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Lagacé M, Tam EWY. Neonatal dysglycemia: a review of dysglycemia in relation to brain health and neurodevelopmental outcomes. Pediatr Res 2024:10.1038/s41390-024-03411-0. [PMID: 38972961 DOI: 10.1038/s41390-024-03411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/09/2024]
Abstract
Neonatal dysglycemia has been a longstanding interest of research in neonatology. Adverse outcomes from hypoglycemia were recognized early but are still being characterized. Premature infants additionally introduced and led the reflection on the importance of neonatal hyperglycemia. Cohorts of infants following neonatal encephalopathy provided further information about the impacts of hypoglycemia and, more recently, highlighted hyperglycemia as a central concern for this population. Innovative studies exposed the challenges of management of neonatal glycemic levels with a "u-shape" relationship between dysglycemia and adverse neurological outcomes. Lately, glycemic lability has been recognized as a key factor in adverse neurodevelopmental outcomes. Research and new technologies, such as MRI and continuous glucose monitoring, offered novel insight into neonatal dysglycemia. Combining clinical, physiological, and epidemiological data allowed the foundation of safe operational definitions, including initiation of treatment, to delineate neonatal hypoglycemia as ≤47 mg/dL, and >150-180 mg/dL for neonatal hyperglycemia. However, questions remain about the appropriate management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to continue to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes. IMPACT STATEMENT: Safe operational definitions guide the initiation of treatment of neonatal hypoglycemia and hyperglycemia. Innovative studies exposed the challenges of neonatal glycemia management with a "u-shaped" relationship between dysglycemia and adverse neurological outcomes. The importance of glycemic lability is also being recognized. However, questions remain about the optimal management of neonatal dysglycemia to optimize neurodevelopmental outcomes. Research collaborations and clinical trials with long-term follow-up and advanced use of evolving technologies will be necessary to progress the fascinating world of neonatal dysglycemia and neurodevelopment outcomes.
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Affiliation(s)
- Micheline Lagacé
- Faculty of Medicine, Clinician Investigator Program, University of British Columbia, Vancouver, BC, Canada
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Emily W Y Tam
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Neurosciences and Mental Health, SickKids Research Institute, Toronto, ON, Canada.
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Guiducci S, Res G, Bonadies L, Savio F, Brigadoi S, Priante E, Trevisanuto D, Baraldi E, Galderisi A. Impact of macronutrients intake on glycemic homeostasis of preterm infants: evidence from continuous glucose monitoring. Eur J Pediatr 2024; 183:3013-3018. [PMID: 38637447 PMCID: PMC11192807 DOI: 10.1007/s00431-024-05532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/22/2024] [Accepted: 03/17/2024] [Indexed: 04/20/2024]
Abstract
Nutritional intake could influence the blood glucose profile during early life of preterm infants. We investigated the impact of macronutrient intake on glycemic homeostasis using continuous glucose monitoring (CGM). We analyzed macronutrient intake in infants born ≤ 32 weeks gestational age (GA) and/or with birth weight ≤ 1500 g. CGM was started within 48 h of birth and maintained for 5 days. Mild and severe hypoglycemia were defined as sensor glucose (SG) < 72 mg/dL and <47 mg/dL, respectively, while mild and severe hyperglycemia were SG > 144 mg/dL and >180 mg/dL. Data from 30 participants were included (age 29.9 weeks (29.1; 31.2), birthweight 1230.5 g (1040.0; 1458.6)). A reduced time in mild hypoglycemia was associated to higher amino acids intake (p = 0.011) while increased exposure to hyperglycemia was observed in the presence of higher lipids intake (p = 0.031). The birthweight was the strongest predictor of neonatal glucose profile with an inverse relationship between the time spent in hyperglycemia and birthweight (p = 0.007). Conclusions: Macronutrient intakes influence neonatal glucose profile as described by continuous glucose monitoring. CGM might contribute to adjust nutritional intakes in preterm infants. What is Known: • Parenteral nutrition may affect glucose profile during the first days of life of preterm infants. What is New: • Continuous glucose monitoring describes the relationship between daily parenteral nutrient intakes and time spent in hypo and hyperglycemic ranges.
