Monitoring the incidence, duration and distribution of hyperglycaemia in very-low-birth-weight newborns and identifying associated factors

Management of Neonatal Hyperglycaemia in Sweden-A Survey Study

AIM

Neonatal hyperglycaemia is associated with a multitude of adverse outcomes, including mortality and impaired neurological development. The aim of this study was to characterise the current management of neonatal hyperglycaemia in Swedish neonatal units.

METHODS

A digital survey was sent to 27 Swedish neonatal units providing care to preterm infants born before 32 completed gestational weeks.

RESULTS

Sixty-eight responses were collected from 21 different units. Thirty-two percent (22/68) of clinicians reported having a local treatment guideline for neonatal hyperglycaemia. Hyperglycaemia was defined as a glucose concentration above a value in the range of 8.0-10.0 mmol/L by 62.5% of clinicians, while 16.7% and 21.8% used a definition between 10.1 and 12.0 mmol/L and > 12 mmol/L, respectively. Intravenous glucose reduction was initiated at higher glucose concentrations by clinicians working at university hospital units (p = 0.006). Glucose concentration threshold for initiation of insulin treatment varied between 8 and 30 mmol/L. Three clinicians (3/35 (8.5%)) reported having experienced problems with frequent hypoglycaemia during ongoing insulin treatment.

CONCLUSIONS

This study demonstrates extensive differences in clinical practice regarding neonatal hyperglycaemia both within and between neonatal units in Sweden. Randomised controlled trials are needed to provide evidence for clinical guidelines and to improve and standardise the care of these infants.

Development and validation of a multivariate nomogram for predicting retinopathy of prematurity in infants with gestational age ≤34 weeks

Purpose

To delineate risk factors and develop a predictive nomogram for retinopathy of prematurity (ROP) in infants with gestational age (GA) ≤34 weeks.

Methods

We conducted a comprehensive retrospective analysis of infants with GA ≤34 weeks, divided into ROP and non-ROP groups based on fundus screening results. Clinical and laboratory data were collected to identify risk factors associated with ROP. Multivariable logistic regression was performed to identify independent predictors, and a nomogram was developed to predict the occurrence of ROP in infants with GA ≤34 weeks.

Results

Our analysis identified five independent risk factors for ROP in infants with GA ≤34 weeks: hypertensive disorders of pregnancy (HDP), number of blood transfusions, oxygen therapy time (OTT), oxygen therapy concentration (OTC) >50%, and blood glucose spikes in the first postnatal week. These predictors were incorporated into a nomogram to estimate individual ROP risk. The predictive model achieved a C-index of 0.923 (95% CI: 0.888-0.959), indicating high predictive accuracy. Internal validation of the nomogram demonstrated excellent calibration and practical utility for clinical decision-making.

Conclusions

The established predictive model, incorporating five key clinical parameters, offers clinicians a practical instrument to stratify ROP risk in neonates born at ≤34 weeks' gestation. This clinical tool demonstrates significant utility in guiding intervention protocols, potentially enhancing patient outcomes through early identification and optimized management strategies.

Registration number

ChiCTR2400086213.

Treatment of Severe Hyperglycemia in Extremely Preterm Infants Using Continuous Subcutaneous Insulin Therapy

Objective

Hyperglycemia in preterm infants is usually treated with adjustment of glucose intake and, if persistent, with continuous insulin infusion. However, hypoglycemia is a well-known complication of intravenous (iv) insulin treatment. The aim of this study was to evaluate the feasibility of continuous subcutaneous insulin infusion (CSII) in extremely preterm infants.

Methods

Clinical data from extremely premature infants (<28 weeks of gestation) undergoing CSII treatment for severe hyperglycemia in the neonatal intensive care unit were included. Blood glucose levels during CSII, as well as the nutritional intake and insulin intake were recorded. Data were analyzed and compared to a control group of very preterm infants receiving iv insulin therapy.

Results

Normoglycemia rates were best in the iv insulin-cohort (n=22, 50.3%) compared to the CSII group (n=15, 15.6%). Hypoglycemia was very rare in both groups (0.4% vs. 0.0%). CSII therapy appears to require higher insulin doses compared to continuous iv therapy to achieve a similar effect. Subcutaneous Insulin therapy in extremely preterm infants is feasible, at least for prevention of hypoglycemia. However, dose control needs to be improved.

