Early Enhanced Parenteral Nutrition, Hyperglycemia, and Death Among Extremely Low-Birth-Weight Infants.
OBJECTIVE
Efforts to optimize early parenteral nutrition (PN) in extremely low-birth-weight (ELBW) infants to promote growth and development may increase hyperglycemia risk. Recent studies have identified an association between early hyperglycemia and adverse outcomes in ELBW infants.


OBJECTIVE
To examine the prevalence of early hyperglycemia and clinical outcomes among ELBW infants before (2002-2005) and after (2006-2011) the implementation of an early enhanced PN protocol and to assess the independent effects of early enhanced PN and early hyperglycemia on mortality.


METHODS
Observational cohort study in a level III neonatal intensive care unit. Prospectively collected clinical data in the neonatal intensive care unit's medical database, nutritional information, and blood glucose levels were merged for analysis. All ELBW infants born between January 1, 2002, and December 31, 2011, without lethal malformations and still alive at 12 hours of life were eligible for inclusion in the study.


METHODS
Mortality was the main outcome measure. Severe hyperglycemia was defined as 2 consecutive blood glucose levels exceeding 216 mg/dL at least 3 hours apart. A multivariable logistic regression model was applied to determine the independent effects of early enhanced PN and hyperglycemia on mortality.


RESULTS
In total, 343 infants were included in the study, 129 in a historical comparison group before the enhanced PN protocol and 214 in the early enhanced PN group. Baseline characteristics were similar between the study groups. After the introduction of early enhanced PN, the prevalence of severe hyperglycemia during the first week of life was higher in the early enhanced PN group (11.6% [15 of 129] vs 41.6% [89 of 214], P < .001), as was the mortality (10.9% [14 of 129] vs 24.3% [52 of 214], P = .003). When adjusting for background characteristics, treatment, and nutritional data, early severe hyperglycemia remained a strong independent risk factor for death (odds ratio, 4.68; 95% CI, 1.82-12.03), together with gestational age (odds ratio, 0.62; 95% CI, 0.49-0.79).


CONCLUSIONS
The implementation of an enhanced PN protocol was correlated with an increased prevalence of severe hyperglycemia and higher mortality. In the multivariable analysis, an enhanced PN regimen per se was not predictive of mortality, whereas early severe hyperglycemia remained strongly predictive of death. To avoid detrimental effects on outcomes in ELBW infants, the optimal composition of early PN to avoid postnatal growth failure must be carefully balanced against hyperglycemia risk.
Women and Children's Division, Department of Neonatology, Oslo University Hospital Rikshospitalet, Oslo, Norway2Norwegian Neonatal Network, Oslo University Hospital Rikshospitalet, Oslo, Norway.
Hans Jorgen
HJ
Stensvold
Women and Children's Division, Department of Neonatology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
Kenneth
K
Strommen
Women and Children's Division, Department of Neonatology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
Astri M
AM
Lang
Women and Children's Division, Department of Pediatrics, Oslo University Hospital, Oslo, Norway4Faculty of Medicine, University of Oslo, Oslo, Norway.
Tore G
TG
Abrahamsen
Medical student at the Faculty of Medicine, University of Oslo, Oslo, Norway.
Eline Kjorsvik
EK
Steen
Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway.
Are H
AH
Pripp
Women and Children's Division, Department of Neonatology, Oslo University Hospital Rikshospitalet, Oslo, Norway2Norwegian Neonatal Network, Oslo University Hospital Rikshospitalet, Oslo, Norway.
Arild E
AE
Ronnestad
D001786:Blood Glucose / Q000032:analysis; D015331:Cohort Studies; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000209:etiology*; D007223:Infant; D007226:Infant Mortality; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D010288:Parenteral Nutrition / Q000009:adverse effects* / Q000379:methods; D012307:Risk Factors
D001786:Blood Glucose