The infant of a diabetic mother etiology treatment prognosis

1. Care of infant of diabetic mother
Kotb Abbass Metwalley
Professor of Pediatric Endocrinology& Diabetes -
Faculty of Medicine -Assiut University-Egypt

2. Agenda
Introduction
Pathophysiology
Evaluation of Infant of diabetic mother
Complications
Management
 Long term prognosis

3. Introduction
Diabetes mellitus in a pregnant woman affect
not only maternal health but can also have
significant implications on the child to be born.
Therefore, timely diagnosis and strict glycemic
control are of utmost importance in achieving a
safe outcome for both the mother and fetus.

4. Epidemiology
Nearly 10.5% of women older than 20 years
have diabetes
 Abnormalities of glucose regulation occur in
3% to 8% of pregnant women
 Compared to weight matched controls, IDM’s
have:
• 2 times the risk of serious birth injury
• 3times the likelihood of C-section
• 4 times the incidence of NICU Admission

5. IDM – Effects on Fetus
Pedersen Hypothesis
 Maternal hyperglycemia
 Fetal hyperglycemia
 Fetal -cell hyperplasia
 Neonatal hyperinsulinemia
• Glucose crosses the placenta
• Insulin does not cross the
placenta
• Fetus produces own insulin in
the presence of elevated glucose
from the mother
• Insulin has mitogenic and
anabolic effects on many tissues
(e.g., adipocytes, skeletal and
cardiac muscle, hepatic and
connective tissue), but not brain

7. Risk of malformation in relation to glycemic control

8. Role of Pediatrician
Care of the IDM neonate needs to focus on
ensuring adequate cardiorespiratory adaptation at
birth, possible birth injuries, maintenance of normal
glucose metabolism, and close observation for
polycythemia, hyperbilirubinemia, and feeding
intolerance.

9. Problems of IDM

10. Evaluation of IDM
• A-History : Type of DM &glycemic control ect
• B-Examination
Birth weight
Plump plethoric facies
Jaundice
Cyanosis
Birth injury
Respiratory rate
Signs of respiratory distress
Femoral pulse

11. Examination (continu)
Murmur
Jitteriness
Hypotonia
Hypothermia
Abdominal distension
Hypertrichiosis (hairy pinna)
 Congenital malformation

12. Associated congenital anomalies
Unilateral microphthalmia.
Bilateral microtia.
Cleft palate.
Micropenis .
Unilateral cryptorchidism.
Bilateral radial hypoplasia.
Unilateral polydactyly.
Bifid tongue.
Single umbilical artery

13. C-Investigation
Complete blood count and hematocrit
Blood sugar-1st hour of birth ,then
2,3,6,8,12,24,48th hours of birth
Calcium, Magnesium
Bilirubin level
Arterial blood gas
Chest radiography
Abdominal and pelvic ultrasound
Echocardiography

14. Congenital malformations

15. Hypoglycemia

17. Hypoglycemia
• Definition: Blood glucose < 40mg/dl (< 2.2 mmol / L) at any
time regardless of gestational age
• Target first day >40 mg/dl and > 40-50 mg/dl thereafter
• Regardless of size, all IDM should subjected to regular
monitoring of blood sugar within first 24 h(very important)

18. Symptoms of hypoglycemia
Hypoglycemia may present within the first few hours
or may persist for as long as one week.
• Asymptomatic.
• Symptomatic
Lethargy, apathy and limpness
Apnea
Cyanosis
Weak or high pitched cry
Seizures, coma
Poor feeding, vomiting
Tremors, jitteriness or irritability

19. Management
• Asymptomatic infants should have a blood glucose determination
between 1 and 2 hours of birth and then every hour for the next 6–
8hr; if clinically well and normoglycemic, oral or gavage feeding
with breast milk or formula should be started as soon as possible and
continued at 3 hours intervals
• Establishing early breast-feeding is very important , since colostrum
as well as breast milk provides a generous concentration of glucose

20. Indications of intravenous therapy
Symptomatic
Inability to tolerate oral feeds
Glucose level < 25 mg%
Oral feedings do not maintain glucose levels

21. For symptomatic hypoglycemia: 10 % dextrose 4
ml/kg
Continuing treatment- 6-8mg/kg/min
Recheck 20-30 min and hourly until stable
 Glucose requirements may be very high (10-15
mg/kg/min).
If glucose is stable-feeding reintroduced and
glucose infusion tapered
Rebound hypoglycemia occurs in response to
large, rapid boluses of glucose

22. Very important
Infant of diabetic mother presents a high risk for cardiac
involvement, either cardiac congenital malformations or
acquired cardiac hypertrophic cardiomyopathy which
justifies early cardiologic screening for all of these newborns
in presence or absence of cardiac signs or symptoms.

23. Cardiomyopathy
Hypertophic cardiomyopathy with intraventricular
hypertrophy may occur in as many as 50% of these
infants.
Infants often are asymptomatic, but 5 to 10 % have
respiratory distress or signs of heart failure.
 Symptomatic infants typically recover after two to
three weeks of supportive care.
 Echocardiographic findings resolve within 6 to 12
months

24. Congenital heart disease

25. Long term complications
IDMs are predisposed to later-life risk of
obesity, insulin resistance , diabetes, and
cardiovascular diseases.

26. Conclusions
Strict glycemic control during pregnancy
Early breast feeding of IDM
Regardless of size, all IDM should subjected to regular
monitoring of blood sugar within first 24 hours
Early Echo cardiologic screening for IDM even in the
absence of cardiac signs or symptoms