Is glycosuria a re liable indicator of
ade quacy of glucose infusion rate in pre te rm infants?
Santa Catarina Hospital (São Paulo) Nursery, Department of Paediatrics, Instituto da Criança,
Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
ABSTRACT
Contex t: Adequacy o f gluco se infusio n may be mo nito red via the glyco suria levels, as there is a relatio nship between glycemia and glyco suria regulated by the renal gluco se thresho ld. In the neo natal perio d, ho wever, this relatio nship is no t so clear.
O bjective: To evaluate the o ccurrence o f glyco suria in preterm infants submitted to gluco se infusio n and to verify the relatio nship between glyco suria and blo o d gluco se level.
Design: Accuracy study.
Setting: Neo natal intensive care unit o f G eneral Maternity Ho spital.
Pa tients: 4 0 preterm newbo rns receiving gluco se infusio n.
Procedures: 5 1 1 co nco mitant determinatio ns o f glycemia and glyco suria were perfo rmed. These 5 1 1 pairs were divided into stable and unstable, acco rding to the clinical status o f the newbo rn at the time o f data co llectio n, and they were studied in relatio n to the gestatio nal age, birth weight and gluco se infusio n rate.
Results: The results revealed a greater frequency o f glyco suria in gestatio nal age ≤ 3 0 weeks, birth weight <1 5 0 0 g and gluco se infusio n rate >6 mg/ kg/ min. Eight (2 5 .8 %) episo des o f po sitive glyco suria o ccurred in the absence o f hyperglycemia, indicating o nly a mo derate co nco rdance between them.
Conclusion: G lyco suria alo ne is an unreliable marker o f blo o d gluco se co ncentratio n and adequacy o f gluco se infusio n rate. It is therefo re necessary to mo nito r blo o d gluco se levels in infants submitted to co ntinuo us gluco se infusio n.
Key w ords: Blo o d G luco se. G lyco suria. Hyperglycemia. Newbo rn Infant. Parenteral Infusio n.
INTRODUCTION
There is at present great interest in adequate nutritio n fo r newbo rns in neo natal intensive care units. Breast milk is the best fo o d, but its use is no t always po ssible. This impo ssibility has led to the develo pment o f parenteral nutritio n. This type o f nutritio n has gluco se as its basic co mpo nent, which can pro vo ke alteratio ns in glycemic levels, especially in unwell newbo rn infants.
Hyperglycemia raises blood osmolarity and it can cause intracranial hemo rrhage and also pro mo te glyco suria and dehydratio n.1
Adeq ua c y o f g luc o se infusio n ma y b e mo nito red via the glyco suria levels, as there is a relatio nship between glycemia and glyco suria regulated by the renal gluco se thresho ld.
In the ne o na ta l pe rio d, ho we ve r, this re la tio nship is no t so c le a r b e c a use o f the influe nc e o f g e sta tio na l a g e , b irth we ig ht, glucose infusion rate and other special conditions tha t mo d ify c a rb o hyd ra te ho me o sta sis. Co mpared to adults, the tubular reabso rptio n o f gluco se is diminished in the embryo nic life o f so me animals.2 ,3 Ro billard et al 4 sho wed that in sheep embryo s, the renal excretio n o f gluco se is higher than in fully-gro wn animals.
