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Blanco CL, Smith V, Ramel SE, Martin CR. Dilemmas in parenteral glucose delivery and approach to glucose monitoring and interpretation in the neonate. J Perinatol 2023; 43:1200-1205. [PMID: 36964206 DOI: 10.1038/s41372-023-01640-5] [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: 07/20/2022] [Revised: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/26/2023]
Abstract
Glucose control continues to be challenging for intensivists, in particular in high-risk neonates. Many factors play a role in glucose regulation including intrinsic and extrinsic factors. Optimal targets for euglycemia are debatable with uncertain short and long-term effects. Glucose measurement technology has continued to advance over the past decade; unfortunately, the availability of these advanced devices outside of research continues to be problematic. Treatment approaches should be individualized depending on etiology, symptoms, and neonatal conditions. Glucose infusions should be titrated based upon variations in organ glucose uptake, co-morbidities and postnatal development. In this article we summarize the most common dilemmas encountered in the NICU: ranges for euglycemia, physiological differences, approach for glucose measurements, monitoring and best strategies to control parenteral glucose delivery.
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Affiliation(s)
- Cynthia L Blanco
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA.
| | - Victor Smith
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Sara E Ramel
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Camilia R Martin
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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2
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Tabery K, Doležalová L, Černý M, Janota J, Zoban P, Štechová K. Feasibility and Safety of Continuous Glucose Monitoring in Infants at Risk of Hypoglycemia in a Rooming-in Setting. Fetal Pediatr Pathol 2022; 41:627-633. [PMID: 34219588 DOI: 10.1080/15513815.2021.1945716] [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] [Indexed: 10/20/2022]
Abstract
Background:Screening of neonatal hypoglycemia uses currently intermittent blood sampling. Continuous glucose monitoring (CGM) allows for tighter glucose control and better comfort for newborns and parents. CGM has previously been used in intensive care setting or blinded to clinicians. Our pilot study uses CGM in real time in rooming-in setting. Methods: CGM was attached within first two hours of life. Low glucose readings were verified to prevent overtreatment. Pairs of sensor readings and corresponding blood glucose measurements were assessed retrospectively. Neurodevelopmental evaluation was performed at 24 months. Results: 44 infants were enrolled. Three had verified hypoglycemia found due to CGM. No patient was below 2 standard deviations in any components of Bayley scales. Median scores were: Cognitive 100, language 86, motor 94. Conclusion: Use of CGM in a rooming-in environment is safe from clinical and neurodevelopmental point of view. Randomized trials are needed to evaluate superiority in longer term outcomes.
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Affiliation(s)
- Kryštof Tabery
- Department of Neonatology, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ladislava Doležalová
- Department of Clinical Psychology, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Miloš Černý
- Department of Neonatology, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan Janota
- Department of Neonatology, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Zoban
- Department of Neonatology, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Kateřina Štechová
- Department of Internal Medicine, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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Abstract
Hypoglycemia is a common condition in the newborn period. Several intrinsic and extrinsic factors play a role in the degree/duration of hypoglycemia. Multiple thresholds have been proposed as a potential point whereby hypoglycemia may have short and long-term adverse effects. Rather than a "numerical" threshold, treatment approaches should be individualized and tailored to the etiology, symptoms, and neonatal underlying conditions. Hyperglycemia in the newborn period is commonly seen in preterm infants and can exert gluco-toxic effects in organs at critical periods of development. Considering the peripheral insulin resistance (IR) of prematurity and contributing factors is key to achieving euglycemia.
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Affiliation(s)
- Cynthia L Blanco
- Division of Neonatology, Department of Pediatrics, UT Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA; Neonatology Services, University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA.
| | - Jennifer Kim
- Division of Neonatology, Department of Pediatrics, UT Health San Antonio, 7703 Floyd Curl, San Antonio, TX 78229, USA
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Ziegler R, Heinemann L, Freckmann G, Schnell O, Hinzmann R, Kulzer B. Intermittent Use of Continuous Glucose Monitoring: Expanding the Clinical Value of CGM. J Diabetes Sci Technol 2021; 15:684-694. [PMID: 32064909 PMCID: PMC8120049 DOI: 10.1177/1932296820905577] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In addition to the continuous use, the intermittent use of continuous glucose monitoring (CGM) is an application of CGM, expanding the typical medical use cases. There are a variety of reasons and occasions that speak in favor of using CGM only for a limited time. To date, these circumstances have not been sufficiently discussed. In this article, we define discontinuous or intermittent CGM use, provide reasons for using it, and expand on the benefits and possibilities of using CGM on a temporary basis. We aim to draw attention to this important topic in the discussion of CGM use and give examples for a different method of CGM use. As well, we would like to foster the allocation of CGM to the right patient groups and indications, especially in cases of limited resources. From a global point of view, intermittent CGM use is more likely to occur than continuous use, primarily for economic reasons.
