Continuous gastric drip versus intravenous fluids in low birthweight infants

This multicentre randomized study compared a continuous gastric drip (CGD) with intravenous (i.v.) fluid administration. Healthy newborns with birthweight from 1501 to 2000 g whose physician ordered i.v. fluids were randomized before the 2nd hour of life to CGD or i.v. fluids. The major outcome variable was the need for an i.v. line in the CGD group. Serum glucose was measured at 30 min, 1 h and every 6 h thereafter. Serum sodium and potassium were measured at least once during the first 72 h of life. Enteral feedings, feeding intolerance, number of venous lines and i.v. line-related complications were recorded until the interruption of CGD or the i.v. line. Twenty-nine infants were randomized to each group. The two groups were comparable in terms of birthweight and gestational age. Ten percent (3/29) of the infants randomized to the CGD group required i.v. fluids and 90% of them received electrolytes and glucose through an orogastric tube. The incidence of hypoglycaemia, hyponatraemia and episodes of feeding intolerance did not differ between the groups. Conclusion: Fluid administration by CGD reduces the need for i.v. lines without increasing the risk of complications.     

Reduction in blood glucose values following indomethacin therapy for patent ductus arteriosus

PURPOSE: To evaluate the effects of indomethacin on blood glucose values in premature infants with patent ductus arteriosus (PDA). METHODS: Twenty-five very low birthweight infants with PDA were given 0.2 mg/kg, i.v., indomethacin for up to three doses. We examined the relationship between blood glucose values and glucose infusion rate before and after indomethacin therapy. RESULTS: There was a significant reduction in blood glucose values between 12 and 96 h following i.v. indomethacin therapy. Eleven of 25 infants (44%) had blood glucose values below 40 mg/dL between 12 and 60 h (mean 32.7 h) after the initial dose. Although the glucose infusion rate during the first 12 h was constant (3.56 +/- 0.98 mg/kg per min), the blood glucose values decreased from 96 +/- 32 mg/dL at the starting point to 75 +/- 29 mg/dL at 12 h (P < 0.05). The maximum blood glucose reduction was 51.6 +/- 34.7 mg/dL and the maximum blood glucose reduction rate was 50.4 +/- 20.2%. CONCLUSIONS: The results suggest that blood glucose values should be measured at least every 6 h for 72 h until they stabilize in order to prevent unexpected hypoglycemia.     

Experience with intravenous glucagon infusions as a treatment for resistant neonatal hypoglycemia

BACKGROUND: Based on limited anecdotal evidence, glucagon is used for the management of intractable neonatal hypoglycemia persisting in the face of high glucose administration rates. OBJECTIVE: To evaluate the short-term response of blood glucose levels to an intravenous infusion of glucagon. DESIGN: A retrospective observational study in which all newborns who received glucagon infusions (usual dose, 0.5-1 mg/d) during a 5-year period were identified (N = 55). The common causes of hypoglycemia were perinatal stress, intrauterine growth restriction, prematurity, and maternal diabetes mellitus. Laboratory blood glucose measurements made between 24 hours before and 72 hours after the start of the glucagon infusion and the rates of glucose administration during the same period were analyzed. The effects of glucagon on sodium and platelet levels were also examined. SETTING: University referral hospital. RESULTS: A statistically and clinically significant rise in blood glucose concentration, from a mean of 36.3 to 93.0 mg/dL (2.02-5.17 mmol/L), was observed within 4 hours of starting glucagon administration. The change was unrelated to the cause of the hypoglycemia. The frequency of hypoglycemic episodes was significantly reduced, and no further episodes of severe hypoglycemia (glucose level, <20 mg/dL [<1.1 mmol/L]) occurred. Five patients, 4 of whom were preterm newborns with intrauterine growth restriction, required additional glycemic treatment. Seventy-five percent of newborns were thrombocytopenic before starting glucagon infusion, and in 9 newborns platelet counts decreased following glucagon infusion. There was no hyponatremia attributable to glucagon. CONCLUSION: Glucagon infusions appear to be beneficial for problematic neonatal hypoglycemia of different causes.     

