Survey of the definition and screening of neonatal hypoglycaemia in Australia

Clinical management and knowledge of neonatal hypoglycaemia in Germany: A national survey of midwives and nurses

AIM

Despite being a common metabolic condition, the detection and care of neonatal hypoglycaemia in Germany largely depends on the infant's health-care provider, rather than a national protocol. Therefore, this study aimed to evaluate midwives' and nurses' knowledge and management of neonatal hypoglycaemia and to determine the need for national guidelines.

METHODS

An anonymous online survey was developed and completed by 127 perinatal nurses and midwives. Descriptive statistics, Mann-Whitney-U, χ² and Fisher's exact tests were used to summarise and analyse the results.

RESULTS

In total, 82% of respondents indicated using guidelines but routine blood glucose screening for neonates at risk for hypoglycaemia was rarely reported (44%). A blood glucose concentration of 2.5 mmol/L (45 mg/dL) was considered the treatment threshold by 52% of the respondents. However, the responses to clinical scenarios showed distinct differences regarding the management of neonatal hypoglycaemia. Finally, 49% of respondents reported insufficient knowledge regarding neonatal hypoglycaemia and 77% indicated that they would advocate the implication of enhanced national guidelines.

CONCLUSIONS

There is considerable variation in knowledge about the prevention, screening and management of neonatal hypoglycaemia among nurses and midwives in Germany. Enhanced guidelines and education of health-care professionals are urgently needed to provide the best possible care to all hypoglycaemic newborns.

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.

Neonatal Hypoglycemia: Risk Factors and Outcomes

BACKGROUND AND AIMS

Severe neonatal hypoglycemia (HG) leads to neurologic damage, mental retardation, epilepsy, personality disorders, impaired cardiac performance and muscle weakness. We aimed to assess the clinical characteristics of children with hypoglycemia in a random population of newborns.

PATIENTS, METHODS AND RESULTS

We investigated 84 patients (M:F=35:48) born at the University Clinic for Gynecology and Obstetrics in Skopje (hospitalized in the NICU) who were found to have hypoglycemia. In total 89.25% of the babies were premature. The mean birth weight was 1795.95 +/596.08 grams, the mean birth length was 41.92+/- 4.62 cm, while the mean gestational age was 33.05±3.19 weeks. 32 children (38.08%) were very low birth weight (<1500g), 38 (45.22%) were low birth weight (1500-2500g), while there were 8 children (9.52%) appropriate for age BW and no high BW for age patients (>4000 g). HG duration was 2.42+/-2.41 hours. In the group as a whole, hypoxic-ischemic encephalopathy (HIE) was found in 3 children (3.57%), infections in 22 (26.18%), respiratory distress syndrome (RDS) in 9 patients (10.62%), intracranial haemorrhage in 2 patients (2.38%). There were no inborn errors of metabolism. There were two deaths (2.38%).

CONCLUSION

Neonatal HG is a significant factor in the overall neonatal mortality. HG can also cause severe invalidity. We found that infections, LBW and low gestational age were most commonly associated with neonatal HG. However the Spearman test showed weak direct correlation, without statistical significance. Neonatal HG requires complex and team interaction of prenatal and postnatal approaches to reduce the incidence of seizures, their consequences and the overall mortality. Special consideration is to be taken in measures that avoid neonatal infections, HIE, LBW and low gestational age. Further studies on a larger population are needed to fully understand and prevent the phenomenon of HG in newborns.

Hypoglycaemia in the Newborn

AIM

Severe neonatal hypoglycaemia (HG) leads to neurologic damage, mental retardation, epilepsy, impaired cardiac performance and muscle weakness. The aim was to assess the frequency and severity of HG in a population of newborns.

