Neurodevelopment after neonatal hypoglycemia: a systematic review and design of an optimal future study

Metabolic factors and perinatal outcomes among pregnant individuals with mild glucose intolerance

AIMS

Metabolic characteristics and outcomes were compared among pregnant individuals with varying levels of glucose intolerance.

METHODS

827 participants from a randomized clinical trial comparing the IADPSG and Carpenter Coustan Criteria were grouped as follows: normal glucose tolerance, mild glucose intolerance (100 g OGTT with one abnormal value) and treated GDM (diagnosed by Carpenter Coustan or IADPSG criteria). Differences in metabolic characteristics and perinatal outcomes were assessed using inverse probability of treatment weighting.

RESULTS

Mild glucose intolerance had lower insulin sensitivity and beta cell response than normal glucose tolerance, and similar findings to treated GDM. Small for gestational age (SGA) (OR 0.13, 95% CI 0.08-0.24) and neonatal composite morbidity were lower (OR 0.53, 95% CI 0.38-0.74), and maternal composite morbidity higher (OR 2.03, 95% CI 1.57-2.62) when comparing mild intolerance to normal glucose tolerance. Large for gestational age (OR 3.42 95% CI 1.39-8.41) was higher while SGA (OR 0.21, 95% CI 0.05-0.81) and neonatal composite morbidity (OR 0.31, 95% CI 0.17-0.57) were lower with mild glucose intolerance compared to treated GDM.

CONCLUSIONS

Mild glucose intolerance has a similar metabolic profile to treated GDM, and outcome differences are likely related to knowledge of diagnosis and treatment.

CLINICAL TRIALS REGISTRY

NCT02309138.

Outcomes in Pregnancies Complicated with Preterm Hypertensive Disorders with and without Late Antenatal Corticosteroids

OBJECTIVE

 This study aimed to determine whether administration of a late preterm (34-36 weeks) course of antenatal corticosteroids (ACS) is associated with improved short-term neonatal outcomes among pregnancies complicated with hypertensive disorders of pregnancy (HDP) who delivered in the late preterm period.

STUDY DESIGN

 A single tertiary center retrospective cohort study, including pregnant individuals with singleton fetuses who delivered between 34.0 and 36.6 weeks following an HDP diagnosis. Exclusion criteria were major fetal anomalies and treatment with ACS before 34 weeks. Cases were divided into two groups: exposed group, consisting of individuals treated with a late ACS course, and nonexposed group, receiving no ACS. The primary outcome was a composite adverse neonatal outcome, including intensive care unit admission, oxygen treatment, noninvasive positive pressure ventilation, mechanical ventilation, respiratory distress syndrome, transient tachypnea, or apnea of prematurity. Secondary neonatal outcomes included birth weight, Apgar score, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, surfactant use, hypoglycemia, hyperbilirubinemia, sepsis, and neonatal death. Multivariable regression models were used to determine adjusted odds ratio (aOR)and 95% confidence intervals (CIs).

RESULTS

Of 7,624 preterm singleton deliveries during the study period, 438 (5.7%) were diagnosed with HDP and delivered between 34.0 and 36.6 weeks. Infants who received ACS were diagnosed more commonly with fetal growth restriction (16.0 vs. 5.6%, p < 0.01) and were delivered at an earlier gestational age (GA) (mean GA: 35.6 vs. 36.3 weeks, p < 0.01). The composite neonatal morbidity did not differ between the groups after adjustments (aOR: 0.97, 95% CI: 0.47, 1.98). Neonatal hypoglycemia and hyperbilirubinemia were more common in the exposed group than in the nonexposed group (46.9 vs. 27.4%; aOR: 2.27; 95% CI: 1.26, 4.08 and 64.2 vs. 46.5%; aOR: 2.08; 95% CI: 1.16, 3.72 respectively).

CONCLUSION

 In people with HDP, a course of ACS given in the late preterm period did not improve neonatal morbidity.

KEY POINTS

· In people with HDP, a late preterm ACS course did not improve neonatal morbidity.. · Respiratory morbidity rate was similar between infants who received late ACS and those who did not.. · Neonatal hypoglycemia and hyperbilirubinemia were more common in infants who received late ACS..

Neonatal hypoglycaemia

Low blood concentrations of glucose (hypoglycaemia) soon after birth are common because of the delayed metabolic transition from maternal to endogenous neonatal sources of glucose. Because glucose is the main energy source for the brain, severe hypoglycaemia can cause neuroglycopenia (inadequate supply of glucose to the brain) and, if severe, permanent brain injury. Routine screening of infants at risk and treatment when hypoglycaemia is detected are therefore widely recommended. Robust evidence to support most aspects of management is lacking, however, including the appropriate threshold for diagnosis and optimal monitoring. Treatment is usually initially more feeding, with buccal dextrose gel, followed by intravenous dextrose. In infants at risk, developmental outcomes after mild hypoglycaemia seem to be worse than in those who do not develop hypoglycaemia, but the reasons for these observations are uncertain. Here, the current understanding of the pathophysiology of neonatal hypoglycaemia and recent evidence regarding its diagnosis, management, and outcomes are reviewed. Recommendations are made for further research priorities.

Diagnosis and Management of Neonatal Hypoglycemia: A Comprehensive Review of Guidelines

Hypoglycemia represents one of the most frequent metabolic disturbances of the neonate, associated with increased morbidity and mortality, especially if left untreated or diagnosed after the establishment of brain damage. The aim of this study was to review and compare the recommendations from the most recently published influential guidelines on the diagnosis, screening, prevention and management of this common neonatal complication. Therefore, a descriptive review of the guidelines from the American Academy of Pediatrics (AAP), the British Association of Perinatal Medicine (BAPM), the European Foundation for the Care of the Newborn Infants (EFCNI), the Queensland Clinical Guidelines-Australia (AUS), the Canadian Pediatric Society (CPS) and the Pediatric Endocrine Society (PES) on neonatal hypoglycemia was carried out. There is a consensus among the reviewed guidelines on the risk factors, the clinical signs and symptoms of NH, and the main preventive strategies. Additionally, the importance of early recognition of at-risk infants, timely identification of NH and prompt initiation of treatment in optimizing the outcomes of hypoglycemic neonates are universally highlighted. All medical societies, except PES, recommend screening for NH in asymptomatic high-risk and symptomatic newborn infants, but they do not provide consistent screening approaches. Moreover, the reviewed guidelines point out that the diagnosis of NH should be confirmed by laboratory methods of BGL measurement, although treatment should not be delayed until the results become available. The definition of NH lacks uniformity and it is generally agreed that a single BG value cannot accurately define this clinical entity. Therefore, all medical societies support the use of operational thresholds for the management of NH, although discrepancies exist regarding the recommended cut-off values, the optimal treatment and surveillance strategies of both symptomatic and asymptomatic hypoglycemic neonates as well as the treatment targets. Over the past several decades, ΝH has remained an issue of keen debate as it is a preventable cause of brain injury and neurodevelopmental impairment; however, there is no clear definition or consistent treatment policies. Thus, the establishment of specific diagnostic criteria and uniform protocols for the management of this common biochemical disorder is of paramount importance as it will hopefully allow for the early identification of infants at risk, the establishment of efficient preventive measures, the optimal treatment in the first hours of a neonate's life and, subsequently, the improvement of neonatal outcomes.

Neonatal hypoglycemia: lack of evidence for a safe management

Neonatal hypoglycemia affects up to 15% of all newborns. Despite the high prevalence there is no uniform definition of neonatal hypoglycemia, and existing guidelines differ significantly in terms of when and whom to screen for hypoglycemia, and where to set interventional thresholds and treatment goals. In this review, we discuss the difficulties to define hypoglycemia in neonates. Existing knowledge on different strategies to approach this problem will be reviewed with a focus on long-term neurodevelopmental outcome studies and results of interventional trials. Furthermore, we compare existing guidelines on the screening and management of neonatal hypoglycemia. We summarize that evidence-based knowledge about whom to screen, how to screen, and how to manage neonatal hypoglycemia is limited - particularly regarding operational thresholds (single values at which to intervene) and treatment goals (what blood glucose to aim for) to reliably prevent neurodevelopmental sequelae. These research gaps need to be addressed in future studies, systematically comparing different management strategies to progressively optimize the balance between prevention of neurodevelopmental sequelae and the burden of diagnostic or therapeutic procedures. Unfortunately, such studies are exceptionally challenging because they require large numbers of participants to be followed for years, as mild but relevant neurological consequences may not become apparent until mid-childhood or even later. Until there is clear, reproducible evidence on what blood glucose levels may be tolerated without negative impact, the operational threshold needs to include some safety margin to prevent potential long-term neurocognitive impairment from outweighing the short-term burden of hypoglycemia prevention during neonatal period.