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Affiliation(s)
- Silvia Guiducci
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | - Giulia Res
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | - Luca Bonadies
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | - Federica Savio
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | - Sabrina Brigadoi
- Department of Developmental and Social Psychology, University of Padua, Padua, Veneto, Italy
| | - Elena Priante
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | | | - Eugenio Baraldi
- Department of Woman and Child's Health, University of Padua, Padua, Italy
- Institute for Pediatric Research (IRP), Padua, Veneto, Italy
| | - Alfonso Galderisi
- Department of Woman and Child's Health, University of Padua, Padua, Italy.
- Institute for Pediatric Research (IRP), Padua, Veneto, Italy.
- Department of Pediatrics, Pediatric Endocrinology, Yale University, 333 Cedar Street, LMP3107-06520, New Haven, CT, USA.
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Morgan C, Parry S, Park J, Tan M. Neurodevelopmental Outcome in Very Preterm Infants Randomised to Receive Two Different Standardised, Concentrated Parenteral Nutrition Regimens. Nutrients 2023; 15:4741. [PMID: 38004135 PMCID: PMC10674254 DOI: 10.3390/nu15224741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
We have previously shown that increasing parenteral protein (target: 3.8 versus 2.8 g/kg/d) and energy (12% versus 10% glucose; 3.8 versus 2.8 g/kg/d) intake using a Standardised, Concentrated with Added Macronutrients Parenteral (SCAMP) nutrition regimen ameliorates early head growth failure in very-preterm infants (VPIs). We hypothesised that the SCAMP nutrition regimen would also improve neurodevelopmental outcome. The original double-blind randomised, controlled study (ISRCTN: 76597892) received ethical approval. VPIs were randomised to either start SCAMP or remain on the control regimen. The consent process included neurodevelopmental assessments (Bayley III), all of which were performed (blinded) at 2-3.5 years of corrected gestational age. Bayley III assessments were performed for 38/60 SCAMP survivors and 41/63 control survivors at means of (sd) 29.2 (3.7) and 20.0 (3.9) months, respectively. Motor, cognitive, language, and combined scores were all higher in the SCAMP intervention group, but none of the differences were statistically significant. Nutrient intake and biochemical monitoring data confirmed that protein/energy ratios were maintained in the SCAMP intervention group without increasing the incidence of hyperglycaemia, insulin treatment, or the derangement of plasma mineral/electrolyte levels. This study did not show a statistically significant improvement in neurodevelopmental outcome when administering higher parenteral protein/energy intakes despite optimal energy and mineral intakes.
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Affiliation(s)
- Colin Morgan
- Liverpool Women’s Hospital, Liverpool L8 7SS, UK
| | - Samantha Parry
- Liverpool Women’s Hospital, Liverpool L8 7SS, UK
- Alder Hey Children’s Hospital, Liverpool L14 5AB, UK
| | - Julie Park
- Alder Hey Children’s Hospital, Liverpool L14 5AB, UK
| | - Maw Tan
- Alder Hey Children’s Hospital, Liverpool L14 5AB, UK
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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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Guiducci S, Meggiolaro L, Righetto A, Piccoli M, Baraldi E, Galderisi A. Neonatal Hyperglycemia and Neurodevelopmental Outcomes in Preterm Infants: A Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101541. [PMID: 36291477 PMCID: PMC9600957 DOI: 10.3390/children9101541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/29/2022] [Accepted: 10/08/2022] [Indexed: 12/05/2022]
Abstract
Glucose impairment is common in preterm infants but the impact of early neonatal hyperglycemia on long term neurodevelopment is still highly controversial. This review reports current evidence of the effect of hyperglycemia on neurodevelopmental outcome. It was conducted according to the PRISMA guidelines. We searched MEDLINE via PubMed; EMBASE via Ovid; the Cochrane Central Register of Controlled Trials; the Cochrane Library; ClinicalTrials.gov; and the World Health Organization's International Trials Registry and Platform. We included studies that investigated the association between hyperglycemia, defined as at least one episode of glycemia ≥8 mmol/L, and neurodevelopment outcome evaluated either through the Griffiths Mental Developmental Scales (GMDS) or the Bayley Scales of Infant Development (BSID) for the first 5 years of life, and the Wechsler Intelligence Scale for Children (WISC) and the Movement Assessment Battery for Children (MABC) for the following age category. We selected six studies, comprising 2226 infants in total and which included 1059 (48%) infants for whom neurodevelopment assessment was available. We found an association between hyperglycemia and neurological delay in the first two years of life, especially for motor functions; this result was confirmed in later childhood. The quality of evidence was poor; therefore, the negative influence of neonatal hyperglycemia on the neurological development of preterm infants must be investigated in further studies.