PATIENTS AND METHODS

We investigated 739 patients with neonatal hypoglycaemia (HG) (M:F=370:369) born at the University Clinic for Gynaecology and Obstetritics in Skopje in the period 2014-2016 and treated at the neonatal intensive care unit (NICU). 1416 babies were treated in the same period in NICU, and HG was observed in 52.18%. The birth weight was dominated by children with low birth weight: very low birth weight (VLBW)(<1500g) 253 children, (34,23%), low birth weight (1500-2500g) 402 (54.39%), appropriate for gestational age (AGA) 78(10.55%), and high birth weight (>4000g) 6 babies (0.81%). The gestational age was also dominated by children with low gestational age: gestational week (GW) 20-25 four children (0.54%), 26-30 GW 133 babies (17.99%), 31-35 GW472 (63.87%), and 36-40 GW130 neonates (17.59 %). 241 mothers (32.61%) have had an infection during pregnancy, 82 preeclampsia or eclampsia (11.09%), 20 diabetes mellitus (2.70%), 78 placental situations (placenta previa, abruption) (10.55%). In this study 47 babies (6.35%) with HG and co-morbidities died. There was a significant positive correlation between HG birth weight (p<0.01), gestational age (p<0.05), and the lowest Apgar score (p<0.01). Neonatal deaths were significantly correlated with GA (р>0,01), co-morbidities of the mothers (р>0,05) but not with the birth weight (р>0,05). In contrast, a significant positive correlation was found between convulsions and body weight (р<0.05). The lowest Apgar score was positively correlated with the gestational age (0.01), but not with the birth weight (0.05).

CONCLUSION

Low birth weight, low gestational age, maternal risk factors, hypoxic-ischemic encephalopathy and neonatal infections are associated with HG and are a significant factor in overall neonatal mortality. Those results indicate that diminishing the frequency of the neonatal HG and the rates of neonatal mortality requires complex interaction of prenatal and postnatal interventions.

Safety and efficacy of antenatal milk expressing for women with diabetes in pregnancy: protocol for a randomised controlled trial

INTRODUCTION

Many maternity providers recommend that women with diabetes in pregnancy express and store breast milk in late pregnancy so breast milk is available after birth, given (1) infants of these women are at increased risk of hypoglycaemia in the first 24 h of life; and (2) the delay in lactogenesis II compared with women without diabetes that increases their infant's risk of receiving infant formula. The Diabetes and Antenatal Milk Expressing (DAME) trial will establish whether advising women with diabetes in pregnancy (pre-existing or gestational) to express breast milk from 36 weeks gestation increases the proportion of infants who require admission to special or neonatal intensive care units (SCN/NICU) compared with infants of women receiving standard care. Secondary outcomes include birth gestation, breastfeeding outcomes and economic impact.

METHODS AND ANALYSIS

Women will be recruited from 34 weeks gestation to a multicentre, two arm, unblinded randomised controlled trial. The intervention starts at 36 weeks. Randomisation will be stratified by site, parity and diabetes type. Women allocated to the intervention will be taught expressing and encouraged to hand express twice daily for 10 min and keep an expressing diary. The sample size of 658 (329 per group) will detect a 10% difference in proportion of babies admitted to SCN/NICU (85% power, α 0.05). Data are collected at recruitment (structured questionnaire), after birth (abstracted from medical record blinded to group), and 2 and 12 weeks postpartum (telephone interview).

DATA ANALYSIS

the intervention group will be compared with the standard care group by intention to treat analysis, and the primary outcome compared using χ(2) and ORs.

ETHICS AND DISSEMINATION

Research ethics approval will be obtained from participating sites. Results will be published in peer-reviewed journals and presented to clinicians, policymakers and study participants.

TRIAL REGISTRATION NUMBER

Australian Controlled Trials Register ACTRN12611000217909.

A survey of the management of neonatal hypoglycaemia within the Australian and New Zealand Neonatal Network

BACKGROUND

Neonatal hypoglycaemia is a common problem linked to both brain damage and death. There is controversy regarding both the definition of and best treatment for neonatal hypoglycaemia.

AIM

To determine current management of neonatal hypoglycaemia within the Australian and New Zealand Neonatal Network (ANZNN).

METHODS

Four questionnaires were sent to the Director of each of the 45 nurseries within the ANZNN. The Director was asked to complete one questionnaire and give the remaining three to other doctors involved with the management of babies with hypoglycaemia in the nursery.

RESULTS

One hundred and eighty surveys were sent and 127 were returned (71%), including at least one from each nursery. Almost all respondents (120, 94%) reported using a protocol to treat hypoglycaemia. Only 2 (2%) reported screening all babies for neonatal hypoglycaemia, with the remainder screening babies at risk. Only 67, (53%) reported that blood glucose levels were tested on an analyser generally considered to be reliable at low levels. Most respondents (99, 78%) reported the clinical threshold for treatment was <2.6 mmol/L. However, when provided with clinical scenarios, respondents reported a variety of interventions, including no treatment.

