Clinical Scenario:
A 26-week, 900-g infant is receiving parenteral nutrition containing 10% glucose at 9 mL/kg/hour. After several hours, blood glucose is persistently 14 mmol/L on repeated measurements.
There is no evidence of sepsis, steroid therapy or significant stress-related illness. The infant is otherwise clinically stable.
What is the most appropriate initial approach?
A. Increase the glucose infusion rate
B. Reduce the glucose infusion rate
C. Stop amino acids
D. Stop intravenous lipids
E. Replace glucose with normal saline
Correct answer & Explanation:
Correct answer: B. Reduce the glucose infusion rate
Explanation
First calculate the GIR:
10% glucose = 100 mg/mL
Thus, the infant is receiving 15 mg/kg/min of glucose.
Persistent hyperglycaemia at this glucose delivery should prompt review and reduction of the glucose infusion rate, while avoiding an abrupt cessation of glucose administration. Neonatal PN should provide glucose progressively according to the infant’s metabolic tolerance. NICE recommends a glucose intake of 9–16 g/kg/day for preterm and term neonates after the initial period, equivalent to approximately 6.25–11.1 mg/kg/min.
Why the other options are wrong
- A. Increase GIR: would worsen hyperglycaemia.
- C. Stop amino acids: protein provision is important for growth and is not the primary treatment for hyperglycaemia.
- D. Stop lipids: lipid restriction does not directly correct excessive glucose delivery.
- E. Replace glucose with saline: glucose remains an essential component of neonatal PN; complete withdrawal is inappropriate.
Exam pearl
10% glucose = 100 mg/mL
Therefore:
GIR = glucose concentration × infusion rate ÷ 60
In this case:
100 × 9 ÷ 60 = 15 mg/kg/min
High GIR + persistent hyperglycaemia → review/reduce glucose delivery and investigate other causes of hyperglycaemia.
Reference: NICE. Neonatal parenteral nutrition (NG154) — recommendations for glucose provision and monitoring in neonatal PN. NICE — Neonatal parenteral nutrition guideline
