Interventions for prevention of neonatal hyperglycemia in very low birth weight infants

Abstract

Glucose infusion rate: There is insufficient evidence from trials comparing lower with higher glucose infusion rates to inform clinical practice. Large randomized trials are needed, powered on clinical outcomes including death, major morbidities and adverse neurodevelopment.Insulin infusion: The evidence reviewed does not support the routine use of insulin infusions to prevent hyperglycemia in VLBW neonates. Further randomized trials of insulin infusion may be justified. They should enrol extremely low birth weight neonates at very high risk for hyperglycemia and neonatal death. They might use real time glucose monitors if these are validated for clinical use. Refinement of algorithms to guide insulin infusion is needed to enable tight control of glucose concentrations within the target range.

2. Neonatal hypoglycaemia: History, clinical picture, investigations, management and outcome

“…First, inadequate glucose supply appears when there is insufficient enteral or parenteral nutritional input (5-7). Secondly, low glycogen stores may be a problem in preterm neonates, because glycogen starts to form in the 3rd trimester of pregnancy (2,5,7,17), and also in the case of in utero growth restriction (IUGR) (2,7,18). Thirdly, impaired glucose production is the result of metabolic disturbances of glycogenolysis, gluconeogenesis, amino acid, carbohydrate and fatty acid metabolism (19).…”

“…Most often it is the consequence of unregulated maternal diabetes (type 1, type 2 or gestational) (25,26). Moreover, a transient increase in insulin concentration may be seen in some other conditions: in IUGR (7,18,27,28), after a stressful peripartum event (2,7,22,29), after maternal treatment with insulin or glucose during labour (30), and in the case of some foetal disorders: haemolytic disease of the newborn, hypothermia, heart failure (2, 7, 22) and in Beckwith-Wiedemann syndrome (BWS) (24,31,32).…”

“…However, increased glucose utilization can also occur in a normoinsulinemic state. It may be seen in asymmetrical small for gestational age (SGA) neonates that have a disproportionately large head compared to their whole body (18). Furthermore fuel requirements are increased in an anaerobic state (2-5) and also in polycythaemia (34).…”

Requerimientos en nutrición parenteral pediátrica

“…Se sugiere además que la glucemia no sobrepase los 150 mg/dL (GdE 5) (43) ya que se asocia con mayores complicaciones particularmente en los RNPT y/o de bajo peso al nacer. Es importante evitar el exceso de energía en forma de glucosa y administrar lípidos conjuntamente siempre que sea posible (sin olvidar que su contenido en glicerol es un sustrato neoglucogénico) (44).…”

“…En los RN no se recomienda el uso rutinario de insulina precozmente para evitar la hiperglucemia debido al riesgo elevado de hipoglucemia e incremento de mortalidad (43,44); solo se propone su administración en casos de hiperglucemia persistente cuando ya se han intentado evitar y/o regular sus causas (43). Se infundirá en perfusión continua conectada en "Y" a la NP o bien, se puede incluir en la bolsa de la NP (esta última posibilidad se contemplará en pacientes estables).…”