CONCLUSION

Doctors within the ANZNN are consistent about definition and screening for neonatal hypoglycaemia. However, frequently, the diagnosis is made using unreliable analysers. There is also wide variation in treatment, suggesting a lack of reliable evidence on which to base practice.

Nursing and midwifery management of hypoglycaemia in healthy term neonates

EXECUTIVE SUMMARY:

OBJECTIVES

The primary objective of this review was to determine the best available evidence for maintenance of euglycaemia* in healthy term neonates, and the management of asymptomatic hypoglycaemia in otherwise healthy term neonates.

INCLUSION CRITERIA

TYPES OF STUDIES: The review included any relevant published or unpublished studies undertaken between 1995 and 2004. Studies that focus on the diagnostic accuracy of point-of-care devices for blood glucose screening and/or monitoring in the neonate were initially included as a subgroup of this review. However, the technical nature and complexity of the statistical information published in diagnostic studies retrieved during the literature search stage, as well as the considerable volume of published research in this area, suggested that it would be more feasible to analyse diagnostic studies in a separate systematic review.

TYPES OF PARTICIPANTS

The review focused on studies that included healthy term (37- to 42-week gestation) appropriate size for gestational age neonates in the first 72 h after birth.

EXCLUSIONS

•  preterm or small for gestational age newborns; •  term neonates with a diagnosed medical or surgical condition, congenital or otherwise; •  babies of diabetic mothers; •  neonates with symptomatic hypoglycaemia; •  large for gestational age neonates (as significant proportion are of diabetic mothers). TYPES OF INTERVENTION: All interventions that fell within the scope of practice of a midwife/nurse were included: •  type (breast or breast milk substitutes), amount and/or timing of feeds, for example, initiation of feeding, and frequency; •  regulation of body temperature; •  monitoring (including screening) of neonates, including blood or plasma glucose levels and signs and symptoms of hypoglycaemia. Interventions that required initiation by a medical practitioner were excluded from the review.

TYPES OF OUTCOME MEASURES

Outcomes that were of interest included: •  occurrence of hypoglycaemia; •  re-establishment and maintenance of blood or plasma glucose levels at or above set threshold (as defined by the particular study); •  successful breast-feeding; •  developmental outcomes. TYPES OF RESEARCH DESIGNS: The review initially focused on randomised controlled trials reported from 1995 to 2004. Insufficient randomised controlled trials were identified and the review was expanded to include additional cohort and cross-sectional studies for possible inclusion in a narrative summary.

SEARCH STRATEGY

The major electronic databases, including MEDLINE/PubMed, CINAHL, EMBASE, LILACS, Cochrane Library, etc., were searched using accepted search techniques to identify relevant published and unpublished studies undertaken between 1995 and 2004. Efforts were made to locate any relevant unpublished materials, such as conference papers, research reports and dissertations. Printed journals were hand-searched and reference lists checked for potentially useful research. The year 1995 was selected as the starting point in order to identify any research that had not been included in the World Health Organisation review, which covered literature published up to 1996. The search was not limited to English language studies. ASSESSMENT OF QUALITY: Three primary reviewers conducted the review assisted by a review panel. The review panel was comprised of nine nurses with expertise in neonatal care drawn from senior staff in several metropolitan neonatal units and education programs. Authorship of journal articles was not concealed from the reviewers. Methodological quality of each study that met the inclusion criteria was assessed by two reviewers, using a quality assessment checklist developed for the review. Disagreements between reviewers were resolved through discussion or with the assistance of a third reviewer.

DATA EXTRACTION AND ANALYSIS

Two reviewers used a data extraction form to independently extract data relating to the study design, setting and participants; study focus and intervention(s); and measurements and outcomes. As only one relevant randomised controlled trial was found, a meta-analysis could not be conducted nor tables constructed to illustrate comparisons between studies. Instead, the findings were summarised by a narrative identifying any relevant findings that emerged from the data.

