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PEDIATRICS Vol. 111 No. 1 January 2003, pp. 220-221

Glucagon Infusion for Treatment of Hypoglycemia: Efficacy and Safety in Sick, Preterm Infants

To the Editor.—

Treatment of sick, preterm infants with persistent hypoglycemia is challenging because of fluid limitations and the need for multiple infusions. An intravenous glucagon infusion can be an effective treatment for hypoglycemia.¹ Recently, its safety has been questioned when as association with hyponatremia and thrombocytopenia was reported in Pediatrics.² For this reason, we examined our experience with the efficacy and safety of glucagon infusions in the preterm infant.

METHODS

We retrospectively reviewed the charts of all preterm infants with persistent hypoglycemia who were treated with glucagon infusions in 1997, 1998, 1999, and 2000. Persistent hypoglycemia was defined as 3 consecutive whole blood glucose values <40 mg/dL, confirmed by a blood serum value, which did not rise >40 mg/dL with an increasing glucose infusion rate (GIR). Hypoglycemia was defined as serum blood glucose <40 mg/dL. Glucagon was infused at 20 to 40 µg/h, and infusions were titrated to obtain a stable glucose level >60 mg/dL.

RESULTS

Of the 2045 preterm infants <37 weeks’ gestation who were admitted to the neonatal intensive care unit from the beginning of 1997 to the end of 2000, 28 received continuous glucagon infusions for persistent hypoglycemia. Their birth weight averaged 1814 ± 780 g; their gestational age was 32 ± 3 weeks; and their 5-minute Apgar score was 8 ± 2.

Glucagon infusions were initiated at an average of 42 hours of life (range: 2–310 hours) and continued for an average of 76 hours (range: 9–344 hours). Glucose levels increased to >60 mg/dL within 2.2 ± 1.6 hours after the infusion began. The blood glucose threshold of >60 mg/dL was chosen to maintain a blood glucose level well above all definitions of hypoglycemia. Table 1 highlights associations with hyponatremia and thrombocytopenia.

View this table: [in this window] [in a new window]   TABLE 1. Characteristics of Glucagon Infusion and Its Association With Hyponatremia and Thrombocytopenia in 28 Preterm Patients

 

DISCUSSION

Our experience has shown that continuous intravenous infusion of glucagon for treatment of hypoglycemia in sick, preterm infants is effective. Further, glucagon infusions were not associated with thrombocytopenia. Severe hyponatremia (<120 mEq/L) occurred infrequently and was easily corrected. Four infants received 3% sodium chloride infusions to correct hyponatremia, and the others were held at their current fluid volume infusion rates and allowed to diurese over time.

Glucagon is an effective glycogenolytic agent. However, preterm infants have very poor glycogen stores and it is thought that glucagon also stimulates gluconeogenesis by inducing phosphoenolpyruvate carboxykinase, the major enzyme of gluconeogenesis, which then results in increased endogenous glucose production.¹ This hypothesis has yet to be proven.

Once glucagon infusion therapy was initiated, a glucose threshold of >60 mg/dL was chosen to maintain a blood glucose level above all definitions of hypoglycemia. Cornblath and Ichord³ advocate treating blood glucose levels <60 mg/dL in low birth weight and very low birth weight infants >72 hours of age.

We feel that the associated hyponatremia is dilutional and likely relates to fluid overload from dextrose boluses and increases in the infusion rates. For example, our study infants received 106 ± 10 mL/kg/day in the first 96 hours of life as compared with our standard protocol of 80 ± 20 mL/kg/day.

We believe glucagon to be both effective and safe in the treatment of persistent hypoglycemia in preterm infants.

Dianne S. Charsha, RNC, MSN, NNP
Pam S. McKinley, RN
Jonathan M. Whitfield, MBChB, FRCP(C)
Division of Neonatology, Department of Pediatrics
Baylor University Medical Center
Dallas, TX 75246, USA

REFERENCES

1. Hawdon JM, Aynsley-Green A, Ward Platt MP. Neonatal blood glucose concentrations: metabolic effects of intravenous glucagon and intragastric medium chain triglyceride. Arch Dis Child.1993; 68(3 spec no) :255 –261[Abstract/Free Full Text]
2. Belik J, Musey J, Trussell RA. Continuous infusion of glucagon induces severe hyponatremia and thrombocytopenia in a premature neonate. Pediatrics.2001; 107 :595 –597[Abstract/Free Full Text]
3. Cornblath M, Ichord R. Hypoglycemia in the neonate. Semin Perinatol.2000; 24 :136 –149[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Charsha, D. S. Articles by Whitfield, J. M. Search for Related Content PubMed PubMed Citation Articles by Charsha, D. S. Articles by Whitfield, J. M. Social Bookmarking                         What's this?