1
|
Harding JE, Alsweiler JM, Edwards TE, McKinlay CJD. Neonatal hypoglycaemia. BMJ MEDICINE 2024; 3:e000544. [PMID: 38618170 PMCID: PMC11015200 DOI: 10.1136/bmjmed-2023-000544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/04/2024] [Indexed: 04/16/2024]
Abstract
Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.
Collapse
Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Te Toka Tumai, Auckland, New Zealand
| | - Taygen E Edwards
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Chris JD McKinlay
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Te Whatu Ora Health New Zealand, Counties Manukau, Auckland, New Zealand
| |
Collapse
|
2
|
Rodgers RL. Glucagon, cyclic AMP, and hepatic glucose mobilization: A half‐century of uncertainty. Physiol Rep 2022; 10:e15263. [PMID: 35569125 PMCID: PMC9107925 DOI: 10.14814/phy2.15263] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 12/14/2022] Open
Abstract
For at least 50 years, the prevailing view has been that the adenylate cyclase (AC)/cyclic AMP (cAMP)/protein kinase A pathway is the predominant signal mediating the hepatic glucose‐mobilizing actions of glucagon. A wealth of evidence, however, supports the alternative, that the operative signal most of the time is the phospholipase C (PLC)/inositol‐phosphate (IP3)/calcium/calmodulin pathway. The evidence can be summarized as follows: (1) The consensus threshold glucagon concentration for activating AC ex vivo is 100 pM, but the statistical hepatic portal plasma glucagon concentration range, measured by RIA, is between 28 and 60 pM; (2) Within that physiological concentration range, glucagon stimulates the PLC/IP3 pathway and robustly increases glucose output without affecting the AC/cAMP pathway; (3) Activation of a latent, amplified AC/cAMP pathway at concentrations below 60 pM is very unlikely; and (4) Activation of the PLC/IP3 pathway at physiological concentrations produces intracellular effects that are similar to those produced by activation of the AC/cAMP pathway at concentrations above 100 pM, including elevated intracellular calcium and altered activities and expressions of key enzymes involved in glycogenolysis, gluconeogenesis, and glycogen synthesis. Under metabolically stressful conditions, as in the early neonate or exercising adult, plasma glucagon concentrations often exceed 100 pM, recruiting the AC/cAMP pathway and enhancing the activation of PLC/IP3 pathway to boost glucose output, adaptively meeting the elevated systemic glucose demand. Whether the AC/cAMP pathway is consistently activated in starvation or diabetes is not clear. Because the importance of glucagon in the pathogenesis of diabetes is becoming increasingly evident, it is even more urgent now to resolve lingering uncertainties and definitively establish glucagon’s true mechanism of glycemia regulation in health and disease.
Collapse
Affiliation(s)
- Robert L. Rodgers
- Department of Biomedical and Pharmaceutical Sciences College of Pharmacy University of Rhode Island Kingston Rhode Island USA
| |
Collapse
|
3
|
A comparison of the glycemic effects of glucagon using two dose ranges in neonates and infants with hypoglycemia. J Perinatol 2020; 40:1841-1848. [PMID: 32801353 DOI: 10.1038/s41372-020-00770-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/11/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Consensus regarding optimal glucagon dosing for management or diagnosis of neonatal/infant hypoglycemia has not been established. OBJECTIVE To investigate glycemic effects of glucagon dosed ≤0.2 mg/kg (Gnlow) vs. >0.2 mg/kg (Gnhigh) in neonatal/infant hypoglycemia. STUDY DESIGN Retrospective, observational, cohort study. RESULTS Glucagon administration at any dose resulted in 75/77 (97.4%) samples meeting criteria for normoglycemia (plasma glucose >60 mg/dL), and plasma glucose increases of >30 mg/dL occurred in 74.2% vs. 63% (NS) of samples in the Gnlow and Gnhigh groups, respectively. Despite equivalent glucagon dosing, there was a trend toward smaller (<2500 g) patients achieving post-glucagon plasma glucose increases of >30 mg/dL less often than their bigger (≥2500 g) counterparts (60% vs. 74.1%, NS). CONCLUSIONS Glucagon is highly effective in raising plasma glucose levels in neonatal/infant hypoglycemia. No differences in glycemic effects were noted between either dosing regimen. However, glycemic effects may be diminished in lower weight patients.