Glycemia and Neonatal Encephalopathy: Outcomes in the LyTONEPAL (Long-Term Outcome of Neonatal Hypoxic EncePhALopathy in the Era of Neuroprotective Treatment With Hypothermia) Cohort

OBJECTIVES

To assess in newborns with neonatal encephalopathy (NE), presumptively related to a peripartum hypoxic-ischemic event, the frequency of dysglycemia and its association with neonatal adverse outcomes.

STUDY DESIGN

We conducted a secondary analysis of LyTONEPAL (Long-Term Outcome of Neonatal hypoxic EncePhALopathy in the era of neuroprotective treatment with hypothermia), a population-based cohort study including 545 patients with moderate-to-severe NE. Newborns were categorized by the glycemia values assessed by routine clinical care during the first 3 days of life: normoglycemic (all glycemia measurements ranged from 2.2 to 8.3 mmol/L), hyperglycemic (at least 1 measurement >8.3 mmol/L), hypoglycemic (at least 1 measurement <2.2 mmol/L), or with glycemic lability (measurements included at least 1 episode of hypoglycemia and 1 episode of hyperglycemia). The primary adverse outcome was a composite outcome defined by death and/or brain lesions on magnetic resonance imaging, regardless of severity or location.

RESULTS

In total, 199 newborns were categorized as normoglycemic (36.5%), 74 hypoglycemic (13.6%), 213 hyperglycemic (39.1%), and 59 (10.8%) with glycemic lability, based on the 2593 glycemia measurements collected. The primary adverse outcome was observed in 77 (45.8%) normoglycemic newborns, 37 (59.7%) with hypoglycemia, 137 (67.5%) with hyperglycemia, and 40 (70.2%) with glycemic lability (P < .01). With the normoglycemic group as the reference, the aORs and 95% 95% CIs for the adverse outcome were significantly greater for the group with hyperglycemia (aOR 1.81; 95% CI 1.06-3.11).

CONCLUSIONS

Dysglycemia affects nearly two-thirds of newborns with NE and is independently associated with a greater risk of mortality and/or brain lesions on magnetic resonance imaging.

TRIAL REGISTRATION

NCT02676063.

Neurocognitive Outcomes at Age 2 Years After Neonatal Hypoglycemia in a Cohort of Participants From the hPOD Randomized Trial

IMPORTANCE

Neonatal hypoglycemia is common, but its association with later neurodevelopment is uncertain.

OBJECTIVE

To examine associations between neonatal hypoglycemia and neurocognitive outcomes at corrected age 2 years.

DESIGN, SETTING, AND PARTICIPANTS

Exploratory cohort analysis of the Hypoglycaemia Prevention With Oral Dextrose (hPOD) randomized clinical trial was conducted. The trial recruited participants from January 9, 2015, to May 5, 2019, with follow-up between January 26, 2017, and July 31, 2021. Infants were recruited from 9 maternity hospitals in New Zealand and assessed at home or in a research clinic. Children born late preterm and at term at risk of neonatal hypoglycemia but without evidence of acute or imminent illness in the first hour after birth were screened and treated to maintain blood glucose concentrations greater than or equal to 47 mg/dL.

EXPOSURES

Hypoglycemia was defined as any blood glucose concentration less than 47 mg/dL, recurrent as 3 or more episodes, and severe as less than 36 mg/dL.

MAIN OUTCOMES AND MEASURES

Neurologic examination and tests of development (Bayley III) and executive function. The primary outcome was neurosensory impairment (any of the following: blindness, deafness, cerebral palsy, developmental delay, or executive function total score worse than 1.5 SD below the mean).

RESULTS

A total of 1197 of 1321 (91%) eligible children were assessed at a mean of corrected age 24 months; 616 (52%) were male. Compared with the normoglycemia group, children who experienced hypoglycemia were more likely to have neurosensory impairment (111 [23%] vs 125 [18%]; adjusted risk ratio [aRR], 1.28; 95% CI, 1.01-1.60), particularly if they experienced severe episodes (30 [28%] vs 125 [18%]; aRR, 1.68; 95% CI, 1.20-2.36), but not recurrent episodes (12 [19%] vs 125 [18%]; aRR, 1.06; 95% CI, 0.63-1.80). The risk of cognitive, language, or motor delay was similar between groups, but children who experienced hypoglycemia had lower Bayley-III composite cognitive (adjusted mean difference [aMD], -1.48; 95% CI, -2.79 to -0.18) and motor scores (aMD, -2.05; 95% CI, -3.30 to -0.79).

CONCLUSIONS AND RELEVANCE

In children born at risk of hypoglycemia but otherwise well, those who experienced neonatal hypoglycemia were more likely to have neurosensory impairment at corrected age 2 years, with higher risks after severe episodes. Further research is required to determine causality.

No Clinically Relevant Memory Effects in Perinatal Hyperglycemia and Hypoglycemia: A 40-Year Follow-Up of a Small Cohort

Maternal diabetes mellitus in pregnancy is associated with impairments in memory functions of the offspring in childhood and adolescence but has not been studied in adulthood. The association of perinatal hypoglycemia with memory has not been studied in adulthood either. The combined sequelae of these two risk factors have not been directly compared. We studied general cognitive ability and memory functions in a prospective follow-up of a cohort born in 1971 to 1974. The sample included participants exposed to prenatal hyperglycemia (n = 24), perinatal hypoglycemia (n = 19), or both (n = 7). It also included controls with no early risks (n = 82). We assessed the participants' Intelligence quotient (IQ), working memory, and immediate and delayed recall of both verbal and visual material at the age of 40. We did not find significant differences in IQ or the memory tests between the groups. We did identify an interaction (p = 0.03) of the early risk with the type of digit span task: compared to the controls, the participants exposed to perinatal hypoglycemia had a larger difference between the forward digit span, a measure of attention, and the backward digit span, a measure of working memory processing (p = 0.022). The interaction remained significant when birth weight was controlled for (p = 0.026). Thus, in this small cohort, prenatal hyperglycemia, perinatal hypoglycemia, and their combination appeared relatively benign disorders. The association of these conditions with neurocognitive impairments in adulthood remains unconfirmed. The significance of the working memory difference needs to be verified with a larger sample.

Perioperative use of glucose containing solutions in infants less than 6 months of age: A clinical practice survey among US academic centers

BACKGROUND

Although there is a wide breadth of literature on glucose homeostasis in infants, standardization of perioperative hypoglycemia diagnosis and management is lacking.

AIMS

Survey of academic pediatric anesthesiology departments across the USA to evaluate institutional policies regarding the perioperative use of glucose containing solutions in infants less than 6 months of age.

METHODS

A questionnaire was sent to 20 United States university affiliated academic pediatric anesthesiology departments.

RESULTS

The responses suggest that, in the centers surveyed, glucose administration in infants is largely practitioner dependent. Two respondents (10%) claim to have a departmental policy regarding glucose administration in infants less than 6 months of age. In premature infants, 75% of respondents administer glucose. When administering glucose, 75% of physicians surveyed replete infants at their maintenance intravenous fluid rate. There was discrepancy among practitioners regarding initiation of hypoglycemia treatment, 35% treat infants at a blood glucose level of 70 mg/dl, 30% at BG 60 mg/dl, 25% at 50 mg/dl, and 10% are unsure.

DISCUSSION

This survey highlights the lack of consensus, at least among pediatric anesthesiologists working in US academic centers, regarding blood glucose management in infants less than 6 months of age. There is a need to define the indications for using glucose containing solutions in infants during the perioperative period, their ideal content, the appropriate thresholds for hypo- and hyperglycemia as well as the optimal point-of care glucose monitoring intervals.

Scoping review of evidence for managing postnatal hypoglycaemia

OBJECTIVES

To identify what is known empirically about the screening, treatment and harm of exposure to neonatal hypoglycaemia.

DESIGN

Scoping review that applied a preregistered protocol based on established frameworks.

DATA SOURCES

Medline and Embase, up to 12 May 2020.

STUDY SELECTION

Comparative and case-series studies, as well as guidelines, published in English or French, on the topic of immediate inpatient postnatal glucose screening in newborns.

DATA GATHERING

Article selection and characterisation were performed in duplicate using predefined data extraction forms specific to primary studies and guidelines.

RESULTS

12 guidelines and 74 primary studies were included. A neurodevelopmental outcome was primary in 32 studies: 30 observational studies followed up posthypoglycaemic, and the 2 intervention studies included 1 randomised controlled trial (RCT) about treatment thresholds. Three other RCTs assessed dextrose gel (two) and oral sucrose (one). 12 of 30 studies that evaluated non-neurodevelopmental primary outcomes were intervention studies. Only one cohort study compared outcomes in screened vs unscreened newborns. The guidelines did not arrive at a consensus definition of postnatal hypoglycaemic, and addressed potential harms of screening more often than primary studies.