Using alpha-metyl-g lyco pyro side, it was
Mário Cícero Falcão Cléa Rodrigues Leone José Lauro Araújo Ramos
Original Article
REVISTA PA ULISTA DE M EDIC IN A
po ssible to study gluco se transpo rtatio n in the embryo ’s kidney. Alpha-methyl-g lyco pyro side shares the carrier o f gluco se-D present in the pro ximal tubule membrane, witho ut interfering in its transpo rt system.4 This transpo rtatio n has been sho wn to be similar to that o f the adult kidney and has also been sho wn to interact with so dium transpo rtatio n.5 This mechanism is catio n-specific, electro genic and pH sensitive,6 being qualitatively similar to that o f the adult. During hyperg lycemic embryo states, g lyco suria and o smo tic diuresis appear, indicating that the physio patho lo g y o f g lyco suria is the same in newb o rns a nd a dults, a ppea ring when the gluco se renal excretio n limit is exceeded.7
The renal excretio n o f gluco se is higher in newbo rns with g estatio nal ag e less than 3 4 weeks.2 The g luco se reabso rptio n fractio n is 9 2 .5 % in these children, 9 9 .2 % in neo nates between 3 4 and 3 7 weeks and 9 9 .4 % in full term newbo rns, justifying the higher frequency o f g lyc o suria in mo re imma ture p re te rm newbo rns.8 ,9 These newbo rns usually have a rela tively lo wer g luc o se exc retio n limit a nd c o nseq uently, hyperg lyc emia ea sily induc es glyco suria. But it is very difficult to determine the level o f glycemia abo ve which glyco suria will o ccur and ho w these preterm infants will react a c c o rd ing to the va rio us b irth w e ig hts, g esta tio na l a g es a nd differenc es in c linic a l co nditio ns they face.1 0
In the lig ht o f the se fa c ts, the use o f g lyc o suria to eva lua te the a deq ua c y o f the g luc o se infusio n ra te in pre te rm ne wb o rns sub mitte d to g luc o se infusio n me rits so me
criticism, since very few studies have emphasized the influence o f the gluco se infusio n rate and clinical co nditio n.1 1
The o bjectives o f this study were to evaluate the o ccurrence o f glyco suria in preterm infants submitted to gluco se infusio n and to verify the rela tio nship b etween g lyc o suria a nd b lo o d gluco se level.
METHODS
This pro spective research was develo ped in the N eo natal Iintensive Care Unit o f Santa Catarina Maternity Ho spital (São Paulo , Brazil), a private ho spital which attends to middle class mo thers. The pro to co l was appro ved by the Hospital Ethics Committee and all newborns were included after co nsent fro m their parents.
Fro m January 1 st to December 3 1 st, 1 9 9 4 , 4 0 pre te rm ne wb o rn infa nts we re studie d, selected thro ugh ro utine tracking in the N ursery, who required gluco se infusio n in the first week o f life.
Prematurity was defined as a gestatio nal age o f less than 3 7 weeks, in acco rdance with the date o f the last menstruatio n o f the mo ther. In the a b se nc e o f this info rma tio n, ultra so no g ra p hic e va lua tio n a nd a lso the Dubo witz Metho d were used.1 2 ,1 3 The preterm newb o rns were c la ssified b y siz e a s sma ll, adequate o r large, acco rding to a birth curve develo ped in the city o f São Paulo and ado pted by this Service.1 4
All o f these 4 0 preterm newbo rn infants ha d the ir q ua lita tive g lyc o suria a nd b lo o d
Ta ble 1 - Distribution of glycosuria episodes in Groups I a nd II, a ccording to gesta tiona l a ge (GA), birth w eight (BW ) a nd glucose infusion ra te (GIR).
G lycosuria episodes
G A (weeks) BW (g) G IR (mg/ kg/ min) <30 >30 <1500 >1500 <6 >6 n(%) n (%) n (%) n (%) n (%) n (%) G roup I 4 (2 3 .5 ) 5 (3 5 .7 ) 3 (1 8 .7 ) 6 (4 0 .0 ) 5 (3 5 .7 ) 4 (2 3 .5 ) G roup II 1 3 (7 6 .5 )* 9 (6 4 .3 ) 1 3 (8 1 .3 )* 9 (6 0 .0 ) 9 (6 4 .3 ) 1 3 (7 6 .5 )*
Tota l 1 7 (1 0 0 .0 ) 1 4 (1 0 0 .0 ) 1 6 (1 0 0 .0 ) 1 5 (1 0 0 .0 ) 1 4 (1 0 0 .0 ) 1 7 (1 0 0 .0 )
g luc o se le ve l d e te rmine d c o nc o mita ntly. Immediately after the co llectio n o f the urine sample, the blo o d fo r g lycemia do sag e was o btained. At least three daily determinatio ns o f the g lyc e mia a nd g lyc o suria p a ir w e re acco mplished.
