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Al-Mouqdad MM, Abdalgader AT, Abdelrahim A, Almosbahi FA, Khalil TM, Asfour YS, Asfour SS. Association of early dysglycemia with intraventricular hemorrhage and mortality in very low birth weight infants. Eur J Pediatr 2024:10.1007/s00431-024-05812-z. [PMID: 39387902 DOI: 10.1007/s00431-024-05812-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 09/28/2024] [Accepted: 10/03/2024] [Indexed: 10/12/2024]
Abstract
To investigate the combined effect of hyperglycemia and hypoglycemia on intraventricular hemorrhage (IVH) and mortality recognizing that previous research has predominantly focused on examining these conditions independently. This study included very preterm infants who were born at King Saud Medical City, a tertiary referral center, and admitted to a level 3 neonatal intensive care unit between January 2020 and January 2024. Modified log-Poisson regression with generalized linear models and a robust variance estimator (Huber-White) were used to adjust for potential confounding factors. A total of 554 infants met the inclusion criteria. Hyperglycemia and/or hypoglycemia developed in 75.5% (418) patients within the first postnatal week. During the study period, IVH occurred in 28.5% (N = 158), and severe IVH occurred in 13% (72) infants. In addition, 13.7% (76) of infants died during the study period. The multivariate regression revealed an association between the isolated hyperglycemia, combined exposure of hypo- and hyperglycemia, and development of IVH (relative risk [RR], 2.10; 95% confidence interval [CI], 1.36, 3.25; RR, 2.33; 95% CI, 1.34, 4.06, respectively). Severe IVH was significantly associated with isolated hyperglycemia (adjusted relative risk [aRR], 2.46; 95% CI, 1.16, 5.23). Death was associated with combined hypo- and hyperglycemia (adjusted hazardous ratio [aHR], 3.19; 95% CI, 1.23, 8.26).Conclusion: Combined hyper- and hypoglycemia in the first week of life of premature babies increases the risk and severity of IVH and neonatal mortality.
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Affiliation(s)
- Mountasser M Al-Mouqdad
- Neonatal Intensive Care, Hospital of Pediatrics, King Saud Medical City, Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, 12746, Riyadh, Saudi Arabia.
| | - Ayman T Abdalgader
- Neonatal Intensive Care, Hospital of Pediatrics, King Saud Medical City, Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, 12746, Riyadh, Saudi Arabia
| | - Adli Abdelrahim
- Neonatal Intensive Care, Hospital of Pediatrics, King Saud Medical City, Al Imam Abdul Aziz Ibn Muhammad Ibn Saud, 12746, Riyadh, Saudi Arabia
| | - Faisal A Almosbahi
- General Pediatrics Department, Hospital of Pediatrics, King Saud Medical City, Riyadh, Saudi Arabia
| | - Thanaa M Khalil
- Obstetric and Gynecology Department, Maternity Hospital, King Saud Medical City, Riyadh, Saudi Arabia
| | - Yasmeen S Asfour
- Obstetric and Gynecology Department, Family Care Hospital, Riyadh, Saudi Arabia
| | - Suzan S Asfour
- Clinical Pharmacy Department, Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
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Predanič Drobne I, Kornhauser Cerar L, Erčulj V, Grosek Š. A Higher Amount of Nutritional Intake as a Possible Cause of Hyperglycemia in Extremely Premature Infants in Parenteral and Enteral Nutrition at the Tertiary Neonatal Intensive Care Unit. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1651. [PMID: 37892314 PMCID: PMC10605466 DOI: 10.3390/children10101651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND This study aimed to find an association between infants who had hyperglycemia and those who did not, those treated with insulin or not and several prenatal and postnatal variables or the suboptimal prescription of parenteral nutrition. METHODS We conducted a retrospective study, which included extremely premature infants (<28 weeks of gestation) admitted to the tertiary NICU, University Medical Centre Ljubljana, between 1 January 2021 and 31 December 2021. Blood glucose measurements, insulin treatment, general characteristics, nutritional data and complications of prematurity were obtained retrospectively from hospital data. RESULTS There were 21 infants included in the study who did not receive insulin and 17 who were treated with insulin. Infants receiving insulin were younger and lighter compared to the non-insulin treatment group (mean gestational age 178 vs. 188 days; median birth weight 680 g vs. 990 g). The younger insulin group of infants received the same daily number of total macronutrients per kg per day compared to the older non-insulin group, i.e., glucose, lipids and amino acids, as recommended for the gestational age and birth weight. After adjusting for gestational age, no significant association with complications of prematurity was found. CONCLUSIONS The postulated explanation (with the prescription of a higher amount of macronutrients during the first seven days) for hyperglycemia and treatment with insulin in the less mature and lighter infants cannot be supported by the data given.