CONCLUSIONS

The primary literature that informs hypoglycaemia screening is a series of studies that relate neurodevelopmental outcomes to postnatal hypoglycaemia. Further research is needed to better define an optimal threshold for hypoglycaemia that warrants intervention, based on long-term neurodevelopmental outcomes and a better delineation of potential screening harms.

Predicting resolution of hypoglycemia with and without dextrose infusion in newborn infant of gestational diabetic mothers

INTRODUCTION

Neonatal hypoglycemia (NH) may lead to significant neurological impairment if left untreated. Infants of gestational diabetic mothers (IGDM) are at increased risk of early NH and need to be screened. However, it is challenging to predict management with or without intravenous dextrose once hypoglycemia is identified. We evaluated the association between hypoglycemia risk scores at 1-hour of life and the need for intravenous dextrose for hypoglycemia resolution in IGDM.

METHODS

This was a retrospective cohort study of IGDM born at a gestational age ≥35 weeks from January 2015 to December 2017. NH was the disease of interest. The outcomes were the association of hypoglycemia risk score (HRS) with and without intravenous dextrose for hypoglycemia resolution. Each infant's hypoglycemia risk score (HRS) was calculated using data extracted from the maternal and neonatal electronic medical records. Resolution of hypoglycemia with and without intravenous dextrose was compared between the low HRS (0-1) group and the high HRS (2-5) group.

RESULTS

Sixty-five infants were included in the study with a mean gestational age of 38.2 ± 1 weeks for low HRS and 38.0 ± 2 weeks for high HRS. While more children with high HRS were delivered by cesarean section (p = 0.04), hypoglycemia resolved more frequently without intravenous dextrose in infants with low HRS (p = 0.03).

CONCLUSION

IGDM is at increased risk of NH. The resolution of hypoglycemia without dextrose infusion is frequently associated with low HRS at 1-hour of life. Early identification using HRS of IGDM whose hypoglycemia will resolve with or without intravenous dextrose may help clinicians triage newborns to either stay in the nursery or transfer for more invasive care.

Long-Term Outcomes after Early Neonatal Hyperglycemia in VLBW Infants: A Systematic Review

INTRODUCTION

Long-term effects of early hyperglycemia in VLBW infants are poorly characterized. The objective of this study was to systematically review the effect of early hyperglycemia on growth, metabolic health, and neurodevelopment after neonatal intensive care unit discharge in VLBW infants.

METHODS

The systematic review was conducted in accordance with the PRISMA guidelines. A study protocol was registered in PROSPERO (CRD42019123335). Data sources included Ovid MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus. Selected studies included infants with a blood glucose concentration >150 mg/dL (8.3 mmol/L) during the first 28 days of life, a gestational age (GA) <32 weeks, and/or a birth weight <1,500 g and longitudinal data on growth, metabolic health, or neurodevelopment outcomes. The GRADE system was used to assess quality of evidence.

RESULTS

Eight studies (n = 987 infants) reported long-term outcomes from 4-month corrected GA to 7 years old. Most studies compared long-term outcomes of preterm infants with and without hyperglycemia. Two studies addressed outcomes related to interventions following early hyperglycemia. Some studies found differences in growth, metabolic health, and neurodevelopment outcomes between VLBW preterm infants with hyperglycemia and without hyperglycemia, while other studies found no differences between groups. The overall graded quality of evidence was low.

CONCLUSIONS

Well-designed randomized controlled and prospective studies are necessary to determine the effect of early hyperglycemia and its treatment on later metabolic and neurodevelopmental outcomes in VLBW infants. Authors propose a potential study design for standardizing the assessment of long-term metabolic and neurodevelopmental outcomes following early hyperglycemia in preterm infants.

Early Transient Hypoglycemia and Test Performance in At-Risk Newborns

OBJECTIVE

 This study aimed to evaluate if early (within the first 3 hours after birth) transient neonatal hypoglycemia (TNH) is associated with poor academic performance in infants at-risk for hypoglycemia.

STUDY DESIGN

 This was a retrospective cohort study of at risk-infants (late preterm infants, small and large for gestational age infants, and infants of diabetic mothers [IDMs]) who were born in 1998 and 1999 at the University of Arkansas for Medical Sciences and had ≥1 recorded glucose concentration. The outcome measure was proficiency on 4th grade literacy and mathematics achievement tests. Three glucose concentration cutoffs for defining hypoglycemia (<35, <40, and <45 mg/dL) were investigated. Logistic regression models were developed to examine the association between early TNH and achievement test proficiency based on perinatal factors.

RESULTS

 Among 726 infants, 472 had one, 233 had two, and 21 had three risk factor(s). Early TNH (glucose concentration <35, <40, and <45 mg/dL) was observed in 6.3, 11.6, and 20.5% of the study cohort, respectively. Irrespective of the cutoff used, the frequency of early TNH (number of patients with early TNH in a risk category divided by the total number of patients in that category) was significantly greater among infants with multiple risk factors. After controlling for perinatal factors, early TNH (cutoffs <35 and <40 mg/dL) was significantly associated with decreased probability of proficiency in literacy but not mathematics. Despite that early TNH was more common in IDMs and infants with three risk factors, the category or number of risk factors did not impact academic proficiency.

CONCLUSION

 Early TNH (<35 and <40 mg/dL) was associated with lower adjusted probability of proficiency on 4th grade literacy achievement tests in at-risk infants. The impact of early TNH on academic performance was similar irrespective of category or number of risk factors.

KEY POINTS

· Transient hypoglycemia was associated with lower proficiency on 4th grade tests in at-risk infants.. · The category of risk factors among at-risk infants did not impact 4th grade academic proficiency.. · The number of risk factors among at-risk infants did not impact 4th grade academic proficiency..

Cost burden and net monetary benefit loss of neonatal hypoglycaemia

BACKGROUND

Neonatal hypoglycaemia is a common but treatable metabolic disorder that affects newborn infants and which, if not identified and treated adequately, may result in neurological sequelae that persist for the lifetime of the patient. The long-term financial and quality-of-life burden of neonatal hypoglycaemia has not been previously examined.

METHODS

We assessed the postnatal hospital and long-term costs associated with neonatal hypoglycaemia over 80 year and 18 year time horizons, using a health-system perspective and assessing impact on quality of life using quality-adjusted life year (QALYs). A decision analytic model was used to represent key outcomes in the presence and absence of neonatal hypoglycaemia.

RESULTS

The chance of developing one of the outcomes of neonatal hypoglycaemia in our model (cerebral palsy, learning disabilities, seizures, vision disorders) was 24.03% in subjects who experienced neonatal hypoglycaemia and 3.56% in those who do did not. Over an 80 year time horizon a subject who experienced neonatal hypoglycaemia had a combined hospital and post-discharge cost of NZ$72,000 due to the outcomes modelled, which is NZ$66,000 greater than a subject without neonatal hypoglycaemia. The net monetary benefit lost due to neonatal hypoglycaemia, using a value per QALY of NZ$43,000, is NZ$180,000 over an 80 year time horizon.

CONCLUSIONS

Even under the most conservative of estimates, neonatal hypoglycaemia contributes a significant financial burden to the health system both during childhood and over a lifetime. The combination of direct costs and loss of quality of life due to neonatal hypoglycaemia means that this condition warrants further research to focus on prevention and effective treatment.

Clinical Aspects of Neonatal Hypoglycemia: A Mini Review

Introduction: Neonatal hypoglycemia is common and a preventable cause of brain damage. The goal of management is to prevent or minimize brain injury. The purpose of this mini review is to summarize recent advances and current thinking around clinical aspects of transient neonatal hypoglycemia. Results: The groups of babies at highest risk of hypoglycemia are well defined. However, the optimal frequency and duration of screening for hypoglycemia, as well as the threshold at which treatment would prevent brain injury, remains uncertain. Continuous interstitial glucose monitoring in a research setting provides useful information about glycemic control, including the duration, frequency, and severity of hypoglycemia. However, it remains unknown whether continuous monitoring is associated with clinical benefits or harms. Oral dextrose gel is increasingly being recommended as a first-line treatment for neonatal hypoglycemia. There is some evidence that even transient and clinically undetected episodes of neonatal hypoglycemia are associated with adverse sequelae, suggesting that prophylaxis should also be considered. Mild transient hypoglycemia is not associated with neurodevelopmental impairment at preschool ages, but is associated with low visual motor and executive function, and with neurodevelopmental impairment and poor literacy and mathematics achievement in later childhood. Conclusion: Our current management of neonatal hypoglycemia lacks a reliable evidence base. Randomized trials are required to assess the effects of different prophylactic and treatment strategies, but need to be adequately powered to assess outcomes at least to school age.

