Hyperglycemia and insulin therapy in preterms

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Very low birth weight infants are born with numerous problems that can interfere with insulin/glucose homeostasis. They have essentially no fat stores and minimal glycogen stores, and the maternal source of glucose is acutely cut off at delivery. They inevitably are stressed and rapidly become catabolic, often with glucose intolerance. Consistent administration of adequate calories soon after birth is complicated by the glucose intolerance, variable fluid needs, and other disease specific therapies (e.g. caffeine for apnea of prematurity, hydrocortisone for low blood pressure). Previous studies have demonstrated that the amount of glucose administered to these infants can be increased by concurrent insulin treatment. However, insulin therapy is not easy because frequent measurements of blood glucose are necessary to avoid hypoglycemia. But, hyperglycemia may have a number of adverse effects on short-term and long-term outcomes. Beardsall et al report that an early intervention to deliver glucose and insulin resulted in better glucose control and increased IGF-1. The normalization of counter-regulating and growth related hormones such as IGF-1 may be important benefits of such therapy. However, a compelling case needs to be made that the intensive management of blood glucose will be of significant long-term benefit before clinicians should routinely attempt such management.