Q.30What initial assessment should babies undergo?

Bibliographic InformationStudy Type & Evidence LevelNumber of PatientsPatient CharacteristicsIntervention & ComparisonFollow-up & Outcome MeasuresEffect SizeStudy SummaryReviewer Comments
Aucott SW;Williams TG;Hertz RH;Kalhan SC;

1994

355
Study Type: Cohort

Evidence level: 2++
78 pregnant women with type 1 diabetes.Pregnant women with type 1 diabetes attending the Cleveland Metropolitan General Hospital between 1984 and 1987. Women with multiple pregnancies or gestational diabetes were excluded.

Country: USA
Intervention:
Women with diabetes receiving intensive antenatal care with either
  1. infusion pump or
  2. split-dose insulin therapy
Comparison:
Women without diabetes and receiving normal antenatal care.
Follow-up period:
Not reported.

Outcome Measures:
  1. Mean HbA1c
  2. Premature delivery
  3. Pre-eclampsia
  4. Caesarean section
  5. Hyperbilirubinemia
  6. Respiratory distress
  7. Apgar score
  8. Mortality
  9. Congenital malformations
Mean HbA1c in the first half of pregnancy was 8.49% ± 2.30%, and 7.34% ± 1.79% in the second half.

Women with type 1 diabetes had higher rates of premature delivery (31% vs 10%, P = 0.003), pre-eclampsia (15% vs 5%, P = 0.035), and caesarean section (55% vs 27%, P = 0.002).

Infants of women with diabetes had higher frequency of large for gestational age (24% vs 10%)

Complications including large size for gestational age (41% vs 16%, P = 0.0002), hypoglycemia (14% vs 1%, P = 0.0025), hyperbilirubinemia (46% vs 23%, P = 0.0002), and respiratory distress (12% vs. 1%, P = 0.008) were common in infants of mothers with diabetesi

Apgar scores and mortality rates were similar in the intervention and control two groups.

Congenital malformations occurred in 6 (7.7%) of infants of mothers with diabetes and 1 (1.3%) of the mothers in the control group (P = 0.05). All the mothers who had infants with congenital malformations presented after 8 weeks’ gestation, past the period of organ formation.
Although the improved medical management of type 1 diabetes decreased neonatal mortality this did not translate into significant reduction in perinatal complications.
Haworth JC, Dilling LA, Vidyasagar D.

1973

356
Study Type: Cohort

Evidence level: 2+
  1. Group 1 (12 infants)
  2. Group 2A (7 infants)
  3. Group 2B (4 infants)
42 infants born to women with diabetes, 30 developed who hypoglycaemia were suitable for this study. However, 23 were selected for treatment and follow-up.

Country: Canada
Intervention:
Group 2A received long-acting epinephrine given every 6 hours for 24 hours, then every 8 hours from 24–48 hours, every 12 hours from 48–72 hours and one dose on the fourth day.

The intervention group also received intravenous glucose.

Comparison:
  1. Group 1 received only intravenous glucose.
  2. Group 2B received long-acting epinephrine only.
Follow-up period:
72 hours post delivery.

Outcome Measures:
  1. Mortality rate
  2. Respiratory distress syndrome
One baby in Group 1 and another in group 2A developed mild respiratory distress.

Five of the 12 infants in Group 1, four of the 7 in Group 2A and 2 out of 4 in Group 2B had one or more recurrent episodes of hypoglycaemia, but the differences were not significant.

Epinephrine-treated infants had significantly higher lactate levels at 12, 24, 48 and 72 hours after delivery.

When lactate levels were analysed excluding the three infants with possible hypoxic respiratory distress, the results did not change.

Two epinephrine-treated infants developed metabolic acidosis, but neither had evidence of significant pulmonary distress.
The hypothesis that epinephrine reduces the rate of mortality in infants born to women with diabetes could neither be confirmed nor rejected.Information on study design and reporting is inadequate to allow a comprehensive quality assessment.
Van Howe RS, Storms
MR

2006

357
Study Type: Case-control

Evidence level: 2+
66 infants born to mothers with long standing diabetes.Infants of mothers with pre-existing diabetes or gestational diabetes at 36–42 weeks’ gestation.

Country: USA
Intervention:
No intervention, the study was to assess risk factors.

Comparison:
Infants of the same birth cohort born to women without diabetes.
Follow-up period: Not reported.

Outcome Measures:
Risk factors for neonatal hypoglycaemia
When compared to singletons of ≥ 36 weeks’ gestation in the same birth cohort, infants of mothers with diabetes were more likely to be born via caesarean section (43.94% versus 20.13%, OR 3.11, 95% CI 1.89 to 5.12).

Only 26 (39.39%) were breastfed exclusively.

Hundred blood glucose determinations in the first 90 minutes of life had a mean of 3.01 mmol/L (54.24 mg/dl, 95% CI 0.99 to 5.04 mmol/L [17.74 to 90.74 mg/dL) with a median value of 2.94 mmol/L (53 mg/dL).

