Effectiveness of hospital-based oral dextrose gel in prevention and treatment of asymptomatic newborns at risk of hypoglycemia

OBJECTIVE

To evaluate the effectiveness of using hospital-based 40% dextrose gel (DG) in preventing and treating asymptomatic hypoglycemia in infants of diabetic mothers (IDM), large for gestational age (LGA), and macrosomic neonates.

METHODS

A medical chart review was conducted to compare data between before (April 2018 to March 2019, epoch 1) and after (September 2020 to November 2021, epoch 2) 40% DG implementation. DG, prepared by the hospital pharmaceutical unit, was applied within 30-45 min after birth, and three additional doses could be repeated during the first 6 h of life in combination with early feeding. The primary outcome was the rate of intravenous dextrose administration. Secondary outcomes were the incidence of hypoglycemia, first capillary blood glucose concentrations, and the length of hospital stay.

RESULTS

Six hundred forty-three at-risk newborns were included (320 before and 323 after implementation of DG). Maternal and neonatal baseline characteristics were not different between the two epochs. The incidence of hypoglycemia was not different (17.8% in before versus 14.6% in after implementation, p = 0.26). The rate of intravenous dextrose administration after DG implementation was significantly lower than that before DG implementation (3.4% versus 10.3%, p < 0.001, risk reduction ratio = 0.33, 95% CI = 0.17-0.64). The length of hospital stay was not different between the two epochs.

CONCLUSIONS

Implementing a protocol for administration of hospital-based 40% DG can reduce the need of intravenous dextrose administration among IDM, LGA and macrosomic neonates.

Outcomes in low-risk patients before and after an institutional policy offering 39-week elective induction of labor

OBJECTIVE

Elective induction of labor versus expectant management at 39 weeks gestation in low-risk nulliparous patients was shown in the ARRIVE randomized trial of over 6000 patients to decrease risks of cesarean delivery without significant change in the composite perinatal outcome. We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) to all low-risk patients.

METHODS

Retrospective cohort study of low-risk nulliparous and multiparous patients delivering live, non-anomalous singletons at a single center at greater than or equal to 39 0/7 weeks gestational age. Those with prior or planned cesarean delivery, ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; 1/2012-3/2014) or after (post-eIOL; 3/2019-12/2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births occurring April 2014 to December 2018 were allocated to a separate cohort (during-eIOL) given increased exposure to eIOL as our center recruited participants for the ARRIVE trial. The primary outcome was cesarean birth. Secondary outcomes included select maternal (e.g. chorioamnionitis, operative delivery, postpartum hemorrhage) and neonatal morbidities (e.g. birthweight, small- and large-for gestational age, hypoglycemia). Characteristics and outcomes were compared between the pre and during-eIOL, and pre and post-eIOL groups; adjusted OR (95% CI) were calculated using multivariable regression. Subgroup analysis by parity was planned.

RESULTS

Of 10,758 patients analyzed, 2521 (23.4%) were pre-eIOL, 5410 (50.3%) during-eIOL, and 2827 (26.3%) post-eIOL. Groups differed with respect to labor type, age, race/ethnicity, marital and payor status, and gestational age at care entry. Post-eIOL was associated with lower odds of cesarean compared to pre-eIOL (aOR 0.83 [95% CI 0.72-0.96]), which was even lower among those specifically undergoing labor induction (aOR 0.58 [0.48-0.70]. During-eIOL was also associated with lower odds of cesarean compared to pre-eIOL (aOR 0.79 [0.69-0.90]). Both during and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonates weighing ≥4000 g, large-for-gestational age infants, and neonatal hypoglycemia compared to pre-IOL.

CONCLUSION

An institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower cesarean birth rate, lower birthweights and lower neonatal hypoglycemia, and an increased risk of chorioamnionitis and hemorrhage.

Factors associated with neonatal hyperinsulinemic hypoglycemia, a case-control study

OBJECTIVES

We aimed to identify perinatal risk factors associated with hyperinsulinemic hypoglycemia in neonates. Secondary objectives included an examination of clinical and biochemical characteristics at the time of diagnosis and an exploration of the duration of diazoxide therapy.

METHODS

A case-control study was conducted, involving individual chart reviews of inborn infants diagnosed with hyperinsulinemic hypoglycemia (the HH group) between 2014 and 2021. These cases were paired with controls (the non-HH group) belonging to the same gestational age (GA) strata who did not exhibit HH or only had transient postnatal hypoglycemia.

RESULTS

A total of 52 infants with HH were matched with corresponding controls. The mean GA in the HH group was 34.4 ± 3.1 weeks. Notably, the HH group exhibited lower mean minimum plasma glucose (PG) levels and required higher glucose infusion rates in comparison to the non-HH group (26.5 ± 15.6 vs. 49.1 ± 37.7 mg/dL and 12.9 ± 3.8 vs. 5.7 ± 2.1 mg/kg/min, respectively; p<0.001 for both). After adjusting for potential confounding factors, only two variables, fetal growth restriction (FGR) and neonatal sepsis, demonstrated significant associations with HH (adjusted odds ratio [95 % confidence interval]: 8.1 [2.1-31.0], p=0.002 and 6.3 [1.9-21.4], p=0.003, respectively). The median duration of diazoxide therapy for the HH group was 4 months.

CONCLUSIONS

FGR and neonatal sepsis emerged as notable risk factors for HH. These infants exhibited lower PG levels and necessitated higher glucose infusion rates compared to their non-HH counterparts. Importantly, a substantial proportion of the HH group received diazoxide therapy, with a median treatment duration of 4 months.

An Evidence-Based Practice Project to Provide Standardized Education on Skin-to-Skin Contact and Neonatal Hypoglycemia

OBJECTIVE

To develop and examine the implications of formalized education with staff and familial caregivers on skin-to-skin in relation to neonatal hypoglycemia, including the impact on NICU admission rate, exclusive breastfeeding, and glucose gel administration.

DESIGN

Evidence-based practice (EBP) project with a comparison of data pre-/postintervention.

SETTING/LOCAL PROBLEM

Implemented at a large health system in the mid-Atlantic, including four hospitals with postpartum care units. The EBP implementation site had approximately 19,400 births in 2021.

PARTICIPANTS

Participants included 320 postpartum nurses in addition to the familial neonatal caregivers these nurses provided care for.

INTERVENTION/MEASUREMENT

All team members were provided with online education via the HealthStream learning platform, a microlearning introduction video, weekly huddle messages, and unit-specific champions who shared a champion information sheet that included information such as the hypoglycemia protocol, how to perform safe skin-to-skin care, and how to effectively administer glucose gel. Familial caregiver education included a handout given upon admission with an explanation from the postpartum nurse if the neonate met the criteria for the hospital system's neonatal hypoglycemia protocol.

RESULTS

We observed a 4% system-wide increase in exclusive breastfeeding rates, a decrease in NICU admissions by 17.3% at 1-month postimplementation at the smallest hospital site (Hospital A), and a 12.3% reduction in NICU admission rates at the largest hospital site (Hospital B). Two hospitals reported a decrease in the need for glucose gel administration to neonates after the educational intervention.

CONCLUSION

This nurse-led project detailed the process of a system-wide EBP project to implement consistent and standardized education regarding neonatal protocols. Although the benefits of skin-to-skin contact are widely known, this project demonstrated that focused, targeted education on skin-to-skin protocols for neonates at risk for neonatal hypoglycemia may be effective at improving outcomes.

Determinants of Hypoglycemia in Premature Vietnamese Infants: A Case-Control Study

Background Premature infants are more likely to experience hypoglycemia. Early recognition and prompt therapy are essential to avoiding neurological sequelae in the future. This study aimed to identify the determinants of hypoglycemia in premature Vietnamese infants. Methodology This was a case-control study conducted at the Neonatal Intensive Care Unit, The Women and Children Hospital of An Giang, Vietnam. Hypoglycemia was defined as a plasma glucose value of less than 2.6 mmol/L (47 mg/dL) after two hours postpartum. Maternal and neonatal information was collected and analyzed. Both bivariate and multiple logistic regression models were used to identify the risk factors of neonatal hypoglycemia (NH) Results A total of 65 cases and 195 controls were included in the study. Gestational diabetes mellitus (GDM) (adjusted odds ratio [AOR] 3.78, 95% confidence interval [CI] 1.69-8.52; P < 0.001) and excessive gestational weight gain (GWG) (AOR 2.80, 95% CI 1.12-6.98; P < 0.026) were associated with NH in the multiple logistic regression model. An observed positive interaction between gestational hypertension and GDM on NH yielded an odds ratio (OR) of 6.29 (95% CI 2.46-16.64). Conclusions GDM, excessive GWG, and the interaction between gestational hypertension and GDM were the determinants of hypoglycemia in premature infants.

Application of glycemic qualification rate based on fingerstick glucose monitoring in women with gestational diabetes mellitus

OBJECTIVE

To explore the appropriate application of glycemic qualification rate (GQR) calculated by fingerstick blood glucose (BG) monitoring for patients with gestational diabetes mellitus (GDM) by analyzing the relationship between BG control and adverse pregnancy outcomes.

METHODS

Fingerstick Blood Glucose data during the second and third trimester of singleton pregnant women diagnosed with GDM were collected. GQR which is defined as the percentage of fingerstick BG values reaching the targets of BG control in a period of time was calculated. Patients were divided into three groups according to tertiles (tertile 1, GQR <56.25%; tertile 2, GQR 56.25-75%; and tertile 3, GQR ≥75%). Pregnant outcomes were compared among the three groups. Univariate analysis and logistic regression were performed to analyze the potential relationship between GQR and pregnancy outcomes. Receiver operating characteristic (ROC) curves were calculated to determine the cutoff values. We also explored that whether twice or three times monitoring per day would be adequate for GQR calculation, so we brought in two or three glucose measuring times per day to explore the relationship between new GQR and adverse outcomes.

