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Although there is no firm empirical evidence base for the management of neonatal hypoglycaemia, an understanding of the underlying physiology and pathophysiology of fuel metabolism in the newborn enables a rational approach to be taken. In this paper, we outline the process of neonatal metabolic adaptation; address the problem of measuring blood glucose and defining hypoglycaemia; consider those babies in whom measurement should be done routinely and the timing of this; and evaluate the various approaches that can be taken in the primary and secondary prevention and management of hypoglycaemia, and its investigation when appropriate.

Summary Background Exogenous surfactant preparations vary in their constitution and biophysical properties. Synthetic and animal-derived preparations lower the rate of death compared with controls. No significant differences in mortality or important long-term clinical outcomes have been shown between them in randomised trials. We did a randomised controlled trial to compare pumactant, a synthetic surfactant, with poractant alfa, an animal-derived surfactant, both of which are widely used in the UK. Methods We enrolled 212 neonates born between 25 weeks' and 29 weeks and 6 days' gestation who were intubated for presumed surfactant deficiency and were free from life-threatening malformations. We randomly assigned 105 neonates poractant alfa, and 107 pumactant. The primary outcome was duration of high-dependency care and mortality was a secondary outcome. Analysis was by intention to treat. Findings Outcome data were analysed for 199 babies. The trial was stopped on the recommendation of the data and safety monitoring committee because mortality assumed a greater importance than the primary outcome. Predischarge mortality differed significantly between groups, in favour of poractant alfa (14·1 vs 31·0%, p=0·006; odds ratio 0·37 [95% Cl 0·18–0·76). This difference was sustained after adjustment for centre, gestation, birthweight, sex, plurality, and use of antenatal steroids. Interpretation Mortality was unexpectedly lower among neonates who received poractant alfa than among those who received pumactant, and was independent of all the variables we investigated. Stopping the trial early may have widened the difference between the treatment groups.