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Affiliation(s)
- Ralph Ziegler
- Diabetes Clinic for Children and
Adolescents, Muenster, Germany
- Ralph Ziegler, MD, Diabetes Clinic
for Children and Adolescents Mondstr. 148, Muenster 48155, Germany.
| | | | - Guido Freckmann
- Institut für Diabetes-Technologie,
Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm,
Germany
| | - Oliver Schnell
- Forschergruppe Diabetes e.V.,
Helmholtz Zentrum, Munich, Germany
| | | | - Bernd Kulzer
- Diabetes Center Bad Mergentheim,
Research Institute of the Diabetes Academy, Bad Mergentheim, University
Bamberg, Germany
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5
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Stechova K. New perspectives on real-time continuous glucose monitoring. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:235-236. [PMID: 33577769 DOI: 10.1016/s2352-4642(20)30393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Katerina Stechova
- University Hospital Motol and Second Faculty of Medicine of Charles University, Prague 15006, Czech Republic.
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Nava C, Modiano Hedenmalm A, Borys F, Hooft L, Bruschettini M, Jenniskens K. Accuracy of continuous glucose monitoring in preterm infants: a systematic review and meta-analysis. BMJ Open 2020; 10:e045335. [PMID: 33361084 PMCID: PMC7768969 DOI: 10.1136/bmjopen-2020-045335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/25/2020] [Accepted: 12/04/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Continuous glucose monitoring (CGM) could be a valuable instrument for measurement of glucose concentration in preterm neonate. We undertook a systematic review and meta-analysis to compare the diagnostic accuracy of CGM devices to intermittent blood glucose evaluation methods for the detection of hypoglycaemic or hypoglycaemic events in preterm infants. DATA SOURCES A structured electronic database search was performed for studies that assessed the accuracy of CGM against any intermittent blood glucose testing methods in detecting episodes of altered glycaemia in preterm infants. No restrictions were used. Three review authors screened records and included studies. DATA EXTRACTION Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. From individual patient data (IPD), sensitivity and specificity were determined using predefined thresholds. The mean absolute relative difference (MARD) of the studied CGM devices was assessed and if those satisfied the accuracy requirements (EN ISO 15197). IPD datasets were meta-analysed using a logistic mixed-effects model. A bivariate model was used to estimate the summary receiver operating characteristic curve (ROC) curve and extract the area under the curve (AUC). The overall level of certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS Among 4481 records, 11 were included. IPD datasets were obtained for five studies. Only two of the studies showed an MARD lower than 10%, with none of the five CGM devices studied satisfying the European Union (EU) ISO 15197 requirements. Pooled sensitivity and specificity of CGM devices for hypoglycaemia were 0.39 and 0.99, whereas for hyperglycaemia were 0.87 and 0.99, respectively. The AUC was 0.70 and 0.86, respectively. The certainty of the evidence was considered as low to moderate. Limitations primarily related to the lack of representative population, reference standard and CGM device. CONCLUSIONS CGM devices demonstrated low sensitivity for detecting hypoglycaemia in preterm infants, however, provided high accuracy for detection of hyperglycaemia. PROSPERO REGISTRATION NUMBER CRD42020152248.
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Affiliation(s)
- Chiara Nava
- Neonatal Intensive Care Unit, Ospedale Alessandro Manzoni, Lecco, Lecco, Italy
| | | | - Franciszek Borys
- Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Cochrane Sweden, Research and Development, Lund University, Skane University Hospital, Lund, Sweden, Lund, Sweden
| | - Kevin Jenniskens
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
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Braune K, Wäldchen M, Raile K, Hahn S, Ubben T, Römer S, Hoeber D, Reibel NJ, Launspach M, Blankenstein O, Bührer C. Open-Source Technology for Real-Time Continuous Glucose Monitoring in the Neonatal Intensive Care Unit: Case Study in a Neonate With Transient Congenital Hyperinsulinism. J Med Internet Res 2020; 22:e21770. [PMID: 33275114 PMCID: PMC7748959 DOI: 10.2196/21770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/15/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited. OBJECTIVE This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period. METHODS The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age. RESULTS Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time. CONCLUSIONS While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient's individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed.