RESULTS

A total of 311 patients diagnosed with GDM were analyzed. In univariate analysis, the incidences of cesarean section of tertile 1-3 groups were 61.4%, 58.7%, and 44.9%, respectively (p < .05). The incidences of neonatal hypoglycemia of tertiles 1-3 groups were 19.8%, 18.6%, and 8.7% (p < .05). The difference of composite outcomes was statistically significant (p = .001). After adjustment, the patients with worse BG control (lower GQR) had higher risk of cesarean section (tertile 1 - aOR = 2.029, 1.128-3.648), neonatal hypoglycemia (tertile 1: aOR = 2.498, 1.082-5.766) as well as composite outcomes. The ROC curve of GQR indicated the predictive value for neonatal hypoglycemia (area under the ROC curve (AUC) 0.612 (0.532-0.692)) and neonatal composite outcomes (AUC 0.593 (0.528-0.657)) with optimal cutoff values of 81.1% and 73.5%, respectively. We also explored that whether twice or three times monitoring per day would be adequate for GQR calculation. The result showed that GQR only calculated by FBG + 2hPG after lunch (2h AL) per day also had well relationship with cesarean section (tertile 1: OR = 2.412, 1.322-4.398), neonatal hypoglycemia (tertile 1: aOR = 4.497, 1.607-12.586), and neonatal composite outcomes (tertile 1: aOR = 1.959, 95% confidence interval (CI): 1.114-3.444, p = .020).

CONCLUSIONS

The GQR calculated by the easily applicable fingerstick BG is related to occurrence of cesarean section and neonatal hypoglycemia in GDM women. GQR ≥ 80% is recommended for better pregnancy outcomes. As for the number of points monitoring per day, GQR calculated by FBG + 2h AL was an optimal option for better pregnancy outcomes if mothers needed to simplify the process of monitoring.

Oral glucose gel in the prevention of neonatal hypoglycemia: A systematic review and meta-analysis

BACKGROUND

Neonatal hypoglycemia (NH) is the most prevalent metabolic disorder in neonates and glucose gel in oral solution is a relatively new treatment option for NH. We aimed to determine whether oral glucose gel can prevent NH.

METHODS

We conducted an open literature search using PubMed, Embase, Cochrane Library, and Web of Science. We used relative risk as the statistical data, expressed each outcome effect as a 95% confidence interval, and conducted a heterogeneity test. If heterogeneity statistics indicated that I2 was ≥ 50%, the random effects model analysis was used; otherwise, the fixed effects model analysis was conducted, and sensitivity analyses were conducted for all outcomes.

RESULTS

In this review, we included a total of 10 studies involving 4801 neonates. Meta-analysis revealed that there were no significant differences between the preventive oral glucose gel group and the control group in terms of blood glucose concentration, glucose concentration 30 minutes after the first breastfeeding, length of stay, Bayley-III composite score, subsequent need for intravenous injection of glucose, 24-hour glucose > 50 mg/dL, separation from mother for treatment of hypoglycemia/admitted to neonatal intensive care unit for hypoglycemia, normoglycemia after 1 to 2 treatments, or normoglycemia after more than 2 treatments, breastfeeding at discharge, delayed feeding, neurosensory impairment, parental satisfaction, developmental delay, and seizure. The subsequent intake was significantly lower in the glucose gel group compared to the control group.

INTERPRETATION

The use of oral glucose gel as a preventative measure may not reduce the incidence of NH. In order to assess the efficacy of glucose gel in preventing NH, a more high-quality, large-sample, and rigorously designed randomized controlled trial is required.

Effects of antenatal dexamethasone on postnatal serum cortisol levels in late preterm infants

OBJECTIVES

To explore whether antenatal dexamethasone impacts postnatal serum cortisol levels in stable late preterm (LPT) infants. Secondary outcomes were to identify short-term hospital outcomes related to antenatal dexamethasone exposure.

METHODS

A prospective cohort study of serial serum cortisol levels in LPT infants within 3 h of birth, and at 1, 3, and 14 postnatal days. Serum cortisol levels were compared between infants exposed to antenatal dexamethasone >3 h and <14 days prior to delivery (aDex) and those who either did not receive dexamethasone or were exposed < 3 h or >14 days prior to delivery (no-aDex).

RESULTS

Thirty-two LPT infants (aDex) were compared with 29 infants (no-aDEX). Group demographic characteristics were similar. Serum cortisol levels were identical between the groups at all 4-time points. Cumulative antenatal dexamethasone exposure ranged from 0 to 12 doses. Post-hoc analysis of the 24-hour serum cortisol levels indicated a significant difference between 1 to 3 cumulative doses versus 4 or more doses (p = .01). Only 1 infant in the aDex group had a cortisol level <3^rd percentile of the reference value. Rates of hypoglycemia (absolute difference [95% CI] - 1.0 [-16.0,15.0]; p = .90) and mechanical ventilation were similar in both groups (absolute difference [95%CI] - 0.3 [-9.3,8.7]; p = .94). No deaths occurred.

CONCLUSION

Antenatal dexamethasone administered 14 days prior to delivery did not affect serum cortisol levels and short-term hospital outcomes in stable LPT infants. Exposure to low cumulative doses of dexamethasone resulted in transient low serum cortisol levels compared to 4 or more doses only at 24-hours.

Second trimester abnormal uterine artery Dopplers and adverse obstetric and neonatal outcomes when PAPP-a is normal

OBJECTIVES

To explore the association between abnormal uterine artery Dopplers (combined PI > 2.5) - with normal PAPP-A - and adverse obstetric/neonatal outcomes.

METHODS

This was a retrospective cohort study of 800 patients between 1 March 2019 - 23 November 2021 in a tertiary UK hospital, where it is routine to measure uterine artery Dopplers of all pregnancies during their anomaly scans. 400 nulliparous women/birthing people with complete data were included. 400 nulliparous controls scanned in the same time frame (1.5 years) with normal PAPP-A and uterine artery Dopplers were matched for age and BMI. Outcomes included: mode of birth, postpartum complications, birth weight/centile, Apgar score, gestational age at delivery, neonatal unit admission, and clinical neonatal hypoglycemia. Multivariable analysis was used.

RESULTS

Compared to controls, pregnancies with abnormal uterine artery Dopplers and normal PAPP-A were at increased risk of induction (46.5% vs 35.5%, p = .042), cesarean section (46.0% vs 38.0%, p = .002), emergency cesarean section (35.0% vs 26.5%, p = .009), and pre-eclampsia 5.8% vs 2.5%, p = .021). Their babies were more likely to be admitted to the neonatal unit - mostly for prematurity (15.3% vs 6.3%, p = .0004), hypoglycemia (4.0% vs 1.0%, p = .007), be small for gestational age (26.5% vs 11.5%, p = .0001), had intrauterine growth restriction (10.8% vs 1.3%, p = .0001), and be born prematurely (10.0% vs 3.5%, p = .002). Routine measurement of uterine artery Dopplers increased the detection rate of small for gestational age fetuses by 15.1%. Over half of the babies admitted with neonatal hypoglycemia in pregnancies with abnormal uterine artery Dopplers had an unexplained cause.

CONCLUSIONS

Pregnancies with abnormal uterine Dopplers are not only at increased risk of pre-eclampsia and small for gestational age fetuses/intrauterine growth restriction, but are also at increased risk of emergency cesarean section and adverse neonatal outcomes. The increased incidence of neonatal hypoglycemia is likely driven to some degree by prematurity and placental complications, but possibly also by undiagnosed glucose dysmetabolism. This may warrant routine measurement of uterine artery Dopplers in all pregnancies (regardless of risk), where feasible, to aid antenatal management and counseling.

Continuous glucose monitoring in individuals undergoing gestational diabetes screening

BACKGROUND

Among guidelines on gestational diabetes mellitus, there is an incongruity about the threshold of maternal hyperglycemia to diagnose gestational diabetes mellitus.

OBJECTIVE

This study aimed to ascertain the association between continuous glucose monitoring metrics and adverse outcomes among individuals undergoing gestational diabetes mellitus screening.

STUDY DESIGN

This was a prospective study (from June 2020 to January 2022) of individuals who underwent 2-step gestational diabetes mellitus screening at ≤30 weeks of gestation. The participants wore a blinded continuous glucose monitoring device (Dexcom G6 Pro; Dexcom, Inc, San Diego, CA) for 10 days starting when they took the 50-g glucose challenge test. The primary outcome was a composite of adverse neonatal outcomes (large for gestational age, shoulder dystocia or neonatal injury, respiratory distress, need for intravenous glucose treatment for hypoglycemia, or fetal or neonatal death). The secondary neonatal outcomes included preterm birth, neonatal intensive care unit admission, hypoglycemia, mechanical ventilation or continuous positive airway pressure, hyperbilirubinemia, and hospital length of stay. The secondary maternal outcomes included weight gain during pregnancy, hypertensive disorders of pregnancy, induction of labor, cesarean delivery, and postpartum complications. Time within the target range (63-140 mg/dL), time above the target range (>140 mg/dL) expressed as a percentage of all continuous glucose monitoring readings, and mean glucose level were analyzed. The Youden index was used to choose the threshold of ≥10% for the time above the target range and association with adverse outcomes.