Neuro Developmental Consequences of Neonatal Hypoglycemia

Neonatal hypoglycemia (HG) can cause neurologic damage, epilepsy, mental retardation, behavioral and personality disorders and death. The longest the HG lasts and the greatest the glucose nadir the consequences are more pronounced. Comorbidities are rather important in development of neurological damage. Hypoxemia and ischemia can cause permanent brain damage. Small for gestational age (SGA), large for gestational age (LGA), intrauterine growth restriction, gestational age bellow the 37th week, low Apgar score, sepsis, children whose mothers have toxemia, diabetes or chorioamnionitis are all newborns with increased HG risk. Comparing 34 patients with NH and 34 children without NH with similar GA, BW, BL, the Apgar score, we found statistically significant differences in motor and mental development using the Griffith scale. Children with neonatal HG fared significantly worse than those without neonatal HG. Therefore, CBG measurements and early recognition of neonatal HG is of significant importance in preventing motor and mental damage in children. A larger and well-balanced cohort of patients followed for a longer period is also necessary to clarify and discern in detail the importance of neonatal HG and other perinatal factors in neurodevelopmental damage.

Neonatal hypoglycemia and the CPT1A P479L variant in term newborns: A retrospective cohort study of Inuit newborns from Kivalliq Nunavut

Introduction

Neonatal hypoglycemia (NH) in the first days of life can largely be prevented by recognizing those at risk and managing accordingly. The CPT1A P479L variant is prevalent in northern Indigenous populations and is a possible risk factor for hypoglycemia. We report on NH incidence in the Kivalliq region of Nunavut, where all Inuit newborns are screened for NH.

Methods

We reviewed clinical charts of 728 Inuit newborns from Kivalliq (January 1, 2010 to December 31, 2013) for blood glucose (BG) levels and infant/maternal characteristics, linking to CPT1A genotype; 616 newborns had BG data from 2 to 48 hours of life. NH was defined using Canadian Paediatric Society guidelines (≤2.0 mmol/L at 2 hours, <2.6 mmol/L at 2 to 48 hours).

Results

NH was documented in 21.4% overall, 24.4% of at-risk newborns and 19.5% of term newborns with no risk factors (≥37 weeks gestation, term-NRF). NH was documented in 22.0% of CPT1A P479L homozygous, 19.8% of P479L heterozygous and 4.8% of noncarrier term-NRF newborns. With multivariable logistic regression, the adjusted ORs for developing NH in term-NRF newborns was 4.97 for CPT1A P479L homozygotes (95% confidence interval [CI]:0.65-38.35, P=0.19) and 4.71 for P479L heterozygotes (95% CI:0.57-37.89, P=0.15).

Conclusion

Term-NRF newborns had a higher NH incidence than previously reported, similar to that for at-risk newborns, possibly due to the CPT1A P479L variant. Since only Inuit newborns from Kivalliq are screened for NH, further study of long-term outcomes of NH in this population and the role of the P479L variant are warranted to determine if neonatal BG screening is indicated in all Inuit newborns.

Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia

BACKGROUND

Worldwide, many newborns who are preterm, small or large for gestational age, or born to mothers with diabetes are screened for hypoglycemia, with a goal of preventing brain injury. However, there is no consensus on a treatment threshold that is safe but also avoids overtreatment.

METHODS

In a multicenter, randomized, noninferiority trial involving 689 otherwise healthy newborns born at 35 weeks of gestation or later and identified as being at risk for hypoglycemia, we compared two threshold values for treatment of asymptomatic moderate hypoglycemia. We sought to determine whether a management strategy that used a lower threshold (treatment administered at a glucose concentration of <36 mg per deciliter [2.0 mmol per liter]) would be noninferior to a traditional threshold (treatment at a glucose concentration of <47 mg per deciliter [2.6 mmol per liter]) with respect to psychomotor development at 18 months, assessed with the Bayley Scales of Infant and Toddler Development, third edition, Dutch version (Bayley-III-NL; scores range from 50 to 150 [mean {±SD}, 100±15]), with higher scores indicating more advanced development and 7.5 points (one half the SD) representing a clinically important difference). The lower threshold would be considered noninferior if scores were less than 7.5 points lower than scores in the traditional-threshold group.

RESULTS

Bayley-III-NL scores were assessed in 287 of the 348 children (82.5%) in the lower-threshold group and in 295 of the 341 children (86.5%) in the traditional-threshold group. Cognitive and motor outcome scores were similar in the two groups (mean scores [±SE], 102.9±0.7 [cognitive] and 104.6±0.7 [motor] in the lower-threshold group and 102.2±0.7 [cognitive] and 104.9±0.7 [motor] in the traditional-threshold group). The prespecified inferiority limit was not crossed. The mean glucose concentration was 57±0.4 mg per deciliter (3.2±0.02 mmol per liter) in the lower-threshold group and 61±0.5 mg per deciliter (3.4±0.03 mmol per liter) in the traditional-threshold group. Fewer and less severe hypoglycemic episodes occurred in the traditional-threshold group, but that group had more invasive diagnostic and treatment interventions. Serious adverse events in the lower-threshold group included convulsions (during normoglycemia) in one newborn and one death.

CONCLUSIONS

In otherwise healthy newborns with asymptomatic moderate hypoglycemia, a lower glucose treatment threshold (36 mg per deciliter) was noninferior to a traditional threshold (47 mg per deciliter) with regard to psychomotor development at 18 months. (Funded by the Netherlands Organization for Health Research and Development; HypoEXIT Current Controlled Trials number, ISRCTN79705768.).

Neurodevelopmental outcomes after moderate to severe neonatal hypoglycemia

The long-term consequences of transient neonatal hypoglycemia are sparsely studied. We performed a follow-up of a cohort of neonates with blood glucose recordings < 1.7 mmol/L (< 30 mg/dL), treated with > 2.5 mmol/L (> 45 mg/dL), compared with healthy siblings. Exclusion criteria were gestational age < 35 weeks, severe asphyxia, head injury, and other cerebral diseases. In 71 children with neonatal hypoglycemia and 32 control siblings, Wechsler IV cognitive test, Movement ABC-2 test, and Child Behavior Checklist were performed at mean age 7.75 and 9.17 years, respectively. No significant changes were detected for cognitive function by using Wechsler IV or for behavior by using Child Behavior Checklist. In univariate analysis, the hypoglycemia group had lower age-adjusted fine motor scores by using the Movement ABC-2 test compared with control siblings, 42.6 ± 31.2 vs. 57.2 ± 30.8 percentile (p = 0.03). In the sibling-paired analysis, the decrease in total motor score was highly significant, p = 0.009, driven by a decrease in fine motor score, p = 0.008. In the hypoglycemia group, adjusted analysis showed a lower fine motor function for boys, β = - 16.4, p = 0.048.Conclusion: Neonatal hypoglycemia treated with > 2.5 mmol/L was associated with lower fine motor scores within the normal range, particularly in boys. No associations with cognitive function or behavior were detected. What is Known: • Transient neonatal hypoglycemia is associated with acute neurologic dysfunction and long-term neurodevelopment impairment in 18 months of age. What is New: • Neonatal hypoglycemia treated with > 2.5 mmol/L is associated with lower fine motor function within the normal range, particularly in boys, but not to changes in cognitive function or behavior.

Brain Injury in Neonatal Hypoglycemia: A Hospital-Based Cohort Study

Background

Neonatal hypoglycemia is more prevalent and can cause severe neurological sequelae. The objective of this study was to assess the patterns of neuroradiologic changes in neonatal hypoglycemia.

Methods

A retrospective cohort study was conducted on 66 neonatal hypoglycemia patients, and the magnetic resonance imaging (MRI) and clinical records were reviewed.

Results

Magnetic resonance imaging showed evidences of abnormality in 54.54% (36 of 66) of hypoglycemic infants. The most common abnormal findings were located on the parietal and occipital lobes of the brains. The number of days with hypoglycemia was significantly higher for abnormal MRI infants (P < .001), and prolonged/recurrent hypoglycemia was remarkably distinguished for abnormal MRI infants (P < .001). Patients with abnormal MRI findings did not have a lower blood glucose than infants without abnormal MRI findings (P > .05), but the lowest blood glucose was significantly lower for the patients with seizures (P < .01).

Conclusions

The pattern of bilateral occipital cortical injury is the most common abnormality for neonatal hypoglycemia. The number of days with hypoglycemia, not the lower blood glucose, was significantly related to abnormal MRI infants.