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Affiliation(s)
- Katarina Braune
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Mandy Wäldchen
- School of Sociology, University College Dublin, Belfield, Ireland
| | - Klemens Raile
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
| | - Sigrid Hahn
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Tebbe Ubben
- #dedoc° Diabetes Online Community, Dedoc Labs GmbH, Berlin, Germany
| | - Susanne Römer
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Daniela Hoeber
- Charité - Universitätsmedizin Berlin, Department of Paediatric Gastroenterology, Nephrology and Metabolic Diseases, Berlin, Germany
| | - Nora Johanna Reibel
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Michael Launspach
- Berlin Institute of Health, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Oliver Blankenstein
- Charité - Universitätsmedizin Berlin, Institute for Experimental Paediatric Endocrinology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Newborn Screening Laboratory, Berlin, Germany
| | - Christoph Bührer
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
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8
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Johnson PJ. Hypoglycaemia, hypoglycorrhachia, neuroglycopenia and glycaemic thresholds. EQUINE VET EDUC 2020. [DOI: 10.1111/eve.13003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- P. J. Johnson
- Department of Veterinary Medicine and Surgery University of Missouri College of Veterinary Medicine Columbia Missouri USA
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Khandare J, Ds M, Ananthan A, Nanavati R. Is Routine Monitoring for Hypoglycemia Required in Intramural Asymptomatic Infant of Diabetic Mother? An Audit in a Tertiary Care Hospital. J Trop Pediatr 2020; 66:194-200. [PMID: 31340046 DOI: 10.1093/tropej/fmz051] [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] [Indexed: 11/13/2022]
Abstract
AIMS This retrospective audit aimed to analyze whether routine frequent monitoring for hypoglycemia is required in asymptomatic infant of diabetic mother born in tertiary care hospital. METHODS The study analyzed the blood sugar level of 196 infants of diabetic mothers. RESULTS The overall incidence of hypoglycemia from 196 study participants was 9.18% (N = 18). The incidence of hypoglycemia at 2 h of life was maximum (83.33%) and it was significant when compared to 3, 6, 9 and 12 h (p < 0.0001). Blood glucose levels were significantly more at 6 (p = 0.0002)), 9 (p = 0.0001) and 12 h (p = 0.0001) when compared to glucose level at 2 h except at 3 h of life (p = 0.062). Similarly blood glucose at 9 (p = 0.0001) and 12 h of life (p = 0.0002) were significantly more than at 3 h of life. Blood glucose at 9 h was significantly more than at 6 h of life (0.032) and at 12 hours of life (p = 0.0237) was significantly higher than at 6 h of life. CONCLUSION The frequent blood glucose monitoring for hypoglycemia in infant of diabetic mother as per American Academy of Pediatrics may be reduced as per the findings in our study. However, this needs to be confirmed by a properly designed observational study/adequately powered randomized controlled trial.
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Affiliation(s)
- Jayant Khandare
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Madhusudhan Ds
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Ruchi Nanavati
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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Chiu CJ, Chou YH, Chen YJ, Du YF. Impact of New Technologies for Middle-Aged and Older Patients: In-Depth Interviews With Type 2 Diabetes Patients Using Continuous Glucose Monitoring. JMIR Diabetes 2019; 4:e10992. [PMID: 30789351 PMCID: PMC6403528 DOI: 10.2196/10992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/23/2018] [Accepted: 12/10/2018] [Indexed: 01/24/2023] Open
Abstract
Background Continuous glucose monitoring (CGM) uses subcutaneous sensors and records the average interstitial sensor current every 5 min in the recorder; data are subsequently exported to a computer 4 to 7 days later when calibration with self-measured blood glucose is made retrospectively. How middle-aged and older patients perceive the added technology intervention is not clear. Objective The study aimed to understand the factors associated with the adoption of new technology in diabetes care, to understand the feelings and behaviors while using it, and to determine the changes in attitudes and behavior after completing the use of the new technology at the 3-month follow-up. Methods Middle-aged and older type 2 diabetes patients who had received professional continuous glucose monitoring (iPro 2 [Medtronic]) were invited for semistructured in-depth interviews on the day of the CGM sensor removal and at 3 months after CGM-based counseling. A phenomenography approach was used to analyze the interview data. Results A total of 20 type 2 diabetes patients (aged 53 to 72 years, 13 males and 7 females, 4 to 40 years duration of diabetes, mean glycated hemoglobin 8.54% [SD 0.71%]) completed 2 sections of semistructured in-depth interviews. Physician guidance and participant motivation toward problem solving were found to be factors associated with adoption of the device. Participants indicated that technology can be a reminder, a supervisor, and a visualizer of blood glucose, all of which are helpful for disease management. However, CGM is somewhat inconvenient, and some participants also reported that the provision of this new technology might be a hint of disease progression. There was a higher percentage of women compared with men who reported that CGM can be a reminder or a supervisor to help them with diet control. Conclusions Physician guidance and participants’ degree of motivation are keys to adopting new technology in the case of middle-aged and older adults. Although the CGM sensor may cause inconvenience to patients on their limited body movement when wearing the device, it is helpful for diet control and is an effective behavioral modification tool that offers support, especially in the case of women.