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Affiliation(s)
- Silvia Guiducci
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
- Correspondence:
| | - Leonardo Meggiolaro
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
| | - Anna Righetto
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
| | - Marco Piccoli
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
| | - Eugenio Baraldi
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
| | - Alfonso Galderisi
- Departement of Woman’s and Child’s Health, University of Padova, 35128 Padova, Italy or
- Hôpital Necker-Enfants Malades, 75015 Paris, France
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Motte-Signoret E, Saint-Martin C, Bellané-Chantelot C, Portha B, Boileau P. Glucocorticoid-Induced Hyperinsulinism in a Preterm Neonate with Inherited ABCC8 Variant. Metabolites 2022; 12:metabo12090847. [PMID: 36144251 PMCID: PMC9506278 DOI: 10.3390/metabo12090847] [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: 08/08/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 12/03/2022] Open
Abstract
Glucose homeostasis is a real challenge for extremely preterm infants (EPIs) who have both limited substrate availability and immature glucose metabolism regulation. In the first days of life, EPIs frequently develop transient glucose intolerance, which has a complex pathophysiology that associates unregulated gluconeogenesis, immature insulin secretion, and peripheral insulin resistance. In this population, glucocorticoid therapy is frequently administrated to prevent severe bronchopulmonary dysplasia. During this treatment, glucose intolerance classically increases and may lead to hyperglycemia. We report a case of neonatal hypoglycemia that was concomitant to a glucocorticoids administration, and that led to a congenital hyperinsulinism diagnosis in an EPI with a heterozygous ABCC8 variant. The variant was inherited from his mother, who had developed monogenic onset diabetes of the youth (MODY) at the age of 23. ABCC8 encodes a beta-cell potassium channel unit and causes congenital hyperinsulinism or MODY depending on the mutation location. Moreover, some mutations have been observed in the same patient to cause both hyperinsulinism in infancy and MODY in adulthood. In our case, the baby showed repeated and severe hypoglycemias, which were undoubtedly time-associated with the betamethasone intravenous administration. This hyperinsulinism was transient, and the infant has not yet developed diabetes at three years of age. We take the opportunity presented by this unusual clinical presentation to provide a review of the literature, suggesting new insights regarding the pathophysiology of the beta-pancreatic cells’ insulin secretion: glucocorticoids may potentiate basal insulin secretion in patients with ABCC8 mutation.
