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Fetal and Neonatal Habituation in Infants of Diabetic Mothers
Fetal and Neonatal Habituation in Infants of Diabetic Mothers N. L. GONZALEZ-GONZALEZ, PHD, V. MEDINA, PHD, E. PADRON, PHD, E. DOMENECH, PHD, N. M. DIAZ GOMEZ, PHD, H. ARMAS, PHD, AND J. L. BARTHA, PHD
Objective To evaluate whether maternal diabetes alters the habituation ability of fetuses and newborns. Study design Two nonrandomized clinical trials were performed. First, we studied prenatal fetuses of women with pregestational diabetes, and control subjects matched for gestational age, and then we studied infants of diabetic mothers (IDM) and control subjects matched for gestational age and mode of delivery. Fetus and newborns were stimulated with vibroacoustic stimulus. Results In fetuses of diabetic mothers, the ability to habituate was lower, and the habituation rate was higher than in control subjects to all habituation tests. In the neonatal period, ability to habituate was lower (59% vs 100%; P < .001), and the habituation rate was higher (18 [14-21] vs 4 [1.2-6.8]; P < .001) in the IDM than in the control infants. We found a significant negative correlation between maternal glycosylated hemoglobin in each trimester of pregnancy and habituation ability in IDM. Conclusions Fetuses and infants of diabetic mothers have impaired habituation ability, which is related to the degree of maternal metabolic control. (J Pediatr 2009;154:492-7)
he most important mechanisms by which the environment can modulate behavior are learning and memory. Sensory and behavioral human capacities start to develop in the fetus. Very few studies have focused on fetal or neonatal periods and even fewer consider perinatal changes, relating pre and postnatal assessments. Studies of higher neurologic function have been performed with older children. One possible approach for evaluating central nervous system (CNS) function is the analysis of habituation capacity. Habituation is a form of nonassociative learning related with implicit or nondeclarative memory. If the stimulus is neither beneficial nor harmful, the subject learns, after repeated exposure, to ignore it. Habituation reflects integrated function of an intact CNS. Implicit memory involves hippocampus function and the specific sensory and motor systems recruited for the task being learned. At the cellular level, decreased synaptic connections by sensory neurons, interneurons, or both are common mechanisms for habituation. These changes occur at several sites in the reflex circuit. Memory is distributed and stored throughout the circuit, and at one particular site.1 Habituation capacity correlates with characteristics of behavioral states and maturational development of the fetal neurologic circuit.2 Fetuses with CNS disease or those exposed to adverse conditions affecting neurologic function require longer stimulation or simply do not habituate.3 Habituation studies can contribute to knowledge about fetal neurologic development and the evaluation of its functional integrity. From the Department of Obstetrics and Diabetic encephalopathy is a recognized complication of untreated diabetes in the Gynecology (N.G., V.M., E.P.) and the Department of Paediatrics (E.D., H.A.), Unichildren or adults resulting in a progressive cognitive impairment accompanied by modversity Hospital of the Canary Islands, the ification of hippocampal function.4 Maternal diabetes mellitus can cause multiple funcNursing School (N.D.), University of La La5 tional and structural anomalies in the progeny. A delay in lung and liver maturation were guna, Tenerife, Canary Islands, and the Department of Obstetrics and Gynaecology, previously reported,6 but studies concerning the effect of chronic hyperglycemia on central University Hospital “Puerta del Mar” (J.B.), nervous system development and functioning are scarce. Early reports on the neurologic Cádiz, Spain. development in infants of diabetic mothers (IDM) indicated serious CNS deficits, even in The authors declare no potential conflicts of interest, real or perceived. the absence of structural malformations. These alterations were significantly less severe Submitted for publication Mar 2, 2008; last when maternal diabetes was medically controlled and treated, but some alterations in revision received Sep 10, 2008; accepted 7 cognitive and motor function may persist throughout childhood. Oct 13, 2008. Reprint requests: Prof. Nieves Luisa González We hypothesized that maternal diabetes mellitus can modify fetal habituation González, Avda de la Universidad no. 27. La capability which may be related to alterations in the development of central nervous Laguna, 38208. Tenerife, Canary Islands, Spain.
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CNS DM GA
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Central nervous system Diabetes mellitus Gestational age
HbA1c IDM
Glycosylated hemoglobin Infants of diabetic mothers
E-mail: [email protected]. 0022-3476/$ - see front matter Copyright © 2009 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2008.10.020
system in the fetus and the newborn. Our objective was to evaluate whether maternal diabetes alters habituation capacity in both fetuses and newborns.
METHODS Prenatal Study Patients Between January 2004 and May 2006 a total of 1928 pregnant women were assessed for eligibility at the University Hospital of the Canary Islands Prenatal Clinic, and 410 fulfilled eligibility criteria. These criteria were a normal, single pregnancy, absence of maternal toxic habits, no obstetric or medical complications except diabetes mellitus (DM) and gestational age (GA) established by ultrasound scanning before 12 weeks. Participants were excluded for the consumption of tobacco, alcohol, coffee (more than 2 cups per day), and other illegal drugs (marijuana, cocaine, or others). The study was approved by the Local Ethical Committee, and all women gave their written consent for the study. Two pregnant women with pregestational DM refused to participate in the study, and 24 women accepted and were included in the DM group. The control group was composed of 24 gestational age–matched nondiabetic pregnant women who agreed to participate in the study from 30 women who were asked to participate. Two subjects from the control group were excluded, one because of lack of fetal response to vibroacoustic stimulation and the other because of postnatal detection of previously unknown maternal cocaine use. Neonatal Study Patients The original set of control newborns used to compare prenatal habituation could not be control subjects for neonatal habituation testing because of GA differences. The 24 control infants used for neonatal habituation testing were healthy infants of consenting nondiabetic mothers selected among 321 who fulfilled the same criteria described for the antenatal control group, with birth weights between 2500 to 4000 g and the same GA and mode of delivery as IDM cases. One IDM was excluded from the study, together with the corresponding control infant, because of early hospital discharge. Because of lack of response to vibroacoustic stimulation, another infant of an IDM and 3 control infants were excluded from the study. None of the control newborns were exposed to prenatal vibroacoustic stimulation. Prenatal Study Design Fetal habituation tests were initiated at 35 weeks GA and repeated at 36, 37, and 38 weeks of GA. All habituation tests were performed blinded with regard to diabetic status, and all were performed in the same room by the same operator, between 9 a.m. and 1 p.m., following the procedure previously described.8 After checking amniotic fluid index, fetal presentation, fetal growth, and maternal adiposity, the ultrasound probe was positioned to observe totally or partially the fetal face, the upper extremities, and the upper part of fetal trunk in the same view. Fetal movements and fetal heart Fetal and Neonatal Habituation in Infants of Diabetic Mothers
rate were monitored at the same time until the pattern corresponded to a fetal active state. An ultrasound observation was started and, after confirming the fetus was in an active state for longer than 10 minutes, the study was initiated. A vibroacoustic stimulus was repeatedly applied to the maternal abdomen above the fetal head for a period of 1 second every minute for up to a maximum of 24 stimuli. A general movement of the fetal trunk upper extremities, the head or the eyes starting in the first second post-stimulus was considered a positive response. If the fetus was moving before stimulation, then a change in the pattern of the previous movements within 1 second after the application of the stimulus was considered as a positive response. Some fetuses remained very active after stimulation, but no cases required an interval between 2 stimuli of longer than 3 minutes to evaluate the reflex response. It was uniformly possible to find an appropriate interval to evaluate the response to a new stimulus. Fetal and neonatal capacity to habituate was a cessation of response to 4 consecutive stimuli and habituation rate was the number of consecutive stimuli applied before a fetus ceased to respond. The number of fetuses of DM included in habituation testing was: test 1 ⫽ 24, test 2 ⫽ 22, test 3 ⫽ 16, test 4 ⫽ 13. The number decreased as deliveries occurred during the study.