RESULTS

Seven studies met the inclusion criteria for the objective of this systematic review. The review provided information on the effectiveness of three categories of intervention - type of feeds, timing of feeds and thermoregulation on two of the outcome measures identified in the review protocol - prevention of hypoglycaemia, and re-establishment and maintenance of blood or plasma glucose levels above the set threshold (as determined by the particular study). There was no evidence available on which to base conclusions for effectiveness of monitoring or developmental outcomes, and insufficient evidence for breast-feeding success. Given that only a narrative review was possible, the findings of this review should be interpreted with caution. The findings suggest that the incidence of hypoglycaemia in healthy, breast-fed term infants of appropriate size for gestational age is uncommon and routine screening of these infants is not indicated. The method and timing of early feeding has little or no influence on the neonatal blood glucose measurement at 1 h in normal term babies. In healthy, breast-fed term infants the initiation and timing of feeds in the first 6 h of life has no significant influence on plasma glucose levels. The colostrum of primiparous mothers provides sufficient nutrition for the infant in the first 24 h after birth, and supplemental feeds or extra water is unnecessary. Skin-to-skin contact appears to provide an optimal environment for fetal to neonatal adaptation after birth and can help to maintain body temperature and adequate blood glucose levels in healthy term newborn infants, as well as providing an ideal opportunity to establish early bonding behaviours.

IMPLICATIONS FOR PRACTICE

The seven studies analysed in this review confirm the World Health Organisation's first three recommendations for prevention and management of asymptomatic hypoglycaemia, namely: 1 Early and exclusive breast-feeding is safe to meet the nutritional needs of healthy term newborns worldwide. 2 Healthy term newborns that are breast-fed on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids. 3 Healthy term newborns do not develop 'symptomatic' hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia, look for an underlying condition. Detection and treatment of the cause are as important as correction of the blood glucose level. If there are any concerns that the newborn infant might be hypoglycaemic it should be given another feed. Given the importance of thermoregulation, skin-to-skin contact should be promoted and 'kangaroo care' encouraged in the first 24 h after birth. While it is important to main the infant's body temperature care should be taken to ensure that the child does not become overheated.

Hypoglycemia in critically ill children

BACKGROUND

The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children.

METHODS

We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English".

RESULTS

A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols.

CONCLUSION

Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.

The Accutrend sensor glucose analyzer may not be adequate in bedside testing for neonatal hypoglycemia

The aim of this prospective observational study was to compare a bedside test with the reference laboratory method in routine postnatal glucose monitoring. Term newborns with increased risk or clinical signs of hypoglycemia were screened with a bedside test. In case of a glucose value below 2.25 mmol/L, a second blood sample was taken and a duplicate glucose measurement done in the laboratory using a bedside test (Accutrend sensor) and the reference laboratory method (hexokinase method) at the same time and from the same sample. From 110 term newborns, 122 blood samples were obtained for duplicate measurements (median 1.69 mmol/L, SD 0.45 mmol/L). Of these 122, Accutrend correctly identified 97% as being <2.25 mmol/L by the laboratory method. A Bland-Altman plot revealed a mean underestimation of the Accutrend of only -0.09 mmol/L. However, due to high scattering, the maximal over- and underestimation was 0.89 and 1.39 mmol/L, respectively. Only 75% of the results from the Accutrend were within +/-20% of the result of the laboratory method. If the cut-off for low glucose concentrations was set 0.6 mmol/L higher for the bedside test as compared to the laboratory method, all patients except one would have been correctly identified as hypoglycemic.

CONCLUSION

When using the Accutrend sensor, single infants with even marked hypoglycemia might be missed. Some delay in receiving accurate measurements might be more helpful for clinical decisions and long-term outcome than immediate but potentially misleading results.

Nursing and midwifery management of hypoglycaemia in healthy term neonates

OBJECTIVES

The primary objective of this review was to determine the best available evidence for maintenance of euglycaemia in healthy term neonates, and the management of asymptomatic hypoglycaemia in otherwise healthy term neonates.

INCLUSION CRITERIA

The review included any relevant published or unpublished studies undertaken between 1995 and 2004. Studies that focus on the diagnostic accuracy of point-of-care devices for blood glucose screening and/or monitoring in the neonate were initially included as a subgroup of this review. However, the technical nature and complexity of the statistical information published in diagnostic studies retrieved during the literature search stage, as well as the considerable volume of published research in this area, suggested that it would be more feasible to analyse diagnostic studies in a separate systematic review.The review focused on studies that included healthy term (37- to 42-week gestation) appropriate size for gestational age neonates in the first 72 h after birth.All interventions that fell within the scope of practice of a midwife/nurse were included:Interventions that required initiation by a medical practitioner were excluded from the review.Outcomes that were of interest included:The review initially focused on randomised controlled trials reported from 1995 to 2004. Insufficient randomised controlled trials were identified and the review was expanded to include additional cohort and cross-sectional studies for possible inclusion in a narrative summary.