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Affiliation(s)
- Ching-Ju Chiu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Hsuan Chou
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Ju Chen
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ye-Fong Du
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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Stewart ZA, Thomson L, Murphy HR, Beardsall K. A Feasibility Study of Paired Continuous Glucose Monitoring Intrapartum and in the Newborn in Pregnancies Complicated by Type 1 Diabetes. Diabetes Technol Ther 2019; 21:20-27. [PMID: 30620640 DOI: 10.1089/dia.2018.0221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To describe the continuous glucose monitoring (CGM) profiles of type 1 diabetes (T1D) offspring in the early neonatal period and its association with maternal intrapartum glucose control. METHODS A prospective observational study of T1D pregnant women and their neonatal offspring. Women had a CGM sensor inserted 2-3 days before delivery. Infants had a masked CGM sensor inserted as soon as possible after delivery. Maternal glycemic outcomes were time-in-target (70-140 mg/dL [3.9-7.8 mmol/L]), hyperglycemia >140 mg/dL (7.8 mmol/L), and mean CGM glucose during the 24 h preceding delivery. Neonatal outcomes included lowest recorded blood glucose concentration, and CGM measures (glucose <47 mg/dL [2.6 mmol/L], time-in-target (47-144 mg/dL [2.6-8.0 mmol/L]), glucose standard deviation [SD]) during the first 72 h of life. RESULTS Data were available for 16 mother-infant pairs. Mothers had a mean age (SD) 32.3 (4.3) years, T1D duration 17.6 (6.8) years, first antenatal glycated hemoglobin 7.4 (0.8)% (57 [8.5] mmol/mol). In the 24 h preceding delivery, mothers spent mean (SD) 72 (20)% time-in-target (70-140 mg/dL [3.9-7.8 mmol/L]), 19 (15)% time >140 mg/dL (7.8 mmol/L), and 9 (9)% time <70 mg/dL (3.9 mmol/L) with mean (SD) CGM glucose 113 (9) mg/dL (6.3 [0.7] mmol/L). Fifteen infants (93.8%) had ≥1 blood glucose concentration <47 mg/dL (2.6 mmol/L), and five had ≥1 blood glucose concentration <18 mg/dL (1.0 mmol/L). The mean infant CGM glucose on days 1, 2, and 3 of life was 63 (14), 67 (13), 76 (11) mg/dL (3.5 [0.8], 3.7 [0.7], and 4.2 [0.6] mmol/L). Four infants (25%) spent >50% time with CGM glucose levels <47 mg/dL (2.6 mmol/L) on day 1. CONCLUSIONS CGM detected widespread neonatal hypoglycemia, even among mothers with good intrapartum glucose control.
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Affiliation(s)
- Zoe A Stewart
- 1 Department of Clinical Biochemistry, Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Lynn Thomson
- 2 Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
- 3 Neonatal Unit, University of Cambridge Addenbrookes Hospital NHS Trust, Cambridge, United Kingdom
| | - Helen R Murphy
- 1 Department of Clinical Biochemistry, Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- 4 Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Kathryn Beardsall
- 2 Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
- 3 Neonatal Unit, University of Cambridge Addenbrookes Hospital NHS Trust, Cambridge, United Kingdom
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