Collapse
|
4
|
Re-evaluating "transitional neonatal hypoglycemia": mechanism and implications for management. J Pediatr 2015; 166:1520-5.e1. [PMID: 25819173 PMCID: PMC4659381 DOI: 10.1016/j.jpeds.2015.02.045] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 01/26/2015] [Accepted: 02/13/2015] [Indexed: 11/20/2022]
|
5
|
Abstract
While hypoglycemia occurs commonly among neonates, treatment can be challenging if hypoglycemia persists beyond the first few days of life. This review discusses the available treatment options for both transient and persistent neonatal hypoglycemia. These treatment options include dextrose infusions, glucagon, glucocorticoids, diazoxide, octreotide, and nifedipine. A stepwise, practical approach to the management of these patients is offered.
Collapse
Affiliation(s)
- Courtney B Sweet
- Department of Pharmaceutical Services, West Virginia University Hospitals, Morgantown, West Virginia
| | | | | |
Collapse
|
6
|
Zijlmans WCWR, van Kempen AAMW, Serlie MJ, Sauerwein HP. Glucose metabolism in children: influence of age, fasting, and infectious diseases. Metabolism 2009; 58:1356-65. [PMID: 19501855 DOI: 10.1016/j.metabol.2009.04.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 04/22/2009] [Accepted: 04/28/2009] [Indexed: 10/20/2022]
Abstract
This review describes the occurrence of hypoglycemia in young children as a common and serious complication that needs to be avoided because of the high risk of brain damage and mortality. Young age, fasting, and severe infectious disease are considered important risk factors. The limited data on the effect of these risk factors on glucose metabolism in children are discussed and compared with data on glucose metabolism in adults. The observations discussed may have implications for further research on glucose kinetics in young children with infectious disease.
Collapse
Affiliation(s)
- Wilco C W R Zijlmans
- Department of Pediatrics, Diakonessen Hospital, PO Box 1814, Paramaribo, Suriname (SA).
| | | | | | | |
Collapse
|
7
|
van Kempen AAMW, Ackermans MT, Endert E, Kok JH, Sauerwein HP. Glucose production in response to glucagon is comparable in preterm AGA and SGA infants. Clin Nutr 2005; 24:727-36. [PMID: 16182036 DOI: 10.1016/j.clnu.2005.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Accepted: 02/10/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Low plasma glucose concentrations are more often detected in small-for-gestational-age (SGA) than in appropriate-for-gestational-age (AGA) infants. This is ascribed to impaired glucose production due to presumed lower liver glycogen stores in SGA infants. The change in glucose production induced by glucagon is considered to be an indicator of liver glycogen content. We compared the effect of glucagon on glucose kinetics in preterm AGA and SGA infants. METHODS In 5 AGA and 5 SGA preterm infants (postnatal age: 3-6 days) glucose production and gluconeogenesis were measured using stable isotopes immediately before and for 1 h after a bolus of glucagon. RESULTS After glucagon the plasma glucose concentration and glucose production increased significantly over time (P<0.05 and P<0.0001, respectively). The changes were comparable between AGA and SGA infants. Glycogenolysis contributed 75-80% to the increase in glucose production. CONCLUSION The increase in glucose production after glucagon was similar in preterm AGA and SGA infants, and mainly due to an increase in glycogenolysis. Based on the assumption that glycogenolysis is an indicator of liver glycogen content, our data do not support the hypothesis that liver glycogen content is lower in preterm SGA compared to AGA infants after the first postnatal day.