SEARCH STRATEGY

The major electronic databases, including MEDLINE/PubMed, CINAHL, EMBASE, LILACS, Cochrane Library, etc., were searched using accepted search techniques to identify relevant published and unpublished studies undertaken between 1995 and 2004. Efforts were made to locate any relevant unpublished materials, such as conference papers, research reports and dissertations. Printed journals were hand-searched and reference lists checked for potentially useful research. The year 1995 was selected as the starting point in order to identify any research that had not been included in the World Health Organisation review, which covered literature published up to 1996. The search was not limited to English language studies.

ASSESSMENT OF QUALITY

Three primary reviewers conducted the review assisted by a review panel. The review panel was comprised of nine nurses with expertise in neonatal care drawn from senior staff in several metropolitan neonatal units and education programs. Authorship of journal articles was not concealed from the reviewers. Methodological quality of each study that met the inclusion criteria was assessed by two reviewers, using a quality assessment checklist developed for the review. Disagreements between reviewers were resolved through discussion or with the assistance of a third reviewer.

DATA EXTRACTION AND ANALYSIS

Two reviewers used a data extraction form to independently extract data relating to the study design, setting and participants; study focus and intervention(s); and measurements and outcomes.As only one relevant randomised controlled trial was found, a meta-analysis could not be conducted nor tables constructed to illustrate comparisons between studies. Instead, the findings were summarised by a narrative identifying any relevant findings that emerged from the data.

RESULTS

Seven studies met the inclusion criteria for the objective of this systematic review. The review provided information on the effectiveness of three categories of intervention - type of feeds, timing of feeds and thermoregulation on two of the outcome measures identified in the review protocol - prevention of hypoglycaemia, and re-establishment and maintenance of blood or plasma glucose levels above the set threshold (as determined by the particular study). There was no evidence available on which to base conclusions for effectiveness of monitoring or developmental outcomes, and insufficient evidence for breast-feeding success.Given that only a narrative review was possible, the findings of this review should be interpreted with caution. The findings suggest that the incidence of hypoglycaemia in healthy, breast-fed term infants of appropriate size for gestational age is uncommon and routine screening of these infants is not indicated. The method and timing of early feeding has little or no influence on the neonatal blood glucose measurement at 1 h in normal term babies. In healthy, breast-fed term infants the initiation and timing of feeds in the first 6 h of life has no significant influence on plasma glucose levels. The colostrum of primiparous mothers provides sufficient nutrition for the infant in the first 24 h after birth, and supplemental feeds or extra water is unnecessary.Skin-to-skin contact appears to provide an optimal environment for fetal to neonatal adaptation after birth and can help to maintain body temperature and adequate blood glucose levels in healthy term newborn infants, as well as providing an ideal opportunity to establish early bonding behaviours.

IMPLICATIONS FOR PRACTICE

The seven studies analysed in this review confirm the World Health Organisation's first three recommendations for prevention and management of asymptomatic hypoglycaemia, namely:1 Early and exclusive breast-feeding is safe to meet the nutritional needs of healthy term newborns worldwide.2 Healthy term newborns that are breast-fed on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids.3 Healthy term newborns do not develop 'symptomatic' hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia, look for an underlying condition. Detection and treatment of the cause are as important as correction of the blood glucose level.If there are any concerns that the newborn infant might be hypoglycaemic it should be given another feed. Given the importance of thermoregulation, skin-to-skin contact should be promoted and 'kangaroo care' encouraged in the first 24 h after birth. While it is important to main the infant's body temperature care should be taken to ensure that the child does not become overheated.

Incidence and risk factors for neonatal hypoglycaemia among women with gestational diabetes mellitus in South Auckland

AIMS

To describe the incidence and risk factors for neonatal hypoglycaemia among the offspring of women with gestational diabetes mellitus (GDM) in South Auckland, New Zealand

METHODS

A retrospective audit was undertaken of singleton pregnancies delivered between 1991 and 1994. Data were obtained for 373 women and their deliveries (57 European, 76 Maori, 198 Pacific Islands, 42 other).

