INFANT OF DIABETIC MOTHER FOLLOW-UP
Category: Child Health
Abstract : Further Outpatient Care (infant of diabetic mother): Basic outpatient care
should consist of routine well-baby care provided by the infant's general
pediatrician. Additional follow-up by consultant subspecialists depends on the
neonatal clinical problems and their resolution. Transfer: Infants of
diabetic mothers having congenital anomalies, heart disease, or significant
res
Further Outpatient Care (infant of diabetic mother):
Basic outpatient care
should consist of routine well-baby care provided by the infant's general
pediatrician. Additional follow-up by consultant subspecialists depends on the
neonatal clinical problems and their resolution.
Transfer:
Infants of
diabetic mothers having congenital anomalies, heart disease, or significant
respiratory illness may require transfer to a tertiary care neonatal intensive
care unit (NICU) for continued care and access to
subspecialists.
Deterrence/Prevention:
The best prevention is
preconceptional diabetes care. Pregnancy planning and accessing early prenatal
care with meticulous attention to glycemic control and good obstetric management
throughout pregnancy aids in optimizing pregnancy outcome. The consideration of
maternal-fetal medicine consultation may be appropriate in many cases of
established diabetes. With excellent glycemic control throughout pregnancy and
regularly scheduled prenatal visits, the overall mortality rate approaches that
of the general population. This should be emphasized excessively, even before
pregnancy, in the population at risk for or with a history of poor glycemic
control during pregnancy. Furthermore, it should be part of all prenatal
counseling.
Complications (infant of diabetic mother):
• All risks are
directly proportional to the degree of maternal hyperglycemia in utero.
•
Thompson and associates found that tight control of euglycemia in the patient
with gestational diabetes led to normal perinatal outcomes. When comparing good
glucose control (mean plasma glucose level <120 mg/dL) with poor glucose
control (mean plasma glucose level >140 mg/dL), the hyperglycemic group was
found to have more preeclampsia, maternal urinary tract infections, premature
deliveries, cesarean deliveries, macrosomia, respiratory distress, neonatal
hypoglycemia, congenital malformations, and perinatal mortality.
•
Congenital anomalies:
The overall risk is 8-15%, with 30-50% of perinatal
fatalities related to major congenital malformations. Poor glycemic control
early in pregnancy directly correlates with a higher incidence of congenital
malformations.
• Perinatal mortality
o In the past, 10-30% of
pregnancies terminated with sudden and unexplained stillbirth. This is believed
to have been secondary to chronic fetal hypoxia with subsequent polycythemia and
vascular sludging. A higher incidence was noted in pregnancies further
complicated by maternal vascular disease.
o A considerable proportion of
perinatal problems are a consequence of fetal macrosomia. Macrosomia is
associated with protracted labor, perinatal asphyxia, shoulder dystocia and
brachial plexus injury, other skeletal and nerve injuries, and an elevated rate
of operative deliveries.
Prognosis (infant of diabetic mother):
•
Prognosis is very good when appropriate care is provided during the perinatal
period.
• As many as 50% of mothers with gestational diabetes develop
insulin-dependent diabetes within 15 years of their pregnancy.
•
Neurodevelopmental outcome
o Overall findings from multiple studies indicate
that infants of mothers with poor glucose control during pregnancy are at
highest risk for neurodevelopmental deficits.
o In 1991, Rizzo et al
published a study that included 223 pregnant women and their singleton
offspring. Of these mothers, 89 had diabetes before pregnancy, 99 had
gestational diabetes, and 35 had normal carbohydrate metabolism. The children
were examined at ages 2, 3, 4, and 5 years.
Mental developmental index
scores at 2 years correlated inversely with the mother's third-trimester plasma
beta-hydroxybutyrate levels, after correcting for socioeconomic status, race,
and ethnicity.
Stanford-Binet Intelligence scores at ages 3, 4, and 5
years were inversely correlated with the third-trimester plasma
beta-hydroxybutyrate and free fatty acid levels of the mothers.
No
correlation was found between perinatal complications and cognitive development
in the same group of infants. Thus, it appears that the metabolic milieu that
the fetus is exposed to in utero may very well affect long-term
neurodevelopmental outcome.
o In another study by the same group, 139
women with diabetes in pregnancy and their singleton offspring were
followed.
After statistically controlling for other influences, Wechsler
Intelligence Scale for Children-Revised (WISC-R) verbal, performance, and full
scale IQ scores, and Bannatyne indices of verbal conceptualization ability,
acquired knowledge, spatial ability, and sequencing ability were inversely
correlated with measures of maternal lipid and glucose metabolism in the second
and third trimesters.
When looking at the neurodevelopmental outcome at
early school-aged children born to mothers with gestational diabetes, Ornoy and
associates followed 32 school-aged children born to 32 mothers with
well-controlled gestational diabetes and 57 control children. They determined
that gestational diabetes induces long-term minor neurological deficits that are
more pronounced in younger children, with differences tending to disappear with
age.
o Concerning episodes of hypoglycemia and overall prognosis, a
recent article examining the long-term effects of neonatal hypoglycemia on brain
growth and psychomotor development in SGA preterm infants was published by
Duvanel et al.
They systematically detected hypoglycemia of less than 47
mg/dL in 85 SGA preterm infants. Through prospective serial evaluations of
physical growth and psychomotor development, they determined that those infants
with repeated episodes of hypoglycemia had significantly reduced head
circumferences at ages 18 months and 3 1/2 years. Furthermore, those with
recurrent episodes were noted to have lower scores of psychometric tests at ages
3 1/2 and 5 years.
Although this article was looking specifically at those
infants who were SGA and, therefore, might be at risk for developmental delays
and small head size caused by other factors, the fact that those with multiple
episodes of hypoglycemia had poorer development and smaller head circumference
measurements may be a concern for IDMs with multiple episodes of
hypoglycemia.
• Growth
o Some evidence indicates that IDMs will have
obesity as they get older.
o Silverman and associates followed physical
growth from birth to age 8. At birth, 50% of the infants weighed more than the
90th percentile. At 12 months, length and weight were both normal. At age 7
years, height was slightly higher than average. In comparison to infants born to
mothers without diabetes, IDMs were noted to have an increase in weight after
age 5 years, resulting in weights higher than the 90th percentile in 50% of
those infants by the age of 8 years.
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