Neonatal developmental and behavioral outcomes of immediate delivery versus expectant monitoring in mild hypertensive disorders of pregnancy: 2-year outcomes of the HYPITAT-II trial

BACKGROUND

Management of preterm hypertensive disorders remains a clinical dilemma. The maternal benefits of delivery need to be weighed against the adverse neonatal consequences of preterm birth. Long-term consequences of obstetric management in offspring of women with hypertensive disorders in preterm pregnancy are largely unknown. We report child neurodevelopmental and behavioral outcomes at 2 years after the Hypertension and Preeclampsia Intervention Trial at near Term (HYPITAT-II) trial, which compared immediate delivery versus expectant monitoring in mild late preterm hypertensive disorders of pregnancy.

OBJECTIVE

To compare effects of immediate delivery vs expectant monitoring on neurodevelopmental and behavioral outcomes at 2 years of age in offspring of women with mild late preterm hypertensive disorders.

MATERIALS AND METHODS

We studied children born in the HYPITAT-II trial, a study in which women (n = 704) with hypertensive disorders of pregnancy who were between 34 and 37 weeks' gestation were randomized to immediate delivery or expectant monitoring. Participating women were asked to complete the Ages and Stages Questionnaire for developmental outcome and the Child Behavior Checklist for behavioral problems when their toddlers were 2 years old.

RESULTS

We approached 545 of 704 randomized women (77%); 330 of 545 (61%) returned the questionnaires. In the immediate delivery group, 45 of 162 infants (28%) had an abnormal Ages and Stages Questionnaire score compared to 27 of 148 (18%) in the expectant monitoring group (risk difference, 9.6%; 95% CI, 0.3-18.0%); P = .045. In the pregnancies (n = 94) that delivered before reaching 36 weeks, 27% (n = 25) had an abnormal Ages and Stages Questionnaire score compared to 22% (n = 47) when delivered after 36 weeks (odds ratio, 0.77; confidence interval, 0.44-1.34). An abnormal Child Behavior Checklist outcome was found in 31 of 175 (18%) in the delivery group vs 24 of 166 (15%) in the expectant monitoring group (risk difference, 3.2%; 95% CI, -4.6% to 11.0%). After correction for maternal education, management strategy remained an independent predictor of abnormal Ages and Stages Questionnaire score (odds ratio, 0.48; confidence interval, 0.24 to -0.96, P = .03). In multivariable analyses, low birth weight, low maternal education, and immediate delivery policy were all significantly associated with an abnormal Ages and Stages Questionnaire score.

CONCLUSION

In this study, we found that early delivery in women with late preterm hypertensive disorders is associated with poorer neurodevelopmental outcomes in their children at 2 years of age. These findings indicate an increased risk of developmental delay after early delivery compared to expectant monitoring. This follow-up study underlines the conclusion of the original HYPITAT-II study that, until the clinical situation deteriorates, expectant monitoring remains the most appropriate management strategy in the light of short- and long-term neonatal outcomes in women with preterm hypertensive disorders.

Continued Enteral Feeding Is Beneficial in Hypoglycemic Infants Admitted to Intensive Care for Parenteral Dextrose Therapy

There is variability in practice among care providers on feeding infants admitted with neonatal hypoglycemia (NH) for parenteral dextrose. We compared clinical outcomes in infants who were fed (NH-Fed) and hypoglycemic infants who were kept nothing per os (NPO) (NH-NPO) at the time of initiation of intravenous (IV) dextrose. We performed a retrospective review of all newborn infants admitted to the neonatal intensive care unit with NH for IV dextrose. Infants were grouped as per the feeding approach at initiation of IV dextrose: NH-Fed or NH-NPO infants. We found that infants in the NH-Fed group had lower maximum glucose infusion rate, less duration of glucose infusion therapy compared with the NH-NPO group, and significantly less number of days of hospital stay compared with the NH-NPO group (5.87 ± 1.4 days vs 4.9 ± 1.4 days, P < .006). In conclusion, feeding infants with hypoglycemia who require IV dextrose offers tangible benefits of shorter duration of parenteral dextrose and shorter length of hospitalization.

Hypoglycemia in the Newborn

This article covers several aspects of the clinical management of neonatal hypoglycemia that have recently evolved, reviewing the evidence informing these recommended changes in practice. Topics covered include use of buccal dextrose gel, rationale for avoiding the traditional "mini dextrose bolus," and benefits of direct breastfeeding for the treatment of asymptomatic hypoglycemia in at-risk newborns. The reasons for increasing use of more accurate point-of-care devices for measuring neonatal glucose concentrations are discussed, as well as the implications of different published opinions regarding the determination of readiness for discharge and the most important considerations when making this determination.

Neonatal Hypoglycemia: Is There a Sweet Spot?

Hypoglycemia is one of the most common neonatal problems. Despite increasing evidence that hypoglycemia is linked to neurologic impairment, knowledge regarding the specific value or duration of hypoglycemia that results in injury to the brain remains unclear. Current published statements/guidelines focused on preventing clinically significant hypoglycemia are conflicting and continue to be based on low evidence. This article reviews transitional events leading to extrauterine euglycemia, risk factors contributing to transient or persistent hypoglycemia, and common treatment approaches. Current information related to neurodevelopmental outcomes and screening strategies to prevent significant hypoglycemia with early treatment is described.

Predictive factors and prognostic value for status epilepticus in newborns

OBJECTIVES

To evaluate the predictive factors for status epilepticus (SE) in neonates and prognostic factors for patient outcomes in newborns suffering either isolated seizures or SE.

METHODS

A retrospective single-center study from January 2010 to December 2014, included 91 newborns who had neonatal seizures. Among them, 50 newborns experienced SE and 41 newborns presented isolated seizures only. SE was defined as a single seizure lasting more than 15 min or repeated seizures without return to preictal neurological baseline for more than 15 min. Isolated seizures were defined as one single seizure lasting less than 15 min or more seizures with complete recovery of consciousness between seizures. Perinatal and electroclinical data were recorded. Outcomes were evaluated at one year follow up.

RESULTS

In multivariate analysis, the factors identified as being predictive of SE were a severely abnormal initial neurological examination (OR 15.7, 95% CI (3.8-109) p = 0.00075) and hypoglycaemia (OR 6.8, 95% CI (1.5-49.2) p = 0.024), found mostly in newborns with hypoxic-ischemic encephalopathy. When studying our global cohort, SE was found to be a negative prognostic factor for outcome only in univariate analysis. In newborns with isolated seizures only, the postictal clinical examination results were the only independent prognostic factor found, normal results being associated with a more favorable evolution (OR 48.9, 95% CI (7.16-571) p = 0.0003).

CONCLUSION

Two independent risk factors for SE in newborns have been identified: a severely abnormal initial neurological examination and hypoglycaemia. In newborns with isolated seizures, the only positive prognostic factor was found to be a normal postictal clinical examination.

Incidence of hypoglycemia in newborn infants identified as at risk

Background: Temporary low plasma glucose concentrations are common in healthy newborns. Although there is no uniform definition of neonatal hypoglycemia, there is a consensus in the current literature that plasma glucose concentrations should be measured in infants at risk. Known risk groups for transient neonatal hypoglycemia include infants of diabetic mothers (IDM), large (LGA) or small (SGA) for gestational age and late preterm (LPT) infants.Objectives: The aim of this retrospective trial was to determine the incidence of hypoglycemia and the impact of the application of a 2011 revised guideline in respect of additional feeding or i.v. glucose administration, admission to a neonatal ward and the number of blood samples taken.Methods: During the period 1 January 2015 to 31 January 2016, the plasma glucose concentrations of all infants at risk were determined. They were screened over a period of 24 hours or until plasma glucose concentration was >45 mg/dL on three occasions. Hypoglycemia was defined as a plasma glucose concentration <40 mg/dL, regardless of the age of the infant.Results: One hundred and thirty-six (13.6%) out of 1017 newborns were identified as at-risk patients, 119 (87.5%) of whom were included in the final data evaluation. Ten study participants had more than one risk factor and 32 (26.9%) newborns (male:female = 1.1:1) had a total of 40 hypoglycemic episodes. Three (9.4%) out of these 32 newborns had to be transferred to the neonatal ward for i.v. glucose treatment. The mean number of blood samples taken was 7.6 ± 2.4.Conclusions: The incidence of hypoglycemia in the studied infants at risk was 27%, and 19.7 blood samples had to be taken to detect one episode of low glucose concentration. Neonatal hypoglycemia can be recognized and avoided in time, which justifies the establishment of a standardized plasma glucose measurement protocol in newborn infants at risk.Brief RationaleFollowing a considerable number of sources, it is recommended that infants at risk be identified, low plasma glucose concentrations prevented and, if necessary, the affected neonates cared for. Our data show that the risk group for neonatal hypoglycemia comprised about one-tenth of all infants at our nursery and hypoglycemia occurred in one-fourth. These results are in accordance with the recommendations to implement this protocol as a screening tool in neonates.

