Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome

Predictors of hypocalcemia among children admitted in the Emergency Pediatric Unit of the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria

OBJECTIVES

To determine the prevalence and pattern of hypoglycemia among children admitted to the Emergency Pediatric Unit (EPU) at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria.

METHODS

A cross-sectional study was conducted between February and September 2020. Blood glucose, along with other relevant laboratory investigations, was measured for each patient upon admission to the EPU using a point-of-care test glucometer (ACCU-CHEK with strips).

RESULTS

Of the 340 children recruited for the study, 54 patients had hypoglycemia (<2.2 mmol/L), giving a prevalence rate of 15.9%. Thirty-six (66.7%) of the children with hypoglycemia were under the age of 5 years (odds ratio [OR]: 6.218 [1.077-35.912], p=0.041) and 26 (48.1%) were severely underweight (OR: 3.692 [1.266-10.971], p=0.017). Factors such as not having eaten for at least 16 h, weakness, and coma at presentation all independently predicted hypoglycemia (OR: 5.696 [1.768-18.352], 6.556 [1.730-24.850], 9.479 [3.092-29.059], p=0.004, 0.006 and <0.001) respectively. Severe malaria was also independently related to hypoglycemia (OR: 2.720 [0.554-13.365], p=0.021).

CONCLUSION

Hypoglycemia is a common occurrence among children admitted to the EPU. Factors such as being under five years old, in a coma, weakness, severe malaria, and prolonged fasting were all identified as independent predictors of hypoglycemia. Therefore, routine blood glucose monitoring of children admitted to the EPU, specifically those at higher risk, is recommended.

Glucocorticoid dysfunction in children with severe malaria

Introduction

Malaria remains a widespread health problem with a huge burden. Severe or complicated malaria is highly lethal and encompasses a variety of pathological processes, including immune activation, inflammation, and dysmetabolism. Previously, we showed that adrenal hormones, in particular glucocorticoids (GCs), play critical roles to maintain disease tolerance during Plasmodium infection in mice. Here, GC responses were studied in Cameroon in children with uncomplicated malaria (UM), severe malaria (SM) and asymptomatic controls (AC).

Methods

To determine the sensitivity of leukocytes to GC signaling on a transcriptional level, we measured the ex vivo induction of glucocorticoid induced leucine zipper (GILZ) and FK506-binding protein 5 (FKBP5) by GCs in human and murine leukocytes. Targeted tracer metabolomics on peripheral blood mononuclear cells (PBMCs) was performed to detect metabolic changes induced by GCs.

Results

Total cortisol levels increased in patients with clinical malaria compared to AC and were higher in the SM versus UM group, while cortisol binding globulin levels were unchanged and adrenocorticotropic hormone (ACTH) levels were heterogeneous. Induction of both GILZ and FKBP5 by GCs was significantly reduced in patients with clinical malaria compared to AC and in malaria-infected mice compared to uninfected controls. Increased activity in the pentose phosphate pathway was found in the patients, but this was not affected by ex vivo stimulation with physiological levels of hydrocortisone. Interestingly, hydrocortisone induced increased levels of cAMP in AC, but not in clinical malaria patients.

Discussion

Altogether, this study shows that patients with SM have increased cortisol levels, but also a decreased sensitivity to GCs, which may clearly contribute to the severity of disease.

What are the barriers preventing the screening and management of neonatal hypoglycaemia in low-resource settings, and how can they be overcome?

Over 25 years ago, the World Health Organization (WHO) acknowledged the importance of effective prevention, detection and treatment of neonatal hypoglycaemia, and declared it to be a global priority. Neonatal hypoglycaemia is common, linked to poor neurosensory outcomes and, if untreated, can cause seizures and death. Neonatal mortality in low and lower-middle income countries constitutes an estimated 89% of overall neonatal deaths. Factors contributing to high mortality rates include malnutrition, infectious diseases, poor maternal wellbeing and resource constraints on both equipment and staff, leading to delayed diagnosis and treatment. The incidence of neonatal hypoglycaemia in low and lower-middle income countries remains unclear, as data are not collected.Data from high-resource settings shows that half of all at-risk babies will develop hypoglycaemia, using accepted clinical thresholds for treatment. Most at-risk babies are screened and treated, with treatment aiming to increase blood glucose concentration and, therefore, available cerebral fuel. The introduction of buccal dextrose gel as a first-line treatment for neonatal hypoglycaemia has changed the care of millions of babies and families in high-resource settings. Dextrose gel has now also been shown to prevent neonatal hypoglycaemia.In low and lower-middle income countries, there are considerable barriers to resources which prevent access to reliable blood glucose screening, diagnosis, and treatment, leading to inequitable health outcomes when compared with developed countries. Babies born in low-resource settings do not have access to basic health care and are more likely to suffer from unrecognised neonatal hypoglycaemia, which contributes to the burden of neurosensory delay and death.

"Prevalence, outcome and factors associated with dysglycemia among critically ill children presenting to Fort Portal Regional Referral Hospital: A cross sectional study"

Introduction

Dysglycemia has been shown to influence outcome among critically ill children. We aimed to determine the prevalence, outcome and factors associated with dysglycemia among critically ill children aged one month to 12 years presenting to Fort Portal regional referral hospital.

Methods

The study employed a descriptive, cross-sectional design for prevalence and factors associated, and longitudinal observational study design to determine the immediate outcome. Critically ill children aged one month to 12 years were systematically sampled and triaged at outpatient department using World Health Organization emergency signs. The random blood glucose was evaluated on admission and at 24 hours. Verbal and written informed consent/assent were obtained after stabilization of the study participants. Those that had hypoglycemia were given Dextrose 10% and those with hyperglycemia had no intervention.

Results

Of the 384 critically ill children, dysglycemia was present in 21.7% (n = 83), of those 78.3% (n = 65) had hypoglycemia and 21.7% (n = 18) had hyperglycemia. The proportion of dysglycemia at 24 hours was 2.4% (n = 2). None of the study participants had persistent hypoglycemia at 24 hours. The cumulative mortality at 48hours was 3.6% (n = 3). At 48 hours 33.2% (n = 27) had stable blood glucose levels and were discharged from the hospital. After multiple logistic regression, obstructed breathing (AOR 0.07(0.02-0.23), inability to breastfeed/drink (AOR 2.40 (1.17-4.92) and active convulsions (AOR 0.21 (0.06-0.74), were the factors that were significantly associated with dysglycemia among critically ill children. The results will guide in the revision of policies and treatment protocols to facilitate better management of children at risk of dysglycemia nationally.

Conclusions

Dysglycemia was found to affect one in five critically ill children aged one month to 12 years presenting to Fort Portal Regional Referral Hospital. Dysglycemia outcomes are good with early intervention.

Comparison of point-of-care glucometers and laboratory based glucose oxidase test in determining blood glucose levels

INTRODUCTION

Alterations in blood glucose levels are common and an important determinant of a patient's admission outcomes, point-of-care glucometers, which are affected by a variety of factors, are increasingly used in clinical care. In this study we compared blood glucose levels determined by two commonly used glucometers (One Touch^® and Accu-check^®) with those of a standard laboratory method and determined the effect of haematocrit on glucose readings.

METHODS

Blood glucose levels were measured with One Touch^® and Accu-Check^® glucometers and the glucose oxidase method at the same time in 295 children aged 0 to 15 years over a 6-month period. Bland-Altman and correlation analysis were used to explore biases among the three methods. For all statistical tests, a p-value of less than 0.05 was considered statistically significant.

RESULTS

Most were males (51.2%) and the median (range) age was 1 year (1 day, 12 years). There was a significant correlation between each of the glucometer methods and laboratory blood sugar, and the correlation between the two glucometers was strong and significant. This correlation remained statistically significant even after controlling for haematocrit values. There was an acceptable level of bias (3.9 mg/dL) between the One Touch^® and Accu-check^® glucometers, but each had a remarkably large bias compared with the glucose oxidase method.

CONCLUSION

The use of a tested glucometer in clinical settings can aid in rapid decision-making, but there is a need to periodically cross-check with the glucose oxidase method in the laboratory to optimise treatment outcomes for children with dysglycaemia.

Prospective cohort study of referred Malawian children and their survival by hypoxaemia and hypoglycaemia status

Objective

To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression.

Methods

The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (SpO₂) and blood glucose were measured at recruitment and on arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between SpO₂ and blood glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching.

Findings

Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (SpO₂: 90-93%) in 13.1% (108/826) and severe (SpO₂: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5-4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality.