Conclusion

The results justify further model validation and clinical trial research to explore a model-based protocol and the use of CSII in this population.

Glucose disturbances in very low-birthweight infants-Results from the prospective LIGHT study

AIM

To describe glucose homeostasis disturbances (dysglycaemia) in very low-birthweight infants (<1500 g) during the admission period and explore associated risk factors.

METHODS

The LIGHT (very low-birthweight infants - glucose and hormonal profile over time) study was a prospective observational cohort study that included 49 very low-birthweight infants admitted to the tertiary neonatal intensive care unit in Umeå, Sweden, during 2016-2019. All glucose concentrations (n = 3515) sampled during the admission period were registered.

RESULTS

Hyperglycaemia >10 mmol/L and hypoglycaemia <2.6 mmol/L were registered in 63% and 55% of the infants, respectively. Onset of dysglycaemia occurred almost exclusively in the first postnatal week. Hyperglycaemia followed 15% of corticosteroid doses given; all were preceded by pre-existing hyperglycaemia. Pre-existing hyperglycaemia was found in 66.7% of hyperglycaemic infants who received inotrope treatment. Upon commencement, 72.5% of antimicrobial treatments given were neither preceded nor followed by hyperglycaemia.

CONCLUSION

Dysglycaemia was common in very low-birthweight infants. Daily means of glucose concentrations seemed to follow a postmenstrual age-dependent pattern, decreasing towards term age suggesting a postmenstrual age-dependent developmental mechanism. The primary mechanism causing hyperglycaemia was independent of sepsis, and corticosteroid and inotrope treatments. No hypoglycaemia was registered during ongoing insulin treatment.

Expanding the horizon of continuous glucose monitoring into the future of pediatric medicine

Glucose monitoring has rapidly evolved with the development of minimally invasive continuous glucose monitoring (CGM) using interstitial fluid. It is recommended as standard of care in the ambulatory setting, nearly replacing capillary glucose testing in those with access to CGM. The newest CGM devices continue to be smaller and more accurate, and integration with automated insulin delivery systems has further revolutionized the management of diabetes, leading to successful improvements in care and quality of life. Many studies confirm accuracy and application of CGM in various adult inpatient settings. Studies in adult patients increased during the COVID 19 Pandemic, but despite reassuring results, inpatient CGM use is not yet approved by the FDA. There is a lack of studies in inpatient pediatric settings, although data from the NICU and PICU have started to emerge. Given the exponential increase in the use of CGM, it is imperative that hospitals develop protocols for CGM use, with a need for ongoing implementation research. In this review we describe how CGM systems work, discuss benefits and barriers, summarize research in inpatient pediatric CGM use, explore gaps in research design along with emerging recommendations for inpatient use, and discuss overall CGM utility beyond outpatient diabetes management. IMPACT: Current CGM systems allow for uninterrupted monitoring of interstitial glucose excursions, and have triggered multiple innovations including automated insulin delivery. CGM technology has become part of standard of care for outpatient diabetes management, endorsed by many international medical societies, now with significant uptake, replacing capillary glucose testing for daily management in patients with access to CGM technology. Although CGM is not approved by the FDA for inpatient hospital use, studies in adult settings support its use in hospitals. More studies are needed for pediatrics. Implementation research is paramount to expand the role of CGM in the inpatient setting and beyond.

Metabolic responses in neonatal sepsis-A systematic review of human metabolomic studies

AIM

To systematically review human metabolomic studies investigating metabolic responses in septic neonates.

METHODS

A systematic literature search was performed in the databases MEDLINE, EMBASE and Cochrane library up to the 1st of January 2021. We included studies that assessed neonatal sepsis and the following outcomes; (1) change in the metabolism compared to healthy neonates and/or (2) metabolomics compared to traditional diagnostic tools of neonatal sepsis. The screened abstracts were independently considered for eligibility by two researchers.

PROSPERO ID

CRD42020164454.

RESULTS

The search identified in total 762 articles. Fifteen articles were assessed for eligibility. Four studies were included, with totally 78 neonates. The studies used different diagnostic criteria and had between 1 and 16 sepsis cases. All studies with bacterial sepsis found alterations in the glucose and lactate metabolism, reflecting possible redistribution of glucose consumption from mitochondrial oxidative phosphorylation to the lactate and pentose phosphate pathway. We also found signs of increased oxidative stress and fatty acid oxidation in sepsis cases.

