M Hewson

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.

Hi Carlos - I would greatly appreciate any observations / feedback / suggestions including any related to ease of use. Michael.

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.

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.

Hi colleagues - many of you will be familiar with nicutools.org neonatal calculators. My new project is a synchronous, multi-participant, instructor-led team simulation in a free browser tool available at neosim.nicutools.org You can set up a virtual neonatal resus case and invite your trainees into the "sim lab" where they can prepare equipment, discuss team roles, then in real time resuscitate the virtual manikin which responds in a life-like fashion to their interventions. T-piece ventilation, intubation, UVC, adrenaline, red cells, needle thoracotomy and more are all modelled. You as teacher / instructor can adapt the sim to suit your teaching requirements and flex the manikin's response mid-sim as you need to support learning. There is a comprehensive debrief timeline provided post sim. Initial user feedback is very positive and is helping with on-going improvements to the project. If you have any trainees interested in the idea of study into the educational value of this specific tool I would be very keen to hear from you as well.

While at Wellington NZ NICU, I created a set of infusion calculators for neonatal use These are mostly fixed rate, and they are built around the specific drug ampoule strengths we stock. Michael

The Kaiser Permanente early onset sepsis calculator gives a great insight into this problem ... http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx Anyway from the data provided the EOS risk is very low and observation is all that is needed unless clinical features of sepsis appear. By the way, why wait to stop antibiotics at 48 hours? EOS cultures are almost always positive by 24 hours or not at all.