RESULTS

Of 136 participants recruited, data were available from 92 individuals (67.6%). The 2-step method diagnosed gestational diabetes mellitus in 2 individuals (2.2%). Continuous glucose monitoring indicated that 17 individuals (18.5%) had time above the target range of ≥10%. Individuals with time above the target range of ≥10% had a significantly higher likelihood of composite adverse neonatal outcomes than individuals with time above the target range of <10% (63% vs 18%; P=.001). Furthermore, compared with neonates born to individuals with time above the target range of <10%, neonates born to individuals with time above the target range of ≥10% had an increased likelihood for hypoglycemia (14.5% vs 47%; P=.009) and had a longer length of stay (2 vs 4 days; P=.03). No difference in maternal outcomes was noted between the groups.

CONCLUSION

In this prospective study of individuals undergoing gestational diabetes mellitus screening, a cutoff of the time above the target range of ≥10% using continuous glucose monitoring was associated with a higher rate of neonatal adverse outcomes. A randomized trial of continuous glucose monitoring vs 2-step screening for gestational diabetes mellitus to lower the rate of adverse outcomes is underway (identification number: NCT05430204).

Development of a prediction model for neonatal hypoglycemia risk factors: a retrospective study

Background

It's challenging for healthcare workers to detect neonatal hypoglycemia due to its rapid progression and lack of aura symptoms. This may lead to brain function impairment for the newborn, placing a significant care burden on the family and creating an economic burden for society. Tools for early diagnosis of neonatal hypoglycemia are lacking. This study aimed to identify newborns at high risk of developing neonatal hypoglycemia early by developing a risk prediction model.

Methods

Using a retrospective design, pairs (470) of women and their newborns in a tertiary hospital from December 2021 to September 2022 were included in this study. Socio-demographic data and clinical data of mothers and newborns were collected. Univariate and multivariate logistic regression were used to screen optimized factors. A neonatal hypoglycemia risk nomogram was constructed using R software, and the calibration curve and receiver operator characteristic curve (ROC) was utilized to evaluate model performance.

Results

Factors integrated into the prediction risk nomogram were maternal age (odds ratio [OR] =1.10, 95% CI: 1.04, 1.17), fasting period (OR=1.07, 95% CI: 1.03, 1.12), ritodrine use (OR=2.00, 95% CI: 1.05, 3.88), gestational diabetes mellitus (OR=2.13, 95% CI: 1.30, 3.50), gestational week (OR=0.80, 95% CI: 0.66, 0.96), fetal distress (OR=1.76, 95% CI: 1.11, 2.79) and neonatal body mass index (OR=1.50, 95% CI: 1.24, 1.84). The area under the curve (AUC) was 0.79 (95% confidence interval [CI]: 0.75, 0.82), specificity was 0.82, and sensitivity was 0.62.

Conclusion

The prediction model of this study demonstrated good predictive performance. The development of the model identifies advancing maternal age, an extended fasting period before delivery, ritodrine use, gestational diabetes mellitus diagnosis, fetal distress diagnosis and an increase in neonatal body mass index increase the probability of developing neonatal hypoglycemia, while an extended gestational week reduces the probability of developing neonatal hypoglycemia.

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.

Congenital hyperinsulinemic hypoglycemia (HH) requiring treatment as the presenting feature of Kabuki syndrome

Kabuki syndrome is a congenital condition characterized by a set of facial dysmorphic features that often help the clinician to suspect the diagnosis. However, more insidious symptoms can rarely occur, such as manifestations of hypoglycemia in newborns with congenital hyperinsulinism hypoglycemia, especially when a variant of the KDM6A gene is found. In those cases, a treatment with diazoxide can be started and can be replaced with lanreotide if a satisfying glycemic control is not achieved. We report the case of a female patient born at 37 weeks of gestational age, without any obvious facial dysmorphic features, after a non-complicated pregnancy, that presented with feeding difficulties, drowsiness, and irritability revealing a hyperinsulinemic hypoglycemia. Further testing at 6 months old found a KDM6A mutation. The patient was initially treated by diazoxide alone, but its dosage had to be lowered because of the occurrence of treatment side effects, and lanreotide had been added to maintain acceptable blood sugar levels. A congenital hyperinsulinemia hypoglycemia revealed heterozygous truncating variant in the KDM6A gene, also known as X-linked Kabuki syndrome in a newborn. In cases of neonatal hypoglycemia, the first-line therapy is diazoxide. Our report shows that analogues of somatostatin such as lanreotide should be considered if the diazoxide regimen is not tolerated.

Neonatal hypoglycemia following antenatal corticosteroid treatment prior to elective cesarean delivery during the early term period: a meta-analysis

OBJECTIVE

The necessity of administering antenatal corticosteroids in early-term neonates delivered by planned cesarean delivery remains arbitrary as their observed benefit addresses a few cases that may need pulmonary resuscitation. However, to date, whether the use of antenatal corticosteroids in the preterm period is associated with neonatal hypoglycemia, which is the most prominent neonatal side effect during this period, remains unknown. This study aimed to determine the effect of antenatal corticosteroids administered during the early term period on neonatal hypoglycemia rates.

DATA SOURCES

The databases of Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar were used.

STUDY ELIGIBILITY CRITERIA

Published clinical trials and observational studies were considered eligible.

METHODS

A modified data form that was based on the Cochrane data collection form for intervention reviews for randomized controlled trials and nonrandomized controlled trials was used. Meta-analysis was performed using RStudio (RStudio, Inc, Boston, MA). The quality of included studies was assessed with the Risk Of Bias In Non-randomized Studies of Interventions tool. Trial sequential analysis was performed to evaluate the sample size.

RESULTS

A total of 6 studies of moderate risk of bias were included in this systematic review consisting of 1273 parturients, of whom 537 received corticosteroids. The risk of neonatal hypoglycemia did not increase with the use of antenatal corticosteroids before early-term elective cesarean delivery (odds ratio, 1.80; 95% confidence interval, 0.45-7.25). Similarly, the risk of admission to the neonatal intensive care unit for respiratory distress syndrome or transient tachypnoea of the newborn was not affected by the use of corticosteroids (odds ratio, 0.61; 95% confidence interval, 0.19-1.99).

CONCLUSION

The use of antenatal corticosteroids did not seem to increase the risk of neonatal hypoglycemia. Given the quality and sample size of included studies, the effect size cannot be accounted for as definitive and cannot be directly applied in clinical practice. However, the provided information can be used as a guide for women participating in future trials.

Third trimester re-screening for gestational diabetes in morbidly obese women despite earlier negative test can reveal risks for obstetrical complications

AIM

We investigated associations of maternal obesity with late gestational diabetes mellitus (GDM) diagnosis (>34 weeks) in women with previous normal glucose screening, and associations of late GDM with obstetrical outcomes.

METHODS

This retrospective cohort study assessed obstetrical and neonatal outcomes of 238 women with normal (24-28 week) glucose screening results, who underwent late repeat oral glucose tolerance tests (OGTT) (>34 weeks) due to a suspected LGA fetus (54.6%) or polyhydramnios (45.4%). A sub-analysis was performed of outcomes of women with late versus mid-trimester GDM.

RESULTS

The GDM rate in repeat OGTT screening was 22.2% for the total sample, and 33% among women with morbid obesity. Among women with late GDM versus without late GDM, rates were higher for macrosomia, large-for-gestational-age fetus induction of labor, neonatal hypoglycemia, jaundice, and the need for phototherapy. Among women with late GDM, a higher pregestational BMI was associated with adverse maternal and perinatal outcomes. Higher risks for macrosomia and CS due to macrosomia were demonstrated in women with late vs. mid-trimester GDM.

CONCLUSION

Late screening in pregnancy may reveal GDM among women with previous normal glucose screening, particularly among those with late third trimester BMI ≥ 35 kg/m² , GDM in a previous pregnancy or fasting glucose >95 mg/dl. Women diagnosed with GDM at >34 weeks following normal glucose screening at 24-28 weeks are at higher risk for adverse perinatal outcomes. For women with morbid obesity, or suspected macrosomia or polyhydramnios in the late third trimester, and normal glucose screening in the second trimester, retesting should be considered.

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

BACKGROUND

Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation.

OBJECTIVE

Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05.

RESULTS

Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001).

CONCLUSION

Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

Evaluating the relationship of in utero nicotine exposure with hypoglycemia after delivery: An observational study

BACKGROUND

Hypoglycemia in neonates is common and contributes to 4.0-5.8% of neonatal intensive care unit (NICU) admissions. In utero nicotine exposure is underexplored as a potential contributor to neonatal hypoglycemia. Rat models have shown that in utero nicotine exposure can be associated with a reduction in pancreatic beta cell mass, leading to glucose dysregulation. The primary aim of this work is to study the risk of developing hypoglycemia after birth in a population of in utero nicotine-exposed neonates.

METHODS

We conducted a retrospective matched cohort study that augmented an existing dataset of neonates admitted to a level IV NICU with household-based in utero nicotine exposure (N = 335). Neonates in the control group parents denied household smoking (N = 325), were born within a 6-month timeframe, and were within a birthweight of 50 grams of a nicotine-exposed neonate. Data reviewed included gestational age, growth parameters, maternal history of diabetes, and glucose levels within the first three hours of life per unit protocol.

RESULTS

660 neonates were included in the analysis. In utero nicotine exposure demonstrated a 94.3% posterior probability (PP) for greater hypoglycemia risk (RR = 1.185, 95% CrI = [0.953, 1.445]). A 94.6% PP was demonstrated when neonates who were small for gestational age, intrauterine growth-restricted, and born to diabetic mothers were excluded (n = 482; RR = 1.271, 95% CrI = [0.946, 1.669]).