313 blood glucose determinations from 91 minutes to 12.5 hours of age had a mean value of 3.29 mmol/L (59.20 mg/dL, 95% CI 1.70 to 4.87 mmol/L [30.68 to 78.72 mg/dL) and a median value of 3.17 mmol/L (57 mg/dL).

107 blood glucose determinations after 12.5 hours of age had a mean value of 3.49 mmol/L (62.79 mg/Dl, 95% CI 1.97 to 5.01 mmol/L [35.50 to 90.09 mg/dL) with a median value of 3.33 mmol/L (60 mg/dL).

Of the 66 infants born to mothers with diabetes, 39 had blood glucose determinations < 2.2 mmol/L (40 mg/dL); 19 had blood glucose determinations < 1.9 mmol/L (35 mg/dL), 9 had blood glucose determinations of < 1.7 mmol/L (30 mg/dL), and 2 had < 1.4 mmol/L (25 mg/dL).

None of the low blood glucose determinations was associated with symptoms consistent with hypoglycaemia.

19 (28.8%) of the patients received interventions with oral feeding for low glucose level, none required intravenous fluids.

Analysis with marginal mixed models with repeated measurements indicated age at which blood glucose was measured as highly significant (t= 3.97; P < 0.0001), with the value increasing by 0.021 mmol/L (0.37 mg/dL) for each hour of age.

In the Poisson regression, episodes of blood glucose determinations < 1.7 mmol/L (30 mg/dL) were more likely to occur with decreasing maternal age (adjusted relative risk [RR, 0.87, 95% CI, 0.79 to 0.94]) and more likely to occur with large weight infants.

None of the other maternal or obstetric factors were statistically significant.
The first 90 minutes of life is the period of greatest risk to the infant born to a woman with diabetes. The risk is determined mainly by maternal age and weight of the infant at delivery.The analysis was detailed and well conducted.
Alam M; Raza SJ; Sherali AR; Akhtar AS;

2006

358
Study Type: Cross-sectional

Evidence level: 2−
40 infants of mothers with diabetesSingleton infants born to mothers with diabetes at the Federal Government Services Hospital, Islamabad and National Institute of Child Health, Karachi, from August 1999 to January 2000.

Country: Pakistan.
Intervention:
Infants born to mothers with diabetes were immediately admitted to the neonatal intensive care unit after delivery.

Comparison:
No comparison
Follow-up period:
Cross-sectional study, no follow-up.

Outcome Measures:
  1. Mode of delivery
  2. Birth injuries
  3. Birth asphyxia
  4. Congenital abnormalities
  5. Weight of infant at delivery
  6. Hypocalcemia
  7. Hyperbilirubinemia
  8. Respiratory distress syndrome
22 (55%) of women had a caesarean section.

7 (17.5%) of mothers who gave birth to large babies vaginally experienced birth injuries.

15% of the infants born to mothers with diabetes experienced birth asphyxia.

Congenital anomalies were found in 10 (25%) of infants.

18 (45%) of infants were macrosomic and 2 (5%) were small for gestational age.

Hypoglycaemia was observed in 35% and hypocalcemia in 15% of the infants.

12 (30%) had hyperbilirubinemia.

Mortality rate was 7.5%.
Mothers with diabetes should be offered regular antenatal follow-up to maintain good glycaemic control during pregnancy.

All deliveries of mothers with diabetes should be attended by experienced pediatricians to minimise complications.

Caesarean section may be allowed especially with clinical evidence of macrosomia to avoid birth injury and asphyxia.
Akera C;Ro S;

2003

354
Study Type: Other

Evidence Level: 3
Intervention:

Comparison:
Neonates

Country: Various
Outcome measures of interest are hyperbilirubinaemia and hypoglycaemiaA clinician’s awareness of the prenatal history of the mother can provide early detection and intervention of many conditions leading to good prognosisThis paper was not specific to infants of women with gestational diabetes
Jones CW;

2001 Sep

359
Study Type: Other

Evidence Level: 3
Intervention: For this non-systematic review, the following have been included:

textbook chapters case reports scientific studies diagnostic studies prospective studies

Comparison:
The review population is neonates

Country: various
The review considers the following:

macrosomia respiratory distress syndrome cardiomyopathy hypoglycaemia hypocalcaemia and hypomagnesaemia polycythaemia and hyperviscosity
Incidences are reported for:

macrosomia: 20–30%
respiratory distress

syndrome: 25–38%
hypoglycaemia - 25%
hypocalcaemia - 50%
polycythaemia - >65%
The author considers the following as key:

early recognition of symptoms in the mother and appropriate treatment for improved outcomes in the infant

education of mothers with gestational diabetes for better long term health

early monitoring and intervention in infants may decrease neonatal morbidity related to gestational diabetes
The review is non-systematic and therefore the information must be considered carefully

From: Evidence tables

Cover of Diabetes in Pregnancy
Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.
NICE Clinical Guidelines, No. 63.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.
Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

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