Views on neonatal care of newborns weighing less than 500 grams

The limit of viability is intensely debated. Newborns below 500 g birthweight are often small for gestational age with an increased risk of short- and long-term mortality and morbidity. The level of given neonatal care must be individualized. A long-term follow-up for newborns with extremely low birthweight is urgently needed.     

The effect of glucose,tolbutamide, and arginine on C-peptide release during remission in type I diabetes mellitus

The insulin secretory capacity was examined in diabetic children at the time of partial clinical remission during which their condition could be managed with low insulin therapy (<0.5 U insulin/kg body weight) and no urinary glucose excretion.The extent of the residual beta cell function in 26 children was assessed either by an i.v. arginine test, a combined i.v. glucose-i.v. arginine test, a combined i.v. tolbutamide-i.v. arginine test, or a combined oral glucose-i.v. arginine test determining the C-peptide response by calculating the area under the curve above baseline levels. Two of the children were tested repeatedly.Under the above conditions i.v. glucose and i.v. tolbutamide did not release C-peptide in diabetic children. In contrast, C-peptide secretion during arginine infusion following i.v. glucose or i.v. tolbutamide was siginficantly enhanced compared to the C-peptide secretion observed during arginine infusion alone. The C-peptide response to oral glucose was sluggish with no effect on the following arginine infusion.The results indicate that during remission in juvenile onset diabetes i.v. glucose and i.v. tolbutamide without themselves being an appropriate signal for C-peptide release amplify the response to a subsequent arginine infusion under appropriate conditions.     

Neonatal hearing screening during the first and second day of life

AIM: Congenital or acquired hearing loss in infanthood has been associated with lifelong deficits in speech and language acquisition, poor school performances and emotional and social maladjustments. The identification of hearing loss through neonatal and infant life can prevent or reduce many of these adverse consequences, permitting early intervention. METHODS: We performed the screening of hearing loss with a technical device, echo-screen Madsen, based on transient evoked otoacoustic emissions (TEOAE). The screening was carried out in 50 newborns during the 1st day of life and in 80 newborns during the 2nd day of life. RESULTS: The 2nd day of life showed a significant better stability of the test and a better symmetry (P<0.001), and less incidence of artefacts (P<0.001). CONCLUSIONS: The results obtained confirm that the 2nd day of life is the most appropriate time for the neonatal hearing assessment with TEOAE.     

Über die Glucoseutilisation von pränatalen Dystrophikern und normalen Neugeborenen sowie solchen mit diabetogener Fetalkrankheit

Zusammenfassung Bei 46 pränatalen Dystrophikern, 49 normalen Neugeborenen sowie 6 mit diabetogener Fetalkrankheit wurde zwischen 4. und 8. Lebenstag die Glucosekonsumation nach Dost auf Grund i. v. Belastung mit 0,5 g Glucose/kg berechnet. Es zeigte sich, daß die Glucoseutilisation bei diabetogener Fetalkrankheit rascher und höher ansteigt als bei normalen Neugeborenen, bei pränatalen Dystrophikern dagegen tagelang sehr niedrig bleibt, um erst relativ spät anzusteigen. Dieses Verhalten wird als Folge unterschiedlicher Entwicklung der Pankreasinseln bei den drei Arten Neugeborener gedeutet, welche Entwicklung von der Größe des diaplacentaren Glucosetransfers abhängt. Die Befunde, zu denen der Verlauf der Nüchternblutzuckerkurven eine Ergänzung bildet, scheinen dafür zu sprechen, daß pränatale Dystrophie, Zweittagshypoglykämie und angeborener transitorischer Diabetes mellitus quantitativ verschiedene Manifestationen eines Geschehens, eines fetalen Glucosemangelsyndroms, sind.