CONCLUSION

Nicotine exposure in utero was found to be a potential risk factor for developing hypoglycemia after birth. Mechanisms of action should be explored, and additional research on in utero nicotine exposure risks should follow.

The Role of Early Pregnancy Maternal pGCD59 Levels in Predicting Neonatal Hypoglycemia-Subanalysis of the DALI Study

CONTEXT

Neonatal hypoglycaemia (NH) is the most common metabolic problem in infants born of mothers with gestational diabetes. Plasma glycated CD59 (pGCD59) is an emerging biomarker that has shown potential in identifying women at risk of developing gestational diabetes. The aim of this study was to assess the association between early maternal levels of pGCD59 and NH.

OBJECTIVE

The aim of this study was to assess the association between early pregnancy maternal levels of plasma glycated CD59 (pGCD59) and neonatal hypoglycemia (NH).

METHODS

This is an observational study of pregnant women with a prepregnancy body mass index (BMI) greater than or equal to 29 screened for eligibility to participate in the Vitamin D and Lifestyle Intervention for Gestational Diabetes (DALI) trial. This analysis included 399 pregnancies. Levels of pGCD59 were measured in fasting maternal samples taken at the time of a 75-g, 2-hour oral glucose tolerance test performed in early pregnancy (< 20 weeks). NH, the study outcome, was defined as a heel-prick capillary glucose level of less than 2.6 mmol/L within 48 hours of delivery.

RESULTS

We identified 30 infants with NH. Maternal levels of pGCD59 in early pregnancy were positively associated with the prevalence of NH (one-way analysis of variance, P < .001). The odds of NH were higher in infants from mothers in tertile 3 of pGCD59 levels compared to those from mothers in tertile 1 (odds ratio [OR]: 2.41; 95% CI, 1.03-5.63). However, this was attenuated when adjusted for maternal BMI (OR: 2.28; 95% CI, 0.96-5.43). The cross-validated area under the curve (AUC) was 0.64 (95% CI, 0.54-0.74), and adjusted for maternal BMI, age, and ethnicity, the AUC was 0.70 (95% CI, 0.56-0.78).

CONCLUSION

Although pGCD59 levels in early pregnancy in women with BMI greater than or equal to 29 are associated with NH, our results indicate that this biomarker by itself is only a fair predictor of NH.

Neurodevelopmental Outcome in Patients with Typical Imaging Features of Injury as a Result of Neonatal Hypoglycemia

Introduction

Previous reports described a pattern of hypoglycemia-induced damage predominantly affecting the parieto-occipital regions. The long-term neurological sequelae of severe neonatal hypoglycemic encephalopathy include developmental delay, poor head growth, learning or behavioral difficulties, visual impairment, and epilepsy. This study reports neurodevelopmental outcome of children with neonatal hypoglycemia-associated parieto-occipital brain injury who were evaluated in our pediatric neurology outpatient clinic for different neurological complaints.

Methods

We retrospectively reviewed patients who were followed at Kocaeli University Hospital, Pediatric Neurology Department between 2007 and 2015. Patients (n=42) with predominately parieto-occipital lesions on magnetic resonance imaging (MRI) with the typical pattern of neonatal hypoglycemia were evaluated. Patients with documented hypoglycemia (n=21) were included in this study. Patients (n=9) with recurrent episodes of hypoglycemia longer than 12 hours were evaluated as prolonged hypoglycemia.

Results

Eleven patients (52.4%) experienced seizures in the neonatal period. Eighteen patients (85.7%) developed epilepsy during the follow-up. Refractory seizures were observed in 8 patients (38.1%). Nine patients (42.9%) manifested microcephaly, seven patients (33.3%) manifested cerebral palsy. Parieto-occipital involvement and the spasticity rate were statistically high in patients with prolonged hypoglycemia (p<0.01). Two patients had autistic features and four patients (19%) had attention deficit hyperactivity disorder. VEP studies could be performed in 18 of 21 patients. All patients had abnormal VEP results.

Conclusion

We are of the opinion that most patients of neonatal hypoglycemia are not always documented. Patients under risk and patients with symptoms of hypoglycemia should be vigorously screened and treated to prevent neurologic impairments including cerebral palsy, epilepsy and visual disturbance.

Association of the Cerebro-Placental Ratio With Adverse Outcomes in Pregnancies Affected by Gestational Diabetes Mellitus

OBJECTIVES

Cerebro-placental ratio (CPR) is a doppler tool contributes to clinical decision-making in pregnancies affected by small for gestational age weight (SGA). Pregnancies affected by gestational diabetes mellitus (GDM) tend to have higher newborn weight, but greater risk of adverse perinatal outcomes. We hypothesized that in GDM-complicated-pregnancies CPR will be associated with adverse perinatal outcomes even in the absence of SGA.

METHODS

This prospective single-center cohort study included non-anomalous singleton pregnancies in women with GDM. Those with pre-pregnancy diabetes mellitus, hypertensive disorder or suspected SGA were excluded. Routine fetal sonographic assessment included CPR-defined as middle cerebral artery pulsatilty index/umbilical artery pulsatilty index. Masked CPR measurement closest to birth was used, classified as >10th (normal) or ≤10th centile (low). Primary outcome was a composite, consisting of stillbirth, Caesarean birth due to abnormal fetal heart rate pattern, 5-minute Apgar <7, cord arterial pH < 7.0, hypoxic ischemic encephalopathy, or NICU admission >24 hours.

RESULTS

Of 281 participants, 24 (8.5%) had low CPR, at a mean gestational age of 36.3 weeks (IQR 34.0-37.4). Birthweight percentile was significantly lower among the low CPR group (35th [IQR 16-31] versus 60th [IQR 31-82]; P = .002). There was no statistically difference in the primary composite outcome between the groups (8.3% versus 7.0%, P = .68). Low CPR was significantly associated with a higher risk of neonatal hypoglycemia (adjusted odds ratio 3.2, 95% CI 1.2-8.3).

CONCLUSION

In pregnancies affected by GDM, CPR ≤10th percentile was not associated with adverse perinatal outcome but was associated with neonatal hypoglycemia.

Latency of late preterm steroid administration to delivery and risk of neonatal hypoglycemia

BACKGROUND

Late preterm antenatal corticosteroid administration has been associated with an increased risk of neonatal hypoglycemia. The mechanism is thought to be secondary to transient fetal hyperinsulinemia, which may be more likely if delivery occurs during peak antenatal corticosteroid levels.

OBJECTIVE

This study aimed to investigate whether there is a latency interval between antenatal corticosteroid administration and delivery that places neonates at the greatest risk of hypoglycemia.

STUDY DESIGN

This was a retrospective matched cohort study of pregnant women who received antenatal corticosteroid vs unexposed women between 34 0/7 and 36 6/7 weeks of gestation from 2016 to 2019. Unexposed women were those who did not receive antenatal corticosteroid matched according to gestational age at delivery, diabetes mellitus status, and maternal body mass index from 2010 to 2015. Latency periods from initial steroid administration to delivery were defined in grouped intervals until ≥72 hours. The primary outcome was neonatal hypoglycemia, defined as a neonatal glucose level of <40 mg/dL within 24 hours of life. Poisson regression was used to generate an adjusted relative risk of hypoglycemia for each latency period adjusting for confounders.

RESULTS

A total of 812 women were included in the analysis (406 exposed and 406 unexposed). Women who received antenatal corticosteroids were more likely to be nulliparous (P=.009); moreover, the women were well matched on pregnancy complications and baseline demographics. Neonatal hypoglycemia was more frequently identified in women receiving antenatal corticosteroids than in women not receiving antenatal corticosteroids (42% vs 26%; P<.001). Severe hypoglycemia, defined as a glucose level of <20 mg/dL, was significantly more common in patients receiving antenatal corticosteroids than in patients not receiving antenatal corticosteroids (8.4% vs 2.7%; P<.001). Latency time intervals of 12 to 71 hours from antenatal corticosteroid administration were significantly associated with neonatal hypoglycemia in exposed women compared with unexposed women after adjustment; within this time frame, the highest risk was 24 to 47 hours after antenatal corticosteroid administration (adjusted relative risk, 2.09; 95% confidence interval, 1.29-3.38).

CONCLUSION

In the late preterm period, the risk of neonatal hypoglycemia is the greatest in the latency period of 12 to 71 hours between steroid administration and delivery. Neonates exposed to antenatal corticosteroids were more likely to experience severe hypoglycemia within 24 hours of life than unexposed neonates.

Lifestyle intervention during pregnancy in patients with gestational diabetes mellitus and the risk of neonatal hypoglycemia: A systematic review and meta-analysis

Objective

Neonatal hypoglycemia is a severe adverse consequence of infants born to mothers with gestational diabetes mellitus (GDM), which can lead to neonatal mortality, permanent neurological consequences, and epilepsy. This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to explore the effect of lifestyle intervention during pregnancy in women with GDM on the risk of neonatal hypoglycemia.

Methods

PubMed, Web of Science, Cochrane Library, CINAHL, and SPORTDiscus databases were searched by 1st April 2022. Data were pooled as the risk ratio (RR) with 95% CIs of neonatal hypoglycemia. Random-effects, subgroup analyses, meta-regression analysis, and leave-one-out analysis were conducted, involving 18 RCTs.

Results

Prenatal lifestyle intervention could significantly reduce the risk of neonatal hypoglycemia (RR: 0.73, 95% CI: 0.54–0.98, P = 0.037). Subgroup analysis further demonstrated that the reduced risk of neonatal hypoglycemia was observed only when subjects were younger than 30 years, initiated before the third trimester, and with dietary intervention. Meta-regression analysis revealed that the risk of neonatal hypoglycemia post lifestyle intervention was lower in mothers with lower fasting glucose levels at trial entry.