Collapse
|
8
|
Jackson L, Burchell A, McGeechan A, Hume R. An inadequate glycaemic response to glucagon is linked to insulin resistance in preterm infants? Arch Dis Child Fetal Neonatal Ed 2003; 88:F62-6. [PMID: 12496230 PMCID: PMC1756004 DOI: 10.1136/fn.88.1.f62] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To define clinical, metabolic, and hormonal characteristics of preterm infants relative to glucagon responsiveness. METHODS Two phase study of 78 preterm infants (25-36 weeks gestation) on regular four hourly feeds anticipating discharge home at 36 weeks mean corrected gestation. In phase 1 infants were fasted until hypoglycaemic, or maximally for eight hours. Endocrine and metabolic profiles were obtained at completion. Phase 2 was performed the following day. A feed was omitted and replaced by a bolus dose of intravenous glucagon (100 micro g/kg). Main outcome measures were measurements of blood glucose and lactate concentrations, taken immediately pre-glucagon, and thereafter every 15 minutes for 60 minutes. A rise in glucose concentration of >1 mmol/l (55 infants) was defined as an adequate response to glucagon. An inadequate glycaemic response was <1 mmol/l (23 infants). RESULTS Several differences in fasting blood glucose and hormone concentrations were identified in infants with an inadequate glycaemic response to glucagon compared to those with an adequate response: relative fasting hyperglycaemia (mean 3.7 v 3.3 mmol/l, p = 0.008); fasting hyperinsulinaemia (mean 4.3 v 2.6 mU/l, p = 0.014); an increased insulin:glucagon ratio (0.19 v 0.11, p = 0.014), and a lower insulin sensitivity QUICKI index (0.19 v 0.22, p = 0.04). There was no distinctive phenotype to reliably predict response to glucagon. CONCLUSION Some preterm infants show an inadequate glycaemic response to glucagon and have features suggestive of insulin resistance. The potential long term implications of such insulin resistance may have appreciable public health consequences.
Collapse
Affiliation(s)
- L Jackson
- Department of Obstetrics and Gynaecology, Tayside Institute of Child Health, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK
| | | | | | | |
Collapse
|
9
|
Belik J, Musey J, Trussell RA. Continuous infusion of glucagon induces severe hyponatremia and thrombocytopenia in a premature neonate. Pediatrics 2001; 107:595-7. [PMID: 11230607 DOI: 10.1542/peds.107.3.595] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report on a 35-week gestation infant who developed severe hyponatremia and thrombocytopenia after continuous infusion of glucagon for the treatment of intractable hypoglycemia. Given these serious side effects,glucagon infusion should be avoided in the treatment of premature infants.hypoglycemia, glucose, small for gestational age. Hypoglycemia is commonly seen in premature infants, and the provision of a standard glucose intake is often not sufficient to maintain euglycemia. For these infants, an increase in glucose infusion to provide 4 to 8 mg/kg/min is initially recommended.1 Should this approach fail, pharmacologic agents such as corticosteroids or diazoxide are indicated.1 When the serum glucose in premature or small for gestational age infants cannot be adequately maintained, a glucagon infusion is now suggested as the best treatment approach.2,3 We report the use of glucagon infusion for the treatment of severe hypoglycemia in a premature infant. A severe hyponatremia associated with transient convulsions and thrombocytopenia was observed in the neonate after treatment. Discontinuation of the glucagon infusion resulted in prompt resolution of these abnormalities.
Collapse
Affiliation(s)
- J Belik
- Department of Pediatrics, University of Calgary, Calgary Alberta T2N 2T9 Canada.
| | | | | |
Collapse
|
10
|
Williams AF. Hypoglycaemia of the newborn: a review. Bull World Health Organ 1997; 75:261-90. [PMID: 9277014 PMCID: PMC2486945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
It is almost a century since hypoglycaemia (a reduction in the glucose concentration of circulating blood) was first described in children, and over 50 years since the condition was first recognized in infants. Nevertheless, controversy still surrounds the definition, significance, and management of neonatal hypoglycaemia. Technological developments such as bedside glucose monitoring have, paradoxically, exacerbated rather than eased the situation. This article reviews the literature on hypoglycaemia of the newborn, and covers the following: historical aspects; glucose homeostasis and metabolic adaptation at birth; the effect of low blood glucose levels on the central nervous system; the definition of hypoglycaemia; screening; prevention; treatment; research needs; and concludes with recommendations for prevention and management.