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Affiliation(s)
- Iza Predanič Drobne
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Lilijana Kornhauser Cerar
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Vanja Erčulj
- Rho Sigma Research & Statistics, 1000 Ljubljana, Slovenia;
- Faculty of Criminal Justice and Security, University of Maribor, 1000 Ljubljana, Slovenia
| | - Štefan Grosek
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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3
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Angelis D, Jaleel MA, Brion LP. Hyperglycemia and prematurity: a narrative review. Pediatr Res 2023; 94:892-903. [PMID: 37120652 DOI: 10.1038/s41390-023-02628-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/01/2023]
Abstract
Hyperglycemia is commonly encountered in extremely preterm newborns and physiologically can be attributed to immaturity in several biochemical pathways related to glucose metabolism. Although hyperglycemia is associated with a variety of adverse outcomes frequently described in this population, evidence for causality is lacking. Variations in definitions and treatment approaches have further complicated the understanding and implications of hyperglycemia on the immediate and long-term effects in preterm newborns. In this review, we describe the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research. IMPACT: Hyperglycemia is common and less well described than hypoglycemia in extremely preterm newborns. Hyperglycemia can be attributed to immaturity in several cellular pathways involved in glucose metabolism in this age group. Hyperglycemia has been shown to be associated with a variety of adverse outcomes frequently described in this population; however, evidence for causality is lacking. Variations in definitions and treatment approaches have complicated the understanding and the implications of hyperglycemia on the immediate and long-term effects outcomes. This review describes the relationship between hyperglycemia and organ development, outcomes, treatment options, and potential gaps in knowledge that need further research.
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Affiliation(s)
- Dimitrios Angelis
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Patidar N, Rath CP, Rao S, Patole S. Outcomes of very preterm infants with hyperglycaemia treated with insulin: A systematic review and meta-analysis. Acta Paediatr 2023; 112:1157-1164. [PMID: 36895111 DOI: 10.1111/apa.16748] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/23/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023]
Abstract
AIM To study the outcomes of very preterm infants with hyperglycaemia treated with Insulin. METHODS This is a systematic review of randomised controlled trials (RCTs) and observational studies. PubMed, Medline, EMBASE, Cochrane Library, EMCARE and MedNar databases were searched in May 2022. Data were pooled separately for adjusted and unadjusted odds ratios (ORs) using random-effects model. MAIN OUTCOME MEASURES Mortality and morbidities (e.g. Necrotising enterocolitis [NEC], retinopathy of prematurity [ROP]) in very preterm (<32 weeks) or very low birth weight infants (<1500 g) after treatment of hyperglycaemia with insulin. RESULTS Sixteen studies with data from 5482 infants were included. Meta-analysis of unadjusted ORs from cohort studies showed that insulin treatment was significantly associated with increased mortality [OR 2.98 CI (1.03 to 8.58)], severe ROP [OR 2.23 CI (1.34 to 3.72)] and NEC [OR 2.19 CI (1.11 to 4)]. However, pooling of adjusted ORs did not show significant associations for any outcomes. The only included RCT found better weight gain in the insulin group, but no effect on mortality or morbidities. Certainty of evidence was 'Low' or 'Very low'. CONCLUSION Very low certainty evidence suggests that Insulin therapy may not improve outcomes of very preterm infants with hyperglycaemia.
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Affiliation(s)
- Nital Patidar
- Paediatrics, Armadale General Hospital, Armadale, Western Australia, 6112, Australia
| | - Chandra Prakash Rath
- Neonatalogy, King Edward Memorial Hospital, Subiaco, Western Australia, 6008, Australia
- Neonatal, Perth Children's Hospital, Nedland, Western Australia, 6009, Australia
| | - Shripada Rao
- Neonatal, Perth Children's Hospital, Nedland, Western Australia, 6009, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Sanjay Patole
- Neonatalogy, King Edward Memorial Hospital, Subiaco, Western Australia, 6008, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Rath CP, Shivamallappa M, Muthusamy S, Rao SC, Patole S. Outcomes of very preterm infants with neonatal hyperglycaemia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:269-280. [PMID: 34330757 DOI: 10.1136/archdischild-2020-321449] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/15/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore the association between hyperglycaemia and adverse outcomes in very preterm infants. DESIGN Systematic review and meta-analysis. Data were pooled separately for adjusted and unadjusted odds ratios (ORs) using random-effects model. Subgroup analysis was conducted based on study design (cohort and case control). MAIN OUTCOME MEASURES Association between hyperglycaemia in preterm neonates (<32 weeks or <1500 g) and mortality and morbidities. FINDINGS Forty-six studies (30 cohort and 16 case control) with data from 34 527 infants were included. Meta-analysis of unadjusted ORs from cohort studies found hyperglycaemia to be significantly associated with mortality, any-grade intraventricular haemorrhage (IVH), severe IVH, any-stage retinopathy of prematurity (ROP), severe ROP, sepsis, chronic lung disease and disability. However, pooling of adjusted ORs found significant associations only for mortality (adjusted OR (CI): 2.37 (1.40 to 4.01); I2: 36%; 6 studies), 'Any grade IVH' (adjusted OR (CI): 2.60 (1.09 to 6.20); I2: 0%; 2 studies) and 'Any stage ROP' (adjusted OR (CI): 3.70 (1.55 to 8.84); I2: 0%; 2 studies). Meta-regression analysis found glucose levels >10 mmol/L to be associated with increased odds of mortality compared with <10 mmol/L. Pooled analysis from case-control studies were similar to cohort studies for most outcomes but limited by small sample size. Longer duration of hyperglycaemia was associated with adverse outcomes. GRADE of evidence was 'Low' or 'Very low'. CONCLUSION Hyperglycaemia in very preterm infants is associated with higher odds of mortality, any-grade IVH and any-stage ROP. A limitation was lack of availability of adjusted ORs from many of the included studies. PROSPERO REGISTRATION NUMBER CRD42020193016.
