Gerda I. Benda

Insulin infusion with parenteral nutrition in extremely low birth weight infants with hyperglycemia

From Nov. 7, 1983, to Nov. 6, 1986, all infants with birth weight less than or equal to 1000 gm admitted to Oregon Health Sciences University who had persistent hyperglycemia and glycosuria were treated with graded insulin infusion while energy intake was increased to at least 100 kcal/kg/day (419 kilojoules/kg/day). The records of these infants were reviewed to define the clinical characteristics of infants likely to develop hyperglycemia and to see whether insulin administration would allow goals for energy intake to be met. There were 76 surviving infants; 34 received insulin and 42 did not. Treated infants were smaller (767 +/- 161 vs 872 +/- 98 gm; p = 0.0004), were more immature (26.8 +/- 1.4 vs 27.7 +/- 2.0 weeks; p = 0.0115), and required mechanical ventilation longer (28 +/- 19 vs 17 +/- 15 days; p = 0.0196). There were no significant differences between the groups at 3, 7, 10, or 14 days for intravenously administered glucose or for total nonprotein energy intake at 3, 7, 10, 14, 28, or 56 days. Treated infants achieved an intake of 100 kcal/kg/day (419 kilojoules/kg/day) at 15 +/- 8 vs 17 +/- 11 days and regained birth weight at 12 +/- 6 vs 13 +/- 6 days (NS). There was no difference in percent change from birth weight at 7, 14, 28, or 56 days. Treated infants had a glucose concentration of 195 +/- 60 mg/dl (10.8 +/- 3.3 mmol/L) while receiving 7.9 +/- 3.0 mg/kg/min (43 +/- 17 mumol/kg/min) of glucose at the start of insulin infusion on days 1 to 14. Insulin was given for 1 to 58 days. The initial dose was 40 to 100 mU/gm of dextrose infused (57 to 142 nmol/mol) and then gradually decreased. Less than 0.5% of blood glucose values were 25 to 40 mg/dl (1.4 to 2.2 mmol/L). We conclude that insulin infusion improves glucose tolerance in extremely low birth weight infants and allows hyperglycemic infants to achieve adequate energy intake similar to that of infants who do not become hyperglycemic.

Prolonged inactive phases during the discontinuous pattern of prematurity in the electroencephalogram of very-low-birthweight infants

A consecutive cohort of 46 very-low-birthweight infants, who had routine electroencephalograms (EEGs) while in the neonatal intensive care unit, were studied. Two infants were lost to follow-up and were excluded, leaving a study population of 44 infants. Their mean birthweight was 945 +/- 166 g, gestation 27.1 +/- 1.7 weeks. Thirteen infants died before discharge. The remaining 31 had a mean corrected age of 26.1 +/- 8.7 months at the time of the last visit. Three groups were distinguished: normal survivors, handicapped survivors and non-survivors. The longest inactive phase encountered in the discontinuous EEG was the yardstick of the study with 3 subdivisions: less than 20 sec. 20-29 sec and equal to or more than 30 sec. The data showed a relative increase in poor outcome with increasing duration of inactivity (P less than 0.05) and, conversely, a favorable outcome with the absence of 20 sec or longer inactivity (P less than 0.001). All infants received therapeutic doses of phenobarbital during the early part of their illness which could have affected their EEG. Mean phenobarbital levels, obtained close to the time of the EEG, however, did not differ significantly and failed to show a significant relationship between the duration of the inactive phase and drug level observed. Inactive phases greater than or equal to 30 sec were more common (P less than 0.01) in infants with intraventricular hemorrhage. We conclude: although full recovery and normal outcome have been documented, prolonged isoelectric phases beyond 30 sec are more common in infants with fatal outcome.

Selenium and Vitamin E Sufficiency in Premature Infants Requiring Total Parenteral Nutrition

A randomized prospective study of LBW infants was undertaken to evaluate the effect of parenteral lipid infusions upon their antioxidant systems. Ten babies received a parenteral nutrition regimen with lipid emulsion, and ten received a regimen without lipid. Although the addition of lipid emulsion to the total parenteral nutrition regimen led to a rise in vitamin E levels, the selenium levels fell in both groups. Neither group showed evidence of deficient antioxidant systems by the peroxide hemolysis test or thiobarbituric acid test. There did not seem to be any adverse effect of the lipid infusion upon the clinical course of the infants except for hyperlipidemia. There was a better weight gain in infants receiving lipid.

Serum Vitamin E Levels in Very Low-Birth Weight Infants Receiving Vitamin E in Parenteral Nutrition Solutions

Serum vitamin E levels were measured in 17 very low-birth weight infants in the first 2 wk of life, before and after the institution of intravenous vitamin E supplementation in a dosage of 4.5 mg/day, as a component of MVI Pediatric multivitamin preparation. Serum vitamin E levels were 0.22 +/- 0.16 (SD) mg/dl before supplementation, and rose to 2.55 +/- 0.65 (SD) mg/dl in nine infants more than 899 g birth weight, and rose to 3.68 +/- 0.70 (SD) mg/dl in six infants less than 900 g at birth. These postsupplementation serum vitamin E levels are in the range in which a reduction of incidence or severity of retinopathy of prematurity and intraventricular cerebral hemorrhage has been reported by others. No toxic effects of the preparation or of the increased vitamin E levels were found.

A scoring system for evaluating the condition of transported neonates

A scoring system for the evaluation of the clinical status of transported small premature infants was modified to make it applicable to the evaluation of both premature and term infants. Blood glucose concentration, systolic blood pressure, blood pH and PO2, and body temperature were assessed and given scores of 0, 1 or 2 for abnormal, borderline and normal values, respectively. The scoring system was used for quality assurance studies of changes in patient status during transport from community hospitals to the neonatal intensive care unit and proved useful in identifying inadequate attention to body-temperature maintenance. The scoring system showed an improvement in the criterion after changes in clinical monitoring and management of body temperature were instituted. An additional use of the scoring system was for the identification of specific problems in neonatal stabilization in referring community hospitals.

VARIABILITY OF PLASMA CORTISOL LEVELS IN EXTREMELY LOW BIRTH WEIGHT INFANTS. † 529

Cortisol is secreted by children and adults in a pulsatile pattern of 15-30 peaks and nadirs each day with a circadian rhythm. Newborns are known to lack the circadian pattern, leading to uncertainty about the appropriate time for blood sampling for assessment of adrenal function. Because extremely low birth weight (ELBW) infants may manifest signs of adrenal insufficiency, knowledge of the pattern of cortisol levels is necessary to guide the appropriate timing of blood sampling. To define the pattern of plasma cortisol levels in 14 ELBW infants, we obtained blood specimens every 20 min over a 6-h period at 4-6 days of life. Although cortisol levels in the 14 infants ranged from 2.0-54.5 micrograms/dL, each infants cortisol levels varied little from his or her own mean cortisol level. The SDs calculated from each infants mean cortisol level were small, ranging from 0.37-4.12 micrograms/dL. Cluster analysis was applied to the data; only 0.6 cortisol pulses/infant 6-h period were detected. Each infants plasma cortisol levels were plotted against time, and regression analysis was performed. The slopes of the resulting lines of regression ranged from -0.0284 to 0.0221. Our data indicate that ELBW infants show little variability in their plasma cortisol levels over time; therefore, a single random measurement provides an adequate reflection of the adrenal status of the ELBW infant.