in fetal/newborn baboons. Fifteen fetal baboons were delivered at 125 day (d) gestational age (GA), 140d GA, and 175d GA (term = 185d GA) via cesarean section and sacrificed at birth. Term and healthy adult baboons were used as controls. Protein content and gene expression of key hepatic gluconeogenic molecules were measured: cytosolic and mitochondrial phosphoenolpyruvate carboxykinase (PEPCK‐C and PEPCK‐M), glucose‐6‐phosphatase‐alpha (G6Pase‐α), G6Pase‐β, fructose‐1,6‐bisphosphatase (FBPase), and forkhead box‐O1 (FOXO1). Protein content of PEPCK‐M increased with advancing gestation in fetal baboons (9.6 fold increase from 125d GA to 175d GA, P < 0.001). PEPCK‐C gene expression was consistent with these developmental differences. Phosphorylation of FOXO1 was significantly lower in preterm fetal baboons compared to adults, and gene expression of FOXO1 was lower in all neonates when compared to adults (10% and 62% of adults respectively, P < 0.05). The FOXO1 target gene G6Pase expression was higher in preterm animals compared to term animals. No significant differences were found in G6Pase‐α, G6Pase‐β, FOXO1, and FBPase during fetal development. In conclusion, significant developmental differences are found in hepatic gluconeogenic molecules in fetal and neonatal baboons, which may impact the responses to insulin during the neonatal period. Further studies under insulin‐stimulated conditions are required to understand the physiologic impact of these maturational differences.

Significant developmental differences were found in several hepatic gluconeogenic molecules. In particular, phosphorylated FOXO1 was significantly reduced in the liver of premature fetal baboons compared to adults and may contribute the increased incidence of hyperglycemia seen in prematurity. In addition, PEPCK increased with advancing gestational age and may play a key role in glucose regulation during the newborn period.

Proactive enteral nutrition in moderately preterm small for gestational age infants: a randomized clinical trial

OBJECTIVE

To investigate the efficacy of a proactive feeding regimen (PFR) in reducing hospital length of stay in a population of moderately preterm small for gestational age (SGA) infants.

STUDY DESIGN

SGA infants (z-score <-1.28) of gestational age (GA) 32-36 weeks and birth weight (BW) >1499 g were allocated at random to receive either a PFR, starting with 100 mL/kg/day and gradually increasing to 200 mL/kg/day by day 4, or a standard feeding regimen, starting with 60 mL/kg/day and gradually increasing to 170 mL/kg/day by day 9. All infants received human milk.

RESULTS

A total of 72 infants were randomized to the 2 groups, 36 to the PFR group (mean GA, 35.1 ± 0.7 weeks; mean BW, 1761 ± 177 g) and 36 to the standard feeding regimen group (mean GA, 35.5 ± 1.2 weeks; mean BW, 1754 ± 212 g). Infants in the PFR group were discharged significantly earlier (mean, 9.8 ± 3.1 days vs 11.9 ± 4.7 days; P = .029). The need for intravenous fluids (2.8% vs 33.3%; P = .0013) and the incidence of hypoglycemia (0 vs 33.3%; P = .00016) were significantly lower in the PFR group. Feeding intolerance and fecal calprotectin levels did not differ between the 2 groups.

CONCLUSION

A PFR in moderately preterm SGA infants is well tolerated and significantly reduces both the length of stay and the risk of neonatal hypoglycemia.

The low birthweight, term infant and the need for admission to special care nurseries

AIM

We aimed to determine, in full-term newborns born between 2000 and 2499 g, what proportion develop problems or the need for interventions that would likely require admission to a special care nursery (SCN) (i.e., needed an intravenous line (IV) or a nasogastric tube (NGT).

METHODS

A multicentre, retrospective audit of all babies born from 1 January to 30 June 2011 was used. Eligible babies were term, inborn at one of four centres in south-east Queensland, with a birthweight between 2000 and 2499 g.

RESULTS

The cohort of 98 babies had a mean (SD) birthweight of 2340 (122.3) g and a mean (SD) gestational age of 38.3 (1.0) weeks. Forty-three had at least one low temperature, 55 had at least one low blood glucose, 35 had an NGT, 22 had an IV cannula. In the entire cohort, 48 babies (49%) required either an IV cannula or an NGT. Fifteen per cent had a second problem (either low blood glucose or low temperature) at a median (interquartile range) age of 11 (5.5-25.5) h: none required a second NGT or IV. The proportion of babies that required either an NGT or an IV was larger in the 2000-2199 g group (P = 0.026).

CONCLUSIONS

About half of the babies born with a birthweight of 2000-2499 g will require some intervention that will require them to be admitted to a SCN. However, about half would be able to avoid an SCN admission if they are well and admitted to the post-natal ward.

Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study

OBJECTIVE

To investigate the risks of adverse pregnancy and birth outcomes for treated and untreated bipolar disorder during pregnancy.

DESIGN

Population based cohort study using data from national health registers.

SETTING

Sweden.

PARTICIPANTS

332,137 women with a last menstrual period anytime after 1 July 2005 and giving birth anytime before the end of 31 December 2009. Women with a record of at least two bipolar diagnoses were identified and grouped as treated (n = 320)-those who had filled a prescription for mood stabilisers (lithium, antipsychotics, or anticonvulsants) during pregnancy-or untreated (n = 554). Both groups were compared with all other women giving birth (n = 331,263).

MAIN OUTCOME MEASURES

Preterm birth, mode of labour initiation, gestational diabetes, infants born small or large for gestational age, neonatal morbidity, and congenital malformations.

RESULTS

Of the untreated women, 30.9% (n = 171) were induced or had a planned caesarean delivery compared with 20.7% (n = 68,533) without bipolar disorder (odds ratio 1.57, 95% confidence interval 1.30 to 1.90). The corresponding values for the treated women were 37.5% (n = 120) (2.12, 1.68 to 2.67). The risks of preterm birth in both treated and untreated women were increased by 50%. Of the untreated women, 3.9% (n = 542) had a microcephalic infant compared with 2.3% (324,844) of the women without bipolar disorder (1.68, 1.07 to 2.62). The corresponding values for the treated women were 3.3% (n = 311) (1.26, 0.67 to 2.37). Similar trends were observed for risks of infants being small for gestational age infants for weight and length. Among infants of untreated women, 4.3% (n = 24) had neonatal hypoglycaemia compared with 2.5% (n=8302) among infants of women without bipolar disorder (1.51, 1.04 to 2.43), and 3.4% (n = 11) of the treated women (1.18, 0.64 to 2.16). The analyses of variation in outcomes did not support any significant differences between treated and untreated women.

CONCLUSIONS

Bipolar disorder in women during pregnancy, whether treated or not, was associated with increased risks of adverse pregnancy outcomes.