Early feeding and neonatal hypoglycemia in infants of diabetic mothers

Primiparity, class 3 obesity, intention to breastfeed and breastfeeding initiation

BACKGROUND

During the 2013-21 period, 674 primiparous women with Class 3 obesity delivered in our institution. Their antenatal infant feeding preference on admission was: 518 (77%) intended to breastfeed (BF) only, 101 (15%) intended to feed formula only and 55 (8%) intended to BF and formula feed combined. Intention to BF only is a predictor of BF initiation, however, data concerning this relationship is limited.

OBJECTIVE

To determine the perinatal variables that influence success or failure of BF among primiparous women with Class 3 obesity who antenatally declared their intention to only BF.

METHODS

Retrospective cohort study of women who delivered live singletons without major malformations at ≥ 34 weeks gestation.

RESULTS

The 518 women who prenatally intended to BF only, were categorized at discharge as exclusive BF (EBF) 197 (38%), any BF (ABF) 212 (41%) and formula feeding (FF) 109 (21%). A lower prevalence of gestational diabetes (10,17 vs 17%), chronic hypertension (16,31 vs 18%), severe preeclampsia (12,22 vs 30%), cesarean delivery (37,55 vs 55%), late preterm (6,17 vs 14%), neonatal hypoglycemia (8,26 vs 22%) and NICU admission (11,25 vs 20%) was present in the EBF group as compared to ABF and FF. African American women were more likely to only FF. Regression analysis showed that the stronger predictors of failure to initiate BF were public healthcare assistance, African American race, preeclampsia, cesarean delivery, neonatal hypoglycemia, prematurity and NICU admission.

CONCLUSION

Among primiparous women with class 3 obesity who intended to BF only but failed to do so, the increased prevalence and severity of maternal and neonatal morbidities are likely obstacles to BF their first infant.

Breastfeeding initiation according to the severity of Class 3 obesity

Background: Class 3 obesity is composed of morbid (BMI 40-49 kg/m2) and extreme (BMI ≥ 50 kg/m2) subgroups. Adverse perinatal outcomes have been associated with obesity; however, data on breastfeeding (BF) initiation for women in either group remains limited.Objective: To compare BF initiation rates (exclusive or partial BF) and related comorbidities of 890 women with morbid and 890 with extreme obesity matched by race, parity, and year of delivery.Methods: Retrospective cohort study of women who delivered singletons at ≥ 34 weeks gestation (2013-2021). Those who had bariatric surgery or infants with major malformations were excluded.Results: Both groups were similar in: primiparity (38%), age (29y), white race (58%), African American (36%), current (10 vs 12%) and former (25 vs 27%) smokers, gestational hypertension (15 vs 16%), polycystic ovary syndrome (5 vs 7%), gastroesophageal reflux disease (10 vs 10%), and anemia (17 vs 17%). Women in the extreme group had a higher prevalence of gestational (17 vs 12%) and pregestational diabetes (12 vs 6%), chronic hypertension (41 vs 17%), severe preeclampsia (18 vs 12%), obstructive sleep apnea (12 vs 3%), asthma (22 vs 16%), and cesarean deliveries (62 vs 44%). Intention to BF (64 vs 71%), exclusive BF (23 vs 34%), and BF initiation (57 vs 64%) rates were lower in the extreme obesity group at discharge.Conclusion: Higher frequency of comorbidities in the extreme obesity group highlights the need for antenatal, intrapartum, and postpartum targeted interventions if the benefits of BF to mothers and infants are to be realized.

Breastfeeding effect on glucose tolerance assessment in women with previous gestational diabetes mellitus: A randomized controlled trial

AIMS

To test whether breastfeeding during the oral glucose tolerance test (OGTT) affects glucose and insulin outcomes (main outcome: 120 min plasma glucose).

METHODS

A randomized crossover trial was conducted in 20 women with prior gestational diabetes mellitus. Each woman undertook two OGTTs in the first 3 months after delivery, breastfeeding the infant in one and avoiding breastfeeding in the other. Glucose and insulin were measured at 0, 30, 60 and 120 min. Statistics included: T-test for paired data, general linear model (GLM) for repeated measures. Analysis of covariance (ANCOVA) was used to adjust for glucose and insulin values at 0 min. Statistical dispersion for GLM and ANCOVA outcomes is expressed as standard error.

RESULTS

In the OGTTs with breastfeeding, higher values were observed for overall glucose and insulin concentrations, glucose and insulin peaks and individual time points of glucose (at 0, 30 and 60 min) and insulin (at 0 and 60 min) but without differences at 120 min (glucose 6.7 ± 0.3 vs. 6.9 ± 0.3 mmol/L, p = 0.506). The rate of abnormal tests was not different. ANCOVA confirmed higher postchallenge glucose values in the OGTT with breastfeeding and similar glucose values at 120 min.