Neonatal Glycaemia and Neurodevelopmental Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Hypoglycaemia is the most common metabolic problem in neonates but there is no universally accepted threshold for safe blood glucose concentrations due to uncertainty regarding effects on neurodevelopment.

OBJECTIVE

To systematically assess the association between neonatal hypoglycaemia on neurodevelopment outcomes in childhood and adolescence.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and PsycINFO from inception until February 2018. We included studies that reported one or more prespecified outcomes and compared children exposed to neonatal hypoglycaemia with children not exposed. Studies of neonates with congenital malformations, inherited metabolic disorders and congenital hyperinsulinism were excluded. Two authors independently extracted data using a customized form. We used ROBINS-I to assess risk of bias, GRADE for quality of evidence, and REVMAN for meta-analysis (inverse variance, fixed effects).

RESULTS

1,665 studies were screened, 61 reviewed in full, and 11 included (12 publications). In early childhood, exposure to neonatal hypoglycaemia was not associated with neurodevelopmental impairment (n = 1,657 infants; OR = 1.16, 95% CI = 0.86-1.57) but was associated with visual-motor impairment (n = 508; OR = 3.46, 95% CI = 1.13-10.57) and executive dysfunction (n = 463; OR = 2.50, 95% CI = 1.20-5.22). In mid-childhood, neonatal hypoglycaemia was associated with neurodevelopmental impairment (n = 54; OR = 3.62, 95% CI = 1.05-12.42) and low literacy (n = 1,395; OR = 2.04, 95% CI = 1.20-3.47) and numeracy (n = 1,395; OR = 2.04, 95% CI = 1.21-3.44). No data were available for adolescents.

CONCLUSIONS

Neonatal hypoglycaemia may have important long-lasting adverse effects on neurodevelopment that may become apparent at later ages. Carefully designed randomized trials are required to determine the optimal management of neonates at risk of hypoglycaemia with long-term follow-up at least to school age.

Frequency and etiology of persistent neonatal hypoglycemia using the more stringent 2015 Pediatric Endocrine Society hypoglycemia guidelines

Objective

To determine if there was a significant increase in Endocrine consultations postinitiation of the more stringent 2015 guidelines for persistent neonatal hypoglycemia.

Methods

A retrospective chart review was conducted using data from November 2011 to October 2016. All infants with persistent hypoglycemia past 72 hours of life were included. Data included age, critical sample values, anthropometric measures, and maternal health. Descriptive statistical analyses were performed as was an interrupted time series analysis assuming a Poisson distribution.

Results

Fifty-eight infants were evaluated. Postintervention, there was a significant increase in the number of consults (P<0.03, 95% confidence interval [CI]: 1.14 to 8.93). Most infants with hypoglycemia persisting >72 hours were hypoglycemic shortly after birth. Half had intrauterine growth restriction; 75% were male. The median age for investigation was 8.3 days. Hyperinsulinism was the most common etiology (52/58 infants); diazoxide treatment was utilized in roughly half (29/52 to 56%) with a median duration of treatment for 91 days. The phenotype of the infants and duration of diazoxide pre- and post-Pediatric Endocrine Society protocol did not differ; two infants on diazoxide developed pulmonary hypertension. Mothers were typically of lower socioeconomic status.

Conclusion

Not surprisingly, there was significant increase in the number of infants with persistent hypoglycemia using the 2015 guidelines. Prolonged hyperinsulinism was the major cause; medical management was typically sufficient and typically well tolerated. Care to reduce adverse effects of diazoxide is advised. We postulate that infants diagnosed using the more stringent 2015 guidelines have real disease based on the protracted medical management required.

Early neonatal morbidities and neurological functioning of preterm infants 2 weeks after birth

OBJECTIVE

To determine the association between potential neonatal risk factors and the quality of general movements (GMs) in preterm infants.

STUDY DESIGN

Prospective cohort study in 67 preterm infants. From video recordings made on Days 8 and 15, we scored the GMs as normal/abnormal and detailed aspects using the general movement optimality score (GMOS). Risk factors included respiratory insufficiency requiring mechanical ventilation, patent ductus arteriosus (PDA), and abnormal blood glucose levels. We used multiple regression analyses.

RESULT

On Day 8 after birth, the presence of a PDA remained in the multivariable model, explaining 17.1% of the variance in GMOS (beta, -0.414). On Day 15, duration of mechanical ventilation and frequency of hypoglycemic episodes explained 38.8% of the variance (betas, -0.382 and -0.466, respectively).

CONCLUSION

In preterm infants, PDA, duration of mechanical ventilation, and frequency of hypoglycemic episodes were associated with poorer neurological functioning during the first 2 weeks after birth.

Incidence of hypoglycemia in newborns at risk and an audit of the 2011 American academy of pediatrics guideline for hypoglycemia

BACKGROUND

Hypoglycemia is low blood glucose level that may negatively affect neurological and developmental prognosis. The American Academy of Pediatrics (AAP), Committee on Fetus and Newborn defined the safe glucose concentrations in the 2011 guideline for newborns at risk for hypoglycemia. This study aimed to investigate the incidence and associated risk factors for hypoglycemia in newborn infants having risk and to assess compliance with the AAP guideline.

METHODS

According to 2011 AAP guideline for hypoglycemia, the newborns at risk for hypoglycemia included in this study were divided to four groups [infant of diabetic mother (IDM), large-for-gestational-age (LGA) infants, small-for-gestational-age (SGA) infants, and late preterm infants (LPI)].

RESULTS

Of the 207 newborn infants, there were 12 cases in IDM group (5.7%), 79 cases in LGA group (38.1%), 66 cases in SGA group (31.8%) and 50 cases in LPI group (24.1%). The incidences of hypoglycemia in these four groups were 2 (16.6%), 10 (12.7%), 8 (12.2%) and 17 (34%), respectively. Although the gender, delivery method, birth weight and 5-min Apgar score at 5-min were not found to be associated with hypoglycemia (P > 0.05), lower gestational age was determined to be associated with higher incidence of hypoglycemia (P = 0.02). Median first feeding time was 55 min and time between first nutrition and blood glucose measurement was 30 min in all cases.

CONCLUSION

Highest risk for hypoglycemia in early postnatal period was present especially in LPI group. Our compliance levels with the AAP guideline was found to be satisfactory.

Moderate neonatal hypoglycemia and adverse neurological development at 2-6 years of age

To determine whether moderate neonatal hypoglycemia in otherwise healthy infants is associated with adverse neurodevelopmental outcome in pre-school children. Population-based cohort study with prospectively collected register data from Sweden. All singletons born July 1st 2008 through December 31st 2012 (n = 101,060) in the region were included. Infants with congenital malformations, infants treated in neonatal intensive care unit, infants with inborn errors of metabolism and infants to mothers with diabetes were excluded. Infants were followed-up until 2014, at 2–6 years of age. Exposure was neonatal moderate hypoglycemia. Main outcomes were a compiled neurological or neurodevelopmental outcome; any developmental delay; motor developmental delay; and cognitive developmental delay. In adjusted regression analyses, the odds ratio (OR) of any neurological or neurodevelopmental outcome was 1.48 (95% confidence interval: 1.17–1.88) in hypoglycemic compared to normoglycemic infants. The adjusted risk of any developmental delay was more than doubled (OR 2.53 [1.71–3.73]), the adjusted risk of motor developmental delay was almost doubled (OR: 1.91 [1.06–3.44]) and the adjusted risk of cognitive developmental delay was almost tripled (OR 2.85 [1.70–4.76]). Infants with early neonatal hypoglycemia (< 6 h) had a double risk (OR 1.94 [1.30–2.89]) of any neurological or neurodevelopmental outcome and a tripled risk of cognitive developmental delay (OR 3.17 [1.35–7.43]), compared to normoglycemic infants. In the first population-based study on this topic, we show that moderate neonatal hypoglycemia is associated with increased risks of impaired neurodevelopment. Current treatment routines for uncomplicated hypoglycemia should be followed.

Cost Analysis of Cot-Side Screening Methods for Neonatal Hypoglycaemia

BACKGROUND

Babies at risk of neonatal hypoglycaemia are often screened using cot-side glucometers, but non-enzymatic glucometers are inaccurate, potentially resulting in over-treatment and under-treatment, and low values require laboratory confirmation. More accurate enzymatic glucometers are available but at apparently higher costs.

