Prevalence and underlying etiologies of neonatal hypoglycemia

Determinants of neonatal hypoglycemia among neonates admitted at Hiwot Fana Comprehensive Specialized University Hospital, Eastern Ethiopia: A retrospective cross-sectional study

Objective

The study aimed to assess the magnitude and determinants of neonatal hypoglycemia among neonates admitted to the Neonatal Intensive Care Unit at Hiwot Fana Specialized University Hospital, Eastern Ethiopia.

Methods

An institutional-based cross-sectional study was conducted among 698 randomly selected neonates at Hiwot Fana Comprehensive Specialized Hospital from 1 January 2018 to 31 December 2020. By looking at the charts, data were gleaned from the medical records. Data were entered into Epi-Data version 3.1 and analysis was performed using SPSS version 22. Bivariable and multivariable logistic regression analyses were conducted to identify determinant factors of neonatal hypoglycemia. Association was described using an adjusted odds ratio along with a 95% CI. Finally, a p-value <0.05 in the adjusted analysis was considered to declare a statistically significant association.

Results

Out of 698 neonates, 148 (21.2%; 95% CI: 18.3, 24.5) neonates had hypoglycemia. Preterm birth (AOR = 3.06; 95% CI: 1.02, 9.17), hypothermia (AOR = 2.65; 95% CI: 1.22, 5.75), neonatal sepsis (AOR = 2.61; 95% CI: 1.03, 6.59), diabetic mother (AOR = 2.34; 95% CI: 1.03, 5.33), and delay in initiation of breastfeeding for more than 1 h (AOR = 3.89; 95% CI: 1.17, 12.89) were identified as determinant factors of neonatal hypoglycemia.

Conclusion

The magnitude of neonatal hypoglycemia was quite common among neonates. Neonatal hypoglycemia was found to be predicted by preterm birth, hypothermia, neonatal sepsis, maternal diabetes mellitus, and delay in starting nursing. We therefore strongly suggest health-care workers work in the postnatal unit to manage and control these and other determinant factors of hypoglycemia to prevent the occurrence of neonatal hypoglycemia.

Investigating Genetic Mutations in a Large Cohort of Iranian Patients with Congenital Hyperinsulinism

OBJECTIVE

Congenital hyperinsulinism (CHI) is the most frequent cause of severe and persistent hypoglycaemia from birth. Understanding the pathophysiology and genetic defects behind hyperinsulinism and its complications provides clues to timely diagnosis and management. The aim of this study was to evaluate the underlying genetic aetiology of a specific Iranian pediatric cohort with CHI.

METHODS

A total of 44 unrelated children, 20 girls and 24 boys, with an initial diagnosis or history of CHI from all regions of Iran were recruited between 2016 and 2019. Targeted next generation sequencing (tNGS) was performed for the genes found in about half of CHI patients.

RESULTS

Mutations were identified in 24 cases (55%). Patients with a confirmed genetic cause were mainly diagnosed below age of one year old (p=0.01), had fewer other syndromic features, excluding seizure, (p=0.03), were less diazoxide responsive (p=0.04) and were more diazoxide unresponsive leading to pancreatectomy (p=0.007) compared to those with no identified mutations. Among 24 patients with identified genetic mutations, 17 (71%) had a mutation in ABCC8, 3 (12%) in KCNJ11, 3 (12%) in HADH, and 1 patient had a mutation in KMT2D. These included five novel mutations in ABCC8, KCNJ11, and KMT2D.

CONCLUSION

This is the biggest genetic study of CHI in Iran. A high frequency of recessive forms of CHI, especially HADH mutations, in our study could be due to a high rate of consanguineous marriage. We recommend tNGS to screen for all the CHI genes.

Congenital Hyperinsulinism Caused by Novel Homozygous KATP Channel Gene Variants May Be Linked to Unexplained Neonatal Deaths among Kurdish Consanguineous Families

INTRODUCTION

Neonatal hypoglycemia due to congenital hyperinsulinism (CHI) is a potentially life-threatening condition. Biallelic pathogenic variants in KATP channel subunit genes (ABCC8, KCNJ11), causing severe forms of CHI, are more prevalent in regions with a significant rate of consanguinity and may lead to unexplained neonatal deaths. We hypothesized that KATP channel gene variants are the cause of CHI in three unrelated children from consanguineous Kurdish families with histories of four unexplained neonatal deaths with convulsions.

