EBNEO COMMENTARY: DEXTROSE GEL PROPHYLAXIS FOR NEONATAL HYPOGLYCEMIA AND NEUROCOGNITIVE FUNCTION AT AN EARLY SCHOOL AGE: A RANDOMIZED DOSAGE TRIAL

[EBNEO]

Ashlee Smith-Patel, Daniela Dinu & Elena Itriago from Baylor College of Medicine, Houston, TX, United States review Wei et al's paper: "Wei X, Franke N, Alsweiler JM, Brown GTL, Gamble GD, McNeill A, Rogers J, Thompson B, Turuwhenua J, Wouldes TA, Harding JE, McKinlay CJD; pre-hPOD Early School-age Outcomes Study Group. Dextrose gel prophylaxis for neonatal hypoglycaemia and neurocognitive function at early school age: a randomised dosage trial. Arch Dis Child Fetal Neonatal Ed. 2024 Jun 19;109(4):421-427. doi: 10.1136/archdischild-2023-326452. PMID: 38307710; PMCID: PMC11186727" for EbNeo.

READ HERE!

Acta Commentary:

Acta Paediatrica - 2024 - Smith%E2%80%90Patel - EBNEO commentary Dextrose gel prophylaxis for neonatal hypoglycemia and.pdf

Neonatal hypoglycemia is a common condition. Symptomatic neonatal hypoglycemia has been associated with white matter injury on brain magnetic resonance imaging, and even transient or undetected hypoglycemia may be associated with impaired executive functioning in early childhood.^1, 2 This has led to studies evaluating prophylactic use of dextrose gel to decrease the incidence of hypoglycemia and, potentially, the incidence of neurodevelopmental impairment (NDI) later in life.^3, 4

In this study, the authors were able to follow up and assess 80% of the initial cohort from the pre-hPOD trial,⁴ which compared various dextrose gel dosages (200 mg/kg, 400 mg/kg, 800 mg/kg, 1000 mg/kg) administered prophylactically at one hour of life with placebo. A previous analysis of the same cohort at two years of age found no difference in the composite neurosensory impairment outcome between placebo and dextrose gel,⁵consistent with another trial (the hPOD trial) which also compared the neurodevelopmental outcome at two years for infants born at risk and found no significant difference between 200 mg/kg 40% dextrose gel and placebo, but was underpowered to detect small but potentially clinically relevant differences in neurosensory impairment.⁶

The investigators evaluated multiple domains (neurocognitive function; visual perception; reading; numeracy, body size and composition; and grip strength) and found no difference in the primary outcome of cognitive impairment at 6–7 years of age for children randomised to various doses of prophylactic dextrose gel compared with control. When sample size was increased by combining all those exposed to intervention there was a lower risk of motor impairment (3% vs. 14%) and higher mean (SD) cognitive scores (106.0 (15.3) vs. 101.1 (15.7). These findings support the hypothesis that certain higher-order cognitive functions may not be fully developed at younger ages, and longer follow-up might be needed to detect poor executive function or visual impairment.³ The improvement in the motor skills at 6–7 years of age in this study which contrasts with previous reports may be due to the poor predictive value of the neurological exam and Bayley exam performed at 2 years of age in predicting motor skills later in childhood.⁷ However, it should also be considered that a limitation of this study were differences in baseline characteristics, with the children who were assessed being more likely to be born to older and more educated mothers, compared to those children lost to follow-up.

The placebo group had a high rate of neurocognitive impairment (56%), compared with the dextrose group (48%). These results supports the hypothesis that the prophylactic gel prevented episodes of hypoglycemia that went undetected with intermittent sampling, as shown by studies using continuous glucose monitoring.²

While there were no identified adverse effects associated with the use of prophylactic dextrose gel, the number needed to treat (NNT) to prevent one case of NDI would likely be high, considering that the initial trial showed an NNT of 21 to prevent one case of hypoglycemia and larger studies.⁶

More studies are needed to evaluate benefits, harms, timing and dosing of prophylactic treatment in infants at risk of developing hypoglycemia.

 

[NHowold]

We tried to implement glucose gel in our delivery room. BUT there simply was no need. We teach antenatal breast expression to high risk mums and practice early breast feeding along with uninterrupted skin to skin contact. I really haven't seen a hypoglycemia in a healthy newborn for years.