Association Between Transient Newborn Hypoglycemia and Fourth-Grade Achievement Test Proficiency

Abstract

IMPORTANCE Prolonged neonatal hypoglycemia is associated with poor long-term neurocognitive function. However, little is known about an association between early transient newborn hypoglycemia and academic achievement.OBJECTIVE To determine if early (within the first 3 hours of life) transient hypoglycemia (a single initial low glucose concentration, followed by a second value above a cutoff) is associated with subsequent poor academic performance. DESIGN, SETTING, AND PARTICIPANTSA retrospective population-based cohort study of all infants born between January 1, 1998, and December 31, 1998, at the University of Arkansas for Medical Sciences who had at least 1 recorded glucose concentration (a universal newborn glucose screening policy was in effect) was conducted. Medical record data from newborns with normoglycemia or transient hypoglycemia were matched with their student achievement test scores in 2008 from the Arkansas Department of Education and anonymized. Logistic regression models were developed to evaluate the association between transient hypoglycemia and school-age achievement test proficiency based on perinatal factors. Common hypoglycemia cutoffs of a glucose level less than 35 mg/dL (primary) and less than 40 and 45 mg/dL (secondary) were investigated. All 1943 normoglycemic and transiently hypoglycemic infants (23-42 weeks' gestation) were eligible for inclusion in the study. Infants with prolonged hypoglycemia, congenital anomalies, or chromosomal abnormalities were excluded from the study. EXPOSURE Hypoglycemia as a newborn. MAIN OUTCOMES AND MEASURESThe primary outcome was proficiency on fourth-grade literacy and mathematics achievement tests at age 10 years. We hypothesized a priori that newborns with early transient hypoglycemia would be less proficient on fourth-grade achievement tests compared with normoglycemic newborns.RESULTS Perinatal data were matched with fourth-grade achievement test scores in 1395 newborn-student pairs (71.8%). Transient hypoglycemia (glucose level <35, <40, and <45 mg/dL) was observed in 6.4% (89 of 1395), 10.3% (143 of 1395), and 19.3% (269 of 1395) of newborns, respectively. After controlling for gestational age group, race, sex, multifetal gestation, insurance status, maternal educational level and socioeconomic status, and gravidity, transient hypoglycemia was associated with decreased probability of proficiency on literacy and mathematics fourth-grade achievement tests. For the 3 hypoglycemia cutoffs, the adjusted odds ratios (95% CIs) for literacy were 0.49 (0.28-0.83), 0.43 (0.28-0.67), and 0.62 (0.45-0.85), respectively, and the adjusted odds ratios (95% CIs) for mathematics were 0.49 (0.29-0.82), 0.51 (0.34-0.78), and 0.78 (0.57-1.08), respectively.CONCLUSIONS AND RELEVANCE Early transient newborn hypoglycemia was associated with lower achievement test scores at age 10 years. Given that our findings are serious and contrary to expert opinion, the results need to be validated in other populations before universal newborn glucose screening should be adopted.

Developmental Outcomes of Preterm Infants With Neonatal Hypoglycemia

“…This was not the case, with infants with hypoglycemia having similar academic and cognitive outcomes and less problem behaviors as those without hypoglycemia. This finding is in contrast to the historic report by Lucas et al 2 and a recent report by Kaiser et al 9 Our results are similar to those of Tin et al 5 and McKinlay et al, 10 who found no significant differences in neurodevelopment of infants with neonatal hypoglycemia.…”

“…More recent studies show conflicting data on long-term developmental outcomes in both term and preterm-born children with neonatal hypoglycemia. 9,10 Several studies have examined the actual level and/or duration of hypoglycemia that is harmful to the infant brain, with inconclusive findings. However, existing reviews generally conclude that welldesigned studies are scarce and more research is needed.…”

“…12 -14 Leading experts comment "the definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology" 15 with insufficient evidence to identify a specific plasma glucose concentration range to describe hypoglycemia, given the person-to-person variability of glucose homeostasis and hypoglycemic symptoms. 16 Despite this, most clinicians define hypoglycemia as a plasma glucose level of ≤40 to 45 mg/dL, 7,9,15,17 although some studies have used higher glucose cutoffs. 2,4,10 The conflicting results of developmental outcomes may be partially due to this inconsistency in the definition of hypoglycemia.…”

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

“…This may be one of the several explanations [12,16–18] why low and hypoglycaemia are common in children in sub-Saharan African hospitals [1,12]. The potential long-term neurological outcomes following hypoglycaemia in acute paediatric illness as described in neonates [19,20] have not been investigated to date.…”

The First Sixty Minutes in Preterm Neonates’ Life: Predicted Morbidities and Interventions

“…However, there is no particular cut off value of blood glucose concentration or hypoglycemic episode duration at which one can expect longterm complications. Despite almost all neonates that experience a transient asymptomatic low blood glucose up to 30 mg/dl in the first few hours of their lives as a normal adaptation to postnatal life, a recent study indicated that there is a relation between transient neonatal hypoglycemia (in the first three hours of life) and poor academic achievement at 10 years old of age [48]. Further studies in this regard are warranted to assess the generalizability of this conclusion -which represents an essential step before endorsing a universal newborn blood glucose screening program.…”