CASES

(1) A girl presented on the 6th day of life with recurrent hypoglycemic convulsions (blood glucose 2.05 mmol/L, insulin 58 mIU/L, C-peptide 2,242 pmol/L). (2) A girl with severe developmental delay was diagnosed with CHI at 3 years of age (blood glucose 2.78 mmol/L, insulin 8.1 mIU/L, C-peptide 761 pmol/L) despite a history of recurrent hypoglycemia since neonatal age. (3) A girl presented at 3 weeks of age with convulsions and unconsciousness (blood glucose 2.5 mmol/L, insulin 14.6 mIU/L, C-peptide 523 pmol/L). Coding regions of the ABCC8 and KCNJ11 genes were tested by Sanger sequencing. Potential variants were evaluated using the American College of Medical Genetics standards. Three novel causative homozygous variants were found - p.Trp514Ter in the ABCC8 gene (Pt2), and p.Met1Val (Pt1) and p.Tyr26Ter (Pt3) in the KCNJ11 gene.

CONCLUSION

CHI caused by KATP channel variants was elucidated in three children, providing a highly probable retrospective diagnosis for their deceased siblings. Future lives can be saved by timely diagnosis of CHI when encountering a neonate with unexplained seizures or other signs of recurrent and/or persistent hypoglycemia.

Triglyceride-to-high density lipoprotein cholesterol ratio and triglyceride-glucose index in the perinatal period of neonates

BACKGROUND

Environmental factors and growth disturbances, either intra-uterine, or post-natal, can result in permanent changes in tissues and also long-term effects that may present themselves as pathological conditions in adulthood, including increased incidence of insulin resistance, impaired glucose tolerance, and also higher likelihood for diabetes mellitus. The triglyceride to glucose index (TyG) and triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-c) have been proposed as reliable and simple alternatives for the evaluation of insulin resistance. To date, there was limited data regarding the TyG index and TG/HDL-c ratio in the perinatal period of neonates. We aimed to investigate the possible relationships between HOMA-IR, TyG index, and TG/HDL-c in the cord blood of neonates.

MATERIALS-METHODS

One hundred and six pregnant women with singleton gestation who gave birth to full-term, normal-weight Turkish neonates without fetal distress were included in the study. The samples of maternal serum and cord blood in neonates were obtained after delivery.

RESULTS

Mean TyG index was 3.71 ± 0.38 and the mean TG/HDL-c ratio was 3.12 ± 3.00 in this group. Correlations were found between maternal age and neonate glucose levels and HOMA-IR (p < .05). HOMA-IR was negatively correlated with triglyceride, TG/HDL-c ratio, TyG index + TG/HDL, and positively correlated with HDL and TyG index.

CONCLUSIONS

Our study indicates that the TyG index and TG/HDL-C may be used as an indicator of insulin sensitivity in the perinatal period of neonates. However, the validity of these results should be tested in other centers with a larger neonate population in order to evaluate whether ethnic and racial diversity influence these relationships.

Follow-up study of neurodevelopment in 2-year-old infants who had suffered from neonatal hypoglycemia

BACKGROUND

Neonatal hypoglycemia is tightly related to adverse neurodevelopmental and brain injury outcomes.

METHODS

A total of 195 infants who were born from diabetic mothers with a low blood glucose level (< 2.6 mM) within 0.5 h after birth were enrolled in this prospective cohort study. Of these, 157 infants who had neonatal hypoglycemia (group A) were followed up, and this group was further divided into A1 [blood glucose concentration (BGC) < 2.6 mM at < 2 h after birth], A2 (BGC < 2.6 mM at 2-24 h after birth), and A3 (BGC < 2.6 mM at > 24 h after birth). A total of 144 infants whose mothers had no high risk for gestational diabetes mellitus were followed up as the control group during the same period. The neurodevelopment of the infants was evaluated by the Gesell scoring method.