Conclusion

Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving hypoxaemia identification and management are needed.

Association between Stress Hyperglycemia and Adverse Outcomes in Children Visiting the Pediatric Emergency Department

Stress hyperglycemia (SH) is often identified in patients visiting the pediatric emergency department (PED), and SH in adults has been associated with adverse outcomes, including mortality. In this retrospective study, we determined the adverse outcomes according to blood glucose (BG) levels of children visiting the PED of tertiary hospitals. Data were collected from the electronic medical records of children aged <18 years between 1 January 2011 and 31 December 2020. A total of 44,905 visits were included in the analysis. SH was identified in 1506 patients, with an incidence rate of 3.4%. Compared to those without SH, patients with SH had significantly higher ward admission rates (52.6% vs. 35.9%, p < 0.001), intensive care unit admission rates (2.6% vs. 0.7%, p < 0.001), and mortality rates (2.7% vs. 0.3%, p < 0.001). Compared to the normoglycemic group of 45 ≤ BG < 150 mg/dL, the odds ratios (95% CI) for mortality were 5.61 (3.35−9.37), 27.96 (14.95−52.26), 44.22 (17.03−114.82), and 39.94 (16.31−97.81) for levels 150 ≤ BG < 200, 200 ≤ BG < 250, 250 ≤ BG < 300 and ≥300 mg/dL, respectively. This suggests that SH is common in children visiting the PED and is associated with higher adverse outcomes. Thus, there is a need to quickly identify its cause and take prompt intervention to resolve it.

Oral dextrose gel for the treatment of hypoglycaemia in newborn infants

BACKGROUND

Neonatal hypoglycaemia, a common condition, can be associated with brain injury. It is frequently managed by providing infants with an alternative source of glucose, often given enterally with milk-feeding or intravenously with dextrose solution, which may decrease breastfeeding success. Intravenous dextrose also often requires that mother and baby are cared for in separate environments. Oral dextrose gel is simple and inexpensive, and can be administered directly to the buccal mucosa for rapid correction of hypoglycaemia, in association with continued breastfeeding and maternal care. This is an update of a previous review published in 2016.

OBJECTIVES

To assess the effectiveness of oral dextrose gel in correcting hypoglycaemia in newborn infants from birth to discharge home and reducing long-term neurodevelopmental impairment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase from database inception to October 2021.  We also searched international clinical trials networks, the reference lists of included trials, and relevant systematic reviews identified in the search.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no treatment, or other therapies for the treatment of neonatal hypoglycaemia in newborn infants from birth to discharge home.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data; they did not assess publications for which they were study authors. We contacted investigators to obtain additional information. We used fixed-effect models and the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included two studies conducted in high-income countries, involving 312 late preterm and at-risk term infants and comparing oral dextrose gel (40% concentration) to placebo gel. One study was at low risk of bias, and the other (an abstract) was at unclear to high risk of bias. Oral dextrose gel compared with placebo gel probably increases correction of hypoglycaemic events (rate ratio 1.08, 95% confidence interval (CI) 0.98 to 1.20; rate difference 66 more per 1000, 95% CI 17 fewer to 166 more; 1 study; 237 infants; moderate-certainty evidence), and may result in a slight reduction in the risk of major neurological disability at age two years or older, but the evidence is uncertain (risk ratio (RR) 0.46, 95% CI 0.09 to 2.47; risk difference (RD) 24 fewer per 1000, 95% CI 41 fewer to 66 more; 1 study, 185 children; low-certainty evidence). The evidence is very uncertain about the effect of oral dextrose gel compared with placebo gel or no gel on the need for intravenous treatment for hypoglycaemia (RR 0.78, 95% CI 0.46 to 1.32; RD 37 fewer per 1000, 95% CI 91 fewer to 54 more; 2 studies, 312 infants; very low-certainty evidence). Investigators in one study of 237 infants reported no adverse events (e.g. choking or vomiting at the time of administration) in the oral dextrose gel or placebo gel group (low-certainty evidence).  Oral dextrose gel compared with placebo gel probably reduces the incidence of separation from the mother for treatment of hypoglycaemia (RR 0.54, 95% CI 0.31 to 0.93; RD 116 fewer per 1000, 95% CI 174 fewer to 18 fewer; 1 study, 237 infants; moderate-certainty evidence), and increases the likelihood of exclusive breastfeeding after discharge (RR 1.10, 95% CI 1.01 to 1.18; RD 87 more per 1000, 95% CI 9 more to 157 more; 1 study, 237 infants; moderate-certainty evidence).   AUTHORS' CONCLUSIONS: Oral dextrose gel (specifically 40% dextrose concentration) used to treat hypoglycaemia in newborn infants (specifically at-risk late preterm and term infants) probably increases correction of hypoglycaemic events, and may result in a slight reduction in the risk of major neurological disability at age two years or older. Oral dextrose gel treatment probably reduces the incidence of separation from the mother for treatment and increases the likelihood of exclusive breastfeeding after discharge. No adverse events have been reported. Oral dextrose gel is probably an effective and safe first-line treatment for infants with neonatal hypoglycaemia in high-income settings.  More evidence is needed about the effects of oral dextrose gel treatment on later neurological disability and the need for other treatments for hypoglycaemia. Future studies should be conducted in low-and middle-income settings, in extremely and moderately preterm infants, and compare oral dextrose gel with other therapies such as intravenous dextrose. There are two ongoing studies that may alter the conclusions of this review when published.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

Predictors of outcome in childhood Plasmodium falciparum malaria

Plasmodium falciparum malaria is classified as either uncomplicated or severe, determining clinical management and providing a framework for understanding pathogenesis. Severe malaria in children is defined by the presence of one or more features associated with adverse outcome, but there is wide variation in the predictive value of these features. Here we review the evidence for the usefulness of these features, alone and in combination, to predict death and other adverse outcomes, and we consider the role that molecular biomarkers may play in augmenting this prediction. We also examine whether a more personalized approach to predicting outcome for specific presenting syndromes of severe malaria, particularly cerebral malaria, has the potential to be more accurate. We note a general need for better external validation in studies of outcome predictors and for the demonstration that predictors can be used to guide clinical management in a way that improves survival and long-term health.

Dysglycemia in Children with Severe Acute Malnutrition: A Systematic Review and Meta-Analysis

Dysglycemia is a common complication of severe acute malnutrition (SAM) in children. Its prevalence and impact on short- and long-term outcomes are not well described. This systematic review was undertaken to review the available evidence on dysglycemia (either hypo- or hyperglycemia) in hospitalized children with SAM. The 2 primary objectives of this systematic review were to understand the prevalence of hypoglycemia and hyperglycemia in children with SAM. A secondary objective was to understand the relation between dysglycemia and clinical outcomes like mortality in children with SAM. MEDLINE was searched with terms related to children, SAM, and dysglycemia. A meta-analysis of proportions was completed to determine the hypoglycemia prevalence and a standard meta-analysis was done to determine the relation between hypoglycemia and mortality. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A total of 2148 articles were identified in the database search of which 16 met the inclusion criteria for the systematic review based on screening done by multiple reviewers. The overall prevalence of hypoglycemia in SAM across studies based on the meta-analysis of proportions was 9% (95% CI: 7%, 12%; I2 = 92%). Meta-analysis results showed that hypoglycemia was associated with a higher chance of mortality during hospitalization in children with SAM (OR: 4.29; 95% CI: 3.04, 6.05; I2 = 0%). According to the GRADE evaluation, the certainty of the evidence for the prevalence of hypoglycemia was low and for hyperglycemia was very low. For the relation between hypoglycemia and mortality, the certainty of the evidence was moderate. A meta-analysis was not carried out for the prevalence of hyperglycemia due to the wide range of definitions used for across studies, but the prevalence ranged from 2% to 38% in the literature. This systematic review highlights the need for further work in this area to include serial glucose measurements to understand the clinical importance of dysglycemia during hospitalization in children with SAM.

Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): a pragmatic, randomised controlled trial

BACKGROUND

Low blood glucose concentrations are common in sick children who present to hospital in low-resource settings and are associated with increased mortality. The cutoff blood glucose concentration for the diagnosis and treatment of hypoglycaemia currently recommended by WHO (2·5 mmol/L) is not evidence-based. We aimed to assess whether increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely ill children at presentation to hospital improves mortality outcomes.