Postnatal Study Design All tests were performed within 1 to 2 days of delivery by the same operator, blinded as to maternal diabetic status. An otoacoustic emission test was performed to test the integrity of the auditory system as universal newborn hearingscreening. For habituation testing the newborns were placed into a soundproof cot in a quiet room, at least than 60 minutes after a feed between 10 and 12 in the morning. The operator waited until the newborn was quiet (neither crying nor having intense general movements). Then the same vibroacoustic stimulator that had been used for the fetal habituation study was indirectly applied against the mastoid of the newborn with the interposition of a solid-liquid interface.8 Newborn stimulation was done by use of the same protocol as that used in the fetal study and with the same criteria to define positive responses, habituation and habituation rate. Instruments Prenatal and neonatal habituation tests ware performed using an artificial larynx as a fetal vibroacoustic stimulator “Servox Inton” (Servox Medizintechnik, Merheim, Germany). Fetal movements were monitored with a Toshbee (Toshiba, Tokyo, Japan) ultrasound equipment. Fetal heart rate (FHR) and fetal movements were monitored (HP 8041 A) at the same time. An experimental model with a solidliquid interface between the membrane of the artificial larynx and the mastoid was used to study habituation in the newborn. This interface was made of muscular animal tissue (2 cm thick) plus a plastic bag of warm saline solution 50 mL to simulate intrauterine conditions, as previously described.8 493
Table I. Demographic and anthropometric characteristics of diabetic and nondiabetic mothers: Results are expressed as means and standard deviations
Age (years) Nulliparous Married or stable Weight (Kg) Height (cm) BMI (Kg/m2) Abdominal wall (cm) AFI† (mm) First test Second test Third test Fourth test
Diabetes group (n ⴝ 24)
Control group (n ⴝ 22)
Statistical test*
df
P value
30.3 ⫾ 4.3 18 (70.5%) 20 (83.3) 73.2 ⫾ 14.3 162.5 ⫾ 7 27.6 ⫾ 5.3 17.6 ⫾ 6.2
33.3 ⫾ 4.2 18 (81.8%) 17 (77.3) 82.4 ⫾ 8 163.9 ⫾ 5 30.6 ⫾ 3.6 19.4 ⫾ 4.9
t ⫽ 2.35 2 ⫽ 0.31 2 ⫽ 0.44 t ⫽ 2.64 t ⫽ 2.64 t ⫽ 2.17 t ⫽ 0.24
44 1 1 44 44 44 44
.02 .30 .44 .01 .44 .03 .80
138 (100-158) 130 (100-135) 125 (100-152) 120 (110-140)
120 (100-215) 120 (100-161) 110 (95-145) 100 (87.5-127.5)
U ⫽ 216.5 U ⫽ 180.0 U ⫽ 75.0 U ⫽ 41.0
.29 .31 .12 .07
AFI, Amniotic fluid index; U, Mann-Whitney U test. *t ⫽ Student t test; 2 ⫽ chi squared with Fisher correction when appropriated. †Results are expressed as medians and 25th-75th percentiles.
Monthly levels of glycosylated hemoglobin levels (Hb A1c) were performed to evaluate the degree of maternal metabolic control.
Statistical Analyses We used SPSS 11.0.1. (SPSS Inc Corp, Chicago, Illinois). Distributions were checked by histograms and the Kolmogorov-Smirnov test. Sample size was estimated from previous studies.9,10 Results for quantitative variables are shown as medians and interquartile range variables or mean and standard deviation depending on the variable distribution (nonparametric or parametric, respectively). Qualitative variables are expressed as absolute frequencies and percentages. Differences between pairs of groups were analyzed with either the Mann Whitney U test or the Student t test for nonparametric or parametric distributed variables respectively. Intragroup differences were evaluated with first the Friedman tests and second the Wilcoxon test as the post hoc test. Proportions were compared with 2 testing, or Fisher exact testing for tables, with some expected values lower than 10. The relationships between quantitative variables were compared by use of the Spearman correlation coefficient (). Habituation ability variable was converted to ordinal variable with to values, 0 ⫽ no habituate ability and 1 ⫽ Habituation ability. A P value ⬍.05 was considered as statistically significant.