RESULTS

The adaptability in the A2 and A3 subgroups was significantly lower than that in the control group (73.9 ± 6.6 vs. 87.9 ± 11.2; 71.5 ± 8.9 vs. 87.9 ± 11.2, respectively). There were significantly more mothers who used insulin during the perinatal period in A3 than in A1 and A2 (31% vs. 2%; 31% vs. 7.9%, respectively). The mothers of babies in subgroups A2 and A3 gained more weight than those of the control group (15.3 ± 1.9 kg vs. 11.1 ± 2.2 kg; 14.8 ± 2.6 kg vs. 11.1 ± 2.2 kg, respectively).

CONCLUSIONS

Long and repeated neonatal hypoglycemia caused poor adaptability. The babies of mothers who used insulin or had a high weight gain during pregnancy were associated with severe or persistent neonatal hypoglycemia.

[Evaluation of the measurement of capillary glucose concentration versus plasma glucose in the newborn]

BACKGROUND

The reliability of blood glucose monitoring in neonatology is not always confirmed. The aim of this study was to evaluate the reliability of blood glucose measurements made with three different devices in newborns.

PATIENTS AND METHODS

The study was prospective, conducted in a medical and neonatal intensive care department over a period of 4 months. Capillary glucose level was measured with three different glucometers and compared with venous glucose level determined using the hexokinase method. An ANOVA and Scheffe test were used for the correlation analysis.

RESULTS

Three hundred and nine infants were included, with a mean age of 55h and a mean term of 39 weeks of gestation. Mean blood glucose in the laboratory was 0.62±0.15g/L, 0.71±0.17g/L for Accu-Chek(®) Active, 0.80±0.17g/L for Accu-Chek(®) Performa, and 0.83±0.12g/L for Bionime. An ANOVA showed statistically significant differences between the measurements made by glucometers compared to the reference blood glucose levels, and the Scheffé method showed that glucometers overestimated the real plasma glucose levels.

CONCLUSION

None of the devices used in this study was satisfactory. However, an estimation of blood glucose taking into consideration this numerical overestimation would allow early detection of hypoglycemia.

Neonatal hypoglycemic brain injury is a cause of infantile spasms

Neonatal hypoglycemic brain injury is one of the causes of infantile spasms. In the present study, the clinical history and auxiliary examination results of 18 patients who developed infantile spasms several months after neonatal hypoglycemia were retrospectively analyzed. Among the 666 patients with infantile spasms admitted to two pediatric centers between January 2008 and October 2012, 18 patients developed infantile spasms after being diagnosed with neonatal hypoglycemia, defined as a whole blood glucose concentration of <2.6 mmol/l. These patients developed infantile spasms from between 2 and 10 months (mean, 4.9 months) following the diagnosis of neonatal hypoglycemia. All 18 patients had abnormal electroencephalographic findings with either classical or modified hypsarrhythmia. Upon examination using brain magnetic resonance imaging (MRI), 10 patients (55.6%) exhibited abnormalities. The MRI results principally showed a disproportional involvement of parietal and occipital cortices and sub-cortical white matter lesions. In conclusion, the results of this study indicate that neonatal hypoglycemic brain injury is associated with the subsequent development of infantile spasms.

Congenital hyperinsulinemia with grade 4 intraventricular hemorrhage: a case report with a 2-year follow-up

Massive intraventricular hemorrhage associated with hypoglycemia has rarely been reported. We present a late preterm baby girl with severe hypoglycemia after birth. Despite high glucose infusion rates, her glucose levels remained in the 30s to 50s (mg/dL) during the first week of life with a brief period of normoglycemia. On day 2, her computed tomography scan of head showed extensive intraventricular hemorrhage with intraparenchymal extension, which was reported as unexpected for an infant born close to term. She was diagnosed with congenital hyperinsulinemia. Her glucose levels normalized on diazoxide therapy started on day 6. In the absence of any other clear cause, the massive brain hemorrhage was thought to be secondary to prolonged severe hypoglycemia the infant suffered. She remains in global developmental delay at her age at 26 months. This case highlights the importance of early referral of neonatal hypoglycemia for prompt diagnosis and management to avoid the consequences of prolonged low blood glucose.