METHODS

We did a pragmatic, randomised controlled trial at two referral hospitals in Malawi. Severely ill children aged 1 month to 5 years presenting to the emergency department with a capillary blood glucose concentration of between 2·5 mmol/L (3·0 mmol/L in severely malnourished children) and 5·0 mmol/L were randomly assigned (1:1) by a computer-generated randomisation sequence, stratified by study site and severe malnutrition, to receive either an immediate intravenous bolus of 10% dextrose at 5 mL/kg followed by a 24-h maintenance infusion of 10% dextrose at 100 mL/kg for the first 10 kg of bodyweight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kg of bodyweight (intervention group) or observation for a minimum of 60 min and standard care (control group). Participants and study personnel were not masked to treatment allocation. The primary outcome was all-cause in-hospital mortality, assessed on an intention-to-treat basis. Safety was also assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02989675.

FINDINGS

Between Dec 5, 2016, and Jan 22, 2019, 10 947 children were screened, of whom 332 were randomly assigned, and 322 were included in the final analysis (n=162 in the control group and n=160 in the intervention group). The study was terminated after an interim analysis at 24% enrolment indicated futility. The median age of participants was 2·3 years (IQR 1·4-3·2), 65 (45%) were female, and the baseline characteristics of participants were similar between the two groups. The number of in-hospital deaths from any cause was 26 (16%) in the control group and 24 (15%) in the intervention group, with an absolute mortality difference of 1·0% (95% CI -6·9 to 9·0). Serious adverse events, including hypoglycaemia, hyperglycaemia, convulsions, reduced consciousness, and death, were reported in 47 (29%) children in the control group and 39 (24%) children in the intervention group.

INTERPRETATION

Increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely sick children in Malawi from 2·5 mmol/L to 5·0 mmol/L did not reduce all-cause in-hospital mortality. Our findings do not support changing the cutoff for dextrose administration, and further research on the optimal management of severely ill children who present to the emergency department with low blood glucose concentrations is warranted.

FUNDING

Swedish Research Council and Stockholm Country Council.

Feeding practices and association of fasting and low or hypo glycaemia in severe paediatric illnesses in Malawi - a mixed method study

BACKGROUND

The presence of low or hypo glycaemia in children upon admission to hospital in low income countries is a marker for poor outcome. Fasting during illness may contribute to low blood glucose and caretakers' feeding practices during childhood illnesses may thus play a role in the development of low or hypo glycaemia. This study aims to describe the caretaker's feeding practices and association of fasting with low or hypo glycaemia in sick children in Malawi.

METHODS

A mixed method approach was used combining quantitative cross-sectional data for children aged 0-17 years admitted to Queen Elizabeth Central Hospital (QECH), a tertiary hospital in Malawi, with qualitative focus group discussions conducted with caretakers of young children who were previously referred to QECH from the five health centres around QECH. Logistic regression was used to analyse the quantitative data and thematic content analysis was conducted for qualitative data analysis.

RESULTS

Data for 5131 children who were admitted through the hospital's Paediatric Accident and Emergency Department (A&E) were analysed whereof 2.1% presented with hypoglycaemia (< 2.5 mmol/l) and 6.6% with low glycaemia (≥2.5mmoll/l - < 5 mmol/l). Fasting for more than eight hours was associated with low glycaemia as well as hypoglycaemia with Adjusted Odds Ratios (AOR) of 2.9 (95% Confidence Interval (CI) of 2.3-3.7) and 4.6, (95% CI 3.0-7.0), respectively. Caretakers demonstrated awareness of the importance of feeding during childhood illness and reported intensified feeding attention to sick children but face feeding challenges when illness becomes severe causing them to seek care at a health facility.

CONCLUSION

Results suggests that caretakers understand the importance of feeding during illness and make efforts to intensify feeding a sick child but challenges occur when illness is severe leading to fasting. Fasting among children admitted to hospitals may serve as a marker of severe illness and determine those at risk of low and hypoglycaemia.

Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

Hypoglycaemia in children is a major risk factor for adverse neurodevelopment with rates as high as 50% in hyperinsulinaemic hypoglycaemia (HH). A key part of management relies upon timely identification and treatment of hypoglycaemia. The current standard of care for glucose monitoring is by infrequent fingerprick plasma glucose testing but this carries a high risk of missed hypoglycaemia identification. High-frequency Continuous Glucose Monitoring (CGM) offers an attractive alternative for glucose trend monitoring and glycaemic phenotyping but its utility remains largely unestablished in disorders of hypoglycaemia. Attempts to determine accuracy through correlation with plasma glucose measurements using conventional methods such as Mean Absolute Relative Difference (MARD) overestimate accuracy at hypoglycaemia. The inaccuracy of CGM in true hypoglycaemia is amplified by calibration algorithms that prioritize hyperglycaemia over hypoglycaemia with minimal objective evidence of efficacy in HH. Conversely, alternative algorithm design has significant potential for predicting hypoglycaemia to prevent neuroglycopaenia and consequent brain dysfunction in childhood disorders. Delays in the detection of hypoglycaemia, alarm fatigue, device calibration and current high cost are all barriers to the wider adoption of CGM in disorders of hypoglycaemia. However, machine learning, artificial intelligence and other computer-generated algorithms now offer significant potential for further improvement in CGM device technology and widespread application in childhood hypoglycaemia.

Glycemia upon admission and mortality in a pediatric intensive care unit

Objectives

To analyze the association between glycemia levels upon pediatric intensive care unit admission and mortality in patients hospitalized.

Methods

A retrospective cohort of pediatric intensive care unit patients admitted to the Instituto Nacional de Salud del Niño between 2012 and 2013. A Poisson regression model with robust variance was used to quantify the association. Diagnostic test performance evaluation was used to describe the sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios for each range of glycemia.

Results

In total, 552 patients were included (median age 23 months, age range 5 months to 79.8 months). The mean glycemia level upon admission was 121.3mg/dL (6.73mmol/L). Ninety-two (16.6%) patients died during hospitalization. In multivariable analyses, significant associations were found between glycemia < 65mg/dL (3.61mmol/L) (RR: 2.01, 95%CI 1.14 - 3.53), glycemia > 200mg/dL (> 11.1mmol/L) (RR: 2.91, 95%CI 1.71 - 4.55), malnutrition (RR: 1.53, 95%CI 1.04 - 2.25), mechanical ventilation (RR: 3.71, 95%CI 1.17 - 11.76) and mortality at discharge. There was low sensitivity (between 17.39% and 39.13%) and high specificity (between 49.13% and 91.74%) for different glucose cut-off levels.

Conclusion

There was an increased risk of death at discharge in patients who developed hypoglycemia and hyperglycemia upon admission to the pediatric intensive care unit. Certain glucose ranges (> 200mg/dL (> 11.1mmol/L) and < 65mg/dL (3.61mmol/L)) have high specificity as predictors of death at discharge.

'We just dilute sugar and give' health workers' reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

Background: Acutely sick children in resource-constrained settings who present with hypoglycaemia have poor outcomes. Studies have questioned the current hypoglycaemia treatment cut-off level of 2.5 mmol/l. Improved knowledge about health workers’ attitudes towards and management of hypoglycaemia is needed to understand the potential effects of a raised cut-off level.

Objective: This research explored health workers’ perceptions about managing acutely ill children with hypoglycaemia in a Malawian referral hospital. A secondary objective was to explore health workers’ opinions about a potential increase in the hypoglycaemia cut-off level.

Methods: We used a qualitative design with semi-structured individual interviews performed with health workers in the Paediatric Accident and Emergency Unit at Queen Elizabeth Central Hospital, Malawi, in October 2016. Data were analysed using latent content analysis. Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee P.01/16/1852.

Results: Four themes were formed that described the responses. The first, ‘Critical and difficult cases need easy treatment’, showed that health workers perceived hypoglycaemia as a severe condition that was easily manageable. The second, ‘Health system issues’, revealed challenges relating to staffing and resource availability. The third, ‘From parental reluctance to demand’, described a change in parents’ attitudes regarding intravenous treatments. The fourth, ‘Positive about the change but need more information’, exposed health workers’ concerns about potential risks of a raised cut-off level for hypoglycaemia treatment, as well as benefits for the patients.

Conclusions: Health workers perceived hypoglycaemia as a severe condition that is easy to manage when the required equipment and supplies are available. Due to the common lack of test equipment and dextrose supplies, health workers have adopted alternative strategies to diagnose and manage hypoglycaemia. A change to the hypoglycaemia treatment cut-off level raised concerns about potential risks, but was also thought to be of benefit for some patients.

Cost Analysis of Treating Neonatal Hypoglycemia with Dextrose Gel

OBJECTIVE

To evaluate the costs of using dextrose gel as a primary treatment for neonatal hypoglycemia in the first 48 hours after birth compared with standard care.

