Hypoglycemia is a common cause of neonatal admission and is often managed with dextrose infusion albeit the early use of 40% glucose gel may have reduced admission rates. Our South Australian guideline recommends IV Dex 10% bolus and infusion at 90/kg/day if BGL is below 1.5 mmol/L, and also recommends iv Dex 10% at 60 ml/kg/day if sugars are between 1.5 and 2.5 despite enteral feeds of 30 mL/kg/day.

But what is the role for higher rates of enteral feeding on Day 1 in the otherwise well infant without significant respiratory distress? Breastfeeding and EBM where possible, but also either a term formula (~7.5 g carb/100mL) or preterm (8.3 g/100mL) with the additional option to add dextrose (eg 4 mL of 50% added to 100 mL of formula) or a dextrose polymer (poly-joule) which would allow even greater amounts to be added without excessive osmolality. How high can we go with these options, both in terms of concentration and volume?

Do any units use Dextrose 10% solutions enterally to manage the sugars without needing formula?

Theoretically we can max-out the gut glucose transporters even when there is no actual gut pathology - quoted max active absorption is 6 to 8 mg/kg/min only but I'm not sure how well-evidenced that is.

I'd like to get a sense of what other teams are doing to optimise enteral feed options in hypoglycemia so will try to post a very short survey.

20 years ago, normal lower values of glucose was 1,7 mmol for term and 1,1 for premature born, for those without symptoms.

I would like to know how we changed and what changed?

In our population we had a large number of LGA and IDMs that were challenging IV sticks. Late in my career we started placing og tubes with continuous formula feeds at 60-150 cc/kg/d with relatively good success. We thought a more continuous feed would not cause so much fluctuation in insulin production. Does anyone else do something similar?

The challenging IV insertion especially in LGA is a problem -anecdotally some infants require multiple attempts on multiple occasions and that is one factor pushing us to re-consider enteral feeds at higher rates with (if required) added dextrose - to reduce infant pain. Continuous feeds may be better tolerated and theoretically reduce insulin surges (imitating iv fluid administration in that regard). And of course the added value with enteral is the protein and fat - substrate for endogenous glucose production.

Which milk to use if EBM unavailable - we usually use a preterm formula - not only more carbs but slightly faster bioavailability as a high percentage is glucose chains rather than lactose (compared to term formula) so the step of hepatic galactose conversion to glucose is nor required.

We try to avoid IV cannulation and prepare the formula milk in 10% Dextrose instead of water. We go upto 100 ml/kg/day on day 1 to avoid IV sticks

Hi Dr Sanghvi - that's very interesting. Back of the envelope maths: Your resultant mixture has 16g sugar per 100 mL, and an osmolality of over 700 mOsm/kg. Giving these feeds at 100 mL/kg/day would be a glucose delivery of 11 mg/kg/min - so yes I can see you would avoid most iv insertion.

Are you giving these feeds by perfusor, or bolus?

Do you see any problems with feed tolerance - any osmotic diarrhoea? The high osmolality would make me worry about mucosal health - and ultimately NEC.

Enteral feeding in hypoglycaemia — reflections and poll results

Thanks to everyone who voted, and especially to those who shared how they actually do this. Twenty-two votes is modest numbers but the feedback was interesting:

• Most push enteral rates well beyond my local guideline 30 mL/kg/day to avoid an IV — 47% to 60 mL/kg/day on day 1, a third to 90+.

• 50% dextrose is the more common additive (59%) over glucose polymer powders (40%) — though 61% use no polymer at all, and those who do start conservatively at 2–3 g/100 mL.

• Enteral 10% dextrose is seldom used

So there's a wide range in volumes and additives (dextrose or glucose polymers or neither)

The comments: roblums emphasised the LGA/IDM infant who has a difficult venous access, sometimes multiple attempts — a strong driver to utilise the gut first. Several favour continuous OG feeds, on the logic that steady delivery smooths the insulin response — essentially imitating an infusion.

Of course milk includes protein and fat — substrate for endogenous glucose production. If EBM isn't available, preterm formula gives more carbohydrate and slightly faster bioavailability, since more is glucose polymer than lactose (no hepatic galactose step).

Fortification variability is interesting. Dr Sanghvi's unit prepares formula in 10% dextrose rather than water, to 100 mL/kg/day on day one — a simple way to avoid almost all intravenous lines. My back-of-envelope: ~16 g sugar/100 mL, osmolality above 700 mOsm/kg, ~11 mg/kg/min at 100 mL/kg/day but it's well over the ~450 mOsm/kg AAP ceiling, so I worry about mucosal-health/NEC. Glucose polymer adds carbohydrate at much lower osmolality than dextrose, so it's probably the safer option— but the evidence for the real osmolality ceiling (and for the quoted 6–8 mg/kg/min active absorption limit) is thin.

lilim's point about changing BGL thresholds - the definition of the cut-off early blood sugar for immediate IV bolus / infusion in asymptomatic infant is quite variable across guidelines: South Australian Guideline mandates IV at <1.5, BAPM uses <1.0, Starship (Auckland NZ) admits at <1.2, Sen et al. trialled 1.1. Is our mandatory-bolus threshold simply too high?

My tentative conclusion is to move from using added dextrose 50% (we typically used to add 2g / 100mL milk) to instead use glucose polymers at 5 g / 100 mL when more sugar is required but volume is constrained. Happy generally to go up to 75 to 90 mL/kg/day enteral on day one but aware that we may max out glucose absorption. Consider continuous where tolerance is a problem, and keep feeds running alongside the IV when IV is unavoidable, reserving the bolus for the lowest sugars. FEED1 and Alshaikh 2025 are reassuring on NEC at these volumes.

Dr Michael Hewson
www.nicutools.org

Does your guideline have any recommendations on when to consider Diazoxide if hyperinsulinism is confirmed?