Conclusion

We found that prenatal lifestyle intervention in women with GDM significantly reduced the risk of neonatal hypoglycemia. Only lifestyle intervention before the third trimester of pregnancy, or dietary intervention only could effectively reduce the risk of neonatal hypoglycemia. Future studies are required to explore the best pattern of lifestyle intervention and to determine the proper diagnostic criteria of GDM in the first/second trimester of pregnancy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, PROSPERO, identifier: CRD42021272985.

Screening for Gestational Diabetes Mellitus and Pregnancy Outcomes: Results from a Multicentric Study in Tajikistan

The prevalence of gestational diabetes parallels the prevalence of type 2 diabetes mellitus and is associated with adverse pregnancy outcomes. However, these data are not available for many parts of the world. We assessed the prevalence of gestational diabetes and pregnancy outcomes in Tajikistan. This cohort study included 2438 consecutively recruited representative pregnant women from 8 locations in two cities in Tajikistan, in whom an oral glucose tolerance test (75 g, fasting, 1 h, 2 h) was performed during gestational weeks 24-28. Women with known diabetes and twin pregnancies were excluded. Associations between glucose tolerance test results and pregnancy outcomes were examined. According to the WHO 2013 thresholds, 32.4% of women qualified as having gestational diabetes, the vast majority (29.7%) based on an elevated fasting glucose level (5.1-5.6 mmol/L), while only 2.8% had elevated 1- or 2-hour values or met more than one threshold. Women with only elevated fasting glucose (impaired gestational fasting glycemia) had no evidence of adverse pregnancy outcomes, while those with elevated 1- and/or 2-hour values (impaired gestational glucose tolerance) had more pregnancy complications (infection of urinary tract 1.8 vs. 8.8% p<0.001; preeclampsia 0.7 vs. 10.3% p<0.001) and emergency cesarean sections (4.4 vs. 13.2% p=0.002). Neonates from pregnancies with impaired gestational glucose tolerance had lower APGARs, lower birth weights, lower 30 min glucose levels, and a lower probability of being discharged alive (all p<0.05). In conclusion, the formal prevalence of gestational diabetes is high in Tajikistan; however, this does not translate into adverse pregnancy outcomes for women with impaired gestational fasting glycemia.

Actual incidence of severe neonatal hypoglycemia in non-risk term neonates: A 10 year survey of all cases in Toyama Prefecture, Japan

BACKGROUND

Severe neonatal hypoglycemia may cause irreversible neurological sequelae. Although blood glucose (BG) screening in term neonates without risk factors for hypoglycemia (non-risk neonates) is not recommended in the current guidelines, severe hypoglycemia can occur in such neonates. To evaluate the necessity of BG screening in non-risk neonates, it is important to determine the accurate incidence of severe hypoglycemia in those neonates.

METHODS

We conducted a 10 year survey of all normal-weight term neonates diagnosed with severe neonatal hypoglycemia who were treated at secondary- and tertiary-level neonatal centers in Toyama Prefecture, Japan, between January 2011 and December 2020.

RESULTS

During the study period, 11 cases of severe neonatal hypoglycemia (six of which occurred in non-risk neonates) were identified. The overall incidence of severe hypoglycemia was 1 in 5,827 normal-weight term births, and the incidence in non-risk neonates was 1 in 10 682 normal-weight term births. All of the cases in non-risk neonates were diagnosed as hyperinsulinemic hypoglycemia.

CONCLUSIONS

This is the first population-based study to have identified the actual incidence of severe pathological neonatal hypoglycemia in non-risk neonates. The incidence was not low compared with those of the newborn screening disorders, justifying the necessity of BG screening even in non-risk neonates.

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.

Different glucose analyzers report different glucose concentration values in term newborns

BACKGROUND

The American Academy of Pediatrics and Pediatric Endocrine Society neonatal hypoglycemia guidelines based their glucose concentration treatment thresholds on studies that predominantly used Beckman and Yellow Springs Glucose Oxidase Analyzers. Currently, a majority (76%) of U.S. hospital laboratories utilizing glucose oxidase methodology use Vitros^® Glucose Analyzers. However, a bias of ~+5% between glucose concentrations from Beckman vs. Vitros Glucose Analyzers has been reported; this could have a clinically significant effect when using published guideline treatment thresholds.

METHODS

To determine if there is similar instrument bias between Beckman and Vitros Analyzers in reported glucose concentrations from term newborns, we compared plasma glucose concentrations measured within the first 3 h after birth by Beckman vs. Vitros Analyzers in a total of 1,987 newborns (Beckman n = 904, Vitros n = 1,083). Data were fit using nonlinear cubic spline models between collection time and glucose concentration.

RESULTS

The non-linear patterns of initial glucose concentrations (during the first 3 h after birth) as measured by Beckman and Vitros Analyzers paralleled each other with no overlap of the fit spline curve 95% confidence intervals, with an approximate +5 mg/dL constant bias. Additionally, in method comparison studies performed in the Chemistry Laboratory on adult samples, there was a +4.2-7.4 mg/dL measured glucose bias for the Beckman vs. Vitros Analyzer.

CONCLUSION

Glucose concentrations from term, appropriate size for gestational age newborns were about 5 mg/dL higher when measured by Beckman vs. Vitros Analyzers. Perhaps, concentrations of 45 mg/dL reported from Beckman Analyzers may be equivalent to 40 mg/dL from Vitros Analyzers. When managing neonatal hypoglycemia, it is important to know which analyzer was used and whether adjusting for potential instrument bias is necessary when following published guidelines.

Maternal Obesity-Associated Neonatal Morbidities in Early Newborn Period

Maternal obesity has been associated with pregnancy-related complications and neonatal morbidities. The primary aim of this study was to evaluate early neonatal morbidities associated with maternal obesity from the infant-mother dyad data set at a single, large Regional Perinatal Center (RPC) in NY. A retrospective chart review of all mother-infant dyads born from January 2009 to December 2019 was done. Maternal obesity was defined using the NIH definition of pre-pregnancy body mass index (BMI) ≥ 30 Kg/m². Maternal data included pre-pregnancy BMI, gestational diabetes, hypertension, and mode of delivery. Neonatal data recorded the birth weight, gestational age, respiratory support after delivery, diagnosis of transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), neonatal hypoglycemia (NH), and hypoxic-ischemic encephalopathy (HIE). Diagnosis of TTN, RDS, NH, and HIE was defined by the service neonatologist and cross-checked by the data system review neonatologist. Medical records of 22,198 infant-mother dyads included in the study had 7,200 infants (32.4%) born to obese mothers and 14,998 infants (67.6%) born to non-obese women. There was a statistically significant increase in the diagnosis of gestational diabetes, gestational hypertension, and cesarean deliveries in obese mothers. Diagnosis of TTN, RDS, and NH was significantly higher in infants born to obese mothers, while HIE incidence was similar in both the groups. Infants born to obese mothers are more likely to be delivered by cesarean section and are at a higher risk of diagnosis of transient tachypnea of newborn, respiratory distress syndrome, and hypoglycemia in the early neonatal period.

Effect of epidural labor analgesia on maternal and infant outcomes in parturients with gestational diabetes mellitus-A prospective cohort study

BACKGROUND

The occurrence of gestational diabetes mellitus (GDM) is caused by a variety of factors and associated with increased risks of several adverse outcomes for both mothers and infants. However, the effects of epidural labor analgesia in parturients with GDM on maternal and infant outcomes have not been characterized.

METHODS

According to parturients' choice, they were divided into the epidural group (n = 133) and no epidural (control) group (n = 135). Data for relative variables in the perinatal period were collected, and the potential associations of epidural labor analgesia with infant outcomes were analyzed by univariate analysis and multivariate logistic regression analyses.

RESULTS

The rate of neonatal admission to the neonatal intensive care unit (NICU) for hypoglycemia was higher in the epidural group (7.52%) than in the control group (1.48%; P < 0.05). Epidural labor analgesia and drug-based diabetes control were independent predictors of the rate of neonate transfer to the NICU for hypoglycemia.

CONCLUSION

Epidural labor analgesia was associated with an increased risk of neonatal transfer to the NICU for hypoglycemia. Thus, monitoring of neonatal blood glucose levels after administration of epidural labor analgesia in parturients with GDM may be beneficial.Trial registration: The study was registered in the China Clinical Registration Center (Registration No. ChiCTR-OOC-17013164, Registered on 30 October 2017).

How Much Glucose Is in the Gel Used to Treat Neonatal Hypoglycemia?

OBJECTIVE

To compare glucose concentrations in three sections of individual tubes and among tubes of commercial oral glucose gels commonly used to treat neonatal hypoglycemia in the United States (Glutose 15 [Perrigo, Minneapolis, MN] and Insta-Glucose [Valeant Pharmaceuticals North America LLC, Bridgewater, NJ]).

DESIGN

A quantitative laboratory study.

METHODS

We measured glucose concentrations in aliquots taken from the top, middle, and bottom sections of three different lots and in whole tubes from different lots of Glutose 15 and Insta-Glucose. We measured the glucose content in the gel using hexokinase and glucose-6-phosphate dehydrogenase enzymes on the Siemens ADVIA 1800 analyzer (Siemens Healthcare Diagnostics, Inc., Tarrytown, NY).