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Affiliation(s)
- Chandra Prakash Rath
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Madhusudhan Shivamallappa
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Saravanan Muthusamy
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Shripada C Rao
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia .,Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,School of Medicine, University of Western Australia, Crawley, Western Australia
| | - Sanjay Patole
- Neonatology, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia.,School of Medicine, University of Western Australia, Crawley, Western Australia
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6
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Perri A, Tiberi E, Giordano L, Sbordone A, Patti ML, Iannotta R, Pianini T, Cota F, Maggio L, Vento G. Strict glycaemic control in very low birthweight infants using a continuous glucose monitoring system: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2022; 107:26-31. [PMID: 34039690 DOI: 10.1136/archdischild-2020-320540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 04/04/2021] [Accepted: 04/20/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a strict glycaemic control protocol using a continuous glucose monitoring (CGM) in infants at high risk of dysglycaemia with the aim of reducing the number of dysglycaemic episodes. DESIGN Randomised controlled trial. SETTING Neonatal intensive care unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome. PATIENTS All infants <1500 g fed on parental nutrition (PN) since birth were eligible. A total of 63 infants were eligible and 48 were randomised. INTERVENTION All participants wore a CGM sensor and were randomised in two arms with alarms set at different cut-off values (2.61-10 mmol/L (47-180 mg/dL) vs 3.44-7.78 mmol/L (62-140 mg/dL)), representing the operative threshold requiring modulation of glucose infusion rate according to an innovative protocol. MAIN OUTCOME MEASURES The primary outcome was the number of severe dysglycaemic episodes (<2.61 mmol/L (47 mg/dL) or >10 mmol/L (180 mg/dL)) in the intervention group versus the control group, during the monitoring time. RESULTS We enrolled 47 infants, with similar characteristics between the two arms. The number of dysglycaemic episodes and of infants with at least one episode of dysglycaemia was significantly lower in the intervention group (strict group): respectively, 1 (IQR 0-2) vs 3 (IQR 1-7); (p=0.005) and 12 (52%) vs 20 (83%); p=0.047. Infants managed using the strict protocol had a higher probability of having normal glycaemic values: relative risk 2.87 (95% CI 1.1 to 7.3). They spent more time in euglycaemia: 100% (IQR 97-100) vs 98% (IQR 94-99), p=0.036. The number needed to treat to avoid dysglycaemia episodes is 3.2 (95% CI 1.8 to 16.6). CONCLUSION We provide evidence that CGM, combined with a protocol for adjusting glucose infusion, can effectively reduce the episodes of dysglycaemia and increase the percentage of time spent in euglycaemia in very low birthweight infants receiving PN in the first week of life.