The glycemia and glyco suria pairs were divided into two gro ups, acco rding to the clinical and labo rato rial characterizatio n o f the clinical status at the time o f the data pair co llectio n: G ro up I (stable clinical mo ment) and G ro up II (unstable clinical mo ment). The o bjective o f this c ha ra c teriz a tio n wa s to put a va lue o n the e xiste nc e o f sta b ility in the me c ha nisms respo nsible fo r the gluco se ho meo stasis at the time o f determinatio n o f the pair.
Pre te rm infa nts in the “ sta b le c linic a l mo me nt” g ro up p re se nte d sta b le b o d y temperature, satisfacto ry hemo dynamic and re sp ira to ry c o nd itio ns, ne uro lo g ic a l e xa m a ppro pria te fo r the g eta tio na l a g e, no rmal a b d o mina l p ro p e d e utic s a nd suc c e ssfully receiving enteral nutritio n.
W hile in re sp ira to ry a ssista nc e , the fo llo wing clinical and labo rato rial parameters were valued fo r “ stability” , in additio n to the elements referred to above: respiratory frequency < 6 0 mo vements/ min; heart frequency between 1 0 0 a nd 1 6 0 b e a ts/ min; a ve ra g e a rte ria l p re ssure b e tw e e n 4 5 a nd 6 0 mmHg ; O2
saturatio n³ 9 2 % (pulse o ximetry); pH between 7 .2 5 and 7 .4 5 ; paO2 > 6 0 mmHg, paCO2 <
4 5 mmHg and diuresis³ 1 ml/ kg/ h.
The clinical “ mo ments” that did no t fulfill the criteria mentio ned abo ve were co nsidered unstable.
The site fo r capillary blo o d co llectio n was
the so le o f the heel (3 heparinized capillary tubes - 2 4 0 ml). The determinatio n o f blo o d gluco se w a s p e rfo rme d via the g luc o se o xid a se co lo rimetric metho d and readings were taken until 3 0 minute s a fte r the c o lle c tio n.1 5 The hyperglycemia was defined as gluco se blo o d co ncentratio n superio r to 1 2 5 mg/ dl.1 6 ,1 7 This va lue c o rre sp o nd s to a p la sma g luc o se co ncentratio n o f 1 5 0 mg/ dl.1 6 ,1 7
A urine sample was co llected (minimum vo lume o f 1 ml) to determine glyco suria, via a collecting bag fixed to the genitalia.15 The technique for determining the qualitative glycosuria consisted o f the same bio chemical metho d as fo r blo o d glucose.18 Glycosuria determinations from the first 12 hours of life were excluded, as this urine could be mixed with the fetal.19
Sta tistic a l M e tho d s. To e va lua te the glyco suria and its relatio n to the glycemic levels, a d a ta b a se w a s b uilt up , p a iring the simulta ne o us me a sure s o f g lyc e mia a nd g lyco suria. These pairs were divided acco rding to : b irth w e ig ht, g e sta tio na l a g e , g luc o se infusio n rate and the clinical “ mo ment” (stable o r unstable). The McN emar Chi-square test and Kappa statistics were used fo r verifying the co nfo rmity between the paired measurements, i.e. the presenc e o f hyperg lyc emia a nd its ag reement with the presence o f g lyco suria. The Chi-Square test was used fo r the co mpariso n o f pro po rtio ns. In all o f the tests, the 0 .0 5 level o f sig nificance was ado pted.