RESULTS Prenatal Study All pregnant women and their partners were white Caucasian. Most of the diabetic and nondiabetic pregnant women were nulliparous. Maternal age, weight, and body mass index at birth were significantly lower in the DM group than in the control group (Table I). Intergroup differences in maternal abdominal wall thickness were not significant. Amniotic fluid volumes were similar in both groups. 494
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All mothers in the DM group had pregestational diabetes, 18 (75%) had type 1, and 6 (25%) had type 2 and were treated with self-regulated intensive insulin therapy. Mean duration of diabetes was 12.2 ⫾ 7.3 years. Retinal examination and renal function tests obtained in each trimester were normal, with the exception of 3 cases of diabetic retinopathy, one of them associated with proteinuria (525 mg/mL in 24-hour urine test). None had hypertension induced or associated with pregnancy. There were differences in maternal Hb A1c levels among the 3 trimesters of pregnancy in the DM group (Friedman test; 2 ⫽ 15.2, df ⫽ 2; P ⫽ .001). First trimester Hb A1c levels 6.9% (5.9%-9.0%) were significantly higher than those in both the second 6.2% (4.7%-6.5%); Wilcoxon’s test; Z ⫽ ⫺3.65; P ⫽ .0003) and the third trimester 5.9% (5.0%-6.5%); Wilcoxon’s test; Z ⫽ ⫺3.70; P ⫽ .0002), respectively. There were not significant differences in HbA1c values between the second and the third trimester of pregnancy (Wilcoxon’s test; Z ⫽ -1.20; P ⫽ .22). We found no significant correlations between maternal Hb A1c levels in the 3 trimesters of pregnancy and fetal habituation capacity or rates. Gestational age at birth was significantly lower in the DM group 38 ⫾ 0.8 versus 39 ⫾ 1.5 weeks in the control group (Student test; t ⫽ ⫺2.78, df ⫽ 31; P ⫽ .009). In the DM group, 29.2% (7/24) of deliveries were normal, 25% (6/24) required forceps, and 45.8% (11/24) were Caesarean sections, versus 63.6% (14/22) normal, 13.6% (3/22) forceps, and 22.7% (5/22) Cesarean sections in the control group (2 ⫽ 5.51, df ⫽ 2; P ⫽ .065). Mean birth weight was 3315 ⫾ 297 g in the control group versus 3707 ⫾ 529 g in the DM group (Student t test; t ⫽ ⫺3.00, df ⫽ 37; P ⫽ .005), and umbilical artery pH values were 7.25 ⫾ 0.08 in the DM group versus 7.26 ⫾ 0.06 in control subjects (Mann Whitney’s U test; U ⫽ 150, P ⫽ .6). Fetal capacity to habituate was significantly lower, and habituation rates were significantly higher in the DM group than in control subjects for all intrauterine tests. These sigThe Journal of Pediatrics • April 2009
Table II. Intrauterine habituation ability of fetuses of diabetic and non-diabetic mothers Habituation ability
Diabetes group
Control group (n ⴝ 22)
2
P value
Type 1 and 2 diabetes (n ⫽ 24) Test 1 2/24 (8.3%) Test 2 8/22 (36.4%) Test 3 6/16 (37.5%) Test 4 7/13 (53.8%)
19/22 (86.4%) 19/22 (95%) 13/14 (93%) 11/11 (100%)
28.16 15.68 9.85 6.76
⬍.0001 ⬍.0001 .002 .013
Type 1 diabetes (n ⫽ 19) Test 1 1/19 (5.3%) Test 2 6/17 (35.3%) Test 3 3/11 (27.3%) Test 4 4/8 (50%)
19/22 (86.4%) 19/20 (95%) 13/14 (93%) 11/11 (100%)
26.83 14.94 11.50 6.96
⬍.0001 ⬍.0001 .002 .018
Chi squared ⫹ Fisher exact test; df ⫽ 1 for all comparisons.
Table III. Fetal habituation rate in infants of diabetic and non-diabetic mothers: Results are expressed as medians and 25th to 75th percentiles Habituation rate
Diabetes group
Control group (n ⴝ 22)
U
P value
Type 1 and 2 diabetes (n ⫽ 24) Test 1 21 (14-21) 9 (8-18) Test 2 21 (12-21) 8 (7-9) Test 3 21 (9-21) 13 (7-20) Test 4 18 (8-18) 6 (5-12)
73.50 62.50 56.00 29.50
⬍.001 ⬍.001 .02 .02
Type 1 diabetes (n ⫽ 19) Test 1 21 (21-21) Test 2 21 (9-21) Test 3 21 (21-21) Test 4 18 (8-18)
73.50 62.50 56.00 29.50
⬍.001 ⬍.001 ⬍.01 .10
9 (8-18) 8 (7-9) 13 (7-20) 6 (5-12)
U, Mann-Whitney U test.
nificant differences were also significant if only women with type 1 diabetes mellitus were considered with the exception of fetal habituation rate for the fourth test (Tables II and III). No significant intragroup differences were found when comparing the habituation ability for the consecutive tests in either the DM (Friedman test; 2 ⫽ 7.1, df ⫽ 3; P ⫽ .06) or the control group (Friedman test; 2 ⫽ 2.4, df 3; P ⫽ .49). Differences in habituation rates among the sequential tests were not significant in either the DM (Friedman test; 2 ⫽ 5.35, df ⫽ 3; P ⫽ .15) or the control group (Friedman test; 2 ⫽ 3.4, df ⫽ 3; P ⫽ .33). Therefore results mean there was a lack of withingroup differences across the 4 testing periods with respect to habituation outcomes.
Postnatal Study Mean birth weight was significantly lower in the DM group than in the control group, 3707 ⫾ 529 versus 3383 ⫾ 390 g (t ⫽ 2.27, df 38; P ⫽ .03). Thirteen newborns from the 22 IDM (59%) newborns who had habituation testing, showed capacity to habituate, in contrast to the 20 (100%) control infants Fetal and Neonatal Habituation in Infants of Diabetic Mothers
Table IV. Correlation between maternal glycosylated hemoglobin levels and both ability and rate of habituation in newborns of diabetic mother Habituation ability
Habituation rate
Hb A1c
%
*
P value
*
P value
First trimester Second trimester Third trimester
7 ⫾ 1.8 6 ⫾ 1.0 5.7 ⫾ 0.9
⫺0.48 ⫺0.47 ⫺0.54
.02 .02 .01
0.50 0.51 0.36
.02 .03 .1
Hb A1c, Glycosylated hemoglobin levels. *Spearman correlation coefficient.
who had habituation testing, and all of them habituated (2 and Fisher exact test; 2 ⫽ 10.41, P ⫽ 0.001). Habituation rate was 18 (14-21) stimuli in the IDM group and 4 (1.2-6.8) in the control group (Mann Whitney U test; U ⫽ 36.50 P ⬍ .001). We found a significant negative correlation between maternal Hb A1c levels in each trimester of pregnancy and habituation ability and a positive significant correlation with habituation rate in neonates of DM (Table IV).
