eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Infant of Diabetic Mother: Follow-up

Author: Charles F Potter, MD, Consulting Neonatologist, Newborn Care Physicians of Southeastern Wisconsin
Coauthor(s): Stephen D Kicklighter, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Neonatology, University of North Carolina at Raleigh and Wake Medical Center
Contributor Information and Disclosures

Updated: Jun 9, 2009

Follow-up

Further Outpatient Care

  • 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 (IDMs) 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 diabetic 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

  • 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.6 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.
  • The overall risk of congenital anomalies 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.
  • 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. 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

  • Prognosis is very good when appropriate care is provided during the perinatal period.
  • Clinical and epidemiological data suggest that elevated insulin levels during perinatal life may program the infant to develop obesity and diabetes later in life.7
  • As many as 50% of mothers with gestational diabetes develop insulin-dependent diabetes within 15 years of their pregnancy.
  • Overall findings from multiple studies indicate that infants of mothers with poor glucose control during pregnancy are at highest risk for neurodevelopmental deficits.
    • In 2005, DeBoer et al demonstrated deficits in mnemonic behavior in infants of diabetic mothers aged 1 year, suggesting a connection between the prenatal environment of the fetus and subsequent memory development.8
    • Iron deficiency due to perinatal polycythemia may also contribute to the decreased neurodevelopmental outcome of infants of diabetic mothers.
    • In 1991, Rizzo et al published a study that included 223 pregnant women and their singleton offspring.9 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, the metabolic milieu suggests that the fetus is exposed to in utero may very well affect long-term neurodevelopmental outcome.
    • In another study by the same group, 139 women with diabetes in pregnancy and their singleton offspring were followed.10
      • After statistically controlling for other influences, Wechsler Intelligence Scale for Children-Revised (WISC-R) verbal, performance, and full scale intelligence quotient (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.11 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.
  • Growth
    • Some evidence indicates that infants of diabetic mothers will develop obesity as they get older.
    • Silverman and associates followed physical growth from birth to age 8 years.12 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, infants of diabetic mothers 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.
    • In 2005, Boney et al demonstrated that large for gestational age (LGA) offspring of diabetic or obese mothers were at significant risk of developing metabolic syndrome (obesity, hypertension, dyslipidemia, glucose intolerance) in childhood.13 Given the relationship of obesity and gestational diabetes, this finding has significant implications for future generations.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize and appropriately treat the infant with hypoglycemia can place the treating clinician at medicolegal risk.
 


More on Infant of Diabetic Mother

Overview: Infant of Diabetic Mother
Differential Diagnoses & Workup: Infant of Diabetic Mother
Treatment & Medication: Infant of Diabetic Mother
Follow-up: Infant of Diabetic Mother
Multimedia: Infant of Diabetic Mother
References
[ CLOSE WINDOW ]

References

  1. Engelgau MM, Herman WH, Smith PJ, et al. The epidemiology of diabetes and pregnancy in the U.S., 1988. Diabetes Care. 1995;18:1029-33. [Medline].

  2. [Guideline] American Diabetes Association (ADA). Detection and diagnosis of gestational diabetes mellitus (GDM). Standards of medical care in diabetes. Diabetes Care. Jan 2008;31(Suppl 1):S15.

  3. Barnes-Powell LL. Infants of diabetic mothers: the effects of hyperglycemia on the fetus and neonate. Neonatal Netw. Sep-Oct 2007;26(5):283-90. [Medline].

  4. Rosenkrantz TS, Knox I, Zalneraitis EL, et al. Cerebral metabolism and electrocortical activity in the chronically hyperglycemic fetal lamb. Am J Physiol. Dec 1993;265(6 Pt 2):R1262-9. [Medline].

  5. Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. May 2000;105(5):1141-5. [Medline]. [Full Text].

  6. Thompson DM, Dansereau J, Creed M, Ridell L. Tight glucose control results in normal perinatal outcome in 150 patients with gestational diabetes. Obstet Gynecol. 1994;83:362-6. [Medline].

  7. Plagemann A. A matter of insulin: developmental programming of body weight regulation. J Matern Fetal Neonatal Med. Mar 2008;21(3):143-8. [Medline].

  8. DeBoer T, Wewerka S, Bauer PJ, et al. Explicit memory performance in infants of diabetic mothers at 1 year of age. Dev Med Child Neurol. Aug 2005;47(8):525-31. [Medline].

  9. Rizzo T, Metzger BE, Burns WJ, Burns K. Correlations between antepartum maternal metabolism and child intelligence. New Eng J Med. 1991;26:911-6. [Medline].

  10. Rizzo TA, Metzger BE, Dooley SL. Early malnutrition and child neurobehavioral development: insights from the study of children of diabetic mothers. Child Dev. 1997;68:26-38. [Medline].

  11. Ornoy A, Wolf A, Ratzon N, et al. Neurodevelopmental outcome at early school age of children born to mothers with gestational diabetes. Arch Dis Child Fetal Neonatal Ed. 1999;81:F10-F14. [Medline].

  12. Silverman BL, Rizzo T, Green OC, et al. Long-term prospective evaluation of offspring of diabetic mothers. Diabetes. 1991;40:121-5. [Medline].

