ESPEYB17 2. Antenatal and Neonatal Endocrinology Neonatal Hypoglycaemia (5 abstracts)
2.3. Lower versus traditional treatment threshold for neonatal hypoglycemia
van Kempen AAMW , Eskes PF , Nuytemans DHGM1 , van der Lee JH , Dijksman LM , van Veenendaal NR , van der Hulst FJPCM , Moonen RMJ , Zimmermann LJI , van't Verlaat EP , van Dongen-van Baal M , Semmekrot BA , Stas HG , van Beek RHT , Vlietman JJ , Dijk PH , Termote JUM , de Jonge RCJ , de Mol AC , Huysman MWA , Kok JH , Offringa M & Boluyt N; HypoEXIT Study Group
To read the full abstract: N Engl J Med. 2020 Feb 6;382(6):534–544. PMID: 32023373
Neonatal hypoglycaemia is one of the most common biochemical findings in the newborn period and is an important cause of brain injury. However, despite being so common there is no consensus regarding the glucose threshold concentration at which treatment for asymptomatic neonatal hypoglycemia should be initiated. Neurodevelopmental outcome studies in infants after neonatal hypoglycaemia have been mostly observational, comparing newborns with and without hypoglycaemia, and these studies have reported inconsistent results. Due to the lack of evidence and consensus, there is no consensus screening or treatment protocol, and this leads to both overtreatment and undertreatment with adverse effects on newborn health, bonding of mother–child, and health care costs. Therefore, well-designed clinical trials are required to devise the appropriate treatment strategies.
This multicenter, randomized, non-inferiority trial involved 689 otherwise healthy newborns born at 35 weeks of gestation or later and identified as being ‘at risk’ for hypoglycemia. The authors compared two glucose threshold values (2 mmol/l and 2.6 mmol/l) for treatment of asymptomatic moderate hypoglycemia. They found no difference between groups with respect to the psychomotor development at age 18 months, assessed by Bayley Scales of Infant and Toddler Development. Based on these observations, the authors suggest that a glucose value of 2 mmol/l is non-inferior to the standard value of 2.6 mmol/l for intervention.
The strengths of this study its multicenter, randomized control trial design involving a large number of newborns. However, follow up was only until 18 months of age. It is known that the neurodevelopment impact of neonatal hypoglycaemia does not manifest until the age of about 4 years (1, 2), so the conclusions should be interpreted with caution. Also, newborns with severe hypoglycaemia were excluded, so the conclusions cannot be applied to that group. Finally, there is a potential for bias, as the caregivers were aware of the treatment group for each newborn. It will be interesting to know the neurodevelopment outcome of all these newborns at age ~4 years, so they should have long-term follow up. The issue question ‘which blood glucose level is safe for brain function and neurodevelopment’ still remains to be answered.
References:
1. Shah R, Harding J, Brown J, McKinlay C. Neonatal glycaemia and neurodevelopmental outcomes: a systematic review and meta-analysis. Neonatology 2019;115:116–26.
2. McKinlay CJD, Alsweiler JM, Anstice NS, et al. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr 2017;171:972–83.
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ESPE Yearbook of Paediatric Endocrinology
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