OBJECTIVE

Our objective was to compare the cost of screening for neonatal hypoglycaemia using point-of-care enzymatic and non-enzymatic glucometers.

METHODS

We used a decision tree to model costs, including consumables and staff time. Sensitivity analyses assessed the impact of staff time, staff costs, probability that low results are confirmed via laboratory testing, false-positive and false-negative rates of non-enzymatic glucometers, and the blood glucose concentration threshold.

RESULTS

In the primary analysis, screening using an enzymatic glucometer cost NZD 86.94 (USD 63.47) while using a non-enzymatic glucometer cost NZD 97.08 (USD 70.87) per baby. Sensitivity analyses showed that using an enzymatic glucometer is cost saving with wide variations in staff time and costs, irrespective of the false-positive level of non-enzymatic glucometers, and where ≥78% of low values are laboratory confirmed. Where non-enzymatic glucometers may be less costly (e.g., false-negative rate exceeds 15%), instances of hypoglycaemia will be missed. Reducing the blood glucose concentration threshold to 1.94 mmol/L reduced the incidence of hypoglycaemia from 52 to 13%, and the cost of screening using a non-enzymatic glucometer to NZD 47.71 (USD 34.83).

CONCLUSIONS

In view of their lower cost in most circumstances and greater accuracy, enzymatic glucometers should be routinely utilised for point-of-care screening for neonatal hypoglycaemia.

Alterations in glucose concentrations affect DNA methylation at Lrg1 in an ex vivo rat cortical slice model of preterm brain injury

Preterm birth affects 5-18% of all babies and is associated with neurodevelopmental impairment and increased neuropsychiatric disease risk. Although preterm birth associates with differential DNA methylation at neurodevelopmental genes in buccal DNA, including leucine-rich alpha-2-glycoprotein 1 (LRG1), it is not known whether these differences also occur in the brain, or whether they persist. Thus, there is a need for animal models or in vitro systems in which to undertake longitudinal and mechanistic studies. We used a combination of in vivo rat studies and ex vivo experiments in rat cortical slices to explore their utility in modelling the human preterm brain. We identified temporal changes in DNA methylation at LRG1 in human buccal DNA over the first year of life and found persistent differences in LRG1 methylation between preterm and term infants at 1 year. These developmental changes also occurred in rat brains in vivo, alongside changes in global DNA hydroxymethylation and expression of the ten-eleven translocation (Tet1) enzyme, and were reproducible in ex vivo rat cortical slices. On the basis of the observation that neonatal glucose homeostasis can modify neurodevelopmental outcome, we studied whether glucose concentration affects Lrg1 methylation using cortical slices. Culture of slices in lower glucose concentration was associated with lower Lrg1 methylation, lower global 5hmC and Tet1 expression. Our results suggest that ex vivo organotypic cultures may be useful in the study of biological and environmental influences on the epigenome and that perturbations during early life including glucose concentration can affect methylation at specific genes implicated in neurodevelopment.

Glucose Gel as a Treatment Strategy for Transient Neonatal Hypoglycemia

BACKGROUND

Transient asymptomatic neonatal hypoglycemia (TANH) is common as infants transition from their mother's energy stores to their own. There is little evidence supporting the blood glucose threshold that indicates a need for treatment although sustained hypoglycemia has been correlated with negative neurodevelopmental consequences. Treatment of TANH includes a stepwise approach from supplemental enteral feedings, buccal glucose gel, intravenous dextrose infusion, and/or transfer to special care units including neonatal intensive care units.

PURPOSE

The purpose of this evidence-based practice brief is to review current evidence on 40% buccal glucose gel administration as a treatment strategy for TANH.

METHODS/SEARCH STRATEGY

CINAHL, Cochrane, Google Scholar, and PubMed were searched using the key words and restricted to English language over the last 7 years.

FINDINGS/RESULTS

The use of buccal dextrose gel for TANH may reduce neonatal intensive care unit admissions, reduce hospital length of stay and cost, support the mother-infant dyad through reduced separation, support exclusive breastfeeding, and improve parental satisfaction without adverse neurodevelopmental consequences.

IMPLICATIONS FOR PRACTICE

Timely collection of blood glucose levels following intervention is critical to support clinical decisions. Clinicians should offer family education regarding the rationale for serial glucose monitoring and treatment indications including buccal glucose administration. Clinical protocols can be revised to include use of buccal dextrose gel.

IMPLICATIONS FOR RESEARCH

There is a need for rigorous long-term studies comparing treatment thresholds and neurodevelopmental outcomes among various treatment strategies for TANH.

Standards of admission capillary blood glucose levels in cesarean born neonates

BACKGROUND

Neonatal hypoglycemia (NH) and cutoffs remain undefined. Our center screens all cesarean-delivered (CD) neonates for NH. We sought to define standards of admission capillary blood glucose levels (ACBGLs) in CD neonates who were at the lowest risk for hypoglycemia.

METHODS

Of 4947 neonates, 519 met all 14 inclusion criteria. These highly-selected neonates were apparently the healthiest, least-stressed, earliest to be admitted to nursery and at lowest-risk for hypoglycemia. For each CD, cord blood gases and glucose were determined and each infant was screened for blood glucose at nursery admission.

RESULTS

Sampling age was 41.6±15.3 minutes, a mean ACBGL of 52.3±10.7 mg/dL, and percentiles as follows: 1st percentile, 29.2; 3rd, 33.6; 5th, 35.0; 10th, 39.0; 25th, 46.0; 50th, 51.0; 75th, 58.0; 90th, 67.0; 95th, 71.0; 97th, 73.0, and 99th, 84.4. ACBGL rose significantly with increasing gestational age (P=0.004), increasing cord blood glucose (P<0.001), decreasing cord blood pH (P<0.001) and decreasing sampling age (P=0.027).

CONCLUSIONS

Setting uniform ACBGL cutoffs for NH definition is unachievable due to the enormous heterogeneity among newborns. Hence, we provide group-based ACBGL standards in CD neonates. We propose setting ACBGL cutoffs for use in CD neonates: 1) hypoglycemia: ACBGL <5th percentile (<35 mg/dL); and 2) interventional hypoglycemia: ACBGL <1st percentile (<30 mg/dL).

Effects of Skin-to-Skin Care on Late Preterm and Term Infants At-Risk for Neonatal Hypoglycemia

Objective

The objective of this study was to evaluate the effects of prolonged skin-to-skin care (SSC) during blood glucose monitoring (12-24 hours) in late preterm and term infants at-risk for neonatal hypoglycemia (NH).

Study design

We conducted a retrospective pre- and postintervention study. We compared late preterm and term infants at-risk for NH born in a 1-year period before the SSC intervention, May 1, 2013, to April 30, 2014 (pre-SSC) to at-risk infants born in the year following the implementation of SSC intervention, May 1, 2014, to April 30, 2015 (post-SSC).

Results

The number of hypoglycemia admissions to neonatal intensive care unit among at-risk infants for NH decreased significantly from 8.1% pre-SSC period to 3.5% post-SSC period (P = 0.018). The number of infants receiving intravenous dextrose bolus in the newborn nursery also decreased significantly from 5.9% to 2.1% (P = 0.02). Number of infants discharged exclusively breastfeeding increased from 36.4% to 45.7%, although not statistically significant (P = 0.074).

Conclusion

This SSC intervention, as implemented in our hospital, was associated with a significant decrease in newborn hypoglycemia admissions to neonatal intensive care unit. The SSC intervention was safe and feasible with no adverse events.

The Successful Immediate Neonatal Transition to Extrauterine Life

Purpose:

To define and describe the processes underlying the successful neonatal transition to extrauterine life and methods to assess the transition.

Method:

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, and Google Scholar were searched using a combination of the key words neonate, neonatal, newborn, transition, respiratory OR pulmonary, cardiac, metabolic, pH, umbilical cord, and assessment. Articles in English and German were reviewed. The final sample of articles consisted of one randomized controlled trial, 30 observational studies using human neonates, one observational study using rabbit pups, one secondary analysis, three systematic reviews, and 23 review articles.

Major Findings:

The pertinent findings in regard to normal events in the respiratory, cardiovascular, and metabolic transitions are reviewed and summarized. We address the underlying factors necessary for the transition to extrauterine life, specify the consequences of a successful transition, and review common assessment approaches.

Conclusion:

Available evidence indicates that the successful immediate transition to extrauterine life should be completed within 1–3 hr after birth, though some adaptive processes can fail as late as 24–48 hr after birth. Further research is necessary to identify a feasible, easily used, noninvasive method to assess the status of a neonate’s transition to extrauterine life.