DISCUSSION Fetuses in the diabetic group had difficulty in achieving habituation or did not habituate after the 4 tests. Also, they required a significantly greater number of stimuli presentations than the nondiabetic group to become habituated. These results are consistent with those of Doherty et al,10 who also observed that the 15 IDMs tested at 28, 32, and 36 weeks GA had lower habituation rates as gestational age increased, which could be attributable to progressive maturation of the CNS. The number of trials required to demonstrate habituation decreases with advancing gestational age.11 In our series we did not observe this pattern in either IDM or control subjects, probably because we initiated tests later in pregnancy, at 35 weeks GA. At this gestational age, most fetuses have achieved sufficient CNS maturity to be capable of habituation.10,11 In a previous study8 we showed that normal fetuses over 38 weeks GA habituated more rapidly when successive habituation tests were performed at intervals of 48 hours, which indicates that memory and learning capacity exist in the prenatal period. Van Heteren et al12 demonstrated this learning capacity on repeating habituation tests at 10 minutes and 24 hours. The use of a longer interval, 1 week, in this study probably explains why we did not observe this effect. The observed differences in habituation abilities between the diabetic and nondiabetic groups suggest a difference in CNS function, which has been postulated to be the consequence of delayed maturation of the CNS in IDM. This hypothesis is supported by Mulder et al,13 who found a delay in the appearance of body activity in fetuses of diabetic mothers. The quality of spontaneous body movements in these infants was also reported to be altered,14 as well as their response to vibroacoustic stimulation.15 Fetal behavioral studies also support the hypothesis that neurologic alterations 495
observed in IDM are due to maturational delay.16,17 Neurologic study of IDM during childhood would allow us to confirm this hypothesis and clarify whether or not these neurologic alterations persist later in life. In our study, less than two thirds of the IDM showed habituation capacity, and those who did required significantly increased vibroacoustic stimulation compared with newborn control subjects who were not exposed to this type of intrauterine stimulation. The difficulties detected before birth in IDM persisted after birth. The lack of response to the vibroacoustic stimulus of some newborns in both groups may result from secretions in the auditive conduct, to the proximity of delivery and to the acoustic superstimulation that all newborns receive after birth. This lack of response has been considered to be physiological.8 There are not longitudinal studies of either habituation or perinatal neurologic development against which we could compare our results. In addition there are only a few reports evaluating neurologic states in IDM. Our results are consistent with DeRegnier et al,18 who observed impaired auditory recognition memory in IDM at 1 year of age by use of objective electrophysiological techniques. Visual impairments19 and cross-modal recognition memory20 have also been described in IDM. Maternal blood glucose was not measured at the time of habituation testing. However, difficulties with habituation persisted in the IDM group in the neonatal period, suggesting that occasional elevations of maternal glycemia did not explain our findings. We found that high levels of maternal HbA1c in any of the 3 trimesters of pregnancy significantly correlated with impaired habituation. This correlation could not be demonstrated in the prenatal study, probably because of the very high proportion of fetuses that did not habituate during both the first and second tests. Cognitive and motor neurologic alterations that can be present in diabetic patients were related to either hyperglycemia or hypoglycemia.21 Rizzo et al22 found a correlation between second- and third-trimester maternal glycemia levels and behavior in newborns of DM. They reported a correlation between maternal beta-hydroxybutyrate levels and child neurologic development evaluated at ages 2 to 6 and 9 years. The frequency of major psychomotor alterations in children of diabetic mothers at the end of adolescence is not higher than that of the general population. However, in adolescents of DM, the lowest indexes of psychomotor and cognitive development were associated with worse maternal metabolic control.23 The evaluating presentation of hippocampal neurogenesis has changed the concept of brain plasticity24 and attracted considerable attention because of its role in cognitive functions such as learning and memory.25 The hippocampus is injured in both hypoxia-ischemia and perinatal iron deficiency, which are comorbidities in infants of diabetic mothers and intrauterine growth restricted infants.26 Siddappa et al27 suggest that impaired auditory recognition memory found in IDM may be related with brain iron deficits, which would adversely affect hippocampus function in the perinatal period. 496
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Previous studies performed with a streptozotocin model of type 1 diabetes suggested that DM is associated with lower neuronal production, proliferation, and survival.28 Stranahan et al29 demonstrated that, in both insulin-deficient rats and insulin-resistant mice, diabetes impairs hippocampus-dependent memory, perforant path synaptic plasticity and adult neurogenesis, and adrenal steroid corticosterone contributes to these adverse effects. These results may shed light on causes of diabetic neuropathology and provide an explanation for the memory deficiencies seen in some adult patients with diabetes. The effect of maternal diabetes on fetal neurogenesis at the hippocampus level could be related with impaired habituation ability that we have found in babies from diabetic mothers.
