We have been discussing hyperglycemia in preterm infants recently, sparkled by an actual case where we had different opinions on what to do. It resolved in an uncomplicated way (without insulin etc) but I thought it would be great to pick everyone's brain about this.

When reading the literature, I feel less enlightened and more confused on a higher level... here some reading:

• Management (AAP Neoreviews)

• Systematic review on long-term outcomes

Please share you management strategies in the poll above and share comments below, looking fw to discuss.

The first thing I would ask is this baby on aminoacid infusion? How much?

10 hours ago, Mariana Oliveira said:

The first thing I would ask is this baby on aminoacid infusion? How much?

Lets assume that this hypothetical patient is given a total of 100 ml/kg/d: enteral feeds of ~20 ml/kg/d and the remaining ~80 ml/kg/d as TPN, individually mixed to reduce glucose intake (TPN solution ~5% glucose). TPN protein intake would correspond to ~2 mg/kg/day

Managing hyperglycemia in a newborn requires identifying the underlying cause and addressing it appropriately. Hyperglycemia is generally defined as blood glucose >150-180 mg/dL in neonates, particularly preterm or critically ill infants.

Causes of Neonatal Hyperglycemia

   •   Excessive glucose infusion (IV fluids, parenteral nutrition)

   •   Stress response (sepsis, surgery, hypoxia)

   •   Extremely low birth weight (ELBW) or very preterm neonates (immature insulin secretion)

   •   Endocrine disorders (e.g., neonatal diabetes mellitus)

   •   Medications (steroids, caffeine, theophylline)

Management Approach

1. Assess and Address the Underlying Cause

   •   Review glucose infusion rate (GIR)

   •   Evaluate for sepsis, hypoxia, or stress-related conditions

   •   Consider endocrine disorders if hyperglycemia is persistent

2. Adjust Glucose Infusion Rate (GIR)

   •   Normal GIR: 4-6 mg/kg/min

   •   Reduce GIR stepwise if glucose levels exceed 180 mg/dL, but avoid hypoglycemia

   •   Target blood glucose <150 mg/dL in neonates

3. Insulin Therapy (If Needed)

   •   Consider only if persistent hyperglycemia (>200-250 mg/dL) despite GIR reduction

   •   Start insulin infusion at 0.05-0.1 U/kg/hr, titrating as needed

   •   Monitor for hypoglycemia and electrolyte imbalances (especially hypokalemia)

4. Monitor and Support

   •   Frequent blood glucose checks (every 4-6 hours initially)

   •   Electrolyte monitoring (Na, K, Ca)

   •   Clinical observation for dehydration, polyuria, weight loss

Special Considerations

   •   Preterm infants (<32 weeks): More prone to hyperglycemia; maintain conservative GIR

   •   Septic or stressed neonates: Treat the underlying infection/inflammation

   •   Neonatal diabetes: Rare but requires further endocrine evaluation

Dr A Jaleel Ahamed

Coimbatore India

Those of you using cont glucose monitoring, do you have some specialised (research?) technology or do you use the ones also used by older kids and adults? We tried one of the latter, and our experience was that "it looks good, but feels bad", i.e. we got a lot of data points, but the precision not good (both over- and under-estimation of the true blood glucose from the validated method)

10 hours ago, Stefan Johansson said:

Lets assume that this hypothetical patient is given a total of 100 ml/kg/d: enteral feeds of ~20 ml/kg/d and the remaining ~80 ml/kg/d as TPN, individually mixed to reduce glucose intake (TPN solution ~5% glucose). TPN protein intake would correspond to ~2 mg/kg/day

I would increase protein intake to 3.5 mg/kg/day and use a glucose rate of at least 5 mg/kg/min (never less than that). If with this adjustments my glucose levels were still around 20 mmol/L I would start continuous insulin.

Interesting case, but I'd definately check serum phosphate concentrations first. Since baby is SGA, a refeeding like syndrome may have resulted in low phosphate levels, which in turn may cause hyperglycemia. One needs a lot of phosphate for successful glycolysis (e.g. Dreyfus 2016 Clin Nutr).

Thus, if phosphate is low, supplement extra phosphate and hyperglyc will likely resolve with no need of insulin.

Only if phosphate is >1.60 mmol/L, I'd start insulin