STUDY DESIGN

We used a decision tree to model overall costs, including those specific to hypoglycemia monitoring and treatment and those related to the infant's length of stay in the postnatal ward or neonatal intensive care unit, comparing the use of dextrose gel for treatment of neonatal hypoglycemia with placebo, using data from the Sugar Babies randomized trial. Sensitivity analyses assessed the impact of dextrose gel cost, neonatal intensive care cost, cesarean delivery rate, and costs of glucose monitoring.

RESULTS

In the primary analysis, treating neonatal hypoglycemia using dextrose gel had an overall cost of NZ$6863.81 and standard care (placebo) cost NZ$8178.25; a saving of NZ$1314.44 per infant treated. Sensitivity analyses showed that dextrose gel remained cost saving with wide variations in dextrose gel costs, neonatal intensive care unit costs, cesarean delivery rates, and costs of monitoring.

CONCLUSIONS

Use of buccal dextrose gel reduces hospital costs for management of neonatal hypoglycemia. Because it is also noninvasive, well tolerated, safe, and associated with improved breastfeeding, buccal dextrose gel should be routinely used for initial treatment of neonatal hypoglycemia.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12608000623392.

Continuous Glucose Monitoring in Resource-Constrained Settings for Hypoglycaemia Detection: Looking at the Problem from the Other Side of the Coin

The appearance, over a decade ago, of continuous glucose monitoring (CGM) devices has triggered a patient-centred revolution in the control and management of diabetes mellitus and other metabolic conditions, improving the patient’s glycaemic control and quality of life. Such devices, the use of which remains typically restricted to high-income countries on account of their elevated costs, at present show very limited implantation in resource-constrained settings, where many other urgent health priorities beyond diabetes prevention and management still need to be resolved. In this commentary, we argue that such devices could have an additional utility in low-income settings, whereby they could be selectively used among severely ill children admitted to hospital for closer monitoring of paediatric hypoglycaemia, a life-threatening condition often complicating severe cases of malaria, malnutrition, and other common paediatric conditions.

Mortality impact of an increased blood glucose cut-off level for hypoglycaemia treatment in severely sick children in Malawi (SugarFACT trial): study protocol for a randomised controlled trial

BACKGROUND

Mortality in children remains high in sub-Saharan African hospitals. While antimalarial drugs, antibiotics and other definitive treatments are well understood, the role of emergency care with supportive therapies, such as maintaining normal glucose and electrolyte balances, has been given limited attention. Hypoglycaemia is common in children admitted to hospital in low-income settings. The current definition of hypoglycaemia is a blood glucose level < 2.5 mmol/L in a well-nourished child. Outcomes for these children are poor, with a mortality rate of up to 42%. An increased mortality has also been reported among acutely ill children with low-glycaemia, defined as a blood glucose level of 2.5-5.0 mmol/L. The reason for increased mortality rates is not fully understood. This proposal is for a randomised controlled trial to determine the impact on mortality of a raised treatment cut-off level for paediatric hypoglycaemia.

METHODS

A total of 1266 severely ill children (age range = 1 month - 5 years) admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi with blood glucose in the range of 2.5-5.0 mmol/L will be randomised into intervention or control groups. The intervention group will be treated with an intravenous bolus of 10% dextrose 5 mL/kg followed by a dextrose infusion in addition to standard care while the control group will receive standard care only. Children will be followed until discharge from hospital or death.

DISCUSSION

The first patient was enrolled in December 2016 and the expected trial deadline is January 2019. This study is the first to evaluate the benefits of increased dextrose administration in children presenting to hospital with low-glycaemia. The findings will inform national and international policies and guidelines for the management of children with blood sugar abnormalities.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02989675 . Registered on 5 December 2016.

Continuous determination of blood glucose in children admitted with malaria in a rural hospital in Mozambique

Background

Hypoglycaemia is a frequent complication among admitted children, particularly in malaria-endemic areas. This study aimed to estimate the occurrence of hypoglycaemia not only upon admission but throughout the first 72 h of hospitalization in children admitted with malaria.

Methods

A simple pilot study to continuously monitor glycaemia in children aged 0–10 years, admitted with malaria in a rural hospital was conducted in Southern Mozambique by inserting continuous glucose monitors (CGMs) in subcutaneous tissue of the abdominal area, producing glycaemia readings every 5 min.

Results

Glucose was continuously monitored during a mean of 48 h, in 74 children. Continuous measurements of blood glucose were available for 72/74 children (97.3%). Sixty-five of them were admitted with density-specific malaria diagnosis criteria (17 severe, 48 uncomplicated). Five children (7.7%) had hypoglycaemia (<54 mg/dL) on admission as detected by routine capillary determination. Analysing the data collected by the CGMs, hypoglycaemia episodes (<54 mg/dL) were detected in 10/65 (15.4%) of the children, of which 7 (10.8%) could be classified as severe (≤45 mg/dL). No risk factors were independently associated with the presence of at least one episode of hypoglycaemia (<54 mg/dL) during hospitalization. Only one death occurred among a normoglycaemic child. All episodes of hypoglycaemia detected by CGMs were subclinical episodes or not perceived by caregivers or clinical staff.

Conclusions

Hypoglycaemia beyond admission in children with malaria appears to be much more frequent than what had been previously described. The clinical relevance of these episodes of hypoglycaemia in the medium or long term remains to be determined.

Hyperglycemia in Acutely Ill Non-diabetic Children in the Emergency Rooms of 2 Tertiary Hospitals in Lagos, Nigeria

OBJECTIVES

The study aimed to determine the prevalence of hyperglycemia in sick children admitted into the emergency rooms and to investigate its relationship with adverse outcomes.

METHODS

A prospective study involving 2 tertiary hospitals in Lagos. Study subjects included all children aged beyond 1 month. An Accu-Chek Active glucometer was used for the bedside blood glucose determination. Hyperglycemia was defined as blood glucose greater than 7.8 mmol/L.

RESULTS

A total of 1045 patients were recruited with hyperglycemia being recorded in 135 patients (prevalence rate of 12.9%). Mean age of the hyperglycemic patients was 29.0 ± 31.23 months. Prevalence rates of hyperglycemia among the leading diagnoses were 17.4% in acute respiratory tract infections, 11% in malaria, 15.3% in septicemia, 14.9% in gastroenteritis, and 18.2% in burns. Other conditions include sickle cell anemia, meningitis, and malnutrition. Mortality rate was significantly higher overall in hyperglycemic compared with the normoglycemic patients (15.4% vs 8.0%, P = 0.011). With regard to specific diagnoses, significantly higher mortality rates were recorded in hyperglycemic patients with acute respiratory tract infections (28% vs 8%, P = 0.011) and malaria (21.4% vs 5.0%, P = 0.006) than in their normoglycemic counterparts.

CONCLUSIONS

Hyperglycemia is common in ill children admitted to the emergency rooms and is associated with 2 to 4 times higher mortality in common childhood diseases encountered. Blood glucose determination is important in all acutely ill children at presentation. The practice of empirical administration of intravenous glucose in some resource-constrained facilities where blood glucose testing facilities are not readily available should be discouraged.

ASIATIC ACID INFLUENCES GLUCOSE HOMEOSTASIS IN P. BERGHEI MURINE MALARIA INFECTED SPRAGUE-DAWLEY RATS

Background:

Glucose homeostasis derangement is a common pathophysiology of malaria whose aetiology is still controversial. The Plasmodium parasite, immunological and inflammatory responses, as well as chemotherapeutics currently used cause hypoglycaemia in malaria. Anti-parasitic and anti-disease drugs are required to combat malaria while ameliorating the pathophysiology of the infection. Asiatic acid has anti-hyperglycaemic, antioxidant, pro-oxidant properties useful in glucose homeostasis but its influence in malaria is yet to be reported. Here we present findings on the influence of asiatic acid on glucose metabolism in vivo using P. berghei-infected Sprague Dawley rats.

Materials and Methods:

Acute as well as sub-chronic studies were carried out in vivo where physicochemical properties and glucose homeostasis were monitored after administration of asiatic acid (10mg/kg) in both non-infected and infected animals. Glucose metabolism associated biochemical changes in malaria were also investigated.

Results:

In acute studies, asiatic acid improved oral glucose response while in the sub-chronic state it maintained food and water intake and suppressed parasitaemia. Normoglycaemic control was maintained in infected animals through insulin suppression and increasing glucagon secretion, in both acute and chronic studies. Asiatic acid administration curtailed lactate concentration towards normal.