REFERENCES 1. Dandel ER, Schwartz JH, Jessell TM. Cellular mechanisms of learning and the bilogical basis of individuality. Principles of Neural Science. Fourth Ed. McGraw-Hill; 2000:1248-79. 2. Morokuma S, Fukushima K, Kkawai N, Tomonaga M, Satoh S, Nakano H. Fetal habituation correlates with functional brain development. Behav Brain Res 2004; 153:459-63. 3. Leader LR, Baillie P. The changes in fetal habituation patterns due to a decrease inspired maternal oxygen. Br J Obstet Gynecol 1988;95:664-8. 4. Duarte JM, Oses JP, Rodrigues RJ, Cunha RA. Modification of purinergic signaling in the hippocampus of streptozotocin-induced diabetic rats. Neuroscience 2007;149:382-91. 5. Gonzalez Gonzalez NL, Ramírez O, Mozas J, Melchor JC, Armas H, García Hernández JA, et al. Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus. Acta Obstet Gynecol Scand 2007;87:43-9. 6. Ornoy A. Growth and neurodevelopmental outcome of children born to mothers with pregestational and gestational diabetes. Pediatr Endocrinol Rev 2005; 2:104-113. 7. Dahlaquist G, Kallen B. School marks for Swedish children shoes mothers had diabetes during pregnancy: a population based study. Diabelología 2007;50:1826-31. 8. González González NL, Suárez MN, Pérez Piñero B, Armas H, Doménech E. Persistent of fetal memory into neonatal life. Acta Obstet Gynecol Scand 2006; 85;1032-6. 9. James DK, Spencer CJ, Stepsis BW. Fetal learning: a prospective randomized controlled study. Ultrasound Obstet Gynecol 2002;20:431-8. 10. Doherty NN, Hepper PH. Habituation in fetuses of diabetic mothers. Early Hum Dev 2000;59:85-93. 11. Groome LJ, Singh KP, Burgard SL, Neely CL, Deason MA. Motor responsivity during habituation testing of normal human fetuses. J Perinatal Med 1995;23:159-66. 12. Van Heteren CF, Boekkooi PF, Jongsma HW, Nijhuis JG. Fetal learning and memory. Lancet 2000;356:1169-70. 13. Mulder EH, O’Brien MJ, Lems YL, Visser GH, Prechtl HF. Body and breathing movements in near-term fetuses and newborn infants of type-1 diabetic women. Early Hum Dev 1990;24:131-52. 14. Kainer F, Prechtl HF, Engele H, Einspieler C. Assessment of the quality of general movements in fetuses and infants of women with type-1 diabetes mellitus. Early Hum Dev 1997;50:13-25. 15. Allen CL, Kisilevsky BS. Fetal behaviour in diabetic and non-diabetic women: an exploratory study. Dev Psycobiol 1999;35:69-80. 16. Mulder EH, Visser GH, Bekedam DJ, Prechtl HF. Emergence of behavioural states in fetuses of type-1 diabetic women. Early Hum Dev 1987;15:231-51. 17. González González NL, Váquez P, Jimenez A, Caballero A, Parache J. Estados de comportamiento intrautero en los hijos de madres con diabetes tipo I. Prog Obstet Gynecol 2001;9:368-74. 18. DeRegnier RA, Nelson CA, Thomas KM, Wewerka S, Georgieff MK. Neurophysiologic evaluation of auditory recognition memory in healthy newborn infants and infants of diabetic mothers. J Pediatr 2000;37:777-84. 19. DeRegnier RAO, Georgieff MK, Nelson CA. Visual event-related brain potentials in 4 month old infants at risk for neurodevelopmental impairments. Dev Psychobiol 1997;30:11-28. 20. Nelson CA, Wewerka SS, Borscheid AJ, DeRegnier RA, Georgieff MK. Electrophysiologic evidence of impaired cross-modal recognition memory in 8 month-old infants of diabetic mothers. J Pediatr 2003;142:575-82. 21. Wessels AM, Scheltens P, Barkhof F, Heine RJ. Hyperglycaemia as a deter-
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minant of cognitive decline in patients with type 1 diabetes. Eur J Pharmacol 2008;585:88-96. 22. Rizzo T, Freinkel N, Metzger BE, Hatcher R, Burns J, Barglow P. Correlations between antepartum maternal metabolism and newborn behavior. Am J Obstet Gynecol 1990;163:1458-64. 23. Rizzo T, Mettger Burns WJ, Burns K. Correlations between antepartum maternal metabolism and child intelligence. N Engl J Med 1991;325:911-6. 24. Waddell J, Shors TJ. Neurogenesis, learning and associative strength. Eur J Neurosci 2008;2:3020-8. 25. Becker S, Wojtowicz JM. A model of hippocampal neurogenesis in memory and mood disorders. TICS 2007;11:70-6.
26. Rao R, Tkac I, Townsend EL, Ennis K, Gruetter R, Georgieff MK. Perinatal iron deficiency predisposes the developing rat hippocampus to greater injury from mild to moderate hypoxia-ischemia. J Cereb Blood Flow Metab 2007;27:729-40. 27. Sidappa AM, Georgieff MK, Weweka S, Worwa C, Nelson CA, DeRegnier RA. Iron deficiency alters auditory recognition memory in newborn infants of diabetic mothers. Pediatr Res 2004;55:1034-41. 28. Zhang WJ, Tan YF, Vranic M, Wojtowicz JM. Impairment of hippocampal neurogenesis in streptozotocin treated diabetic rats. Acta Neurol Scand 2008;117:205-10. 29. Stranahan AM, Arumugam TV, Cutler RG, Lee K, Egan JM, Mattson MP. Diabetes impairs hippocampal function through glucocorticoid-mediated effects on new and mature neurons. Nat Neurosci 2008;11:309-17.
50 Years Ago in The Journal of Pediatrics HEMANGIOMA
WITH
THROMBOCYTOPENIA
Dargeon HW, Adiao AC, Pack GT. J Pediatr 1959;54:285-95
In 1940, Kasabach and Merritt were the first to report the association of a “capillary hemangioma” with profound thrombocytopenia.1 This association is re-addressed in Dargeon’s article almost 20 years later, in which the cases of 14 patients with “hemangiomas” and thrombocytopenia were reviewed. Critical observations were noted: most lesions occurred in early infancy; splenectomy, although performed in half the patients, was not effective; steroids helped in some cases; and irradiation was successful in half the patients. It was not until 1982 that a classification system was proposed for vascular anomalies,2 and not until 1997 that tumors called Kaposiform hemangioendotheliomas and tufted angiomas were identified as the “hemangiomas” that caused profound thrombocytopenia.3 For many “vascular anomaly specialists,” the patients identified in Dargeon’s paper had a spectrum of vascular anomalies (tumors, malformations, congenital hemangiomas) and not the more common infantile hemangioma. Fifty years later, we have made some progress. Steroids are used for the treatment of hemangiomas and other vascular tumors with varying response, but other therapies such as vincristine and anti-angiogenic agents are beginning to be studied in clinical trials verses retrospective case reports.4 The genetic and biologic characteristics of these anomalies are being investigated with vigor. Organizations such as the International Society for the Study of Vascular Anomalies (ISSVA) and patient support groups have helped with the new interest in this expanding field. Currently, the proper care of patients with vascular anomalies requires the expertise of multiple medical specialists with clinical acumen in surgery, radiology, dermatology, hematology, oncology, pathology, neurology, cardiology, gastroenterology, and basic sciences. This comprehensive multidisciplinary approach offers the best opportunity for proper diagnosis, management, and scientific progress in this field. Denise M. Adams, MD Associate Professor of Pediatrics Medical Director of the Hemangioma and Vascular Malformations Center Inpatient Clinical Director Cincinnati Children’s Hospital Medical Center University of Cincinnati Cincinnati, Ohio 10.1016/j.jpeds.2008.09.045
REFERENCES 1. Kasabach H, Merritt K. Capillary hemangioma with extensive purpura: report of a case. Am J Dis Child 1940;59:1063-70. 2. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412-22. 3. Sarkar M, Mulliken JB, et al. Thrombocytopenic coagulopathy (Kasabach-Merritt phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma. Plast Reconstr Surg 1997;100:1377-86. 4. Adams DM, Wentzel MS. The role of the hematologist/oncologist in the care of patients with vascular anomalies. Pediatr Clin North Am 55:339-55 2008.