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On the glucose utilization of prenatal dystrophic normal newborns and others with a diabetogenic foetal disorder

Summary The glucose consumption according to Dost was estimated after i.v. loading with 0.5 g glucose/kg in 46 prenatal dystrophic, 49 normal newborns and in 6 newborns with a diabetogenic foetal disorder on the 4th to the 8th day of life. The glucose utilisation rose more rapidly and steeply in diabetogenic foetal disorders than in normal newborns whereas it remained at very low levels for several days and rose only relatively late in prenatal dystrophic newborns. This conditions is interpreted as resulting from the different developmental rats of the pancreatic islets in the three types of newborns, depending on the development and magnitude of the diaplacental glucose transfer. These findings, supplemented by the behavior of the fasting blood sugar curves, support the assumption that the two day hypoglycamia in prenatal dystrophy and the congenital transitory diabetes mellitus are quantitatively different manifestations of a foetal deficient glucose syndrome.

     

Calcium intake in the first five days of life in the low birthweight infant. Effects of calcium supplements.

Sixteen low birthweight infants were allocated to two groups. Both groups 1 and 2 received a formula with Ca/PO4 ratio of 1.21. Group 2 infants received a supplement of 800 mg/kg per day of Ca and Mg lactate, and the daily Ca, Mg, and PO4 levels were measured. Calcium intakes (mg/kg per day) were, comparing groups 2 and 1: 82 v. 33 on the 1st day; 133 v 45 on 2nd; 170 v. 56 on 3rd; 224 v 72 on 4th; 263 v. 88 on 5th. Magnesium intake (mg/kg per day) was 4.9 v. 3.8 on the 1st day; 8.3 v. 5.3 on 2nd; 9.8 v. 6.5 on 3rd; 15.5 v. 8.3 on 4th; 16.0 v. 10.0 on 5th. Phosphate intake was similar in both groups. Mineral content of vomits and regurgitations showed more Ca than P, with a ratio of 1:68. Comparing the two groups, in the supplemented infants, serum Ca rose from the 3rd day by an amount which was related to Ca intake: serum Mg was lower from the 4th day and was negatively correlated with Ca intake.     

Inter-relationship between serum concentrations of glucose, glucagon and insulin during the first two days of life in healthy newborns

The relationship between serum concentrations of glucose, insulin and glucagon during the first two days of life was studied in healthy newborns. The first capillary blood sample was obtained at 3–15 h of age (median 6h; day 0) and a second sample approximately 24 h later (day 1). Serum glucose concentrations in the first sample averaged 2.1 ± 0.07mmol/l (mean ± SEM; n = 60) and were positively correlated with postnatal age ( p < 0.01). Serum glucagon concentrations in the first sample averaged 570 ± 32pg/ml and were inversely correlated with glucose concentrations ( p < 0.0001). At the second sampling, serum glucose concentrations had increased to 2.9 ± 0.07mmol/l ( p < 0.001; n = 57) and serum glucagon concentrations had decreased to 403 ± 22pg/ml ( p < 0.001). Serum insulin concentrations were 11.7 f 0.3 μU/ml and 10.2 ± 0.3 μU/ml at the two samplings and did not correlate with serum glucose concentrations. The relationship of serum glucose and hormone concentrations to maternal and infant characteristics was studied by stepwise regression analysis. Serum glucose concentration on day 0 was positively correlated with postnatal age ( p < 0.01) and birth weight ( p 0.05) but inversely correlated with duration of labour ( p < 0.05). Serum glucose concentration on day 1 was positively correlated with birth weight ( p < 0.0001) and inversely correlated with maternal prep-pregnancy weight ( p < 0.05). Similar analyses of serum hormone concentrations did not demonstrate any relationships with maternal or infant characteristics. It is suggested that glucagon secretion is part of the counter-regulation against hypoglycaemia in healthy newborns and that neonatal energy stores, as indicated by birth weight, influence the ability to increase circulating glucose concentrations in response to counter-regulatory hormones.     

Mycologic monitoring of newborn infants at risk during preventive administration of nystatin

Altogether 80 newborns at risk were prophylactically treated with 3 x 150,000 IU nystatin/d per os for 14-21 d respectively on every second day for 14-21 d. The content of yeasts in the faeces was determined. In preterm infants with birth-weight below 1500 g the intestinal yeasts--especially Candida albicans--persisted much longer during nystatin application than in infants with higher birthweight and longer gestation-time. In newborns at risk, daily nystatin doses of 3 x 150,000 IU/d are recommended for the duration of disposition for systemic candidosis.     