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Affiliation(s)
- Alessandro Perri
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy
| | - Eloisa Tiberi
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy
| | - Lucia Giordano
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy
| | - Annamaria Sbordone
- Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy
| | - Maria Letizia Patti
- Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy
| | - Rossella Iannotta
- Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy.,Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Rome, Italy
| | - Teresa Pianini
- Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy.,Neonatology and Neonatal Intensive Care Department, Policlinico Casilino General Hospital, Rome, Italy
| | - Francesco Cota
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy.,Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy
| | - Luca Maggio
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy.,Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy
| | - Giovanni Vento
- Child Health Area, University Hospital Agostino Gemelli Department of Woman and Child Health Sciences, Rome, Lazio, Italy.,Department of Woman and Child Health Sciences, Child Health Area, Catholic University of the Sacred Heart Seat of Rome, Rome, Lazio, Italy
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Perinatal complications and maximising lamb survival in an adolescent paradigm characterised by premature delivery and low birthweight. PLoS One 2021; 16:e0259890. [PMID: 34780509 PMCID: PMC8592415 DOI: 10.1371/journal.pone.0259890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
The competition for nutrients in overnourished and still-growing adolescent sheep negatively impacts gestation length, colostrum supply and lamb birthweight, all of which may affect neonatal morbidity and survival to weaning. Herein perinatal complications and the requirement for supplementary feeding were analysed in relation to gestational-intake, and the degree of premature delivery and prenatal growth-restriction exhibited. Pregnancies were established by embryo transfer and the mean/standard deviation (SD) gestation length and birthweight of the optimally-fed control group (n = 100) was used to define early delivery and reduced birthweight categories (1.5 and 3.0 SDs below the control mean for each aspect). Control lambs were largely delivered at term (94%), and had a normal birthweight (92%), while very preterm (≤139days, 18.5%) and preterm delivery (140-142days, 54.8%), extremely low birthweight (ELBW; females ≤2838g and males ≤3216g, 21.1%) and low birthweight (LBW; females 2839 to ≤4001g and males 3217 to ≤4372g, 32.2%), were common in the overnourished group (n = 270, P<0.001). Accordingly, overnourished dams were more likely to lamb without assistance while the incidence of major dystocia was greater in controls. Initial lamb vigour at birth was independent of gestational-intake, delivery or birthweight category but both ELBW and very premature lambs required more assistance with feeding in the first 24h postnatal, primarily reflecting low colostrum availability. Indeed, relative to normal, ELBW lambs had a greater risk of experiencing mismothering, and enhanced likelihood of requiring supplementary feeding throughout the neonatal period (P<0.001). ELBW lambs also had a greater possibility of respiratory issues at birth (P<0.01) and renal complications (P<0.001), while very preterm delivery was associated with an increased risk of gastrointestinal tract problems (P<0.01). In spite of these complications, all-cause mortality was low (5.4%) suggesting that our proactive neonatal care regime can overcome many of the issues associated with extreme prematurity and low birthweight.
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8
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Abstract
Hyperglycemia after birth is common in extremely preterm infants (<28 weeks of gestation). Lower gestational age, lower birthweight, presence of severe illness, and higher parenteral glucose intake increase the risk for hyperglycemia, while provision of higher amounts of amino acids and lipids in parenteral nutrition and early initiation and faster achievement of full enteral feeding decrease the risk. Hyperglycemia is associated with increased mortality and morbidity in the neonatal period. Limited data show an association with long-term adverse effects on growth, neurodevelopment, and cardiovascular and metabolic health. Lowering the glucose infusion rate and administration of insulin are the 2 treatment options. Lowering the glucose infusion could lead to calorie deficits and long-term adverse effects on growth and neurodevelopment. Conversely, insulin use increases the risk for hypoglycemia and requires close blood glucose monitoring and frequent adjustments to glucose infusion and insulin dosage. Randomized trials of varying strategies of nutrient provision and/or insulin therapy and long-term follow-up are needed to improve clinical care and overall health of extremely preterm infants with hyperglycemia.
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Affiliation(s)
- Sara Ramel
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN
| | - Raghavendra Rao
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN.,Center for Neurobehavioral Development, University of Minnesota, Minneapolis, MN
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9
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Beardsall K, Thomson L, Elleri D, Dunger DB, Hovorka R. Feasibility of automated insulin delivery guided by continuous glucose monitoring in preterm infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:279-284. [PMID: 31399480 PMCID: PMC7363782 DOI: 10.1136/archdischild-2019-316871] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/08/2019] [Accepted: 07/08/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Closed-loop systems have been used to optimise insulin delivery in children with diabetes, but they have not been tested in neonatal intensive care. Extremely preterm infants are prone to hyperglycaemia and hypoglycaemia; both of which have been associated with adverse outcomes. Insulin sensitivity is notoriously variable in these babies and glucose control is time-consuming, with management requiring frequent changes of dextrose-containing fluids and careful monitoring of insulin treatment. We aimed to evaluate the feasibility of closed-loop management of glucose control in these infants. DESIGN AND SETTING Single-centre feasibility study with a randomised parallel design in a neonatal intensive care unit. Eligibility criteria included birth weight <1200 g and <48 hours of age. All infants had subcutaneous continuous glucose monitoring for the first week of life, with those in the intervention group receiving closed-loop insulin delivery in a prespecified window, between 48 and 72 hours of age during which time the primary outcome was percentage of time in target (sensor glucose 4-8 mmol/L). RESULTS The mean (SD) gestational age and birth weight of intervention and control study arms were 27.0 (2.4) weeks, 962 (164) g and 27.5 (2.8) weeks, 823 (282) g, respectively, and were not significantly different. The time in target was dramatically increased from median (IQR) 26% (6-64) with paper guidance to 91% (78-99) during closed loop (p<0.001). There were no serious adverse events and no difference in total insulin infused. CONCLUSIONS Closed-loop glucose control based on subcutaneous glucose measurements appears feasible as a potential method of optimising glucose control in extremely preterm infants.
