Extremely preterm infants are prone to hyperglycemia which is associated with increased mortality and morbidity. Insulin sensitivity is variable in extreme prematurity, and its monitoring, prevention, and treatment are a significant challenge in the NICU. Frequent changes in fluid composition and volumes, as well as large growth and adaptational nutrient requirements are limited by difficult vascular access and blood sampling and risk of drug incompatibilities. Insulin treatment requires specific access and significantly increases fluid intake and sampling. Clinicians, therefore, often compromise by reducing glucose intake and accepting higher glycemia. We discuss a case series of 11 extremely low birth weight (ELBW) preterms, born between 23 5/7 and 27 6/7 weeks of gestation, treated for transient hyperglycemia during the first 2 weeks of life by continuous subcutaneous insulin infusion.