Conclusion:

Per oral post-infection asiatic acid administration preserved drinking and eating habits, inhibited sickness behaviour while suppressing parasitaemia. Reciprocal relationship between insulin and glucagon concentrations was maintained influencing glucose homeostasis positively and inhibition of hyperlactaemia in malaria.

Abbreviations: ip -intraperitoneal, po -per oral, ig -intragastric, AA-Asciatic acid, OGTT-oral glucose tolerance test, OS-oxidative stress, ROS-reactive oxygen species, NO-nitric oxide, ONOO^- - peroxynitrite, BRU-Biomedical Research Unit, SD-Sprague Dawley,

Management of Seizures in Children with Falciparum Malaria

Falciparum malaria is the most common cause of convulsions in children admitted to hospital in malaria endemic areas. Detection of convulsions requires close monitoring and one should be on the look out for signs of subtle convulsions. About a third of acute seizures in children with cerebral malaria, do not manifest as convulsions, but as changes in eye deviation, salivation and/or eye deviation. It is important to terminate convulsions lasting more than 5 min, since prolonged convulsions are associated with neurological deficits in survivors of children with severe malaria. Initial management should include putting the child into the left lateral position, checking the blood glucose and administering oxygen if hypoxic. The benzodiazepines, particularly diazepam, are used as the initial anticonvulsants. Phénobarbital and Phenytoin are used as second-line treatments. Prompt and effective management of falciparum malaria associated convulsions may contribute to a better outcome in children with severe malaria.

High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country

INTRODUCTION

Hypoglycemia is a recognized feature of severe malaria but its diagnosis and management remain problematic in resource-limited settings. There is limited data on the burden and prognosis associated with glycemia dysregulation in non-neonate children in non-malaria areas. We prospectively assessed the abnormal blood glucose prevalence and the outcome and risk factors of deaths in critically ill children admitted to a national referral hospital in Laos.

METHODS

Consecutive children (1 month-15 years) admitted to the pediatric ward of Mahosot hospital, were categorized using the integrated management of childhood illness (IMCI). Blood glucose was assessed once on admission through a finger prick using a bedside glucometer. Glycemia levels: hypoglycemia: < 2.2 mmol/L (< 40 mg⁄ dl), low glycemia: 2.2-4.4 mmol/L (40-79 mg⁄ dl), euglycemia: 4.4-8.3 mmol/L (80-149 mg⁄ dl), and hyperglycemia: > 8.3 mmol/L (≥150 mg⁄ dl), were related to the IMCI algorithm and case fatality using univariate and multivariate analysis.

RESULTS

Of 350 children, 62.2% (n = 218) were severely ill and 49.1% (n = 172) had at least one IMCI danger sign. A total of 15 (4.2%, 95%CI: 2.4-6.9) had hypoglycemia, 99 (28.2%, 95%CI: 23.6-33.3) low glycemia, 201 (57.4%, 95% CI: 52.0-62.6) euglycemia and 35 (10.0%, 95% CI: 7.0-13.6) hyperglycemia. Hypoglycemia was associated with longer fasting (p = 0.001) and limited treatment before admission (p = 0.09). Hypoglycemia and hyperglycemia were associated with hypoxemia (SaO2) (p = 0.001). A total of 21 (6.0%) of the children died: 66.6% with hypoglycemic, 6.0% with low glycemic, 5.7% with hyperglycemic and 1.4% with euglycemic groups. A total of 9 (2.5%) deaths occurred during the first 24 hours of admission and 5 (1.7%) within 3 days of hospital discharge. Compared to euglycemic children, hypoglycemic and low glycemic children had a higher rate of early death (20%, p<0.001 and 5%, p = 0.008; respectively). They also had a higher risk of death (OR: 132; 95%CI: 29.0-596.5; p = 0.001; and OR: 4.2; 95%CI: 1.1-15.6; p = 0.02; respectively). In multivariate analyses, hypoglycemia (OR: 197; 95%CI: 33-1173.9), hypoxemia (OR: 5.3; 95%CI: 1.4-20), presence of hepatomegaly (OR: 8.7; 95%CI: 2.0-37.6) and having an illiterate mother (OR: 25.9; 95%CI: 4.2-160.6) were associated with increased risk of death.

CONCLUSION

Hypoglycemia is linked with a high risk of mortality for children in non malaria tropical settings. Blood sugar should be monitored and treatment provided for sick children, especially with danger signs and prolonged fasting. Further evaluations of intervention using thresholds including low glycemia is recommended in resource-limited settings. Research is also needed to determine the significance, prognosis and care of hyperglycemia.

Hypoglycemia and Risk Factors for Death in 13 Years of Pediatric Admissions in Mozambique

Hypoglycemia is a life-threatening complication of several diseases in childhood. We describe the prevalence and incidence of hypoglycemia among admitted Mozambican children, establishing its associated risk factors. We retrospectively reviewed clinical data of 13 years collected through an ongoing systematic morbidity surveillance in Manhiça District Hospital in rural Mozambique. Logistic regression was used to identify risk factors for hypoglycemia and death. Minimum community-based incidence rates (MCBIRs) for hypoglycemia were calculated using data from the demographic surveillance system. Of 49,089 children < 15 years hospitalized in Manhiça District Hospital, 45,573 (92.8%) had a glycemia assessment on admission. A total of 1,478 children (3.2%) presented hypoglycemia (< 3 mmol/L), of which about two-thirds (972) were with levels < 2.5 mmol/L. Independent risk factors for hypoglycemia on admission and death among hypoglycemic children included prostration, unconsciousness, edema, malnutrition, and bacteremia. Hypoglycemic children were significantly more likely to die (odds ratio [OR] = 7.11; P < 0.001), with an associated case fatality rate (CFR) of 19.3% (245/1,267). Overall MCBIR of hypoglycemia was 1.57 episodes/1,000 child years at risk (CYAR), significantly decreasing throughout the study period. Newborns showed the highest incidences (9.47 episodes/1,000 CYAR, P < 0.001). Hypoglycemia remains a hazardous condition for African children. Symptoms and signs associated to hypoglycemia should trigger the verification of glycemia and the implementation of life-saving corrective measures.

New technologies for essential newborn care in under-resourced areas: what is needed and how to deliver it

Globally, the largest contributors to neonatal mortality are preterm birth, intrapartum complications and infection. Many of these deaths could be prevented by providing temperature stability, respiratory support, hydration and nutrition; preventing and treating infections; and diagnosing and treating neonatal jaundice and hypoglycaemia. Most neonatal health-care technologies which help to accomplish these tasks are designed for high-income countries and are either unavailable or unsuitable in low-resource settings, preventing many neonates from receiving the gold standard of care. There is an urgent need for neonatal health-care technologies which are low-cost, robust, simple to use and maintain, affordable and able to operate from various power supplies. Several technologies have been designed to meet these requirements or are currently under development; however, unmet technology needs remain. The distribution of an integrated set of technologies, rather than separate components, is essential for effective implementation and a substantial impact on neonatal health. Close collaboration between stakeholders at all stages of the development process and an increased focus on implementation research are necessary for effective and sustainable implementation.

Abnormal blood glucose as a prognostic factor for adverse clinical outcome in children admitted to the paediatric emergency unit at komfo anokye teaching hospital, kumasi, ghana

Dysglycaemia (hyper- or hypoglycaemia) in critically ill children has been associated with poor outcome. We compared the clinical outcomes in children admitted to Pediatric Emergency Unit (PEU) at Komfo Anokye Teaching Hospital (KATH) for acute medical conditions and presenting with euglycaemia or dysglycaemia. This is a prospective case matching cohort study. Eight hundred subjects aged between 3 and 144 months were screened out of whom 430 (215 with euglycaemia and 215 with dysglycaemia) were enrolled. The median age was 24 months (range: 3-144 months). In the dysglycaemia group, 28 (13%) subjects had hypoglycemia and 187 (87%) had hyperglycemia. Overall, there were 128 complications in 116 subjects. The number of subjects with complications was significantly higher in dysglycaemia group (n = 99, 46%) compared to euglycaemia group (n = 17, 8%) (P < 0.001). Forty subjects died out of whom 30 had dysglycaemia (P = 0.001). Subjects with dysglycaemia were 3 times (95% CI: 1.5-6.0) more likely to die and 4.8 times (95% CI: 3.1-7.5) more likely to develop complications (P = 0.001). Dysglycaemia is associated with increased morbidity and mortality in children with acute medical conditions and should lead to intensive management of the underlying condition.