RESULTS

The percent difference observed among the three sections of the Glutose 15 tubes was 12.3% to 53.8%. The difference among the three sections of the Insta-Glucose tubes was 40.7% to 79.6%. The concentration of glucose gel is labeled as 40%, but the actual concentration in aliquots of Glutose 15 ranged from 39.64% to 70.96%. The actual concentration in aliquots of Insta-Glucose ranged from 16.45% to 27.47%. The difference in the concentration of glucose among three lots of whole tubes of Glutose 15 was 1.6%, and the difference in concentration among three lots of whole tubes of Insta-Glucose was 8.8%. In Glutose 15, the concentration ranged from 48.3% to 49.1%, and Insta-Glucose, the concentration ranged from 17.2% to 18.8%.

CONCLUSION

Glucose was not uniformly distributed within tubes of Glutose 15 and Insta-Glucose, and this may account for variable results on the efficacy of oral glucose gel as a treatment for neonatal hypoglycemia.

Type 2 diabetes and neonatal hypoglycemia: role of route of delivery and insulin infusion

OBJECTIVE

To compare the rate of neonatal hypoglycemia among newborns delivered by individuals with Type 2 diabetes mellitus (T2DM) in two clinical scenarios: who attempted vaginal delivery vs. had a planned cesarean delivery (CD); who had intrapartum insulin infusion vs. who did not.

METHODS

This was a retrospective cohort study of individuals with insulin-treated T2DM who had non-anomalous singleton pregnancy and delivered at a single tertiary center (March 2012 and May 2018). Individuals with chronic renal failure, proliferative retinopathy, or major congenital anomalies were excluded. The primary outcome was neonatal hypoglycemia (blood glucose < 40 mg/dl <24 h of age or < 50 mg/dl >24 h of age). Secondary outcomes included neonatal outcomes. Multivariable Poisson regression models with robust error variance were used to examine the association between groups and the primary outcome. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated.

RESULTS

Of 233 individuals with T2DM, 215 (92.2%) met the inclusion criteria, of whom 95 (44%) attempted vaginal delivery and 120 (56%) had a planned CD. Individuals who labored had a higher gestational age at delivery (36.6 vs. 35.8 weeks, p = .005), and higher blood glucose levels upon admission (125 vs 103, p < .001) compared to those with a planned CD. After adjustment for potential confounders, there was no difference in risk of neonatal hypoglycemia between the groups (41.2 vs 44.1%, aRR 1.05, 95% CI = 0.75-1.45). Among those who attempted vaginal delivery, 34 (35.8%) required insulin infusion. There was no difference in the risk of neonatal hypoglycemia (aRR = 0.79, 95% CI = 0.45-1.37) between newborns delivered by individuals who required insulin infusion and those who did not.

CONCLUSION

Over 40% of newborns delivered by individuals with insulin-dependent T2DM had hypoglycemia; however, there was no significant difference in the risk of hypoglycemia, irrespective of the route of delivery and the use of insulin infusion.

Detemir vs neutral protamine Hagedorn insulin for diabetes mellitus in pregnancy: a comparative effectiveness, randomized controlled trial

BACKGROUND

Insulin detemir, being used increasingly during pregnancy, may have pharmacologic benefits compared with neutral protamine Hagedorn.

OBJECTIVE

We evaluated the probability that compared with treatment with neutral protamine Hagedorn, treatment with insulin detemir reduces the risk for adverse neonatal outcome among individuals with type 2 or overt type 2 diabetes mellitus (gestational diabetes mellitus diagnosed at <20 weeks' gestation).

STUDY DESIGN

We performed a multiclinic randomized controlled trial (September 2018 to January 2020), which included women with singleton gestation with type 2 or overt type 2 diabetes mellitus who sought obstetrical care at ≤21 weeks' gestation. Participants were randomized to receive either insulin detemir or neutral protamine Hagedorn by a clinic-stratified scheme. The primary outcome was a composite of adverse neonatal outcomes, including shoulder dystocia, large for gestational age, neonatal intensive care unit admission, respiratory distress (defined as the need of at least 4 hours of respiratory support with supplemental oxygen, continuous positive airway pressure or ventilation at the first 24 hours of life), or hypoglycemia. The secondary neonatal outcomes included gestational age at delivery, small for gestational age, 5-minute Apgar score of <7, lowest glucose level, need for intravenous glucose, respiratory distress syndrome, need for mechanical ventilation or continuous positive airway pressure, neonatal jaundice requiring therapy, brachial plexus injury, and hospital length of stay. The secondary maternal outcomes included hypoglycemic events, hospital admission for glucose control, hypertensive disorder of pregnancy, maternal weight gain, cesarean delivery, and postpartum complications. We used the Bayesian statistics to estimate a sample size of 108 to have >75% probability of any reduction in the primary outcome, assuming 80% power and a hypothesized effect of 33% reduction with insulin detemir. All analyses were intent to treat under a Bayesian framework with neutral priors (a priori assumed a 50:50 likelihood of either intervention being better; National Clinical Trial identifier 03620890).

RESULTS

There were 108 women randomized in this trial (57 in insulin detemir and 51 in neutral protamine Hagedorn), and 103 women were available for analysis of the primary outcome (n=5 for pregnancy loss before 24 weeks' gestation). Bayesian analysis indicated an 87% posterior probability of reduced primary outcome with insulin detemir compared with neutral protamine Hagedorn (posterior adjusted relative risk, 0.88; 95% credible interval, 0.61-1.12). Bayesian analyses for secondary outcomes showed consistent findings of lower adverse maternal outcomes with the use of insulin detemir vs neutral protamine Hagedorn: for example, maternal hypoglycemic events (97% probability of benefit; posterior adjusted relative risk, 0.59; 95% credible interval, 0.29-1.08) and hypertensive disorders (88% probability of benefit; posterior adjusted relative risk, 0.81; 95% credible interval, 0.54-1.16).

CONCLUSION

In our comparative effectiveness trial involving individuals with type 2 or overt type 2 diabetes mellitus, use of insulin detemir resulted in lower rates of adverse neonatal and maternal outcomes compared with neutral protamine Hagedorn.

The danger of diazoxide in the neonatal intensive care unit

Background

The most common cause of persistent hypoglycemia in infancy is hyperinsulinemic hypoglycemia. When conservative measures fail, providers often use medications to treat persistent hypoglycemia. Diazoxide is first-line therapy for neonatal hypoglycemia and works by inhibiting insulin secretion. Diazoxide is associated with fluid retention, and less commonly with respiratory decompensation and pulmonary hypertension. Case reports documenting these severe adverse events exist in the literature, although the overall incidence, risk factors, and timing for these effects in a newborn are not clearly defined.

Methods

We performed a retrospective chart review of all infants admitted to the neonatal intensive care unit (NICU) at Regional One Health from 1 January 2013 until 15 August 2019, who received diazoxide as a treatment for persistent hypoglycemia secondary to hyperinsulinism. Patients were stratified as either having no adverse event or having an adverse outcome to the medication. A severe adverse outcome was defined as any known major side effect of the medication, which a patient developed within 2 weeks of medication initiation that led to medication discontinuation.

Results

From our pharmacy database, we identified a total of 15 babies who received diazoxide for persistent hypoglycemia. Of these patients, eight (53%) were classified as having a complication requiring discontinuation of the medication. Six out of eight patients required intubation with mechanical ventilation and five out of eight patients developed pulmonary hypertension. All patients returned to their baseline respiratory support after drug discontinuation.

Conclusions

A total of 53% of our study population had an adverse outcome to diazoxide. Previous studies suggest 5% of patients may have respiratory decompensation and require ventilatory support while on diazoxide; however, 40% of our patients deteriorated and then required mechanical ventilation. Based on our data, respiratory deterioration may be more likely to occur when diazoxide is used in preterm infants, those with lower birth weight and intrauterine growth restriction.

Plain language summary

The dangers in diazoxide Newborns could experience a transient period of low blood glucose levels soon after birth. However, some may progress to persistent low blood glucose levels that cannot be controlled with adequate glucose infusion and may require other ways of treatment. Diazoxide is the first-line drug approved by the US Food and Drug Administration (FDA) for this condition. However, certain cases have reported the development of respiratory deterioration, including increased blood pressure in lung circulation after its use. This prompted a black box warning in 2015 by the FDA. The incidence of neonatal low blood glucose levels seems to have increased and so has the use of this drug. Our study identifies 15 newborns who received diazoxide at Regional One Health neonatal intensive care unit in the past 6 years and reports a significantly higher rate of adverse events in our population leading to drug discontinuation in almost 53% of our cases.

A Graded Approach to Intravenous Dextrose for Neonatal Hypoglycemia Decreases Blood Glucose Variability, Time in the Neonatal Intensive Care Unit, and Cost of Stay

OBJECTIVE

To determine associations between a graded approach to intravenous (IV) dextrose treatment for neonatal hypoglycemia and changes in blood glucose (BG), length of stay (LOS), and cost of care.

STUDY DESIGN

Retrospective cohort study of 277 infants born at ≥35 weeks of gestation in an urban academic delivery hospital, comparing the change in BG after IV dextrose initiation, neonatal intensive care unit (NICU) LOS, and cost of care in epochs before and after a hospital protocol change. During epoch 1, all infants who needed IV dextrose for hypoglycemia were given a bolus and started on IV dextrose at 60 mL/kg/day. During epoch 2, infants received IV dextrose at 30 or 60 mL/kg/day based on the degree of hypoglycemia. Differences in BG outcomes, LOS, and cost of hospital care between epochs were compared using adjusted median regression.