  13. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics. Mar 2005;115(3):e290-6. [Medline]. [Full Text].

  14. Al-Najashi SS. Control of gestational diabetes. Int J Gynaecol Obstet. 1995;49:131-5. [Medline].

  15. Bromiker R, Rachamim A, Hammerman C, Schimmel M, Kaplan M, Medoff-Cooper B. Immature sucking patterns in infants of mothers with diabetes. J Pediatr. Nov 2006;149(5):640-3. [Medline].

  16. Cordero L, Landon MB. Infant of the diabetic mother. Clin Perinatol. 1993;20:635-48. [Medline].

  17. Cowett RM, Schwartz R. The infant of the diabetic mother. Pediatr Clin North Am. 1982;29:1213-31. [Medline].

  18. Duvanel CB, Fawer CL, Cotting J, et al. Long-term effects of neonatal hypoglycemia on brain growth and psychomotor development in small-for-gestational-age preterm infants. J Pediatr. Apr 1999;134(4):492-8. [Medline].

  19. Georgieff MK. The effect of maternal diabetes during pregnancy on the neurodevelopment of offspring. Minn Med. Mar 2006;89(3):44-7. [Medline].

  20. Greco P, Vimercati A, Scioscia M, et al. Timing of fetal growth acceleration in women with insulin-dependent diabetes. Fetal Diagn Ther. Nov-Dec 2003;18(6):437-41. [Medline].

  21. Hod M, Levy-Shiff R, Lerman M, et al. Developmental outcome of offspring of pregestational diabetic mothers. J Pediatr Endocrinol Metab. 1999;12:867-72. [Medline].

  22. Landon MB, Gabbe SG. Diabetes Mellitus and Pregnancy. Obstetrics and Gynecology Clinics of North America. 1992;19:633-53. [Medline].

  23. McElvy SS, Miodovnik M, Rosenn B, et al. A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels. J Matern Fetal Med. Jan-Feb 2000;9(1):14-20. [Medline].

  24. Nold JL, Georgieff MK. Infants of diabetic mothers. Pediatr Clin North Am. Jun 2004;51(3):619-37, viii. [Medline].

  25. Reece EA, Sivan E, Francis G, Homko CJ. Pregnancy outcomes among women with and without diabetic microvascular disease (White's classes B to FR) versus non-diabetic controls. Am J Perinatol. 1998;15(9):549-55. [Medline].

  26. Rizzo TA, Dooley SL, Metzger BE. Prenatal and perinatal influences on long-term psychomotor development in offspring of diabetic mothers. Am J Obstet Gynecol. 1995;173:1753-8. [Medline].

  27. Rizzo TA, Ogata ES, Dooley SL, et al. Perinatal complications and cognitive development in 2- to 5-year-old children of diabetic mothers. Am J Obsted Gynecol. 1994;171:706-13. [Medline].

  28. Siddiqui F, James D. Fetal monitoring in type 1 diabetic pregnancies. Early Hum Dev. May 2003;72(1):1-13. [Medline].

  29. Stenninger E, Lindqvist A, Aman J, Ostlund I, Schvarcz E. Continuous Subcutaneous Glucose Monitoring System in diabetic mothers during labour and postnatal glucose adaptation of their infants. Diabet Med. Apr 2008;25(4):450-4. [Medline].

  30. Suevo DM. The infant of the diabetic mother. Neonatal Netw. 1997;16:25-33. [Medline].

  31. Tyrala E. The infant of the diabetic mother. Obstetrics and Gynecology Clinics of North America. 1996;23:221-41. [Medline].

  32. Weintrob N, Karp M, Hod M. Short- and long-range complications in offspring of diabetic mothers. J Diabetes Complications. Sep-Oct 1996;10(5):294-301. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

infant of diabetic mother, IDM, diabetic mother, glucose intolerance, respiratory distress, macrosomia, polycythemia, hypoglycemia, congenital malformations, hypocalcemia, hypomagnesemia, fetal glucose control, maternal hyperglycemia, gestational diabetes mellitus, diabetes mellitus type 1, diabetes mellitus type 2, large for gestational age, LGA, small for gestational age, SGA, macrosomia, hepatosplenomegaly, cardiomegaly, fetal hyperglycemia, hyperinsulinemia, prematurity, outflow tract obstruction, excessive fetal growth, impaired fetal growth, transient tachypnea of the newborn, pneumonia, necrotizing enterocolitis, renal vein thrombosis, cardiomyopathy, congenital heart defects, ventricular septal defect, VSD, transposition of the great arteries, spina bifida, hydronephrosis, renal agenesis, ureteral duplication, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Charles F Potter, MD, Consulting Neonatologist, Newborn Care Physicians of Southeastern Wisconsin
Charles F Potter, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen D Kicklighter, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Neonatology, University of North Carolina at Raleigh and Wake Medical Center
Stephen D Kicklighter, MD is a member of the following medical societies: American Academy of Pediatrics and National Perinatal Association
Disclosure: Nothing to disclose.

Medical Editor

George Cassady, MD, Clinical Professor, Department of Pediatrics, Stanford University School of Medicine
George Cassady, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, National Hospice and Palliative Care Organization, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.