Insulin infusions in infants of birthweight less than 1250 g and with glucose intolerance

Abstract Fifteen preterm babies (mean gestation: 26.7 weeks; mean birthweight 860 g) with significant glucose intolerance were treated with insulin infusions. During the insulin infusions there was a significant increase in both the mean energy intake (60.8 ± 25.1 cal/kg per day to 79.9 ± 24.5 cal/kg per day; P < 0.001) and the mean amount of intravenous dextrose tolerated (7.0 ± 2.7 mg/kg per min to 9.2 ± 2.6 mg/kg per min; P < 0.01). The infusions were initiated at a mean postnatal age of 5.3 days (range: 2–12 days) and were continued for 1.5–17.5 days. Of the 998 blood glucose estimations performed during the insulin infusions, 28 (2.8%) were <2 mmol/l and 216 (21.6%) > 8 mmol/l. We conclude that continuous insulin infusion is a safe and effective way of managing glucose intolerance in very low birthweight infants, provided adequate means for continuous monitoring of blood glucose are available.     

Bilirubin-IXalpha and -IXbeta pigments, coproporphyrins and bile acids in meconium and stools from full-term and preterm neonates during the first month of life

Individual bilirubin pigments in the excreta were quantitated by newly developed methods. In meconium, bilirubin-IXbeta predominated, whereas bilirubin-IXgamma and -IXdelta remained undetectable. The daily excretion of bilirubin-IXalpha plus -IXbeta was 0.03-1.00 and 0.04-2.00 micromoles kg(-1) of birthweight in preterm and full-term infants, respectively. The ratio of bilirubin-IXalpha to -IXbeta in meconium was 0.25 +/- 0.34, 0.32 +/- 0.30 and 0.46 +/- 0.55 in newborns of gestational ages below 30, from 31 to 36 and above 36 wk, respectively. The predominance of bilirubin-IXbeta disappeared within the first week in those with gestational age >31 wk but more slowly in the very preterm group. The ratio of monoconjugated to diconjugated bilirubin-IXalpha was 4 to 5 in full-term infants, whereas this ratio was only reached after 1 mo in preterm infants. The ratio of glucuronide or glucoside to xyloside varied widely, independent of gestational age. No correlation between faecal UCB-IXalpha and beta-glucuronidase was observed. The daily coproporphyrin excretion fell from a median of 500 microg on day 1 to below 20 microg from day 7 onwards; this decrease correlated with that of bilirubin-IXbeta. The daily 3alpha-hydroxylated bile acid loss in the excreta was two- to fivefold higher than in the adult; this, together with the higher neonatal serum levels (12-90 nmoles ml(-1)), indicates an immature intestinal reabsorption and an enhanced bile acid synthesis. CONCLUSION: Both zinc coproporphyrin and bilirubin-lXbeta are characteristic compounds of human meconium, diconjugated bilirubin-IXalpha is low or absent in meconium of very preterm infants, and faecal and serum bile acids are high.     

Expiratory CO2 as the first sign of successful ventilation during neonatal resuscitation

Three‐lead electrocardiography and expired CO₂ monitoring were used during positive pressure ventilation of seven non‐intubated newborns (gestational age, 31–37 weeks; birthweight, 1503–2885 g). In all cases, adequate CO₂ (>15 mmHg) was detected prior to the achievement of stable heart rate (>100 beats/min). The delay between detection of adequate CO₂ and improvement of bradycardia ranged from 8 to 73 s (median, 15 s). Inadequate expired CO₂ during positive pressure ventilation indicates airway obstruction or poor aeration of the newborn lungs. Thus, positive expiratory CO₂ can be the first recognizable sign of successful ventilation during neonatal resuscitation.     

Screening for hypoglycemia in exclusively breastfed high-risk neonates

Objective

To determine incidence of hypoglycemia in exclusively breastfed, high-risk but healthy newborns, and risk factors for its development.