Both Low Blood Glucose and Insufficient Treatment Confer Risk of Neurodevelopmental Impairment in Congenital Hyperinsulinism: A Multinational Cohort Study

BACKGROUND/AIMS

Congenital hyperinsulinism (CHI) is a heterogeneous disease most frequently caused by KATP-channel (ABCC8 and KCNJ11) mutations, with neonatal or later onset, variable severity, and with focal or diffuse pancreatic involvement as the two major histological types. CHI confers a high risk of neurological impairment; however, sparsely studied in larger patient series. We assessed the neurodevelopmental outcome in children with CHI at follow-up in a mixed international cohort.

METHODS

In two hyperinsulinism expert centers, 75 CHI patients were included (Russian, n = 33, referred non-Scandinavian, treated in Denmark n = 27, Scandinavian, n = 15). Hospital files were reviewed. At follow-up, neurodevelopmental impairment and neurodevelopmental, cognitive and motor function scores were assessed.

RESULTS

Median (range) age at follow-up was 3.7 years (3.3 months-18.2 years). Neurodevelopmental impairment was seen in 35 (47%). Impairment was associated with abnormal brain magnetic resonance imaging (MRI); odds ratio (OR) (95% CI) 15.0 (3.0-74.3), p = 0.001; lowest recorded blood glucose ≤1 mmol/L; OR 3.8 (1.3-11.3), p = 0.015, being non-Scandinavian patient, OR 3.8 (1.2-11.9), p = 0.023; and treatment delay from first symptom to expert center >5 days; OR 4.0 (1.0-16.6), trend p = 0.05. In multivariate analysis (n = 31) for early predictors with exclusion of brain MRI, treatment delay from first symptom to expert center >5 days conferred a significantly increased risk of neurodevelopment impairment, adjusted OR (aOR) 15.6 (1.6-146.7), p = 0.016, while lowest blood glucose ≤1 mmol/L had a trend toward increased risk, aOR 3.5 (1.1-14.3), p = 0.058. No associations for early vs. late disease onset, K_ATP-channel mutations, disease severity, focal vs. diffuse disease, or age at follow-up were seen in uni- or multivariate analysis.

CONCLUSION

Not only very low blood glucose, but also insufficient treatment as expressed by delay until expert center hospitalization, increased the risk of neurodevelopmental impairment. This novel finding calls for improvements in spread of knowledge about CHI among health-care personnel and rapid contact with an expert CHI center on suspicion of CHI.

An emerging evidence base for the management of neonatal hypoglycaemia

Neonatal hypoglycaemia is common, and screening and treatment of babies considered at risk is widespread, despite there being little reliable evidence upon which to base management decisions. Although there is now evidence about which babies are at greatest risk, the threshold for diagnosis, best approach to treatment and later outcomes all remain uncertain. Recent studies suggest that treatment with dextrose gel is safe and effective and may help support breast feeding. Thresholds for intervention require a wide margin of safety in light of information that babies with glycaemic instability and with low glucose concentrations may be associated with a higher risk of later higher order cognitive and learning problems. Randomised trials are urgently needed to inform optimal thresholds for intervention and appropriate treatment strategies.

Developmental Outcomes of Preterm Infants With Neonatal Hypoglycemia

BACKGROUND AND OBJECTIVES

Neonatal hypoglycemia has been associated with abnormalities on brain imaging and a spectrum of developmental delays, although historical and recent studies show conflicting results. We compared the cognitive, academic, and behavioral outcomes of preterm infants with neonatal hypoglycemia with those of normoglycemic controls at 3 to 18 years of age.

METHODS

A secondary analysis of data from the Infant Health and Development Program, a national, multisite, randomized controlled longitudinal intervention study of long-term health and developmental outcomes in preterm infants. Of the 985 infants enrolled in the Infant Health and Development Program, 745 infants had glucose levels recorded. Infants were stratified into 4 groups by glucose level. By using standardized cognitive, academic, and behavioral assessments performed at 3, 8, and 18 years of age, we compared groups after adjusting for intervention status, birth weight, gestational age, sex, severity of neonatal course, race, maternal education, and maternal preconception weight.

RESULTS

No significant differences were observed in cognitive or academic skills between the control and effected groups at any age. Participants with more severe neonatal hypoglycemia reported fewer problem behaviors at age 18 than those without hypoglycemia.

CONCLUSIONS

No significant differences in intellectual or academic achievement were found between preterm infants with and without hypoglycemia. A statistical difference was found in behavior at age 18, with hypoglycemic children showing fewer problematic behaviors than normoglycemic children. This difference was not clinically meaningful. Using extended outcomes, our results are consistent with previous studies that found no significant neurodevelopmental outcomes associated with neonatal hypoglycemia in preterm-born children.

Improving the Diagnosis of Neonatal Hypoglycemia in a Well-Baby Nursery

Point of care glucose (POCG) measurements, used for detecting neonatal hypoglycemia, can have variable accuracy. The appropriate diagnosis of neonatal hypoglycemia in babies with low POCG measurements involves confirmatory serum glucose (CSG) testing. At our institution, no babies with low POCG measurements had CSG testing in their evaluation of neonatal hypoglycemia over a three year period. Our aim was to increase the percentage of CSG testing in babies with a low POCG. A secondary aim was to decrease the percentage of low-risk, asymptomatic babies who received POCG testing. Interventions included the design and implementation of an evidence-based protocol for the diagnosis and management of neonatal hypoglycemia (cycle 1), along with supportive education for multi-disciplinary providers on best practices related to neonatal hypoglycemia (cycle 2). Data were analyzed using statistical process control. During Cycle 1, the percentage of CSG testing in babies with POCG ≤40 mg/dL significantly increased from 0 to 33%, and increased further to 63% during Cycle 2. The initial gain was sustained over 2 years. The percentage of POCG testing among low-risk asymptomatic babies was 40% at baseline and did not change during the project period. 18 babies with low POCG results were spared from a diagnosis of neonatal hypoglycemia based on CSG testing. Implementation of a neonatal hypoglycemia protocol, along with supportive education, significantly improved rates of CSG testing, but not POCG overutilization, in our newborn population. Factors related to POCG overutilization should be further explored.

Late Pregnancy β Blocker Exposure and Risks of Neonatal Hypoglycemia and Bradycardia

BACKGROUND AND OBJECTIVES

β blockers are widely used in the treatment of hypertensive disorders during pregnancy. These medications cross the placenta and may cause physiologic changes in neonates exposed in utero. We sought to define the risks of neonatal hypoglycemia and bradycardia associated with maternal exposure to β blockers at the time of delivery in a large, nationwide cohort of Medicaid beneficiaries.

METHODS

We used a cohort of 2 292 116 completed pregnancies linked to liveborn infants of Medicaid-enrolled women from 2003 to 2007. We examined the risks of neonatal hypoglycemia and neonatal bradycardia associated with maternal exposure to β blockers at the time of delivery. Propensity score matching was used to control for potential confounders including maternal demographics, obstetric and medical conditions, and exposure to other medications.

RESULTS

There were 10 585 (0.5%) pregnancies exposed to β blockers at the time of delivery. The risk of neonatal hypoglycemia was 4.3% in the β blocker-exposed neonates versus 1.2% in the unexposed; the risk of neonatal bradycardia was 1.6% in the exposed versus 0.5% in the unexposed. After controlling for confounders, risk remained elevated for both neonatal hypoglycemia and bradycardia among exposed pregnancies versus unexposed (adjusted odds ratio, 1.68, 95% confidence interval, 1.50-1.89 and adjusted odds ratio, 1.29, 95% confidence interval, 1.07-1.55, respectively).

CONCLUSION

Our findings suggest that neonates born to mothers exposed to β blockers in late pregnancy, including labetalol, are at elevated risk for neonatal hypoglycemia and bradycardia.

New approaches to management of neonatal hypoglycemia

Despite being a very common problem after birth, consensus on how to manage low glucose concentrations in the first 48 h of life has been difficult to establish and remains a debated issue. One of the reasons for this is that few studies have provided the type of data needed to establish a definitive approach agreed upon by all. However, some recent publications have provided much needed primary data to inform this debate. These publications have focused on aspects of managing low blood glucose concentrations in the patients most at-risk for asymptomatic hypoglycemia—those born late-preterm, large for gestational age, small for gestational age, or growth restricted, and those born following a pregnancy complicated by diabetes mellitus. The goal of this review is to discuss specific aspects of this new research. First, we focus on promising new data testing the role of buccal dextrose gel in the management of asymptomatic neonatal hypoglycemia. Second, we highlight some of the clinical implications of a large, prospective study documenting the association of specific glycemic patterns with neurodevelopmental outcomes at two years of age.