RESULTS

In epoch 2, the median (IQR) rise in BG after initiating IV dextrose (19 [10, 31] mg/dL) was significantly lower than in epoch 1 (24 [14,37] mg/dL; adjusted β = -6.0 mg/dL, 95% CI -11.2, -0.8). Time to normoglycemia did not differ significantly between epochs. NICU days decreased from a median (IQR) of 4.5 (2.1, 11.0) to 3.0 (1.5, 6.5) (adjusted β = -1.9, 95% CI -3.0, -0.7). Costs associated with NICU hospitalization decreased from a median (IQR) $14 030 ($5847, $30 753) to $8470 ($5650, $19 019) (adjusted β = -$4417, 95% CI -$571, -$8263) after guideline implementation.

CONCLUSIONS

A graded approach to IV dextrose was associated with decreased BG lability and length and cost of NICU stay for infants with neonatal hypoglycemia.

Neonatal Hypoglycemia and Brain Vulnerability

Neonatal hypoglycemia is a common condition. A transient reduction in blood glucose values is part of a transitional metabolic adaptation following birth, which resolves within the first 48 to 72 h of life. In addition, several factors may interfere with glucose homeostasis, especially in case of limited metabolic stores or increased energy expenditure. Although the effect of mild transient asymptomatic hypoglycemia on brain development remains unclear, a correlation between severe and prolonged hypoglycemia and cerebral damage has been proven. A selective vulnerability of some brain regions to hypoglycemia including the second and the third superficial layers of the cerebral cortex, the dentate gyrus, the subiculum, the CA1 regions in the hippocampus, and the caudate-putamen nuclei has been observed. Several mechanisms contribute to neuronal damage during hypoglycemia. Neuronal depolarization induced by hypoglycemia leads to an elevated release of glutamate and aspartate, thus promoting excitotoxicity, and to an increased release of zinc to the extracellular space, causing the extensive activation of poly ADP-ribose polymerase-1 which promotes neuronal death. In this review we discuss the cerebral glucose homeostasis, the mechanisms of brain injury following neonatal hypoglycemia and the possible treatment strategies to reduce its occurrence.

Comparison of a subcutaneous versus intravenous insulin protocol for managing hyperglycemia following antenatal betamethasone in women with diabetes: a pilot randomized controlled trial

INTRODUCTION

Evaluate the safety and efficacy of a subcutaneous insulin (SC-I) versus intravenous insulin (IV-I) protocol for optimizing maternal blood glucose levels (BGLs) post-betamethasone administration.

METHODS

Randomized controlled in-patient pilot study in pregnant women with diabetes, excluding type 1 diabetes, receiving betamethasone ≥24 weeks' gestation. Interventions were stratified SC-I and IV-I protocols, titrated to hourly BGLs (IV-I) or predicted maternal hyperglycemia and 2-4 hourly BGLs (SC-I). Primary outcome was percentage at-target BGL 4.0-8.0 mmol/L over 48 h post-betamethasone. Secondary outcomes were rates of maternal hyperglycemia (>8.0 mmol/L), hypoglycemia (<4.0 mmol/L) and neonatal hypoglycemia (≤2.5 mmol/L).

RESULTS

19 women (3 with type 2 diabetes [T2DM], 4 with gestational diabetes [GDM]-diet, 12 GDM-insulin) were randomized to a SC-I (n = 13) or IV-I (n = 6) protocol in a 9-month period. There was a non-significant trend for higher mean percentage at-target BGLs with SC-I vs IV-I (87% vs 81%; p = .055); this was significant when the cohort was restricted to women with GDM (89% vs 81%; p = .04). Maternal hyperglycemia (85% vs 100%; p = .31) and hypoglycemia (54% vs 33%; p = .41) were not significantly different, but there were no BGLs <3.8 mmol/L with IV-I (vs 4 women with SC-I; p = .13). The rate of neonatal hypoglycemia was not different between groups.

CONCLUSION

A SC-I or IV-I protocol controls maternal BGLs following betamethasone, but SC-I appears safe and minimizes labor intensive IV-I in GDM. An adequately powered RCT to assess superiority of SC-I is planned.

A Randomized Control Trial of Oral Sucrose Solution for Prevention of Hypoglycemia in High Risk Infants

BACKGROUND

Neonatal hypoglycemia is found in up to 15% of neonates and 50% of those with risk factors. Hypoglycemia can cause brain damage and increase risk of developmental delay. Nevertheless, the data regarding hypoglycemia prevention by oral sucrose are still limited. The present study aimed to investigate whether oral sucrose solution can prevent hypoglycemia in high-risk infants.

PATIENTS AND METHODS

Four hundred and twenty-five infants with high hypoglycemic risk were randomized into two groups (214 infants in the intervention and 211 infants in the control groups). The intervention group received one dose of 0.8 ml/kg of 24% oral sucrose solution followed by enteral feed and was compared to the control group receiving enteral feed alone. Glucose levels were evaluated by Dextrostrix.

RESULTS

There was no significant difference in antenatal and perinatal risk factors of neonatal hypoglycemia between groups. Glucose level on admission was 72.1±20.3 and 72.1±24.1 mg/dl in the intervention and control groups, respectively. Although no significant difference was recognized in terms of capillary blood glucose levels between groups, data analysis revealed that the glucose increase over time was significantly higher in the intervention group at 1 h (mean±SE=3.61±1.27 mg/dl; p<0.005), 3 h (mean±SE=7.95±1.57 mg/dl, p<0.001), and 6 h (mean±SE=6.31±1.62 mg/dl, p<0.001) in comparison to those of the control. No serious adverse event was observed in either group.

CONCLUSION

A single dose of 24% sucrose solution enhanced the increase of glucose level at 1, 3 and 6 h. However, routine early feeding alone is not inferior to the addition of an oral sucrose solution.

An Overview of Hypoglycemia in Children Including a Comprehensive Practical Diagnostic Flowchart for Clinical Use

Hypoglycemia is the result of defects/impairment in glucose homeostasis. The main etiological causes are metabolic and/or endocrine and/or other congenital disorders. Despite hypoglycemia is one of the most common emergencies in neonatal age and childhood, no consensus on the definition and diagnostic work-up exists yet. Aims of this review are to present the current age-related definitions of hypoglycemia in neonatal-pediatric age, to offer a concise and practical overview of its main causes and management and to discuss the current diagnostic-therapeutic approaches. Since a systematic and prompt approach to diagnosis and therapy is essential to prevent hypoglycemic brain injury and long-term neurological complications in children, a comprehensive diagnostic flowchart is also proposed.

Open-Source Technology for Real-Time Continuous Glucose Monitoring in the Neonatal Intensive Care Unit: Case Study in a Neonate With Transient Congenital Hyperinsulinism

BACKGROUND

Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited.

OBJECTIVE

This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period.

METHODS

The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age.

RESULTS

Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time.

CONCLUSIONS

While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient's individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed.

Glucose concentrations in enterally fed preterm infants

OBJECTIVES

Determine the prevalence of glucose concentrations below the Pediatric Endocrine Society (PES) term and late preterm-focused guideline target for mean glucose concentrations (≥70 mg/dL) among preterm NICU infants on full enteral nutrition and assess the impact on monitoring practices.

STUDY DESIGN

Retrospective cohort study.

RESULTS

We analyzed 1717 infants who were at least 2 days old and 48 hours after parenteral fluids were discontinued. Glucose concentrations were ≥70, 60-69, 50-59, and <50 mg/dL in 76.6, 16.2, 5.9, and 1.3% of measurements, respectively. In multivariate models, concentrations <60 mg/dL were common among male infants at lower postnatal age, small-for-gestational age, and born to women with hypertension (p < 0.05). After PES guideline, infants were more likely to have >3 glucose measurements (p < 0.05).

CONCLUSIONS

Glucose concentrations <70 mg/dL are not uncommon among preterm infants receiving full enteral nutrition. Monitoring increased after guideline publication. Applying PES threshold to well-appearing preterm infants may promote increased monitoring and intervention without clear long-term benefit.

Hereditary Tyrosinemia Compounded With Hyperinsulinemic Hypoglycemia: Challenging Diagnosis of a Rare Case

Hereditary tyrosinemia type 1 (HT-1) is a rare autosomal recessive disorder caused by a deficiency in the enzyme fumarylacetoacetate hydrolase (FAH), which catalyzes the final step in the tyrosine degradation pathway. Hereditary tyrosinemia is a heterogeneous disease with a wide spectrum of clinical manifestations involving hepatic, renal, or nervous systems. It has grave consequences if left untreated. Some of the late complications of hereditary tyrosinemia include cirrhosis, liver nodules, hepatocellular carcinoma, hypophosphatemic rickets, nephrocalcinosis, glomerulosclerosis, and chronic renal failure. Rarely, infants with hereditary tyrosinemia may present with persistent hypoglycemia, which may be a result of acute liver failure or hyperinsulinism. Hyperinsulinemic hypoglycemia (HH), caused by dysregulation of insulin secretion from pancreatic β-cells, leads to insulin driven glucose entry into the tissues and inhibits glycolysis, gluconeogenesis, fatty acid release, and ketone body synthesis. Hyperinsulinemic hypoglycemia can cause severe, persistent hypoketotic hypoglycemia. Diagnosing tyrosinemia type 1 can be a challenge as it is a heterogeneous disorder with a wide variety of clinical manifestations and complications. We herein report a rare case of a three-day-old male neonate with HT-1 compounded with HH.