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Affiliation(s)
- Kathryn Beardsall
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, UK
- Neonatal Unit, Cambridge University Hospitals NHS Trust, Cambridge
| | - Lynn Thomson
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, UK
| | - Daniela Elleri
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, UK
| | - David B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, UK
| | - Roman Hovorka
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, Cambridgeshire, UK
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10
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Effects of preterm birth induced with or without exogenous glucocorticoids on the ovine glucose-insulin axis. J Dev Orig Health Dis 2020; 12:58-70. [PMID: 31937391 DOI: 10.1017/s2040174419000916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antenatal exogenous glucocorticoids (ANG) are standard management for women at risk of preterm birth but are reputed to impair glucose tolerance in preterm offspring. We compared lambs born preterm (137 days gestation) following labour induced with exogenous glucocorticoids (G-Prem, glucocorticoid-induced preterm group), or with a progesterone synthesis inhibitor (NG-Prem, non-glucocorticoid-induced preterm group), with term-born lambs (Term; 149 days). We assessed glucose tolerance, insulin secretion and sensitivity at 4 and 10 months n = 11-14/group) and pancreatic and hepatic gene and protein expression at 4 weeks post-term (4 weeks; n = 6/group) and 12 months (12 months; n = 12-13/group). NG-Prem had higher plasma glucose concentrations than G-Prem, but not Term, at 4 months (Mean[SEM] mM: NG-Prem = 4.1[0.1]; G-Prem = 3.4[0.1]; Term = 3.7[0.1]; p = 0.003) and 10 months (NG-Prem = 3.9[0.1]; G-Prem = 3.5[0.1]; Term = 3.7[0.1]; p = 0.01). Insulin sensitivity decreased from 4 to 10 months, in NG-Prem but not in Term (Mean[SEM] µmol·ml-1·kg-1·min-1·ng-1, 4 vs. 10 months: NG-Prem = 18.7[2.5] vs. 9.5[1.5], p < 0.01; Term: 12.1[2.8] vs. 10.4[1.5], p = 0.44). At 12 months, β-cell mass in NG-Prem was reduced by 30% vs. G-Prem (p < 0.01) and 75% vs. Term (p < 0.01) and was accompanied by an increased β-cell apoptosis: proliferation ratio at 12 months. At 12 months, pancreatic glucokinase, igf2 and insulin mRNA levels were reduced 21%-71% in NG-Prem vs. G-Prem and 42%-80% vs. Term. Hepatic glut2 mRNA levels in NG-Prem were 250% of those in G-Prem and Term. Thus, induction of preterm birth without exogenous glucocorticoids more adversely affected pancreas and liver than induction with exogenous glucocorticoids. These findings do not support that ANG lead to long-term adverse metabolic effects, but support an effect of preterm birth itself.
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11
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Abstract
Hypoglycaemia and hyperglycaemia are common in infants requiring intensive care and are associated with worse clinical outcomes. However, glucose levels are taken infrequently, and there remains controversy regarding optimal management. In adults and children continuous glucose monitoring (CGM) is now established as an important adjunct to caring for patients at risk from dysglycaemia. This technology is also increasingly providing insights into glucose regulation in the newborn, demonstrating significant periods of clinically silent hypoglycaemia and hyperglycaemia. This baseline data will be important to allow the significance of glucose dysregulation on long-term outcomes to be assessed. Small studies have also shown the potential for CGM to safely support targeting of glucose control in preterm infants, and a large multicentre trial is ongoing. Current technology is not specifically designed for use in NICU, but with rapid technological developments, CGM holds promise for the future care of babies in NICU.
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12
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Alsweiler JM, Bloomfield FH, Harding JE. Early-Stage Translational Research in Perinatal Medicine. Neonatology 2019; 115:182-188. [PMID: 30522108 DOI: 10.1159/000493004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/20/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pre-clinical research, which encompasses studies in animals and in the laboratory, has made significant contributions to the improvement of neonatal outcomes. METHODS Here, we describe examples of how pre-clinical research can be the starting point on the journey to the development of new interventions to improve neonatal care and outcomes and discuss recent progress in ensuring methodological and ethical rigour in pre-clinical research involving animal models. RESULTS Studies in pregnant sheep led to the serendipitous discovery that preterm lambs born after exogenous corticosteroid exposure were able to aerate their lungs. Subsequent clinical trials confirmed that antenatal corticosteroids given to women at risk of preterm delivery substantially reduce mortality and morbidity in babies born preterm. Animal research also contributed to discoveries in the mechanism of brain injury after hypoxic ischaemic encephalopathy, leading to the use of therapeutic hypothermia as an effective treatment. However, animals are sentient creatures and there are significant ethical concerns with their use in studies to benefit human health. Mandated institutional animal research ethics committees ensure adherence to ethical requirements. To provide high-quality data which can be translated into clinical research, pre-clinical research needs to follow rigorous standards of study design and reporting. The ARRIVE guidelines provide guidance for pre-clinical research similar to that provided in the CONSORT guidelines for clinical trials and are gaining acceptance among researchers and journal editors. CONCLUSION Improved scientific rigour in the use of animal research will increase the likelihood that pre-clinical research will continue to translate into improved neonatal outcomes.