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Affiliation(s)
- Emmanuelle Motte-Signoret
- Department of Neonatal Intensive Care Unit, Poissy St Germain Hospital, 10 rue du Champ Gaillard, 78300 Poissy, France
- Biologie de la Reproduction, Environnement, Epigénétique et Développement (BREED), Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Versailles St Quentin University—Paris-Saclay University, 78350 Jouy-en-Josas, France
- Correspondence: ; Tel.: +331-39-27-52-40; Fax: +331-39-27-44-30
| | - Cécile Saint-Martin
- Department of Medical Genetics, Pitié-Salpêtrière Hospital, Sorbonne University, AP-HP, 75013 Paris, France
| | | | - Bernard Portha
- Unité de Biologie Fonctionnelle et Adaptive, Laboratoire B2PE, CNRS UMR 8251, Campus Grands Moulins, Université Paris Cité, 75205 Paris, France
| | - Pascal Boileau
- Department of Neonatal Intensive Care Unit, Poissy St Germain Hospital, 10 rue du Champ Gaillard, 78300 Poissy, France
- Physiologie et Physiopathologie Endocriniennes, Inserm, Paris-Saclay University, 94276 Le Kremlin-Bicêtre, France
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Yauch LM, Ennis-Czerniak K, Frey WH, Tkac I, Rao RB. Intranasal Insulin Attenuates the Long-Term Adverse Effects of Neonatal Hyperglycemia on the Hippocampus in Rats. Dev Neurosci 2022; 44:590-602. [PMID: 36041414 PMCID: PMC9928603 DOI: 10.1159/000526627] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/16/2022] [Indexed: 11/19/2022] Open
Abstract
Hyperglycemia due to relative hypoinsulinism is common in extremely preterm infants and is associated with hippocampus-mediated long-term cognitive impairment. In neonatal rats, hypoinsulinemic hyperglycemia leads to oxidative stress, altered neurochemistry, microgliosis, and abnormal synaptogenesis in the hippocampus. Intranasal insulin (INS) bypasses the blood-brain barrier, targets the brain, and improves synaptogenesis in rodent models, and memory in adult humans with Alzheimer's disease or type 2 diabetes, without altering the blood levels of insulin or glucose. To test whether INS improves hippocampal development in neonatal hyperglycemia, rat pups were subjected to hypoinsulinemic hyperglycemia by injecting streptozotocin (STZ) at a dose of 80 mg/kg i.p. on postnatal day (P) 2 and randomized to INS, 0.3U twice daily from P3-P6 (STZ + INS group), or no treatment (STZ group). The acute effects on hippocampal neurochemical profile and transcript mRNA expression of insulin receptor (Insr), glucose transporters (Glut1, Glut4, and Glut8), and poly(ADP-ribose) polymerase-1 (Parp1, a marker of oxidative stress) were determined on P7 using in vivo 1H MR spectroscopy (MRS) and qPCR. The long-term effects on the neurochemical profile, microgliosis, and synaptogenesis were determined at adulthood using 1H MRS and histochemical analysis. Relative to the control (CONT) group, mean blood glucose concentration was higher from P3 to P6 in the STZ and STZ + INS groups. On P7, MRS showed 10% higher taurine concentration in both STZ groups. qPCR showed 3-folds higher Insr and 5-folds higher Glut8 expression in the two STZ groups. Parp1 expression was 18% higher in the STZ group and normal in the STZ + INS group. At adulthood, blood glucose concentration in the fed state was higher in the STZ and STZ + INS groups. MRS showed 59% higher brain glucose concentration and histochemistry showed microgliosis in the hippocampal subareas in the STZ group. Brain glucose was normal in the STZ + INS group. Compared with the STZ group, phosphocreatine and phosphocreatine/creatine ratio were higher, and microglia in the hippocampal subareas fewer in the STZ + INS group (p < 0.05 for all). Neonatal hyperglycemia was associated with abnormal glucose metabolism and microgliosis in the adult hippocampus. INS administration during hyperglycemia attenuated these adverse effects and improved energy metabolism in the hippocampus.