RESULTS
The po pulatio n co nsisted o f 4 0 preterm infa nts, 2 3 ma le (5 7 . 5 %) a nd 1 7 fe ma le
Ta ble 2 - Distribution of glycosuria episodes, a ccording to the presence of hyperglycemia in Groups I a nd II
G lycosuria Hyperglycemia G roup I n (%) G roup II n (%) Total n (%) + + 8 (3 4 .8 ) 1 5 (6 5 .2 ) 2 3 (1 0 0 .0 ) + - 1 (1 2 .5 ) 7 (8 7 .5 ) * 8 (1 0 0 .0 )
- + 9 (5 0 .0 ) 9 (5 0 .0 ) 1 8 (1 0 0 .0 ) - - 2 1 0 (5 4 .6 ) 2 5 2 (5 4 .4 ) 4 6 2 (1 0 0 .0 )
Tota l 2 2 8 (4 4 .6 ) 2 8 3 (5 5 .4 ) 5 1 1 (1 0 0 .0 )
(4 2 .5 %). Their birth weights varied fro m 8 2 0 to 2 4 9 0 g (average: 1 8 4 6 .5 g). The gestatio nal age varied between 2 8 and 3 6 weeks (average: 3 4 .4 3 weeks); 2 8 infants were o f adequate size fo r the gestatio nal age (7 0 .0 %) and 1 2 infants were small fo r the age (3 0 .0 %).
A to ta l o f 5 1 1 c o nc o mita nt de te rmina tio ns o f g lyc e mia a nd q ua lita tive g lyco suria were perfo rmed in the first week o f life (a ve ra g e : 1 2 . 8 p e r ne w b o rn): 2 2 8 (4 4 .6 %) in G ro up I and 2 8 3 (5 5 .4 %) in G ro up II. Fro m the se , 5 9 (1 1 . 5 % ) e p iso d e s o f hyperg lycemia, 1 4 (2 .7 %) o f hypo g lycemia and 4 3 8 (8 5 .8 %) o f no rmal g lycemia were o btained. G lyco suria was po sitive in 3 1 (6 .1 %) determinatio ns, 9 (2 9 .1 %) in G ro up I and 2 2 (7 0 .9 %) in G ro up II (p <0 .0 5 ).
Table 1 exhibits the distributio n o f the variables studied in bo th gro ups: gestatio nal age (
≤
3 0 and >3 0 weeks), birth weight (<1 5 0 0 and3 1 5 0 0 g) and gluco se infusio n rate (≤
6 and >6 mg/ kg/ min).The distributio n o f co nco rdance o bserved between hyperglycemia and glyco suria in the two gro ups is presented in Table 2 .
Fo r the a na lysis o f g lyc emic levels fo r predic ting g lyc o suria , two c ut-o ff po ints fo r glycemia were evaluated: glycemia >1 2 5 mg/ d l (this le ve l w a s a d o p te d to d e fine hyperg lycemia), and g lycemia >1 5 0 mg / dl. C o mp a riso n o f the d isc o rd a nt p a irs hype rg lyc e mia with g lyc o suria a b se nt a nd no rmo g lycemia with g lyco suria present was do ne, as sho wn in Table 3 .
DISCUSSION
In this analysis o f the renal excretio n o f g luc o se in p re te rm ne w b o rn infa nts w ith
suppo sed no rmal renal functio n, co nsidering the differences in maturity, birth weig ht, g luco se infusio n rate, glycemia and clinical co nditio n, glyco suria was po sitive in 3 1 (6 .1 %) episo des a nd it wa s sig nific a ntly mo re freq uent a t a gestatio nal age
≤
3 0 weeks, birth weight <1 5 0 0 g and g luco se infusio n rate >6 mg / kg / min (p<0 .0 5 ) (Table 1 ).The urina ry c o nc entra tio n o f g luc o se in full-term infa nts is slig htly hig her tha n in o lder children and adults. In infants belo w 3 2 weeks o f g esta tio na l a g e, it is even hig her.2 0 The hig he r fre q ue nc y o f g lyc o suria a t lo w e r g esta tio na l a g es a nd b irth weig hts is direc tly linked to imma turity, sinc e nephro g enesis is co mpleted aro und 3 4 weeks o f g estatio n and, in mo re p re ma ture ne w b o rns, g lyc o suria appears at lo wer g lycemia levels.2 0 Reg arding the g luc o se infusio n ra te, a s it is a predic to r o f hyperg lyc emia , it ma y b e suppo sed tha t the hig he r it is, the hig he r the g lyc o suria freq uenc y will b e.1 1
Co mparing g ro ups I and II, it co uld be o bserved that the episo des o f g lyco suria were stro ng ly asso ciated to clinical instability at the time o f sa mp le c o lle c tio n (p < 0 . 0 5 ). The episo des o f g lyco suria witho ut hyperg lycemia we re a lso a sso c ia te d sig nific a ntly with the clinical mo ment (p<0 .0 5 ). Therefo re, g reater attentio n sho uld be g iven to the presence o f g lyco suria witho ut hyperg lycemia, as it was o bserved in o nly o ne episo de in G ro up I and in 7 in G ro up II (Table 2 ).