CONCLUSIONS

According to the results of this randomized trial, we conclude that breastfeeding during the OGTT resulted in similar 120 min glucose concentration and glycaemic status categorization. However, breastfeeding during the OGTT led to clear differences in glucose and insulin values in the first hour, that warrant further studies.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus

OBJECTIVE

To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF.

METHODS

Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation.

RESULTS

CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM.

CONCLUSION

Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

BACKGROUND

Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent's declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes.

OBJECTIVES

This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care.

METHODS

A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised.

RESULTS

One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised.

CONCLUSION

This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

Decreasing early hypoglycemia frequency in at-risk newborns after implementing a new hypoglycemia screening algorithm

BACKGROUND

Neonatal hypoglycemia may affect long-term neurodevelopment.

METHODS

Quality improvement (QI) initiative for Mother-Baby-Unit (MBU) admissions (birthweight ≥ 2100 g; ≥35 weeks' gestation) over two epochs from 2016-2019 to reduce the frequency of early (≤3 h) neonatal hypoglycemia in small and large newborns.

INTERVENTION

New algorithm using Olsen's growth curves, hypoglycemia thresholds of <2.22 mmol/L [40 mg/dL] (0-3 h) and <2.61 mmol/L [47 mg/dL] (>3 to 24 h), feeding optimization and 24-hour glucose checks for small for gestational age and preterm newborns.

RESULTS

Among 39,460 newborns, using subsets with identical screening criteria, early hypoglycemia decreased significantly after QI implementation among large for gestational age newborns with birthweight >3850 g (66%) and small for gestational age newborns with birthweight <2500 g (70%). Among all MBU admissions, the adjusted odds of any hypoglycemia in 24 h decreased (P < 0.001).

CONCLUSIONS

Feeding optimization may decrease early hypoglycemia frequency in large and small newborns.

Breastfeeding initiation among women with preeclampsia with and without severe features

BACKGROUND

Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure.

OBJECTIVE

To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4.

METHODS

Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM).

RESULTS

PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM.

CONCLUSION

BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks

AIM

Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.

METHODS

A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.

RESULTS

Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.

CONCLUSION

An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.

Neonatal Hypoglycemia: Is There a Sweet Spot?

Hypoglycemia is one of the most common neonatal problems. Despite increasing evidence that hypoglycemia is linked to neurologic impairment, knowledge regarding the specific value or duration of hypoglycemia that results in injury to the brain remains unclear. Current published statements/guidelines focused on preventing clinically significant hypoglycemia are conflicting and continue to be based on low evidence. This article reviews transitional events leading to extrauterine euglycemia, risk factors contributing to transient or persistent hypoglycemia, and common treatment approaches. Current information related to neurodevelopmental outcomes and screening strategies to prevent significant hypoglycemia with early treatment is described.

Pancreatic heterotopia in a neonatal abdominopelvic cyst

Pancreatic heterotopia is a rare congenital anomaly more commonly incidentally found in adults. While intra-abdominal cysts found on prenatal imaging are not uncommon, we examine a case of pancreatic heterotopia presenting in an abdominopelvic cyst on prenatal imaging. At birth, the neonate was found to have hypoglycemia unresponsive to treatment that resolved after cyst resection. We will review the etiology, imaging findings and clinical course of this anomaly, which should be considered in the differential diagnosis of newborns presenting with unexplained hypoglycemia.

In-hospital formula supplementation and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM).

METHODS

Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth.

RESULTS

Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3-6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1-24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge.

CONCLUSION

Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.

Early feeding, hypoglycemia and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To examine the effects of early breastfeeding (eBF) or early formula feeding (eFF) on hypoglycemia and on BF initiation in infants born to women with pregestational diabetes mellitus (PGDM) who intended to BF.

METHODS

Retrospective cohort investigation of 554 women with PGDM and their infants (IDMs) who delivered during 2008-2016. The first feeding (BF or FF) was considered early if given within 4 hours from birth.

RESULTS

282 (51%) IDMs were admitted to the Well Baby Nursery. Of the 134 IDMs whose early feeding was BF, hypoglycemia affected 30% which was corrected with oral feedings in 78% of the cases. At discharge, 49% BF exclusively while 45% BF partially. Of the 148 IDMs whose early feeding was FF, hypoglycemia affected 40% which was corrected with oral feedings in 69% of the cases. At discharge, 14% BF exclusively while 48% BF partially. There were 272 (49%) IDMs admitted to the NICU. Their early feeding was BF (14%) and FF (86%). Hypoglycemia developed in 50% and 43% of these groups, respectively. Benefits of early feedings on hypoglycemia were masked by the routine use of IV dextrose infusions. At discharge, early BF led to exclusive BF in 45% and partial BF in 50% of the cases. Early FF led to exclusive BF in 17% and partial BF in 42% of the cases.