Methods

This observational study enrolled 407 exclusively breastfed high-risk (low birth weight newborns (1800-2499 g), late preterms, small-for-gestation, large-for-gestation and infant of diabetic mother), who did not require admission to neonatal intensive care unit and were kept in postnatal wards with mother. Hypoglycemia was defined as blood glucose ≤46 mg/dL (2.6 mmol/L). Blood glucose was monitored till 48 hours of life.

Results

27% of the screened newborns developed hypoglycemia in first 48 hours. 31 (7.6%) developed recurrent (>2) episodes, 28 (6.8%) had moderate (<37mg/dL) while 8 (1.9%) developed symptomatic hypoglycemia. With increase in birthweight, risk of hypoglycemia reduced significantly (P=0.003). Hypoglycemia was observed more frequently in first 2 hours as compared to next 48 hours (P=0.0001). Low birth-weight, preterm gestation and male gender was significantly associated with increased risk of hypoglycemia.

Conclusion

Healthy, high-risk exclusively breastfed newborns in postnatal wards need close monitoring for hypoglycemia in first 24 hrs of life.

     

Effects of fentanyl administration on general and cerebral haemodynamics in sick newborn infants

Despite the wide use of fentanyl for analgesia in newborns, concerns have been raised about potential haemodynamic side-effects. Since sick newborns may lose their cerebral blood flow autoregulation, a drug-induced haemodynamic instability could lead to brain injury. We assessed the effects of a 15-min infusion of fentanyl (3μg/kg) on the general and cerebral haemodynamics in I5 newborns (median gestational age 29 weeks, 25th–75th percentile, range 28–31 weeks; birthweight 1170 g. range 955–1790 g). The heart rate and mean arterial blood pressure were continuously recorded. Mean cerebral blood flow velocity and pulsatility index were measured using pulsed Doppler ultrasound before, during and up to 60 min after the onset of fentanyl administration. No significant modification of general or cerebral haemodynamics was observed. In conclusion, the infusion or 3μg/kg of fentanyl did not lead to any deleterious effect on the general or cerebral haemodynamics in sick normovolaemic newborns.     

Low birthweight infants and total parenteral nutrition immediately after birth. II. Randomised study of biochemical tolerance of intravenous glucose,amino acids,and lipid.

This randomised study aimed to compare the biochemical tolerance of three parenteral regimens administered during the first 48 hours of life. Twenty nine infants were randomised to either: (a) glucose 10%; (b) glucose 10%/amino acids; (c) glucose 10%/amino acids/lipid. Blood samples for plasma amino acid profiles, cholesterol, and triglyceride concentrations were taken on arrival in the neonatal unit and again between 36 and 48 hours of life. Arterial or capillary blood gas analysis and blood glucose estimates were performed routinely during the first 48 hours of life. There was a sharp decline in plasma amino acid concentrations in the group following (a) compared with the two groups following (b) and (c) regimens. In all groups plasma triglyceride and cholesterol were not significantly different before and after 48 hours of lipid infusion. Peak mean (SE) bilirubin concentrations (203 (12) v 181 (19) v 220 (20) mumol/l) and the need for phototherapy (nine v eight v five infants) were similar for each of the groups. Hypoglycaemia occurred most frequently during the (b) regimen and least commonly in the (c) group. There are potential health gains from giving parenteral nutrition to low birthweight infants immediately after birth, and this study indicates that restriction of nutritional intake immediately after birth in preterm infants may cause significant metabolic disturbance. This can be prevented by starting a regimen of intravenous amino acids and lipid immediately after birth.     