Tempo rary variatio ns o f the renal blo o d flo w in unstable clinical co nditio ns o r in unwell pre te rm ne wb o rn infa nts c o uld pre suma b ly influence the renal excretio n o f gluco se, even if alteratio ns in renal functio n were no t detectable. In o rder to establish whether there is a
Ta ble 3 - Different cut-off points for glycemia , compa ring discorda nt pa irs, using M cN ema r Chi-squa re test a nd Ka ppa sta tistics.
Cut-off points Chi-square Co-positivity (%) Co-negativity (%) Kappa Statistics glycemia > 1 2 5 mg/ dl 1 6 .6 * 3 9 .9 9 8 .2 0 .4 6 * * glycemia > 1 5 0 mg/ dl 6 .9 * 7 7 .8 9 6 .5 0 .5 5 * *
co nco rdant relatio nship between the glycemic le ve ls a nd the pre se nc e o f g lyc o suria , the M c N e ma r C hi-sq ua re te st w a s use d . The d isc o rd a nt p a irs o f hyp e rg lyc e mia w ith g lyco suria absent and no rmal g lycemia with g lyco suria present were studied. Two cut-o ff po ints were used: glycemia greater than 1 2 5 mg/ dl and 1 5 0 mg/ dl. W ith the first cut-o ff, 1 6 .6 % o f disco rdance was o bserved (p<0 .0 5 ), and with the seco nd, this disco rdance reduced to 6 .9 %, but remained sig nificant (Table 3 ). Ano ther metho d to study the disco rdant pairs is via Kappa statistics, which evaluate their co -po sitivity and co -negativity. The same two cut-o ff po ints were used a nd fo r b o th o f them the c o nfo rmity wa s mo dera te, 0 .4 6 a nd 0 .5 5 , respectively (Table 3 ).
Fro m this result, sho wing o nly a mo derate c o nfo rmity b etween levels o f g lyc emia a nd g lyc o suria , it is p o ssib le to sa y tha t hyperglycemia is neither the o nly variable no r the mo st impo rtant predicto r o f glyco suria. In the same way, glyco suria is no t always an indicato r o f high glycemic level.
In healthy full-term infants with normal blood gluco se levels, o nly traces o f gluco se are fo und in urine.2 1 Ho wever, these values are unkno wn fo r unwell immature infants, in who m glyco suria may be o bserved even in co nditio ns o f no rmal glycemia.2 2 In newbo rns with a gestatio nal age o f 2 9 weeks this limit is 1 5 2 ± 8 mg / dl o f g lyc e mia , c o nfirming the g re a te r g luc o se excretio n in preterm infants.2 3
O ne explanatio n fo r these findings co uld be based o n the co ncept o f basal glyco suria, in which the excretio n o f endo g eno us g luco se wo uld no t depend o n the maximum value o f the tubular reabso rptio n but wo uld appear to be determined by the tubular flux.2 1
Increased excretio n o f gluco se in preterm newbo rns with sepsis, intracranial hemo rrhage a nd se rio us re sp ira to ry d istre ss ha s b e e n demonstrated.11 These results suggest that clinical insta b ility, to g e the r w ith imma turity, c o uld co ntribute to the diminished tubular reabso rptio n o f gluco se.1 1
The relatio nships o bserved in o ur study
between glycemic levels and glyco suria suggest that the clinical instability o f the newbo rn was a relevant facto r in the g enesis o f g lyco suria, followed by glucose infusion, gestational age and birth weight. The presence o f hyperglycemia was no t sho w n to b e e sse ntia l fo r g lyc o suria , demo nstrating that this canno t be used as a unique parameter in the evaluatio n o f gluco se infusio n rate adequacy.
