50 Years Ago in TheJournalofPediatrics: How Sweet It Is: Hyperglycemia in Infants on Parenteral Nutrition

Abstract

Driscoll JM, Heird WC, Schullinger JN, Gongaware RD, Winters RW. Total intravenous alimentation in low-birth-weight infants: a preliminary report. J Pediatr 1972;81:145-53. In 1972, Dr Driscoll reported the outcomes of 9 very low birth weight infants receiving parenteral nutrition (PN). Full nutrition was provided with glucose, aminosol, electrolytes, and vitamins infused at a constant rate. The glucose content was gradually increased based on blood and urine glucose levels. Compared with conventionally managed infants, this group met or exceeded expected weight gain and were quicker to regain birth weight. These early results were encouraging; PN could provide adequate nutrition in this high-risk group. Metabolic derangements were the most frequent complication, with recurrent hyperglycemia occurring in 5 patients. Two infants had dehydration from osmotic diuresis and 2 required insulin. Fifty years later, hyperglycemia is a known complication of PN and is associated with significant morbidity and mortality.1Sinclair J.C. Bottino M. Cowett R.M. Interventions for prevention of neonatal hyperglycemia in very low birth weight infants.Cochrane Database Syst Rev. 2011; 5 (Available from:): CD007453https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007615.pub3/fullGoogle Scholar Monitoring of blood glucose levels and ramping infusion rates to prevent hyper or hypoglycemia are now routine practice. In 2011, guidelines from the American Society of Parenteral and Enteral Nutrition were published recommending a serum glucose goal of less than 150 mg/dL in neonates.2Arsenault D. Brenn M. Kim S. Gura K. Compher C. Simpser E. et al.A.S.P.E.N. clinical guidelines: hyperglycemia and hypoglycemia in the neonate receiving parenteral nutrition.J Parenter Enter Nutr. 2012; 36: 81-95Crossref PubMed Scopus (35) Google Scholar Fat emulsions, which were not approved for children until 1981, were also recommended to allow for reduction in glucose infusions rate from increased gluconeogenesis. There are ongoing advancements in our ability to detect hyperglycemia. A study of very low birth weight infants demonstrated improved glycemic control using a continuous glucose monitor to adjust glucose infusions rate compared with standard of care glucometer.3Galderisi A. Facchinetti A. Steil G.M. Ortiz-Rubio P. Cavallin F. Tamborlane W.v. et al.Continuous Glucose Monitoring in Very Preterm Infants: A Randomized Controlled Trial [Internet].http://publications.aap.org/pediatrics/article-pdf/140/4/e20171162/1097183/peds_20171162.pdfGoogle Scholar Lipids are now a key component of modern PN, and the use of omega-3 fish oil-based formulations have helped mitigate the risk of intestinal failure-associated liver disease.4Khalaf R.T. Sokol R.J. New insights into intestinal failure-associated liver disease in children.Hepatology. 2020; 71: 1486-1498Crossref PubMed Scopus (27) Google Scholar The urgency of supporting premature infants with complete nutrition is as relevant now as it was 50 years ago. Balancing the morbidity of prematurity with the risks of medical therapy continues to be a priority in the care of these patients.