THE EXCRETION OF C6–C10-DICARBOXYLIC ACIDS IN THE URINE OF NEWBORN INFANTS DURING STARVATION

ABSTRACT. Gregersen, N. and Ingerslev, J. (Research Laboratory for Metabolic Disorders, University Department of Clinical Chemistry and University Department of Obstetrics and Gynaecology, Aarhus kommunehospital, Aarhus, Denmark). The excretion of C₆–C₁₀-dicarboxylic acids in the urine of newborn infants during starvation. Acta Paediatr Scand, 68: 677, 1979.—The excretion of C₆–C₁₀-dicarboxylic acids, i.e. adipic, suberic and sebacic acids, was measured during the three first days of life in 3 fasting newborns, 2 newborns fed with isocaloric glucose and 2 newborns given mothers'-milk. On the second and third day of life the starved children excreted 27–84 mmol adipic acid/mol creatinine, 6–22 mmol suberic acid/mol creatinine and 4–7 mmol sebacic acid/mol creatinine. The excretion of C₆–C₁₀-dicarboxylic acids in the neonates given glucose or mothers'-milk was, for the first three days of life, 0–9 mmol adipic acid/mol creatinine, 0–10 mmol suberic acid/mol creatinine and 0–4 mmol sebacic acid/mol creatinine. The latter amounts are equivalent to the excretion of dicarboxylic acids in older children. It is argued that the detected dicarboxylic acids are formed by ω-oxidation of long-chain monocarboxylic acids followed by β-oxidation, and that the excreted amounts reflect ω-oxidation activity. It is speculated that the substantial ω-oxidation activity in the starving newborn serve to provide succinyl-CoA-substrate for the citric acid cycle and for gluconeogenesis.     

Low birthweight infants and total parenteral nutrition immediately after birth. III. Randomised study of energy substrate utilisation,nitrogen balance,and carbon dioxide production.

This study aimed to investigate energy substrate utilisation and nitrogen balance in low birthweight infants receiving total parenteral nutrition during the first days of life, and in particular, to determine the effect of two different glucose intakes on carbon dioxide production. Twenty infants (mean (SE) birthweight 1314 (65) g, mean (SE) gestation 30.9 (0.4) weeks) were recruited to the study. Immediately after birth they were randomised to a carbohydrate intake of 8 g/kg/day (5.5 mg/kg/minute) or 12 g/kg/day (8.3 mg/kg/minute). After 24 hours they were changed to the alternative regimen which was continued for a further 24 hours. Fat and protein intakes were kept constant throughout the study. Indirect calorimetry was performed during each of the regimens, urine was collected for urinary nitrogen, and substrate utilisation calculated for 12 infants. The carbohydrate utilisation rate was increased during the higher carbohydrate intake. Lipid utilisation rates were significantly different, with net lipid synthesis occurring during high carbohydrate intake. Protein utilisation rates were not influenced by the different carbohydrate intakes. The mean plasma glucose concentration was higher during the high carbohydrate intake but the mean highest and lowest values were not significantly different during the two study periods. A plasma glucose below 2.6 mmol/l was recorded more frequently during the low glucose intake (9/20 v 5/20). Capillary PCO2 values measured during high and low glucose intakes were similar (5.9 (0.2) v 6.2 (0.3) kPa. Carbon dioxide production rates were increased during the higher carbohydrate intake but the differences were not significant. Similarly, there was no significant difference in the respiratory quotients (RQ), oxygen consumption, or energy expenditure during the two study periods.     

Heparin lock intravenous line. Use in newborn infants. A controlled trial

The heparin lock technique has been available for parenteral access in older children and adults but has not yet been described for use in newborns. We randomized 39 newborns who needed parenteral medication in the intermediate care nursery to receive a heparin lock catheter (17) or an intravenous line kept patent by continuous low infusion rate (22). There were no differences between study groups with regard to birthweight, gestational age, or distribution of diagnoses. Infants in the heparin lock group were enrolled in the study on average 1 day longer than the continuous intravenous group (p less than 0.05). Subcutaneous infiltration occurred twice as frequently with the continuous intravenous line (p = 0.0015), and the life span was significantly less than heparin lock (1.0 +/- 0.5 days versus 2.1 +/- 1.0 days, p = 0.0003). Infants with continuous intravenous lines received approximately 20 ml/kg/day greater quantity of fluid (p less than 0.0001). There was no difference between groups with regard to mean heparin activity level. None of the infants developed hemorrhagic complications, thrombophlebitis, or documented nosocomial infection. Nurses significantly favored heparin locks over continuous intravenous lines for ease of use. The heparin lock technique is a safe and reasonable alternative to a continuous low infusion intravenous line for administering parenteral medications to intermediate care newborns.