RESULTS

Pacific Islands women were most likely to have large babies with neonatal hypoglycaemia in spite of a high use of insulin. Postnatally Maori and Pacific Islands women had a high incidence of Type 2 diabetes mellitus (21.4, 21.7 vs. 4.3% Europeans, 12.0% others, P =0.035). Babies experiencing hypoglycaemia were more likely to have a mother with past GDM (51.2 vs. 27.2%, P = 0.01) and greater hyperglycaemia (at diagnosis fasting 6.8 +/- 1.7 vs. 5.7 +/- 1.1 mmol/l, P < 0.001; finger-prick glucose 5.7 +/- 1.0 vs. 5.2 +/- 0.8 mmol/l, P < 0.001). Macrosomia, Caesarian section and special care baby unit admission were more common in pregnancies complicated by neonatal hypoglycaemia.

CONCLUSIONS

Maternal hyperglycaemia was a major contributing factor to neonatal hypoglycaemia in this population. Undiagnosed Type 2 diabetes was common among Maori and Pacific Islands women, confirming the need for earlier detection and treatment.

Determining the best method for first-line assessment of neonatal blood glucose levels

OBJECTIVE

To evaluate and compare the accuracy and performance of two electrochemical glucose meters. To determine the user acceptability of these glucose meters and the ABL 620 Blood Gas Analyser (Radiometer, Copenhagen, Denmark) with an electrochemical glucose oxidase electrode for use in a Level 2 special care baby unit.

METHODOLOGY

A total of 108 blood samples were collected from 47 babies at risk for hypoglycaemia. The blood glucose level was measured with two glucose meters, the Advantage Glucose Meter (Roche Diagnostics, Castle Hill, Australia) and the Precision-G Blood Glucose Testing System (Medisense, Melbourne, Australia), and the true blood glucose (TBG) measured with the ABL 620 blood gas analyser. Results from the glucose meters were compared with the TBG (as a percentage of the TBG).

RESULTS

The mean (SD) percentage difference between the Advantage Glucose Meter and TBG was 4.5% (12. 5), and Precision-G Glucose Meter and TBG was 15.4% (12.4). The sample haematocrit did not significantly influence the glucose meter/TBG differences. There was an overall preference by the nursing staff for the Advantage Glucose Meter.

CONCLUSIONS

The Advantage Glucose Meter was significantly more accurate than the Precision-G with similar precision. It was the preferred method of screening for neonatal hypoglycaemia.

Neonatal hypoglycaemia in infants of diabetic mothers

OBJECTIVE

To determine whether umbilical cord blood glucose correlates with subsequent hypoglycaemia after birth in infants of well-controlled diabetic mothers.

METHODOLOGY

Thirty-eight term infants of well-controlled diabetic mothers were enrolled. Five mothers had pre-existing diabetes. Of the 33 gestational diabetic mothers, 16 were managed on insulin and 17 on diet. Maternal blood glucose was maintained between 4 and 8 mmol/L during labour and delivery. Infants' plasma glucose levels were measured from venous cord blood and serially, at less than 30 min, 1 h and 2 h of life by glucose hexokinase method. Blood glucose levels were further monitored by bedside Dextrostix for 24 h.

RESULTS

Eighteen (47%) infants developed hypoglycaemia (blood glucose level less than 2 mmol/L) during the first 2 h of life. There was no difference in the cord blood glucose levels between infants with or without hypoglycaemia (3.7 +/- 1.1 vs 4.5 +/- 1.1 mmol/L, respectively). Infants of mothers with diabetes diagnosed prior to 28 weeks gestation were at a higher risk of developing hypoglycaemia (8 of 10 vs 10 of 28, OR 7.2, 95%CI 1.3-40.7). Hypoglycaemic infants were of significantly higher birthweight, and were more likely to be born to Caucasian mothers and by Caesarean section. Raised maternal fructosamine blood level, the need for insulin treatment or the infant's haematocrit were not different between infants with or without hypoglycaemia.

CONCLUSIONS

In well-controlled diabetic mothers, the incidence of early hypoglycaemia in infants is still high, particularly in those mothers who had a longer duration of diabetes. Cord blood glucose level did not identify the infants with hypoglycaemia.

Glucose and the newborn baby: sweet justice?

Neonatal hypoglycaemia remains a controversial issue. Uncertainty surrounds what constitutes the optimal safe blood glucose for newborn babies. There are good reasons and evidence for maintaining blood glucose greater than 2.5 mmol/L in newborn babies. Since 1986 neonatal paediatricians have changed in their definition of neonatal hypoglycaemia. Ideally, screening of blood glucose in neonatal intensive care units should be done with an on-site glucose analyzer.