The practical significance o f this wo rk is that glyco suria alo ne is an unreliable marker fo r blo o d g luco se co ncentratio n and fo rg luco se infusio n adequacy. It is therefo re necessary to mo nito r blo o d gluco se levels in infants who are o n co ntinuo us gluco se infusio n.
REFERENCES
1. Pildes RS, Pyati SP. Hypo glycemia and hyperglycemia in tiny infants. Clin Perinato l 1986;13:351-75.
2. Arant BS. Develo pmental patterns o f renal functio n maturatio n co m-pared in the human neo nate. J Pediatr 1978;92:705-12.
3. Merlet-Benicho u C, Pego rier M, Muffat-Jo ly M, Augero n C. Functio nal and mo rpho lo gical patterns o f renal maturatio n in the develo ping guinea pig. Am J Physio l 1981;241:618-24.
4. Ro billard JE, Sessio ns C, Kennedy RL, Smith FG. Maturatio n o f the gluc o se transp o rt p ro c e ss b y the fe tal kid ne y. Pe d iatr Re s 1978;12:680-4.
5. Lelievre-Pego rier M, Gelo so JP. Onto geny o f sugar transpo rt in fetal rat kidney. Bio l Neo nate 1980;38:16-24.
6. Beck JC, Lipko witz MS, Abramso n RG. Characterizatio n o f the fe-tal gluco se transpo rter in rabbit kidney - co mpariso n with the adult brush bo rder electro genic Na+ - gluco se transpo rt. J Clin Invest 1988; 82:379-87.
7. Smith FC, Lumbers ER. Effects o f maternal hyperglycemia o n fetal renal functio n in sheep. Am J Physio l 1988; 255:111-4.
8. Co wett RM, OH W, Po llak A, Schwartz R, Sto nestreet BS. Gluco se dispo sal o f lo w birth weight infants: steady state hyperglycemia pro -d uc e -d b y c o nstant intrave no us gluc o se infusio n. Pe -d iatric s 1979;63:389-96.
9. Ogata ES. Maternal metabo lism during pregnancy. In: Po lin RA, Fo x WW, edito rs. Fetal and neo natal physio lo gy. Philadelphia: WB Saunders; 1992:372-3.
10. Bro dehl JA, Frankin A, Gellisen K. Maximal tubular reabso rptio n o f g lu c o s e in in fan ts an d c h ild re n . Ac ta Pae d iatr Sc an d 1979;61:413-20.
11. Wilkins BH. Renal functio n in sick very lo w birth weight infants: 4.Glu-co se excretio n. Arch Dis Child 1992; 67:1162-5.
12. Hadlo ck FP, Deler RL, Harrist RB, Park SK. Estimated age: co mputer assisted analysis o f multiple fetal gro wth parameters. Radio lo gy 1984;152:497-501.