Postmortem diagnosis of PPA2-associated sudden cardiac death from dried blood spot in a neonate presenting with vocal cord paralysis

Biallelic variants in inorganic pyrophosphatase 2 (PPA2) are known to cause infantile sudden cardiac failure (OMIM #617222), but relatively little is known about phenotypic variability of these patients prior to their death. We report a 5-wk-old male with bilateral vocal cord paralysis and hypertension who had a sudden unexpected cardiac death. Subsequently, molecular autopsy via whole-genome sequencing from newborn dried blood spot identified compound heterozygous mutations in PPA2, with a paternally inherited, pathogenic missense variant (c.514G > A; p.Glu172Lys) and a novel, maternally inherited missense variant of uncertain significance (c.442A > T; p.Thr148Ser). This report expands the presenting phenotype of patients with PPA2 variants. It also highlights the utility of dried blood spots for postmortem molecular diagnosis.

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.

Glucose Profiles in Healthy Term Infants in the First 5 Days: The Glucose in Well Babies (GLOW) Study

OBJECTIVES

To determine postnatal changes in plasma and interstitial glucose concentrations of healthy infants receiving current recommended care and to compare the incidence of low concentrations with recommended thresholds for treatment of at-risk infants.

STUDY DESIGN

A prospective masked observational study in Hamilton, New Zealand. Healthy, term, appropriately grown singletons had continuous glucose monitoring and repeated heel-prick plasma glucose measurements (4 in the first 24 hours then twice daily using the glucose oxidase method) from birth to 120 hours.

RESULTS

The 67 infants had a mean birth weight of 3584 ± 349 g, and gestational age of 40.1 ± 1.2 weeks. The mean glucose concentrations increased over the first 18 hours, remained stable to 48 hours (59 ± 11 mg/dL; 3.3 ± 0.6 mmol/L)] before increasing to a new plateau by the fourth day (89 ± 13 mg/dL; 4.6 ± 0.7 mmol/L). Plasma glucose concentrations of 47 mg/dL (2.6 mmol/L) approximated the 10th percentile in the first 48 hours, and 39% of infants had ≥1 episode below this threshold. Early term infants had lower mean glucose concentrations than those born at later gestational ages and were more likely to have episodes <47 mg/dL (<2.6 mmol/L) (19/32 [59%] vs 7/35 [20%]; relative risk, 3.0; 95% CI, 1.4-6.1; P = .001).

CONCLUSIONS

Healthy infants seem to complete their metabolic transition by day 4. Many have glucose concentrations below the accepted thresholds for treatment of hypoglycemia.

TRIAL REGISTRATION

ACTRN: 12615000986572.

The association between novel glucose indices in parturients with type 1 diabetes mellitus and clinically significant neonatal hypoglycemia

The aim of this study was to determine the association between glucose control indices of parturient with type 1 diabetes (T1DM), treated with an insulin pump and utilizing continuous glucose monitoring (CGM), and clinically significant neonatal hypoglycemia. This was a retrospective cohort study which included 37 pregnant women with T1DM. All women were followed at a single tertiary center and had available CGM data. The association between maternal glucose indices before delivery and the risk for neonatal hypoglycemia requiring IV glucose (clinically significant hypoglycemia) was assessed using logistic regression. Mothers to neonates that experienced clinically significant hypoglycemia had a higher glucose standard deviation (SD) before delivery than did mothers to neonates who did not (25.5 ± 13 mg/dL vs. 14.7 ± 6.7 mg/dl respectively; p = .008). This association persisted after adjustment for maternal age, maternal pregestational body mass index (BMI), gestational age at delivery, neonatal birth weight, large for gestational age (LGA) and gender. This study demonstrates an association between high maternal glucose standard deviation before delivery and the risk for clinically significant neonatal hypoglycemia. Larger studies are needed to confirm these results and further explore the role of intrapartum glucose variability in the prediction and prevention of significant neonatal hypoglycemia.

Congenital hyperinsulinsim: case report and review of literature

Neonatal hypoglycemia (NH) is one of the most common abnormalities encountered in the newborn. Hypoglycemia continues to be an important cause of morbidity in neonates and children. Prompt diagnosis and management of the underlying hypoglycemia disorder is critical for preventing brain damage and improving outcomes. Congenital hyperinsulinism (CHI) is the most common and severe cause of persistent hypoglycemia in neonates and children, it represents a group of clinically, genetically and morphologically heterogeneous disorders characterised by dysregulation of insulin secretion from pancreatic β-cells. It is extremely important to recognize this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, CHI is divided mainly into two types focal and diffuse disease. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localized to a small region of the pancreas. Recent discoveries of the genetic causes of CHI have improved our understanding of the pathophysiology, but its management is complex and requires the integration of clinical, biochemical, molecular, and imaging findings to establish the appropriate treatment according to the subtype. Here we present a case of sever congenital hyperinsulinism in a girl admitted for lethargy, irritability and general seizures accompanied with profound hypoglycemia, in spite of aggressive medical treatment, she died because of sever congenital hyperinsulinism diazoxide unresponsive.

[Hypoglycemia in neonates: a review of the literature and a case report]

Hypoglycemia in the neonatal period is one of the urgent problems of pediatric endocrinology. The main factors that lead to disruption of carbohydrate homeostasis are generally known, but the issues of neonatal hypoglycemia continue to be actively studied. In the last few years, the effect of low blood glucose on brain neurons has been studied, the issues of glycemia monitoring in the first days of life have been outlined, and strategies for managing newborns with hypoglycemic syndrome are being discussed.

Implementation of an antenatal late-preterm corticosteroid protocol at a high-volume tertiary care center

Background

Since publication of the sentinel antenatal late preterm steroids clinical trial, the use of antenatal steroids has become a routine aspect of the management of pregnancies at risk for late preterm delivery. However, in practice, the administration of antenatal corticosteroids in the late preterm period is widely varied across provider and institution, and the process of implementation of this new practice as well as outcomes associated with implementation are not well understood.

Objective

The objective was to evaluate institutional adherence to an antenatal late preterm corticosteroid protocol and to assess neonatal outcomes associated with its introduction.

Study Design

This is a retrospective cohort study of all women with singleton pregnancies admitted between 34 to 36 5/7 weeks who presented in the year before ("pre-protocol": November 2012 to October 2013) and after implementation ("post-protocol": April 2016 to March 2017). The protocol recommends corticosteroid administration to women 34 to 36 5/7 weeks gestation at risk for preterm birth who have not received prior corticosteroids. Women with fetal anomalies or pregestational or gestational diabetes were excluded from analysis. The frequency with which eligible women received corticosteroids and ineligible women were appropriately excluded (adherence) was calculated on a monthly basis. Neonatal outcomes of interest were hypoglycemia, receipt of dextrose, birth weight, 5 minute Apgar less than 7, receipt of surfactant, respiratory distress syndrome, transient tachypnea of the newborn, neonatal intensive care unit length of stay, intraventricular hemorrhage, necrotizing enterocolitis, culture positive sepsis, bronchopulmonary dysplasia, and death. Bivariable and multivariable analyses were used to compare neonatal outcomes between 1) all women in the post-protocol cohort to those in the pre-protocol cohort and 2) only women who received adherent care in the post-protocol cohort to all women in the pre-protocol cohort.

Results

A total of 452 women were included in the pre-protocol cohort and 451 in the post-protocol cohort. The majority of the post-protocol women (N=366, 81.2%) received adherent care. Women in both cohorts were similar with the exception that women in the post-protocol cohort were more likely to be nulliparous (p=0.013). Compared to the pre-protocol period, neonates of women in the post-protocol period had significantly higher odds of hypoglycemia <50 mg/dL in the first 24 hours of life (aOR 1.37, 95% CI 1.05-1.80), without improvements in respiratory outcomes. Results were similar when restricting the analysis to only women in the post-protocol cohort who received care adherent care (glucose <50 mg/dL: aOR 1.52, 95% CI 1.14-2.03). No differences in composite respiratory morbidity or other neonatal outcomes were observed.

Conclusion

Uptake of a new institutional protocol for antenatal late preterm corticosteroids was rapid. Compared with historic controls, neonates exposed to antenatal late preterm corticosteroid experienced increased odds of hypoglycemia, without significant improvements in respiratory morbidities.

Effects of Dextrose Gel in Newborns at Risk for Neonatal Hypoglycemia in a Baby-Friendly Hospital

OBJECTIVE

To describe the effects of the introduction of dextrose gel to the neonatal hypoglycemia (NH) protocol on exclusive breastfeeding rates at discharge and NICU admission rates among clinically well newborns born at 35 weeks gestation or greater who were at risk for NH in a Baby-Friendly hospital.

DESIGN

Quasi-experimental, pre- and postintervention.

SETTING

A suburban, Baby-Friendly hospital with approximately 2,000 births annually.

PARTICIPANTS

Clinically well newborns born at 35 weeks gestation or greater at risk for NH who were admitted to the mother-baby unit.

METHODS

We compared 198 newborns at risk for NH born in the 6-month period before the introduction of dextrose gel (November 15, 2016, through May 14, 2017) versus 203 newborns born in the 6-month period after the introduction (May 15, 2017, through November 14, 2017). In the preintervention group, the NH protocol included blood glucose monitoring, prolonged skin-to-skin contact, feeding, and dextrose administered intravenously. In the postintervention group, oral dextrose gel was added to the NH protocol.

RESULTS

We found no differences in maternal or newborn characteristics between the pre- and postintervention groups. Dextrose gel was given to 50 newborns (approximately 25%) of 203 in the postintervention group. The proportion of newborns who were exclusively breastfed at discharge was similar between groups (56.6% of 198 vs. 59.1% of 203, p = .62), as were the NICU admission rates for hypoglycemia (2.5% of 198 vs. 1.5% of 203, p = .50).

CONCLUSIONS

In a suburban Baby-Friendly hospital, introduction of dextrose gel into the NH protocol had no significant effect on exclusive breastfeeding at discharge or NICU admission rates.