A novel algorithm in the management of hypoglycemia in newborns

Study Objective. To evaluate the safety of a new protocol in comparison to the standard protocol for managing hypoglycemia in neonates. Methods. Open label RCT-pilot study. Neonates admitted to NICU with hypoglycemia and requiring intravenous fluids were included. Fifty-seven eligible neonates were randomly allocated to either intervention group (starting fluids with 10% dextrose and increments of 1.5%) or standard protocol group (GIR of 6 mg/kg/min with increments of 2 mg/kg/min) till control of hypoglycemia. Primary outcome of the study was to know proportion of infants with subsequent hypoglycemia and hyperglycemia after enrolment. Results. The initial GIR (6 ± 0 mg/kg/min versus 4.8 ± 1.4 mg/kg/min, P < 0.001), the mean maximum GIR (6.7 ± 1.6 mg/kg/min versus 5.6 ± 2 mg/kg/min, P = 0.03), the maximum concentration of glucose infused (13.8 ± 2.9% versus 10.9 ± 1.9%, P < 0.001), and the total amount of glucose infused were significantly lower in the intervention group. The mean maximum blood sugar was significantly higher (129 ± 57 mg/dL versus 87 ± 30 mg/dL, P = 0.001) and there was a trend towards high proportion of infants with Hyperglycemia in the standard protocol group (n = 10, 39% versus n = 5, 16%, P = 0.07). The median difference between the highest and the lowest recorded sugar for any infant was significantly higher in the standard protocol group (median 93 mg/dL, IQR 52 to 147 mg/dL versus median 50 mg/dL, IQR 38 to 62.5 mg/dL, P = 0.03). Conclusion. A new and novel algorithm in the management of hypoglycemia in neonates is as safe as the standard protocol and requires further testing before routine implementation.

Improving the management of dysglycemia in children in the developing world

Improving the availability of point-of-care (POC) diagnostics for glucose is crucial in resource-constrained settings (RCS). Both hypo and hyperglycemia have an appreciable frequency in the tropics and have been associated with increased risk of deaths in pediatrics units. However, causes of dysglycemia, including hyperglycemia, are numerous and insufficiently documented in RCS. Effective glycemic control with glucose infusion and/or intensive insulin therapy can improve clinical outcomes in western settings. A non-invasive way for insulin administration is not yet available for hyperglycemia. We documented a few causes and developed simple POC treatment of hypoglycemia in RCS. We showed the efficacy of sublingual sugar in two clinical trials. Dextrose gel has been recently tested for neonate mortality. This represents an interesting alternative that should be compared with sublingual sugar in RCS. New studies had to be done to document dysglycemia mechanism, frequency and morbid-mortality, and safe POC treatment in the tropics.

Hyperglycemia in critically ill children

OBJECTIVES

To determine the incidence and study association of hyperglycemia with outcome of critically ill children.

SETTING AND DESIGN

This was a prospective observational study conducted in eight bedded pediatric intensive care unit (PICU) of a tertiary care hospital.

MATERIALS AND METHODS

One hundred and one critically ill non-diabetic children between ages of 1 month to 16 years were studied from the day of admission till discharge or death. Serial blood sugars were determined first at admission, thereafter every 12 hourly in all children. Blood glucose level above 126 mg/dl (>7 mmol/dl) was considered as hyperglycemia. Children with hyperglycemia were followed 6 hourly till blood glucose fell below 126 mg/dl. Hyper and non-hyperglycemic children were compared with respect to length of stay, mechanical ventilation, use of inotrops and final outcome. Survivors and non-survivors were compared in relation to admission blood glucose, peak blood glucose level and duration of hyperglycemia.

RESULTS

Seventy (69.3%) children had hyperglycemia. Requirement of ventilation [(23) 32.9% vs.(3) 9.7%], requirement of inotropic support [(27) 38.6% vs.(5) 16.1%], Mean length of stay in PICU (7.91 ± 5.01 vs. 5.58 ± 1.95 days) and mortality (28.6% vs. 3.2%) among hyperglycemic children was significantly higher (P < 0.05) than that of non-hyperglycemic. Logistic regression analysis showed Peak blood glucose level and duration of hyperglycemia has independent association with increased risk of death.

CONCLUSION

Incidence of hyperglycemia is high in critically ill children and it is associated with high morbidity and mortality.

Adaptation of glucose metabolism to fasting in young children with infectious diseases: a perspective

Hypoglycemia is a frequently encountered complication in young children with infectious diseases and may result in permanent neurological damage or even death. Mortality rate in young children under 5 years of age is increased four- to six-fold when severe infectious disease is complicated by hypoglycemia. Young age, prolonged fasting and severity of disease are considered important risk factors. This perspective describes the combined results of recently conducted studies on the effect of these risk factors on glucose metabolism in children with different infectious diseases. The results of these studies have nutritional implications for the approach in clinical practice towards young children with infectious diseases and specific recommendations are made. A unique finding is the existence of infectious disease-related differences in the adaptation of glucose metabolism during fasting in young children.

Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Neonatal hypoglycaemia is common, and a preventable cause of brain damage. Dextrose gel is used to reverse hypoglycaemia in individuals with diabetes; however, little evidence exists for its use in babies. We aimed to assess whether treatment with dextrose gel was more effective than feeding alone for reversal of neonatal hypoglycaemia in at-risk babies.

METHODS

We undertook a randomised, double-blind, placebo-controlled trial at a tertiary centre in New Zealand between Dec 1, 2008, and Nov 31, 2010. Babies aged 35-42 weeks' gestation, younger than 48-h-old, and at risk of hypoglycaemia were randomly assigned (1:1), via computer-generated blocked randomisation, to 40% dextrose gel 200 mg/kg or placebo gel. Randomisation was stratified by maternal diabetes and birthweight. Group allocation was concealed from clinicians, families, and all study investigators. The primary outcome was treatment failure, defined as a blood glucose concentration of less than 2·6 mmol/L after two treatment attempts. Analysis was by intention to treat. The trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12608000623392.

FINDINGS

Of 514 enrolled babies, 242 (47%) became hypoglycaemic and were randomised. Five babies were randomised in error, leaving 237 for analysis: 118 (50%) in the dextrose group and 119 (50%) in the placebo group. Dextrose gel reduced the frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0·57, 95% CI 0·33-0·98; p=0·04). We noted no serious adverse events. Three (3%) babies in the placebo group each had one blood glucose concentration of 0·9 mmol/L. No other adverse events took place.

INTERPRETATION

Treatment with dextrose gel is inexpensive and simple to administer. Dextrose gel should be considered for first-line treatment to manage hypoglycaemia in late preterm and term babies in the first 48 h after birth.

FUNDING

Waikato Medical Research Foundation, the Auckland Medical Research Foundation, the Maurice and Phyllis Paykel Trust, the Health Research Council of New Zealand, and the Rebecca Roberts Scholarship.

Blood glucose as a predictor of mortality in children admitted to the hospital with febrile illness in Tanzania

Data from a prospective study of 3,319 children ages 2 months to 5 years admitted with febrile illness to a Tanzanian district hospital were analyzed to determine the relationship of blood glucose and mortality. Hypoglycemia (blood sugar < 2.5 mmol/L and < 45 mg/dL) was found in 105 of 3,319 (3.2%) children at admission, and low-normal blood glucose (2.5–5 mmol/L and 45–90 mg/dL) was found in 773 of 3,319 (23.3%) children. Mortality was inversely related to admission blood sugar; compared with children with an admission blood glucose of > 5 mmol/L, the adjusted odds of dying were 3.3 (95% confidence interval = 2.1–5.2) and 9.8 (95% confidence interval = 5.1–19.0) among children with admission blood glucose 2.5–5 and < 2.5 mmol/L, respectively. Receiver operating characteristic (ROC) analysis suggested an optimal cutoff for admission blood sugar of < 5 mmol/L in predicting mortality (sensitivity = 57.7%, specificity = 75.2%). A cutoff for admission blood glucose of < 5 mmol/L represents a simple and clinically useful predictor of mortality in children admitted with severe febrile illness to hospital in resource-poor settings.

Childhood dysglycemia: prevalence and outcome in a referral hospital

INTRODUCTION

Hypoglycemia is a defining feature of severe malaria and several other infectious diseases in children but the prevalence, significance, and prognosis of abnormal blood glucose, including hyperglycemia, have rarely been addressed in severely ill children in non-malaria endemic areas.

