Why are infants of diabetic mothers poor feeders

I recently was talking with a student Occupational Therapist who was working on a project on infant's of a diabetic mother. She said that there is proven research that infants whose mother did not control her glucose levels throughout pregnancy had neurological defects which are portrayed through features such as hypotonia, poor feeding, and being LGA. These effects on the brain are not necessarily those that could be seen on MRI or CT. We see this problem all the time in our NICU.

Our group has recently conducted a first-in-infants pilot trial of pairing transcutaneous auricular vagus nerve stimulation (taVNS) with feeding to assist learning oromotor skills. We are enrolling preterm and HIE infants who are failing to learn oral feeds and clinically determined to need a G-tube. In preliminary data, taVNS paired with one or two daily feedings for 2 weeks resulted in 50% of infants attaining full feeds and avoiding G-tube.

A notable number of non-responders were infants of diabetic mothers (IDM) exposed to poor glucose control during pregnancy, all of whom required a G-tube. Uncontrolled maternal hyperglycemia is associated with increased systemic and neuro-inflammation, CNS oxidative stress, DNA damage, and worse neonatal outcomes compared to infants of euglycemic mothers. In neonatal animal models, hyperglycemia has been shown to decrease BDNF, alter long-term synaptogenesis and hippocampal neurochemistry, with ongoing CNS oxidative stress and inhibition of the cortical neuronal plasticity required for learning. In our pilot trial of taVNS-paired feeding, CNS glutathione concentrations (GSH), a MR spectroscopy (MRS) marker of oxidative stress, had significant interaction with IDM in predicting outcome, strongly suggesting that ongoing CNS oxidative stress contributes to neuropathology in IDMs failing oral feeding.

NAC is an FDA-approved antioxidant that is safe and crosses the blood brain barrier, increasing CNS GSH. NAC reduces CNS oxidative stress, enhances learning and provides a neuroprotective effect after brain injury in our and others neonatal HI and neuroinflammatory animal models. Both GSH and BDNF enhance neuroplasticity. Therefore, we hypothesize that pre-treatment with NAC in IDMs who are failing oral feeding, followed by taVNS-paired feeding, will decrease oxidative stress induced by maternal hyperglycemia and IDM-associated brain injury, and increase response to taVNS-paired feeding rehabilitation.

Gestational diabetes. This term refers to a mother who does not have diabetes before becoming pregnant but develops a resistance to insulin because of the hormones of pregnancy.

With both types of diabetes, there can be complications for the baby. It is very important to keep tight control of blood sugar during pregnancy.

What causes diabetes in pregnancy?

The placenta supplies a growing fetus with nutrients and water. It also produces a variety of hormones to maintain the pregnancy. Some of these hormones (estrogen, cortisol, and human placental lactogen) can block insulin. This usually begins about 20 to 24 weeks into the pregnancy.

As the placenta grows, more of these hormones are produced, and insulin resistance becomes greater. Normally, the pancreas is able to make additional insulin to overcome insulin resistance, but when the production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes results.

Pregnancy also may change the insulin needs of a woman with preexisting diabetes. Insulin-dependent mothers may require more insulin as pregnancy progresses.

Who is affected by diabetes in pregnancy?

About 5 percent of all pregnant women in the U.S. are diagnosed with gestational diabetes. Gestational diabetics make up the vast majority of pregnancies with diabetes. Some pregnant women require insulin to treat their diabetes.

Why is diabetes in pregnancy a concern?

The mother's excess amounts of blood glucose are transferred to the fetus during pregnancy. This causes the baby's body to secrete increased amounts of insulin, which results in increased tissue and fat deposits. The infant of a diabetic mother  is often larger than expected for the gestational age.

The infant of a diabetic mother may have higher risks for serious problems during pregnancy and at birth. Problems during pregnancy may include increased risk for birth defects and stillbirth. It also increases the risk for birth defects, including problems with the formation of the heart, brain, spinal cord, urinary tract, and gastrointestinal system.

Unlike insulin-dependent diabetes, gestational diabetes generally does not cause birth defects.  Women with gestational diabetes generally have normal blood glucose levels during the critical first trimester when baby's organs form.

A newborn infant of a diabetic mother may develop one, or more, of the following:

• Hypoglycemia
  Hypoglycemia refers to low blood glucose in the baby immediately after delivery. This problem occurs if the mother's blood glucose levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. After delivery, the baby continues to have a high insulin level, but it no longer has the high level of glucose from its mother, resulting in the newborn's blood glucose level becoming very low. The baby's blood glucose level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously.

• Macrosomia
  Macrosomia refers to a baby that is considerably larger than normal. All of the nutrients the fetus receives come directly from the mother's blood. If the maternal blood has too much glucose, the pancreas of the fetus senses the high glucose levels and produces more insulin in an attempt to use this glucose. The fetus converts the extra glucose to fat. Even when the mother has gestational diabetes, the fetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the fetus results in large deposits of fat which causes the fetus to grow excessively large.

• Birth injury
  Birth injury may occur due to the baby's large size and difficulty being born.

• Respiratory distress (difficulty breathing)
  Too much insulin in a baby's system due to diabetes can delay surfactant production which is needed for lung maturation.

Treatment for infants of diabetic mothers

Treatment of a baby born to a diabetic mother often depends upon the control of diabetes during the last part of pregnancy and during labor. Specific treatment will be determined by your baby's physician based on:

• Your baby's gestational age, overall health, and medical history

• Extent of the condition

• Your baby's tolerance for specific medications, procedures, or therapies

• Expectations for the course of the condition

• Your opinion or preference

Treatment may include:

• Monitoring of blood glucose levels
  Blood may be drawn from a heel stick, with a needle in the baby's arm, or through an umbilical catheter (a tube placed in the baby's umbilical cord).

• Giving the baby a quick source of glucose
  This may be as simple as giving a glucose and water mixture as an early feeding. Or, the baby may need glucose given intravenously. The baby's blood glucose levels are closely monitored after treatment in case hypoglycemia occurs again.

• Checking for hypocalcemia (low calcium levels)

• Giving oxygen or using a breathing machine (if respiratory distress occurs)

• Care for any problems arising from a birth injury

• Care for any problems that occur with a birth defect

Prevention of problems associated with infants of diabetic mothers

Prenatal care is essential to a healthy outcome when a mother has diabetes in pregnancy. Careful diet management, blood glucose monitoring, and insulin therapy can help keep a mother's blood glucose levels at normal levels and decrease many of the risks to her baby.

Why are infants of diabetic mothers fed early?

How does diabetic mother affect baby?