13. Dubo witz LM, Dubo witz V, Go ldberg C. Clinical assessment o f ges-tatio nal age in the newbo rn infant. J Pediatr 1970;77:1-10. 14. Ramo s JLA. Evaluatio n o f intrauterine gro wth using anthro po metric
Fro m Santa Catarina Ho spital (São Paulo ) N ursery, Department o f Paediatrics, Instituto da Criança, Ho spital das Clínicas, Faculdade de Medicina da Universidade de São Paulo , São Paulo , Brazil
Authors
M á rio Cícero Fa lcã o - Children’s Institute, Clinical Ho spital (Nursery), Medical Scho o l, University o f São Paulo Cléa Rodrigues Leone - Children’s Institute, Clinical Ho spital (Nursery), Medical Scho o l, University o f São Paulo José La uro Ara újo Ra m os - Pro fesso r, Department o f Pediatrics, Clinical Ho spital, Medical Scho o l, USP
Sources of Funding: No t declared Conflict of interest: No t declared La st received: 1 September 1 9 9 8 Accepted: 1 1 September 1 9 9 8 Address for correspondence: Mário Cícero Falcão
R. Vieira de Mo raes, 4 5 - ap.5 1 São Paulo / SP - Brasil CEP 0 4 6 1 7 -0 1 0
RESUMO
O bjetivos: Avaliar a o co rrência de glico súria em recém-nascido s pré-termo submetido s à infusão parenteral de glico se e verificar a relação entre glicemia e glico súria.
M etodologia : Fo ram realizadas 5 1 1 determinaçõ es co nco mitantes de glicemia e glico súria em 4 0 recém-nascido s pré-termo recebendo infusão parenteral de glico se. Estes 5 1 1 pares fo ram dico to mizado s co nfo rme o “ mo mento ” clínico do recém-nascido no instante da co leta, em estáveis e instáveis, e estudado s em relação à idade gestacio nal, peso de nascimento e velo cidade de infusão de glico se.
Resulta dos: O s resultado s revelaram maio r frequência de glico súria em idade gestacio nal £ 3 0 semanas, peso de nascimento < 1 5 0 0 g e velo cidade de infusão de glico se > 6 mg/ kg/ min. Ho uve a o co rrência de 8 (2 5 ,8 %) episó dio s de glico súria po sitiva na ausência de hiperglicemia mo strando so mente uma co nco rdância mo derada entre o s do is fenô meno s. Conclusões: A glico súria não deve ser utilizada co mo indicado ra de níveis glicêmico s nem de adequação da taxa da infusão de glico se. É necessário , po rtanto , a mo nito rização frequente da glicemia em recém-nascido s pré-termo submetido s à infusão de glico se.
ACKNOWLEDGEMENT
The autho rs thank Crésio Ro meu Pereira fo r the statistical analysis.
15. Hughes WT, Buescher ES. Pediatric pro cedures. 2nd ed. Philadelphia: WB Saunders; 1980.
16. Stanley C, Levitt-Katz LE. Diso rders o f gluco se and o ther sugars. In: Spitzer AR, ed. Intensive care o f the fetus and neo nate. St Lo uis: Mo sby; 1996:982-92.
17. Po lk DH. Diso rders o f carbo hydrate metabo lism. In: Taeush HW, Ballard RA, Avery ME, edito rs. Diseases o f the newbo rn. 6th ed. Phila-delphia: WB Saunders; 1991:965-71.
18. Schumann GB. Examinatio n o f the urine. In: Henry JB, ed. Clinical diagno sis and management by labo rato ry metho ds. 18th ed. Phila-delphia: WB Saunders; 1991:411-56.
19. Grupe WE. The kidney. In: Klaus MH, Fanaro ff MB, edito rs. Care o f the high-risk neo nate. 2nd ed. Philadelphia: WB Saunders; 1979:324-39.
20. Wilkins BH. Renal functio n in sick very lo w birth weight infants: 3.So d ium , p o tas s ium and wate r e xc re tio n. Arc h Dis Child 1992;67:1154-61.
21. Bro dehl J. Renal gluco suria. In: Edelmann Jr CM, edito r. Pediatric kidney disease. 2nd ed. Bo sto n: Little Bro wn 1992:1801-10. 22. Falcão MC. Effe cts o f gluco se infusio n in gluco suria and
glu-co se b lo o d le ve l in he althy and ill pre te rm infants. Do cto ral the sis (in Po rtugue se ). Faculty o f Me dicine , Unive rsity o f São Paulo ; 1996.