Fetal and Neonatal Habituation in Infants of Diabetic Mothers
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Objective To evaluate whether maternal diabetes alters the habituation ability of fetuses and newborns. Study design Two nonrandomized clinical trials were performed. First, we studied prenatal fetuses of women with pregestational diabetes, and control subjects matched for gestational age, and then we studied infants of diabetic mothers (IDM) and control subjects matched for gestational age and mode of delivery. Fetus and newborns were stimulated with vibroacoustic stimulus. Results In fetuses of diabetic mothers, the ability to habituate was lower, and the habituation rate was higher than in control subjects to all habituation tests. In the neonatal period, ability to habituate was lower (59% vs 100%; P < .001), and the habituation rate was higher (18 [14-21] vs 4 [1.2-6.8]; P < .001) in the IDM than in the control infants. We found a significant negative correlation between maternal glycosylated hemoglobin in each trimester of pregnancy and habituation ability in IDM. Conclusions Fetuses and infants of diabetic mothers have impaired habituation ability, which is related to the degree of maternal metabolic control. (J Pediatr 2009;154:492-7)
he most important mechanisms by which the environment can modulate behavior are learning and memory. Sensory and behavioral human capacities start to develop in the fetus. Very few studies have focused on fetal or neonatal periods and even fewer consider perinatal changes, relating pre and postnatal assessments. Studies of higher neurologic function have been performed with older children. One possible approach for evaluating central nervous system (CNS) function is the analysis of habituation capacity. Habituation is a form of nonassociative learning related with implicit or nondeclarative memory. If the stimulus is neither beneficial nor harmful, the subject learns, after repeated exposure, to ignore it. Habituation reflects integrated function of an intact CNS. Implicit memory involves hippocampus function and the specific sensory and motor systems recruited for the task being learned. At the cellular level, decreased synaptic connections by sensory neurons, interneurons, or both are common mechanisms for habituation. These changes occur at several sites in the reflex circuit. Memory is distributed and stored throughout the circuit, and at one particular site.1 Habituation capacity correlates with characteristics of behavioral states and maturational development of the fetal neurologic circuit.2 Fetuses with CNS disease or those exposed to adverse conditions affecting neurologic function require longer stimulation or simply do not habituate.3 Habituation studies can contribute to knowledge about fetal neurologic development and the evaluation of its functional integrity. From the Department of Obstetrics and Diabetic encephalopathy is a recognized complication of untreated diabetes in the Gynecology (N.G., V.M., E.P.) and the Department of Paediatrics (E.D., H.A.), Unichildren or adults resulting in a progressive cognitive impairment accompanied by modversity Hospital of the Canary Islands, the ification of hippocampal function.4 Maternal diabetes mellitus can cause multiple funcNursing School (N.D.), University of La La5 tional and structural anomalies in the progeny. A delay in lung and liver maturation were guna, Tenerife, Canary Islands, and the Department of Obstetrics and Gynaecology, previously reported,6 but studies concerning the effect of chronic hyperglycemia on central University Hospital “Puerta del Mar” (J.B.), nervous system development and functioning are scarce. Early reports on the neurologic Cádiz, Spain. development in infants of diabetic mothers (IDM) indicated serious CNS deficits, even in The authors declare no potential conflicts of interest, real or perceived. the absence of structural malformations. These alterations were significantly less severe Submitted for publication Mar 2, 2008; last when maternal diabetes was medically controlled and treated, but some alterations in revision received Sep 10, 2008; accepted 7 cognitive and motor function may persist throughout childhood. Oct 13, 2008. Reprint requests: Prof. Nieves Luisa González We hypothesized that maternal diabetes mellitus can modify fetal habituation González, Avda de la Universidad no. 27. La capability which may be related to alterations in the development of central nervous Laguna, 38208. Tenerife, Canary Islands, Spain.
T
CNS DM GA
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Central nervous system Diabetes mellitus Gestational age
HbA1c IDM
Glycosylated hemoglobin Infants of diabetic mothers
E-mail: [email protected]. 0022-3476/$ - see front matter Copyright © 2009 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2008.10.020
system in the fetus and the newborn. Our objective was to evaluate whether maternal diabetes alters habituation capacity in both fetuses and newborns.
METHODS Prenatal Study Patients Between January 2004 and May 2006 a total of 1928 pregnant women were assessed for eligibility at the University Hospital of the Canary Islands Prenatal Clinic, and 410 fulfilled eligibility criteria. These criteria were a normal, single pregnancy, absence of maternal toxic habits, no obstetric or medical complications except diabetes mellitus (DM) and gestational age (GA) established by ultrasound scanning before 12 weeks. Participants were excluded for the consumption of tobacco, alcohol, coffee (more than 2 cups per day), and other illegal drugs (marijuana, cocaine, or others). The study was approved by the Local Ethical Committee, and all women gave their written consent for the study. Two pregnant women with pregestational DM refused to participate in the study, and 24 women accepted and were included in the DM group. The control group was composed of 24 gestational age–matched nondiabetic pregnant women who agreed to participate in the study from 30 women who were asked to participate. Two subjects from the control group were excluded, one because of lack of fetal response to vibroacoustic stimulation and the other because of postnatal detection of previously unknown maternal cocaine use. Neonatal Study Patients The original set of control newborns used to compare prenatal habituation could not be control subjects for neonatal habituation testing because of GA differences. The 24 control infants used for neonatal habituation testing were healthy infants of consenting nondiabetic mothers selected among 321 who fulfilled the same criteria described for the antenatal control group, with birth weights between 2500 to 4000 g and the same GA and mode of delivery as IDM cases. One IDM was excluded from the study, together with the corresponding control infant, because of early hospital discharge. Because of lack of response to vibroacoustic stimulation, another infant of an IDM and 3 control infants were excluded from the study. None of the control newborns were exposed to prenatal vibroacoustic stimulation. Prenatal Study Design Fetal habituation tests were initiated at 35 weeks GA and repeated at 36, 37, and 38 weeks of GA. All habituation tests were performed blinded with regard to diabetic status, and all were performed in the same room by the same operator, between 9 a.m. and 1 p.m., following the procedure previously described.8 After checking amniotic fluid index, fetal presentation, fetal growth, and maternal adiposity, the ultrasound probe was positioned to observe totally or partially the fetal face, the upper extremities, and the upper part of fetal trunk in the same view. Fetal movements and fetal heart Fetal and Neonatal Habituation in Infants of Diabetic Mothers
rate were monitored at the same time until the pattern corresponded to a fetal active state. An ultrasound observation was started and, after confirming the fetus was in an active state for longer than 10 minutes, the study was initiated. A vibroacoustic stimulus was repeatedly applied to the maternal abdomen above the fetal head for a period of 1 second every minute for up to a maximum of 24 stimuli. A general movement of the fetal trunk upper extremities, the head or the eyes starting in the first second post-stimulus was considered a positive response. If the fetus was moving before stimulation, then a change in the pattern of the previous movements within 1 second after the application of the stimulus was considered as a positive response. Some fetuses remained very active after stimulation, but no cases required an interval between 2 stimuli of longer than 3 minutes to evaluate the reflex response. It was uniformly possible to find an appropriate interval to evaluate the response to a new stimulus. Fetal and neonatal capacity to habituate was a cessation of response to 4 consecutive stimuli and habituation rate was the number of consecutive stimuli applied before a fetus ceased to respond. The number of fetuses of DM included in habituation testing was: test 1 ⫽ 24, test 2 ⫽ 22, test 3 ⫽ 16, test 4 ⫽ 13. The number decreased as deliveries occurred during the study.