METHODS

In Madagascar, consecutive children (1 month-15 years) admitted to the pediatric ward of a referral hospital, were categorized using the integrated management of childhood illness (IMCI). Samples were taken once on admission for measuring blood glucose concentration. Glycemia levels (hypoglycemia <2.2 mmol/l; low glycemia: 2.2-4.4 mmol/l; normoglycemia >4.4-8.3 mmol/l; and hyperglycemia >8.3 mmol/l) were related to the IMCI algorithm and case fatality. Factors associated with blood glucose concentration and case fatality were analysed using univariate and multivariate analysis.

RESULTS

Of 420 children, 48.1% (n = 202) were severely ill; 3.1% (n = 13) had hypoglycemia; 20.0% (n = 84) low glycemia; 65.9% (n = 277) normoglycemia; and 10.9% (n = 46) hyperglycemia. In univariate analysis, hypoglycemia and hyperglycemia both showed significant increase in the risk of death, as compared to normal blood glucose (RR: 12.2, 95% CI: 6.2-23.7 and RR: 2.5, 95% CI: 1.0-6.2, respectively). Children with low glycemia had no increased risk of death (RR: 1.2, 95% CI: 0.4-3.2) despite a poorer IMCI status on admission. After logistic regression, hypoglycemia (RR: 19.4, 95% CI: 5.0-.74.7, hepatomegaly (RR: 12.2, 95% CI: 3.3-44.9) and coma (RR: 4.8, 95% CI: 1.3-17.6) were the features on admission associated with an increased risk of death.

CONCLUSIONS

Dysglycemia in non-neonates is associated with increased mortality. These findings underline the need for the use of rapid screening tests to initiate early treatment. Alternative treatments such as oral or sublingual administration of glucose should be developed in structures with limited resources.

Fasting predisposes to hypoglycemia in Surinamese children with severe pneumonia, and young children are more at risk

The objective of this study was to investigate glucose kinetics during controlled fasting in children with severe pneumonia. Plasma glucose concentration, endogenous glucose production and gluconeogenesis were measured in 12 Surinamese children (six young: 1-3 years, six older: 3-5 years) with severe pneumonia during a controlled 16 h fast using stable isotopes [6,6-(2)H2]glucose and (2)H2O at a hospital-based research facility. On admission, the glucose concentrations were comparable in both groups: young children: 5.1 ± 1.3 mmol/l, older children: 4.8 ± 0.6 mmol/l, p = 0.685, with a decrease during the first 8 h of fasting in the young children only to 3.6 ± 0.5, p = 0.04. Glucose production was comparable in both groups: young: 24.5 ± 8.3, older: 24.9 ± 5.9 µmol/kg(•)min, p = 0.926. Between 8 and 16 h of fasting, the glucose concentration decreased comparably in both groups (young: - 0.9 ± 0.7, p = 0.004; older: -1.0 ± 0.4 mmol/l, p = 0.001), as did glucose production (young: -6.8 ± 6.3, p = 0.003; older: -5.3 ± 3.4 µmol/kg(•)min, p = 0.001). Gluconeogenesis decreased in young children only: -5.0 ± 7.4, p = 0.029. We conclude that fasting predisposes to hypoglycemia in children with severe pneumonia. Young children are more at risk than older children. Glucose production is an important determinant of the plasma glucose concentration in young children with pneumonia, indicating an inability to reduce glucose usage. Our results are largely in agreement with the literature on the adaptation of glucose metabolism in children with malaria, although there seem to be disease-specific differences in the regulation of gluconeogenesis.

Hyperglycemia in severe falciparum malaria: a case report

Occasionally, malaria may present with unusual signs and symptoms. We report a case of an uncommon presentation of Plasmodium falciparum infection in a 59-year-old Ethiopian immigrant, which initially presented with hyperglycaemia and multiple organ dysfunction syndrome (MODS). Reports of unusual presentations of malaria are few and cases of severe malaria with hyperglycaemia are rarely described. As hyperglycaemia is associated to most severe malaria and high mortality, our aim is to catch the attention of the physicians on this entity.

Point-of-admission hypoglycaemia among under-five Nigerian children with plasmodium falciparum malaria: prevalence and risk factors

BACKGROUND

Hypoglycaemia is a well recognized complication of falciparum malaria in children but its diagnosis may be overlooked because all the clinical features may be mimicked by severe malaria. To determine the prevalence of hypoglycaemia at the point of hospital admission of under-fives with falciparum malaria and identify its risk factors in patients seen in a Nigerian secondary-health-care institution.

METHODS

During a 12-month period and at the point of hospital admission, venous blood sample was collected into an appropriate sample bottle (fluoride-oxalate bottle) from 502 children who were below 5 years of age with positive falciparum malaria parasitaemia. The blood sample was analysed using the glucose-oxidase method. The duration of illness, degree of parasitaemia and time of last meal were noted for each child.

RESULTS

Ninety two (18.3%) out of 502 children below five years old with falciparum malaria had hypoglycaemia ( blood glucose below 2.6 mmol/L or 50 mg/dl) at the point of hospital admission. Twenty three percent (78 out of 339) of children below 36 months old were hypoglycaemic compared to 8.6% (14 out of 163) children aged 36 months and above; (p=0.01). Prevalence of hypoglycaemia was higher in girls (20.7%) than boys (16.3%) [Odd ratio, OR=0.75 (95% Confidence Interval, CI=0.48-1.18)]. Forty (13.1%) out of 305 children whose time of last meal was 12 hours and below had hypoglycaemia compared to 52(26.4%) out of 197 whose time of last meal was greater than 12 hours; (p=0.02). Hypoglycaemia at admission point was associated with a significant increase in mortality rate; (p=0.00). The duration of illness and the degree of parasitaemia did not have significant difference with the prevalence of hypoglycaemia.

CONCLUSION

In falciparum malaria, a greater interval (between 2 meals) than 12 hours in children below 36 months old predisposed them to hypoglycaemia. Routine monitoring of blood glucose at the admission point is suggested in malaria endemic region.

Pediatric Sepsis Guidelines: Summary for resource-limited countries

Justification:

Pediatric sepsis is a commonly encountered global issue. Existing guidelines for sepsis seem to be applicable to the developed countries, and only few articles are published regarding application of these guidelines in the developing countries, especially in resource-limited countries such as India and Africa.

Process:

An expert representative panel drawn from all over India, under aegis of Intensive Care Chapter of Indian Academy of Pediatrics (IAP) met to discuss and draw guidelines for clinical practice and feasibility of delivery of care in the early hours in pediatric patient with sepsis, keeping in view unique patient population and limited availability of equipment and resources. Discussion included issues such as sepsis definitions, rapid cardiopulmonary assessment, feasibility of early aggressive fluid therapy, inotropic support, corticosteriod therapy, early endotracheal intubation and use of positive end expiratory pressure/mechanical ventilation, initial empirical antibiotic therapy, glycemic control, and role of immunoglobulin, blood, and blood products.

Objective:

To achieve a reasonable evidence-based consensus on the basis of published literature and expert opinion to formulating clinical practice guidelines applicable to resource-limited countries such as India.

Recommendations:

Pediatric sepsis guidelines are presented in text and flow chart format keeping resource limitations in mind for countries such as India and Africa. Levels of evidence are indicated wherever applicable. It is anticipated that once the guidelines are used and outcomes data evaluated, further modifications will be necessary. It is planned to periodically review and revise these guidelines every 3–5 years as new body of evidence accumulates.

Hypoglycaemia in severe malaria, clinical associations and relationship to quinine dosage

BACKGROUND

Hypoglycaemia is an independent risk factor for death in severe malaria and a recognized adverse treatment effect of parenteral quinine. In 2006 our hospital changed quinine treatment policy from 15 mg/kg loading (plus 10 mg/kg 12-hourly) to 20 mg/kg loading (plus 10 mg/kg 8-hourly) to comply with new WHO guidelines. This presented us with the opportunity to examine whether there was any dose relationship of quinine and hypoglycaemia occurrence.

METHODS

Retrospective case notes review of all children admitted to hospital with severe falciparum malaria between April 2002 - July 2009, before and after the introduction of the new WHO quinine regimen. Four-hourly bedside glucose levels were measured until intravenous quinine was discontinued. Clinical events immediately preceding or concurrent with each episode of hypoglycaemia (glucose < = 3.0 mmol/l) were recorded.

RESULTS

954 children received the old quinine regime and 283 received the new regime. We found no evidence of an increased prevalence of hypoglycaemia (< = 3.0 mmol/L) on the new regime compared to former (15% vs. 15%); similar findings were noted for profound hypoglycaemia (< 2.2 mmols/L) 8% v 5%, P = 0.07. Episodes were co-incident with disease severity markers: coma (57%), circulatory failure (38%) and respiratory distress (21%) but less commonly with seizures (10%). Disruption of maintenance fluids and/or blood transfusion concurred with 42% of the hypoglycaemia episodes. Post admission hypoglycaemia increased odds of fatal outcome (24%) compared to euglycaemic counterparts (8%), odds ratio = 3.45 (95% confidence interval = 2.30-5.16) P < 0.01.