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Affiliation(s)
- Jane Marie Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Bloomfield FH. Impact of prematurity for pancreatic islet and beta-cell development. J Endocrinol 2018; 238:R161-R171. [PMID: 29895718 DOI: 10.1530/joe-18-0021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/12/2018] [Indexed: 12/22/2022]
Abstract
As increasing numbers of babies born preterm survive into adulthood, it is becoming clear that, in addition to the well-described risks of neurodevelopmental sequelae, there also are increased risks for non-communicable diseases, including diabetes. Epidemiological studies indicate that risks are increased even for birth at late preterm and early term gestations and for both type 1 and type 2 diabetes. Thus, factors related to preterm birth likely affect development of the fetal and neonatal beta-cell in addition to effects on peripheral insulin sensitivity. These factors could operate prior to preterm birth and be related to the underlying cause of preterm birth, to the event of being born preterm itself, to the postnatal care of the preterm neonate or to a combination of these exposures. Experimental evidence indicates that factors may be operating during all these critical periods to contribute to altered development of beta-cell mass in those born preterm. Greater understanding of how these factors impact upon development of the pancreas may lead to interventions or management approaches that mitigate the increased risk of later diabetes.
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Relationships Between Early Nutrition and Blood Glucose Concentrations in Very Preterm Infants. J Pediatr Gastroenterol Nutr 2018; 66:960-966. [PMID: 29481441 DOI: 10.1097/mpg.0000000000001929] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study was to determine whether changes to early nutrition are associated with levels of glycemia in very preterm infants. METHODS A retrospective, observational study of infants <1500 g or <30 weeks' gestation admitted to Neonatal Intensive Care, National Women's Hospital, New Zealand, before (Old Protocol) and after (New Protocol) a change in nutritional protocol. Nutritional intakes were calculated and averaged by day for postnatal days 1 to 7 (week 1) and 1 to 28 (month 1). Relationships between glycemia measures, macronutrient intakes, and achievement of 10% enteral feeds (≥10% total intake) were explored using logistic regression. RESULTS Old Protocol (n = 190) and New Protocol (n = 267) groups had similar baseline characteristics. In week 1, New Protocol infants received more protein, less fat, and carbohydrate, had lower mean blood glucose concentrations (BGCs) (mean ± SD 4.9 ± 1.2 vs 5.6 ± 1.4 mmoll/L, P < 0.0001), less hyperglycemia (BGC > 8.5 mmol/L, 71 [27%] vs 80 [42%], P = 0.0005), but similar hypoglycemia (BGC < 2.6). In month 1, New Protocol infants also had less hyperglycemia (105 [39%] vs 96 [51%], P = 0.02) and lower mean BGC (5.0 ± 1.1 vs 5.5 ± 1.1 mmol/L, P < 0.0001), but insulin usage was similar. After adjustment for birth weight z score and gestational age, hyperglycemia was significantly associated with week 1 intakes (g · kg · day) of protein (odds ratio [95% confidence intervals] 0.47 [0.23-0.79], P = 0.004), fat (0.54 [0.40-0.74], P < 0.0001), and carbohydrate (1.25 [1.09-1.44], P < 0.0001). These relationships were similar for month 1. Each additional day to achieve 10% enteral feeds was associated with increased odds of hypoglycemia (1.09 [1.00-1.18], P = 0.04) and hyperglycemia (1.16 [1.06-1.28], P = 0.002). CONCLUSIONS In very preterm infants, macronutrient balance and small, early enteral feeds may assist glycemic control.