CONCLUSIONS

Early and continued feeding (BF preferably or FF if BF is not feasible) should be the first line of treatment for hypoglycemia. Early BF is paramount for BF initiation. Early FF is an obstacle, albeit not absolute, to BF initiation, thus it should not deter continued efforts to start or resume BF.

Maternal and neonatal demographics of macrosomic infants admitted to the neonatal intensive care unit

OBJECTIVE

The objective of this study is to determine the incidence, significance, associated demographics and impact of macrosomic infants (⩾4 kg) admitted to the Neonatal Intensive Care Unit (NICU) on NICU census and resources.

STUDY DESIGN

A retrospective cohort review was performed from 2010 to 2015. Descriptive statistical analyses were used.

RESULTS

Of 19 308 deliveries, 1823 were infants ⩾4000 g and 213 were admitted to the NICU. Cesarean delivery occurred in 70% of the admitted infants, most (74.1%) were Grade 1 macrosomia and male (63%). Preterm birth occurred in 4%. The incidence of maternal diabetes was 25%. Primary admitting diagnoses were respiratory distress, suspected sepsis, hypoglycemia and perinatal depression. The average length of stay was 8±6 days for all macrosomic infants admitted, increased to 22±13 days for infants with Grade 3 macrosomia.

CONCLUSION

Macrosomic infants are a growing population, who increase the demand on existing NICU resources. A larger multi-centered study is needed to determine the overall relevance of these findings in other populations.

The value of real-time continuous glucose monitoring in premature infants of diabetic mothers

To determine the feasibility of using a real-time continuous glucose monitoring system (RTGMS) in intensive care units, our study focus on preterm infants with diabetic mothers owing to their high risk of blood sugar abnormalities. Thirty preterm babies (M = 15 and F = 15; ≤ 36 week gestation age) were studied from within 72 hours of delivery. These babies were admitted to the newborn intensive care and were further categorized into groups based on whether their mothers with or without diabetic mellitus. Blood sugar levels were monitored by both RTGMS and the traditional intermittent arterial line (A-Line) glucose method. Continuous glucose monitoring were well tolerated in 30 infants. There were good consistency between RTGMS and A-Line glucose concentration measurements. Of the preterm infants, 33.33% experienced abnormal glucose levels (hypoglycemia or hyperglycemia) between the checkpoint intervals of the intermittent A-Line blood sugar measurements. RTGM showed advantages with regards to reduced pain, greater comfort, the provision of real-time information, high sensitivity (94.59%) and specificity (97.87%) in discovering abnormalities of blood sugar, which are especially valuable for premature infants of diabetic mothers. RTGMS is comparable to A-line measurement for identifying fluctuations in blood glucose in premature infants. RTGMS detects more episodes of abnormal glucose concentration than intermittent A-line blood glucose measurement. High risk infants, especially premature infants with diabetic mothers, should receive more intensive blood sugar level checks by using continuous RTGMS.

Delivery room triage of large for gestational age infants of diabetic mothers

Objective:

To review our 4-year experience (2008–2011) with delivery room triage of large for gestational age infants of diabetic mothers.

Design/Methods:

Retrospective cohort investigation of 311 large for gestational age infants of diabetic mothers (White’s Class A1 (77), A2 (87), B (77), and C-R (70)).

Results:

Of 311 women, 31% delivered at 34–36 weeks gestational age and 69% at term. While 70% were delivered by cesarean, 30% were vaginal deliveries. A total of 160 asymptomatic infants were triaged from the delivery room to the well baby nursery. Of these, 55 (34%) developed hypoglycemia. In 43 cases, the hypoglycemia was corrected by early feedings; in the remaining 12, intravenous dextrose treatment was required. A total of 151 infants were triaged from the delivery room to the neonatal intensive care unit. Admission diagnoses included respiratory distress (51%), prevention of hypoglycemia (27%), prematurity (21%), and asphyxia (1%). Hypoglycemia affected 66 (44%) of all neonatal intensive care unit infants.

Conclusion:

Safe triage of asymptomatic large for gestational age infants of diabetic mothers from the delivery room to well baby nursery can be accomplished in the majority of cases. Those infants in need of specialized care can be accurately identified and effectively treated in the neonatal intensive care unit setting.