Prevalence, Associated Factors and Management of Hyperglycemia in Neonates Admitted With Sepsis at Kenyatta National Hospital

Abstract

Background Neonatal sepsis is among the leading causes of neonatal mortality globally and locally. Hyperglycemia is one of the metabolic derangements that occur in neonatal sepsis and it is associated with increased morbidity and mortality in neonates. Knowledge on the prevalence, associated factors and current standards of care of hyperglycemia in neonates with sepsis will provide a better understanding of the problem and will help in identifying areas where strategies for prevention and improving care can be applied. Objectives The study objectives were to determine the prevalence of hyperglycemia in neonates admitted with suspected or proven neonatal sepsis at Kenyatta National Hospital (KNH), to determine the associated factors and to describe the management of these neonates in terms of fluid management, enteral feeds and use of insulin. Study Methods This was a hospital based descriptive cross sectional study carried out among neonates under 28 days of age admitted with suspected or proven sepsis to the KNH newborn unit (NBU) and paediatric wards. Neonates who fit the case definition were recruited after consent was obtained from their mothers or caregivers. Consecutive sampling was applied and participants were enrolled over a randomly selected time block of 8 hours every day. Data of the recruited neonates were collected using a pre tested structured questionnaire. The random blood sugar taken at admission was then recorded and levels above 8.3 mmol/l were considered as hyperglycemia. Neonates noted to have hyperglycemia had additional data on the initial management at admission obtained from their files, treatment sheets and fluid/feeding charts. Data Management and Analysis Data were analysed using SPSS version 23. Categorical data were tabulated and summarized as frequencies and proportions while continuous variables were reported as means with standard deviation or medians with interquartile ranges depending on the distribution. The prevalence of hyperglycemia was computed as a proportion along with 95% confidence interval. Univariate associations of factors (independent variables) with hyperglycemia (dependent variable) was explored with chi square test (categorical data) and student’s T-test (continuous variables). A p-value of<0.05 was considered significant. Results A total of 303 neonates admitted to KNH with a diagnosis of neonatal sepsis were recruited into the study. Hyperglycemia was present in 80 of these neonates yielding a prevalence of 26.4% (95% CI 21.6- 31.8). The Median blood glucose level in the hyperglycemic group was 13.3 mmol/l (IQR 9.8-21.9). Inability to breastfeedOR 2.17(95%CI 1.05-4.46), p=0.035, hypernatremiaOR 7.08 (95%CI 3.37-14.90), p=<0.001, thrombocytopenia OR 2.86 (95% CI,1.40-5.88), P= 0.004 and a temperature of <35.50C OR 4.96 (0.9-32), (P= 0.46) were significantly associated with hyperglycemia in the multivariate logistic regression. Data on the initial management of hyperglycemia in neonatal sepsis, at admission, were analysed for 75 out of the 80 neonates found to be hyperglycemic after 5 neonates who had documented contraindications to enteral feeding were excluded for this analysis. For the neonates who were eligible for enteral feeds, 32/75 (42.7%) were not initiated on enteral feeds. Dextrose was prescribed in the intravenous fluids for 39 neonates and 10/39(25.6 %) had more than the recommended amount of dextrose prescribed. 19/75 (25.3%) neonates had insulin prescribed at admission before the other measures of reducing blood glucose levels were applied with 11/19 (57.9%) of these having higher than the recommended starting dose of insulin given and 12/19(63.8%) having intermittent mode of administration prescribed as opposed to the recommended continuous infusion. Appropriate overall management as per the recommendations in terms of all the three components (enteral feeding, amount of dextrose and insulin), was prescribed for 33/75(44%) neonates. Conclusion The prevalence of hyperglycemia, at admission, in neonates admitted to KNH with a diagnosis of neonatal sepsis was found to be 26.4%. Inability to breastfeed, hypernatremia, thrombocytopenia and a temperature of <35.5 0C were significantly associated with hyperglycemia. Appropriate management as per the recommendations (in terms of all the three components combined) was found in 33/75(44%) neonates with the largest gaps in the management being in the initiation of enteral feeds for the eligible neonates and insulin, in terms of dosage and mode of administration.