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McKinlay CJ, Chase JG, Dickson J, Harris DL, Alsweiler JM, Harding JE. Continuous glucose monitoring in neonates: a review. Matern Health Neonatol Perinatol 2017; 3:18. [PMID: 29051825 PMCID: PMC5644070 DOI: 10.1186/s40748-017-0055-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/24/2017] [Indexed: 12/17/2022] Open
Abstract
Continuous glucose monitoring (CGM) is well established in the management of diabetes mellitus, but its role in neonatal glycaemic control is less clear. CGM has provided important insights about neonatal glucose metabolism, and there is increasing interest in its clinical use, particularly in preterm neonates and in those in whom glucose control is difficult. Neonatal glucose instability, including hypoglycaemia and hyperglycaemia, has been associated with poorer neurodevelopment, and CGM offers the possibility of adjusting treatment in real time to account for individual metabolic requirements while reducing the number of blood tests required, potentially improving long-term outcomes. However, current devices are optimised for use at relatively high glucose concentrations, and several technical issues need to be resolved before real-time CGM can be recommended for routine neonatal care. These include: 1) limited point accuracy, especially at low or rapidly changing glucose concentrations; 2) calibration methods that are designed for higher glucose concentrations of children and adults, and not for neonates; 3) sensor drift, which is under-recognised; and 4) the need for dynamic and integrated metrics that can be related to long-term neurodevelopmental outcomes. CGM remains an important tool for retrospective investigation of neonatal glycaemia and the effect of different treatments on glucose metabolism. However, at present CGM should be limited to research studies, and should only be introduced into routine clinical care once benefit is demonstrated in randomised trials.
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Affiliation(s)
- Christopher J.D. McKinlay
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - J. Geoffrey Chase
- Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Dickson
- Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Deborah L. Harris
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Neonatal Intensive Care Unit, Waikato District Health Board, Hamilton, New Zealand
| | - Jane M. Alsweiler
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Private Bag 92019, Victoria St West, Auckland, 1142 New Zealand
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Tottman AC, Alsweiler JM, Bloomfield FH, Pan M, Harding JE. Relationship between Measures of Neonatal Glycemia, Neonatal Illness, and 2-Year Outcomes in Very Preterm Infants. J Pediatr 2017. [PMID: 28647271 DOI: 10.1016/j.jpeds.2017.05.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To investigate relationships between early neonatal glycemia, neonatal characteristics, neonatal illness, and developmental outcomes in very preterm infants. STUDY DESIGN A retrospective, observational cohort study of 443 infants born weighing <1500 g or <30 weeks of gestation, and admitted within 24 hours to National Women's Hospital, Auckland, New Zealand. Glucose variability was defined as the standard deviation around the mean after log transformation of all blood glucose concentrations. Absolute glycemic excursions in the first week were used to divide the infants into 4 groups: normoglycemic; hypoglycemic; hyperglycemic, and unstable. RESULTS Compared with normoglycemic infants, hypoglycemic and unstable infants had lower birth weight z-scores, and hyperglycemic and unstable infants were of lower birth weight. Hypoglycemic infants had similar outcomes to normoglycemic infants. Hyperglycemic and unstable infants were less likely to survive without neonatal morbidity and less likely to survive without neurodevelopmental impairment at 2 years of age. Higher mean blood glucose concentration was seen in the hyperglycemic and unstable groups, and was associated with worse neonatal and 2-year outcomes. Greater glucose variability was seen in the hypoglycemic and unstable groups, and was associated with worse neonatal illness but not outcome at 2 years. No associations between measures of neonatal glycemia and neonatal or 2-year outcomes remained after correction for gestation, birth weight z-score, and socioeconomic status. CONCLUSIONS In very preterm infants, measures of neonatal glycemia are markers of gestational age and intrauterine growth, and are not independent predictors of neonatal illness or outcomes at 2 years of age.
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Affiliation(s)
| | - Jane Marie Alsweiler
- Department of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand; National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Frank Harry Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand; National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Maggie Pan
- Department of Pediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Harding JE, Cormack BE, Alexander T, Alsweiler JM, Bloomfield FH. Advances in nutrition of the newborn infant. Lancet 2017; 389:1660-1668. [PMID: 28443560 DOI: 10.1016/s0140-6736(17)30552-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 01/07/2023]
Abstract
Nutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. New developments include recommendations to increase protein supply, improve formulations of parenteral lipids, and provide mineral supplements while encouraging human milk feeding. However, high quality evidence of the risks and benefits of these developments is lacking. Clinical trials are also needed to assess the effect on preterm infants of experiencing the smell and taste of milk, to determine whether boys and girls should be fed differently, and to test effects of insulin and IGF-1 supplements on growth and developmental outcomes. Moderate-to-late preterm infants have neonatal nutritional challenges that are similar to those infants born at earlier gestations, but even less high quality evidence exists upon which to base clinical decisions. The focus of research in nutrition of infants born at term is largely directed at new formula products that will improve cognitive and metabolic outcomes. Providing the most effective nutrition to preterm infants should be prioritised as an important focus of neonatal care research to improve long-term metabolic and developmental outcomes.