Collapse
Affiliation(s)
- A F Williams
- St George's Health Care Trust, St George's Hospital, London, England
| |
Collapse
|
11
|
Affiliation(s)
- A Mehta
- Department of Child Health, Ninewells Hospital and Medical School, Dundee
| |
Collapse
|
12
|
Hawdon JM, Ward Platt MP, Aynsley-Green A. Prevention and management of neonatal hypoglycaemia. Arch Dis Child Fetal Neonatal Ed 1994; 70:F60-4; discussion F65. [PMID: 8117132 PMCID: PMC1064070 DOI: 10.1136/fn.70.1.f60] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J M Hawdon
- Institute of Child Health, University of Liverpool
| | | | | |
Collapse
|
13
|
Platt MP, Hawdon JM. Hypoglycaemia in the neonate. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1993; 7:669-82. [PMID: 8379910 DOI: 10.1016/s0950-351x(05)80213-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- M P Platt
- Princess Mary Maternity Hospital, Newcastle upon Tyne, UK
| | | |
Collapse
|
14
|
Hawdon JM, Aynsley-Green A, Ward Platt MP. Neonatal blood glucose concentrations: metabolic effects of intravenous glucagon and intragastric medium chain triglyceride. Arch Dis Child 1993; 68:255-61. [PMID: 8466259 PMCID: PMC1590376 DOI: 10.1136/adc.68.3_spec_no.255] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Neonatal hypoglycaemia is a common clinical problem and the traditional treatment for the condition is intravenous glucose administration. The glycaemic effects of two additional treatments were investigated, in a randomised trial, in 23 neonates who were receiving intravenous glucose as treatment for hypoglycaemia. Eleven infants received an intravenous bolus dose of glucagon (200 micrograms/kg) and 12 infants received intragastric medium chain triglyceride (MCT) (5 ml/kg). Blood concentrations of glucose and intermediary metabolites were measured before and one hour after treatment, and, using stable isotope infusion, glucose production rates were calculated. After glucagon, there was a mean rise in blood glucose concentration of 1.6 mmol/l and in the glucose production rate of 2.6 mg/kg/min. After MCT, there was a small mean rise in blood glucose concentration of 0.4 mmol/l, but the effect of MCT on glucose production rate was variable. Intravenous bolus glucagon administration exerted a glycaemic effect which was associated with an increase in glucose production rate. The use of glucagon, as an alternative treatment to intravenous glucose, should be investigated further.
Collapse
Affiliation(s)
- J M Hawdon
- Department of Child Health, University of Newcastle upon Tyne
| | | | | |
Collapse
|
15
|
Abstract
Glucagon is a pancreatic polypeptide hormone that has diverse utility as both a therapeutic and diagnostic agent. Many of its pharmacologic actions are pertinent to the practice of emergency medicine. The author reviews the literature supporting each potential use of the drug and the purported physiologic mechanisms by which glucagon exerts these actions. The indications and proper dosages for glucagon in the acute care setting are summarized.
Collapse
Affiliation(s)
- C V Pollack
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona
| |
Collapse
|
16
|
|
17
|
|
18
|
Collins JE, Leonard JV, Teale D, Marks V, Williams DM, Kennedy CR, Hall MA. Hyperinsulinaemic hypoglycaemia in small for dates babies. Arch Dis Child 1990; 65:1118-20. [PMID: 2248501 PMCID: PMC1792359 DOI: 10.1136/adc.65.10.1118] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Blood glucose concentrations were measured prospectively in 27 small for dates infants in the first 48 hours after birth: 10 infants became hypoglycaemic. Of these, five had inappropriately raised plasma insulin concentrations. Plasma free fatty acids were lower and carbohydrate intake higher in these five infants, further supporting the diagnosis of hyperinsulinism. The hypoglycaemia recurred in four of the five hyperinsulinaemic infants, but in none of those who were not hyperinsulinaemic. Hyperinsulinism is common in small for dates babies. It is important to recognise this because hypoglycaemia is likely to recur and appropriate treatment is needed to prevent long term sequelae.
Collapse
Affiliation(s)
- J E Collins
- Department of Child Health, Institute of Child Health, London
| | | | | | | | | | | | | |
Collapse
|
19
|
Affiliation(s)
- A Mehta
- Department of Medicine, University College London, Rayne Institute
| |
Collapse
|
20
|
Abstract
Twenty five infants who were small for gestational age received glucagon (0.5 mg/day by continuous infusion) in the treatment of hypoglycaemia. Twenty responded within three hours with a rise in blood glucose concentration to above 4 mmol/l. Five subjects subsequently required hydrocortisone to maintain glucose concentrations. Rebound hypoglycaemia occurred in nine infants after rapid discontinuation of glucagon or interruption of the intravenous infusions. Response was poor after maternal beta blockade.
Collapse
Affiliation(s)
- P E Carter
- Neonatal Unit, Aberdeen Maternity Hospital
| | | | | |
Collapse
|