Postnatal Study Design All tests were performed within 1 to 2 days of delivery by the same operator, blinded as to maternal diabetic status. An otoacoustic emission test was performed to test the integrity of the auditory system as universal newborn hearingscreening. For habituation testing the newborns were placed into a soundproof cot in a quiet room, at least than 60 minutes after a feed between 10 and 12 in the morning. The operator waited until the newborn was quiet (neither crying nor having intense general movements). Then the same vibroacoustic stimulator that had been used for the fetal habituation study was indirectly applied against the mastoid of the newborn with the interposition of a solid-liquid interface.8 Newborn stimulation was done by use of the same protocol as that used in the fetal study and with the same criteria to define positive responses, habituation and habituation rate. Instruments Prenatal and neonatal habituation tests ware performed using an artificial larynx as a fetal vibroacoustic stimulator “Servox Inton” (Servox Medizintechnik, Merheim, Germany). Fetal movements were monitored with a Toshbee (Toshiba, Tokyo, Japan) ultrasound equipment. Fetal heart rate (FHR) and fetal movements were monitored (HP 8041 A) at the same time. An experimental model with a solidliquid interface between the membrane of the artificial larynx and the mastoid was used to study habituation in the newborn. This interface was made of muscular animal tissue (2 cm thick) plus a plastic bag of warm saline solution 50 mL to simulate intrauterine conditions, as previously described.8 493
Table I. Demographic and anthropometric characteristics of diabetic and nondiabetic mothers: Results are expressed as means and standard deviations
Age (years) Nulliparous Married or stable Weight (Kg) Height (cm) BMI (Kg/m2) Abdominal wall (cm) AFI† (mm) First test Second test Third test Fourth test
Diabetes group (n ⴝ 24)
Control group (n ⴝ 22)
Statistical test*
df
P value
30.3 ⫾ 4.3 18 (70.5%) 20 (83.3) 73.2 ⫾ 14.3 162.5 ⫾ 7 27.6 ⫾ 5.3 17.6 ⫾ 6.2
33.3 ⫾ 4.2 18 (81.8%) 17 (77.3) 82.4 ⫾ 8 163.9 ⫾ 5 30.6 ⫾ 3.6 19.4 ⫾ 4.9
t ⫽ 2.35 2 ⫽ 0.31 2 ⫽ 0.44 t ⫽ 2.64 t ⫽ 2.64 t ⫽ 2.17 t ⫽ 0.24
44 1 1 44 44 44 44
.02 .30 .44 .01 .44 .03 .80
138 (100-158) 130 (100-135) 125 (100-152) 120 (110-140)
120 (100-215) 120 (100-161) 110 (95-145) 100 (87.5-127.5)
U ⫽ 216.5 U ⫽ 180.0 U ⫽ 75.0 U ⫽ 41.0
.29 .31 .12 .07
AFI, Amniotic fluid index; U, Mann-Whitney U test. *t ⫽ Student t test; 2 ⫽ chi squared with Fisher correction when appropriated. †Results are expressed as medians and 25th-75th percentiles.
Monthly levels of glycosylated hemoglobin levels (Hb A1c) were performed to evaluate the degree of maternal metabolic control.
Statistical Analyses We used SPSS 11.0.1. (SPSS Inc Corp, Chicago, Illinois). Distributions were checked by histograms and the Kolmogorov-Smirnov test. Sample size was estimated from previous studies.9,10 Results for quantitative variables are shown as medians and interquartile range variables or mean and standard deviation depending on the variable distribution (nonparametric or parametric, respectively). Qualitative variables are expressed as absolute frequencies and percentages. Differences between pairs of groups were analyzed with either the Mann Whitney U test or the Student t test for nonparametric or parametric distributed variables respectively. Intragroup differences were evaluated with first the Friedman tests and second the Wilcoxon test as the post hoc test. Proportions were compared with 2 testing, or Fisher exact testing for tables, with some expected values lower than 10. The relationships between quantitative variables were compared by use of the Spearman correlation coefficient (). Habituation ability variable was converted to ordinal variable with to values, 0 ⫽ no habituate ability and 1 ⫽ Habituation ability. A P value ⬍.05 was considered as statistically significant.