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Affiliation(s)
- Lauren McClure Yauch
- Division of Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Kathleen Ennis-Czerniak
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA
| | - William H. Frey
- HealthPartners Center for Memory and Aging, HealthPartners Neurosciences, St. Paul, MN, 55130, USA
- Graduate Program in Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Ivan Tkac
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Raghavendra B. Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA
- Graduate Program in Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
- Masonic Institute for the Developing Brain, University of Minnesota, Minneapolis, MN, 55414, USA
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Abstract
This article summarizes the available evidence reporting the relationship between perinatal dysglycemia and long-term neurodevelopment. We review the physiology of perinatal glucose metabolism and discuss the controversies surrounding definitions of perinatal dysglycemia. We briefly review the epidemiology of hypoglycemia and hyperglycemia in fetal, preterm, and term infants. We discuss potential pathophysiologic mechanisms contributing to dysglycemia and its effect on neurodevelopment. We highlight current strategies to prevent and treat dysglycemia in the context of neurodevelopmental outcomes. Finally, we discuss areas of future research and the potential role of continuous glucose monitoring.
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Affiliation(s)
- Megan E Paulsen
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414.
| | - Raghavendra B Rao
- Department of Pediatrics, University of Minnesota Medical School, Academic Office Building, 2450 Riverside Avenue S AO-401, Minneapolis, MN 55454, USA; Masonic Institute for the Developing Brain, 2025 East River Parkway, Minneapolis, MN 55414
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Naseh N, Canto Moreira N, Vaz TF, Gonzalez Tamez K, Ferreira H, Kaul YF, Johansson M, Diderholm B, Ahlsson F, Ågren J, Hellström-Westas L. Early Hyperglycemia in Very Preterm Infants Is Associated with Reduced White Matter Volume and Worse Cognitive and Motor Outcomes at 2.5 Years. Neonatology 2022; 119:745-752. [PMID: 36108597 DOI: 10.1159/000524923] [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: 11/25/2021] [Accepted: 04/25/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Hyperglycemia in very preterm infants is associated with increased morbidity and mortality. We aimed to investigate potential associations between early hyperglycemia, neonatal cerebral magnetic resonance imaging (MRI), and neurodevelopment at 2.5 years. METHODS The study population included 69 infants with gestational age (GA) 22.3-31.9 weeks (n = 29 with GA <28 weeks), born 2011-2014. Plasma glucose concentrations during the first week were checked according to clinical routines. Hyperglycemia was defined as glucose concentrations above 8.3 mmol/L (150 mg/dL) and above 10 mmol/L (180 mg/dL), respectively, categorized as the highest glucose days 0-2, number of days above 8.3 and 10 mmol/L, and prolonged (yes/no) 2 days or more above 8.3 and 10 mmol/L. The MRI analysis included morphological assessment, regional brain volumes, and assessment of apparent diffusion coefficient (ADC). Neurodevelopmental impairment (NDI) developed in 13 of 67 infants with available outcomes, of which 57 were assessed with the Bayley-III. Univariate and multiple linear and logistic regressions were performed with adjustments for GA, birth weight z-scores, and illness severity expressed as days on mechanical ventilation. RESULTS Hyperglycemia above 8.3 mmol/L and 10 mmol/L was present in 47.8% and 31.9% of the infants. Hyperglycemia correlated independently with lower white matter volume, but not with other regional brain volumes, and was also associated with lower ADC values in white matter. Hyperglycemia also correlated with lower Bayley-III cognitive and motor scores in infants with GA <28 weeks, but there was no significant effect on NDI. CONCLUSION Early hyperglycemia is associated with white matter injury and poorer neurodevelopment in very preterm infants.
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Affiliation(s)
- Nima Naseh
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Nuno Canto Moreira
- Departments of Neuroradiology, Uppsala University Hospital and Karolinska University Hospital, Uppsala, Sweden
| | - Tânia F Vaz
- Faculty of Sciences, Institute of Biophysics and Biomedical Engineering, University of Lisbon, Lisbon, Portugal
| | - Karla Gonzalez Tamez
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Hugo Ferreira
- Faculty of Sciences, Institute of Biophysics and Biomedical Engineering, University of Lisbon, Lisbon, Portugal
| | | | - Martin Johansson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Barbro Diderholm
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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