CONCLUSION

There was no evidence to indicate a dose relationship between quinine and occurrence of hypoglycaemia. Hypoglycaemia concurred with severity features, disruption of glucose infusion and transfusion. Careful glucose monitoring should be targeted to these complications where resources are limited.

Mini-review: Management of hypoglycaemia in children aged 0-59 months

Hypoglycaemia is associated with poor prognosis in many severe childhood illnesses especially in sub-Saharan Africa where the prevalence of malaria, diarrhoea and malnutrition remains high. Uncertainty, however, still persists regarding the significance, definition and management of childhood hypoglycaemia. As a step towards defining optimal, evidence-based diagnostic and management criteria, we (i) reviewed the evidence underlying current recommendations for the management of hypoglycaemia, and (ii) analysed a large set of data on blood glucose levels and associated outcomes of paediatric admissions in a rural hospital over an 11-year period. Current definitions and treatment protocols for hypoglycaemia are based on observational data and expert opinion. Future large pragmatic randomized trials would help define optimal treatment thresholds. Emerging evidence suggests that sublingual sugar is a feasible and effective therapy for correction of hypoglycaemia, and should be considered where intravenous glucose is delayed or impossible.

Glucose metabolism in children: influence of age, fasting, and infectious diseases

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.

Predictors of anti-convulsant treatment failure in children presenting with malaria and prolonged seizures in Kampala, Uganda

Background

In endemic areas, falciparum malaria remains the leading cause of seizures in children presenting to emergency departments. In addition, seizures in malaria have been shown to increase morbidity and mortality in these patients. The management of seizures in malaria is sometimes complicated by the refractory nature of these seizures to readily available anti-convulsants. The objective of this study was to determine predictors of anti-convulsant treatment failure and seizure recurrence after initial control among children with malaria.

Methods

In a previous study, the efficacy and safety of buccal midazolam was compared to that of rectal diazepam in the treatment of prolonged seizures in children aged three months to 12 years in Kampala, Uganda. For this study, predictive models were used to determine risk factors for anti-convulsant treatment failure and seizure recurrence among the 221 of these children with malaria.

Results

Using predictive models, focal seizures (OR 3.21; 95% CI 1.42–7.25, p = 0.005), cerebral malaria (OR 2.43; 95% CI 1.20–4.91, p = 0.01) and a blood sugar ≥200 mg/dl at presentation (OR 2.84; 95% CI 1.11–7.20, p = 0.02) were independent predictors of treatment failure (seizure persistence beyond 10 minutes or recurrence within one hour of treatment). Predictors of seizure recurrence included: 1) cerebral malaria (HR 3.32; 95% CI 1.94–5.66, p < 0.001), 2) presenting with multiple seizures (HR 2.45; 95% CI 1.42–4.23, p = 0.001), 3) focal seizures (HR 2.86; 95% CI 1.49–5.49, p = 0.002), 4) recent use of diazepam (HR 2.43; 95% CI 1.19–4.95, p = 0.01) and 5) initial control of the seizure with diazepam (HR 1.96; 95% CI 1.16–3.33, p = 0.01).

Conclusion

Specific predictors, including cerebral malaria, can identify patients with malaria at risk of anti-convulsant treatment failure and seizure recurrence.

Very young children with uncomplicated falciparum malaria have higher risk of hypoglycaemia: a study from Suriname

OBJECTIVE

To measure glucose kinetics and the influence of age, nutritional status and fasting duration in children with uncomplicated falciparum malaria (UFM) under the age of 5 years.

METHODS

Plasma glucose concentration, endogenous glucose production (EGP) and gluconeogenesis (GNG) were measured using [6,6-(2)H(2)]glucose and (2)H(2)O in 17 very young (<3 years) and 7 older (3-5 years) Surinamese children with UFM admitted to the Distrikt Hospital Stoelmanseiland and Diakonessen Hospital Paramaribo over 17 months.

RESULTS

Plasma glucose concentration was lower in the group of very young children than in the older children (P = 0.028). There were no differences in EGP and GNG between the groups. Overall GNG contributed 56% (median, range 17-87%) to EGP, with no differences between the groups (P = 0.240). Glucose clearance was lower in the older children (P = 0.026). Glucose concentration did not differ between children with weight for length/height less than -1.3 SD and children with weight for length/height greater than -1.3 SD (P = 0.266). Plasma glucose concentration was not predicted by fasting duration (P = 0.762).

CONCLUSIONS

Our data suggest a higher risk of hypoglycaemia in very young children with uncomplicated malaria as plasma glucose concentration was lower in this study group. Since this could not be attributed to an impaired EGP, and because glucose clearance was lower in the older children, we presume that older children were better capable of reducing glucose utilization during fasting. Studies on glucose kinetics are feasible in very young children with malaria and give more insight in the pathophysiology of hypoglycaemia.

[Hyperglycemia and mortality in critically ill children]

Several pathologic conditions are accompanied by stress-induced hyperglycemia in non-diabetic individuals which influences mortality and morbidity.

AIMS

Prospective studies in adults support that glycemic control is an independent predictor of survival and normoglycemia has a beneficial effect on the outcome of patients. Few data are available in children, however a retrospective study documented significant correlation between mortality and duration, intensity and peak value of hyperglycemia. In the present study, the authors investigated the relationship between blood glucose level and pathological process in a multidisciplinary pediatric intensive care department retrospectively.

RESULTS

It has been shown that highest blood glucose values were associated with fatal outcome independent of diagnosis (mean: 14,38 mmol/l) and with septicemia independent of final outcome (mean: 13,97 mmol/l). Patients with fatal outcome were hyperglycemic during the total duration (mean: 7,59 mmol/l) and on the last day (mean: 7,00 mmol/l) of treatment. Patients who survived had significantly lower blood glucose over the whole duration (mean: 6,52 mmol/l; p < 0,01) and on the last day of treatment (mean: 5,28 mmol/l; p < 0,01) than those who died. Percent of treatment days with blood glucose > = 6,1 mmol/l was significantly lower in case of survival as compared with fatal cases (42,68 vs. 74.07 %; p < 0,01) and the highest rate was observed in those with fatal septcemia (mean: 76,52 %).

CONCLUSIONS

These data support that, similarly to adults, critical condition in children induces sustained hyperglycemia and higher peak values and longer duration of elevated blood glucose are associated with higher mortality rate. Septicemia proved to be potent inductor of abnormalities of carbohydrate metabolism.

Role of TOPS (a simplified assessment of neonatal acute physiology) in predicting mortality in transported neonates

AIM

To evaluate role of TOPS (a simplified assessment of neonatal acute physiology) in predicting mortality in transported neonates and to compare it with SNAP II.

DESIGN

Prospective study.

SETTING

Referral Neonatal Unit of a teaching hospital.

SUBJECTS

175 neonates > 1000 g admitted to referral nursery.

METHODS

Temperature, oxygenation, capillary refill time (proxy for perfusion) and blood sugar (given the acronym of TOPS) were recorded at admission. SNAP II was also recorded for first 12 hours following admission.

RESULTS

All the TOPS variables had significant correlation with fatality on univariate analysis. Fatality was 100% when all the four TOPS variables were deranged. The sensitivity, specificity, positive and negative predictive values of derangements of two or more TOPS parameters in predicting mortality were 81.6%, 77.39%, 65.3% and 89%, respectively All the variables of SNAP II significantly correlated with mortality. A cut-off score of 24 was derived from the ROC curve. The sensitivity, specificity, positive and negative predictive values of SNAP II score > 24 in predicting mortality were 78.3%, 86.1%, 74.6% and 88.4%, respectively. The area under ROC curve for derangements of 2 or more TOPS parameters was 0.89 while that for SNAP II was 0.88. Both models were well calibrated (p value for Hosmer Lemeshow goodness of fit for TOPS was 0.75 while that for SNAP II was 0.80). The total correct classification rate for TOPS was 81.7%, while that for SNAP II was 83.4%.

CONCLUSION

TOPS has an equally good prediction for mortality as SNAP II and can be used as a simple and useful method of assessment of risk of fatality that can be assessed immediately, at admission.

Critical appraisal of the management of severe malnutrition: 3. Complications

The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20-40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.