CONCLUSION

We found signs of metabolomic signatures in neonatal sepsis. This may lead to better understanding of sepsis pathophysiology and detection of new candidate biomarkers. Results should be validated in large-scale multicentre studies.

Real-time continuous glucose monitoring in preterm infants (REACT): an international, open-label, randomised controlled trial

BACKGROUND

Hyperglycaemia and hypoglycaemia are common in preterm infants and have been associated with increased risk of mortality and morbidity. Interventions to reduce risk associated with these exposures are particularly challenging due to the infrequent measurement of blood glucose concentrations, with the potential of causing more harm instead of improving outcomes for these infants. Continuous glucose monitoring (CGM) is widely used in adults and children with diabetes to improve glucose control, but has not been approved for use in neonates. The REACT trial aimed to evaluate the efficacy and safety of CGM in preterm infants requiring intensive care.

METHODS

This international, open-label, randomised controlled trial was done in 13 neonatal intensive care units in the UK, Spain, and the Netherlands. Infants were included if they were within 24 h of birth, had a birthweight of 1200 g or less, had a gestational age up to 33 weeks plus 6 days, and had parental written informed consent. Infants were randomly assigned (1:1) to real-time CGM or standard care (with masked CGM for comparison) using a central web randomisation system, stratified by recruiting centre and gestational age (<26 or ≥26 weeks). The primary efficacy outcome was the proportion of time sensor glucose concentration was 2·6-10 mmol/L for the first week of life. Safety outcomes related to hypoglycaemia (glucose concentrations <2·6 mmol/L) in the first 7 days of life. All outcomes were assessed on the basis of intention to treat in the full analysis set with available data. The study is registered with the International Standard Randomised Control Trials Registry, ISRCTN12793535.

FINDINGS

Between July 4, 2016, and Jan 27, 2019, 182 infants were enrolled, 180 of whom were randomly assigned (85 to real-time CGM, 95 to standard care). 70 infants in the real-time CGM intervention group and 85 in the standard care group had CGM data and were included in the primary analysis. Compared with infants in the standard care group, infants managed using CGM had more time in the 2·6-10 mmol/L glucose concentration target range (mean proportion of time 84% [SD 22] vs 94% [11]; adjusted mean difference 8·9% [95% CI 3·4-14·4]), equivalent to 13 h (95% CI 5-21). More infants in the standard care group were exposed to at least one episode of sensor glucose concentration of less than 2·6 mmol/L for more than 1 h than those in the intervention group (13 [15%] of 85 vs four [6%] of 70). There were no serious adverse events related to the use of the device or episodes of infection.

INTERPRETATION

Real-time CGM can reduce exposure to prolonged or severe hyperglycaemia and hypoglycaemia. Further studies using CGM are required to determine optimal glucose targets, strategies to obtain them, and the potential effect on long-term health outcomes.

FUNDING

National Institute for Health Research Efficacy and Mechanisms Evaluation Programme.

Hyperglycaemia in the Newborn Infant. Physiology Verses Pathology

Hyperglycemia is common in newborns requiring intensive care, particularly in preterm infants, in sepsis and following perinatal hypoxia. The clinical significance, and optimal intervention strategy varies with context, but hyperglycaemia is associated with increased mortality and morbidity. The limited evidence for optimal clinical targets mean controversy remains regarding thresholds for intervention, and management strategies. The first consideration in the management of hyperglycaemia must be to ascertain potentially treatable causes. Calculation of the glucose infusion rate (GIR) to insure this is not excessive, is critical but the use of insulin is often helpful in the extremely preterm infant, but is associated with an increased risk of hypoglycaemia. The use of continuous glucose monitoring (CGM) has recently been demonstrated to be helpful in targeting glucose control, and reducing the risk from hypoglycaemia in the preterm infant. Its use in other at risk infants remains to be explored, and further studies are needed to provide a better understanding of the optimal glucose targets for different clinical conditions. In the future the combination of CGM and advances in computer algorithms, to provide intelligent closed loop systems, could allow a safer and more personalized approached to management.