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Affiliation(s)
- Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Barbara E Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand; Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Tanith Alexander
- Liggins Institute, University of Auckland, Auckland, New Zealand; Neonatal Unit, Middlemore Hospital, Auckland, New Zealand
| | - Jane M Alsweiler
- Liggins Institute, University of Auckland, Auckland, New Zealand; Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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Neonatal milk supplementation in lambs has persistent effects on growth and metabolic function that differ by sex and gestational age. Br J Nutr 2016; 116:1912-1925. [DOI: 10.1017/s0007114516004013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractThe perinatal environment has a major influence on long-term health and disease risk. Preterm birth alters early-life environment and is associated with altered metabolic function in adulthood. Whether preterm birthper seor the early nutritional interventions used to support growth in preterm infants underpins this association is unknown. Lambs born preterm, following dexamethasone induction of labour, or spontaneously at term were randomised to receive nutrient supplementation, analogous to the milk fortifier used clinically or water as a control for the first 2 weeks after birth. Thereafter, nutrition was not different between groups. Growth was monitored, and the glucose–insulin axis function was assessed in juvenile (4 months) and adult life (14 months). Early nutrition influenced adult metabolic function and body composition to a greater extent than preterm birth. In supplemented females, arginine-stimulated insulin secretion was increased in preterm but reduced in term-born juveniles compared with controls (repeated-measures ANOVAP<0·01). In supplemented preterm males, adult weight, ponderal index (PI) and fasting insulin concentrations were elevated compared with preterm controls (weight, 75 (sem3)v. 69 (sem2) kg; PI, 48·0 (sem2·1)v. 43·7 (sem1·7) kg/m3; fasting insulin, 0·19 (sem0·02)v. 0·10 (sem0·02) ng/ml). Conversely, supplemented term-born males had reduced adult weight, PI and fasting insulin concentrations compared with term-born controls (weight, 64 (sem2)v. 70 (sem2) kg; PI, 44·4 (sem1·8)v. 48·2 (sem1·7) kg/m3; fasting insulin, 0·09 (sem0·02)v. 0·14 (sem0·02) ng/ml; all group×supplement interactionsP<0·05). Adult metabolic health may reflect both gestational age at birth and early nutrition. Human studies are urgently needed to investigate the adult sex-specific health implications of neonatal nutritional strategies.
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Shorten PR, Pleasants AB, Buckels EJ, Jaquiery AL, Boston RC, Alsweiler JM. Determining insulin sensitivity from glucose tolerance tests in sheep1. J Anim Sci 2016; 94:3711-3721. [DOI: 10.2527/jas.2016-0521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- Sean W Limesand
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona 85719
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Bansal A, Bloomfield FH, Connor KL, Dragunow M, Thorstensen EB, Oliver MH, Sloboda DM, Harding JE, Alsweiler JM. Glucocorticoid-Induced Preterm Birth and Neonatal Hyperglycemia Alter Ovine β-Cell Development. Endocrinology 2015. [PMID: 26204462 DOI: 10.1210/en.2015-1095] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Adults born preterm are at increased risk of impaired glucose tolerance and diabetes. Late gestation fetuses exposed to high blood glucose concentration also are at increased risk of impaired glucose tolerance as adults. Preterm babies commonly become hyperglycemic and are thus exposed to high blood glucose concentration at an equivalent stage of pancreatic maturation. It is not known whether preterm birth itself, or complications of prematurity, such as hyperglycemia, alter later pancreatic function. To distinguish these, we made singleton preterm lambs hyperglycemic (HYPER) for 12 days after birth with a dextrose infusion and compared them with vehicle-treated preterm and term controls and with HYPER lambs made normoglycemic with an insulin infusion. Preterm birth reduced β-cell mass, apparent by 4 weeks after term and persisting to adulthood (12 mo), and was associated with reduced insulin secretion at 4 months (juvenile) and reduced insulin mRNA expression in adulthood. Hyperglycemia in preterm lambs further down-regulated key pancreatic gene expression in adulthood. These findings indicate that reduced β-cell mass after preterm birth may be an important factor in increased risk of diabetes after preterm birth and may be exacerbated by postnatal hyperglycemia.
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Affiliation(s)
- Amita Bansal
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Frank H Bloomfield
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Kristin L Connor
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Mike Dragunow
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Eric B Thorstensen
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Mark H Oliver
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Deborah M Sloboda
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Jane E Harding
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
| | - Jane M Alsweiler
- Liggins Institute (A.B., F.H.B., K.L.C., E.B.T., M.H.O., D.M.S., J.E.H., J.M.A.), Department of Paediatrics: Child and Youth Health (F.H.B., J.M.A.), Faculty of Medical and Health Sciences, and Centre of Brain Research (M.D.), Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand; and Gravida: National Centre for Growth and Development (A.B., F.H.B., K.L.C., M.D., M.H.O., D.M.S.), Auckland 1023, New Zealand
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