RESULTS Prenatal Study All pregnant women and their partners were white Caucasian. Most of the diabetic and nondiabetic pregnant women were nulliparous. Maternal age, weight, and body mass index at birth were significantly lower in the DM group than in the control group (Table I). Intergroup differences in maternal abdominal wall thickness were not significant. Amniotic fluid volumes were similar in both groups. 494
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All mothers in the DM group had pregestational diabetes, 18 (75%) had type 1, and 6 (25%) had type 2 and were treated with self-regulated intensive insulin therapy. Mean duration of diabetes was 12.2 ⫾ 7.3 years. Retinal examination and renal function tests obtained in each trimester were normal, with the exception of 3 cases of diabetic retinopathy, one of them associated with proteinuria (525 mg/mL in 24-hour urine test). None had hypertension induced or associated with pregnancy. There were differences in maternal Hb A1c levels among the 3 trimesters of pregnancy in the DM group (Friedman test; 2 ⫽ 15.2, df ⫽ 2; P ⫽ .001). First trimester Hb A1c levels 6.9% (5.9%-9.0%) were significantly higher than those in both the second 6.2% (4.7%-6.5%); Wilcoxon’s test; Z ⫽ ⫺3.65; P ⫽ .0003) and the third trimester 5.9% (5.0%-6.5%); Wilcoxon’s test; Z ⫽ ⫺3.70; P ⫽ .0002), respectively. There were not significant differences in HbA1c values between the second and the third trimester of pregnancy (Wilcoxon’s test; Z ⫽ -1.20; P ⫽ .22). We found no significant correlations between maternal Hb A1c levels in the 3 trimesters of pregnancy and fetal habituation capacity or rates. Gestational age at birth was significantly lower in the DM group 38 ⫾ 0.8 versus 39 ⫾ 1.5 weeks in the control group (Student test; t ⫽ ⫺2.78, df ⫽ 31; P ⫽ .009). In the DM group, 29.2% (7/24) of deliveries were normal, 25% (6/24) required forceps, and 45.8% (11/24) were Caesarean sections, versus 63.6% (14/22) normal, 13.6% (3/22) forceps, and 22.7% (5/22) Cesarean sections in the control group (2 ⫽ 5.51, df ⫽ 2; P ⫽ .065). Mean birth weight was 3315 ⫾ 297 g in the control group versus 3707 ⫾ 529 g in the DM group (Student t test; t ⫽ ⫺3.00, df ⫽ 37; P ⫽ .005), and umbilical artery pH values were 7.25 ⫾ 0.08 in the DM group versus 7.26 ⫾ 0.06 in control subjects (Mann Whitney’s U test; U ⫽ 150, P ⫽ .6). Fetal capacity to habituate was significantly lower, and habituation rates were significantly higher in the DM group than in control subjects for all intrauterine tests. These sigThe Journal of Pediatrics • April 2009
Table II. Intrauterine habituation ability of fetuses of diabetic and non-diabetic mothers Habituation ability
Diabetes group
Control group (n ⴝ 22)
2
P value
Type 1 and 2 diabetes (n ⫽ 24) Test 1 2/24 (8.3%) Test 2 8/22 (36.4%) Test 3 6/16 (37.5%) Test 4 7/13 (53.8%)
19/22 (86.4%) 19/22 (95%) 13/14 (93%) 11/11 (100%)
28.16 15.68 9.85 6.76
⬍.0001 ⬍.0001 .002 .013
Type 1 diabetes (n ⫽ 19) Test 1 1/19 (5.3%) Test 2 6/17 (35.3%) Test 3 3/11 (27.3%) Test 4 4/8 (50%)
19/22 (86.4%) 19/20 (95%) 13/14 (93%) 11/11 (100%)
26.83 14.94 11.50 6.96
⬍.0001 ⬍.0001 .002 .018
Chi squared ⫹ Fisher exact test; df ⫽ 1 for all comparisons.
Table III. Fetal habituation rate in infants of diabetic and non-diabetic mothers: Results are expressed as medians and 25th to 75th percentiles Habituation rate
Diabetes group
Control group (n ⴝ 22)
U
P value
Type 1 and 2 diabetes (n ⫽ 24) Test 1 21 (14-21) 9 (8-18) Test 2 21 (12-21) 8 (7-9) Test 3 21 (9-21) 13 (7-20) Test 4 18 (8-18) 6 (5-12)
73.50 62.50 56.00 29.50
⬍.001 ⬍.001 .02 .02
Type 1 diabetes (n ⫽ 19) Test 1 21 (21-21) Test 2 21 (9-21) Test 3 21 (21-21) Test 4 18 (8-18)
73.50 62.50 56.00 29.50
⬍.001 ⬍.001 ⬍.01 .10
9 (8-18) 8 (7-9) 13 (7-20) 6 (5-12)
U, Mann-Whitney U test.
nificant differences were also significant if only women with type 1 diabetes mellitus were considered with the exception of fetal habituation rate for the fourth test (Tables II and III). No significant intragroup differences were found when comparing the habituation ability for the consecutive tests in either the DM (Friedman test; 2 ⫽ 7.1, df ⫽ 3; P ⫽ .06) or the control group (Friedman test; 2 ⫽ 2.4, df 3; P ⫽ .49). Differences in habituation rates among the sequential tests were not significant in either the DM (Friedman test; 2 ⫽ 5.35, df ⫽ 3; P ⫽ .15) or the control group (Friedman test; 2 ⫽ 3.4, df ⫽ 3; P ⫽ .33). Therefore results mean there was a lack of withingroup differences across the 4 testing periods with respect to habituation outcomes.
Postnatal Study Mean birth weight was significantly lower in the DM group than in the control group, 3707 ⫾ 529 versus 3383 ⫾ 390 g (t ⫽ 2.27, df 38; P ⫽ .03). Thirteen newborns from the 22 IDM (59%) newborns who had habituation testing, showed capacity to habituate, in contrast to the 20 (100%) control infants Fetal and Neonatal Habituation in Infants of Diabetic Mothers
Table IV. Correlation between maternal glycosylated hemoglobin levels and both ability and rate of habituation in newborns of diabetic mother Habituation ability
Habituation rate
Hb A1c
%
*
P value
*
P value
First trimester Second trimester Third trimester
7 ⫾ 1.8 6 ⫾ 1.0 5.7 ⫾ 0.9
⫺0.48 ⫺0.47 ⫺0.54
.02 .02 .01
0.50 0.51 0.36
.02 .03 .1
Hb A1c, Glycosylated hemoglobin levels. *Spearman correlation coefficient.
who had habituation testing, and all of them habituated (2 and Fisher exact test; 2 ⫽ 10.41, P ⫽ 0.001). Habituation rate was 18 (14-21) stimuli in the IDM group and 4 (1.2-6.8) in the control group (Mann Whitney U test; U ⫽ 36.50 P ⬍ .001). We found a significant negative correlation between maternal Hb A1c levels in each trimester of pregnancy and habituation ability and a positive significant correlation with habituation rate in neonates of DM (Table IV).
DISCUSSION Fetuses in the diabetic group had difficulty in achieving habituation or did not habituate after the 4 tests. Also, they required a significantly greater number of stimuli presentations than the nondiabetic group to become habituated. These results are consistent with those of Doherty et al,10 who also observed that the 15 IDMs tested at 28, 32, and 36 weeks GA had lower habituation rates as gestational age increased, which could be attributable to progressive maturation of the CNS. The number of trials required to demonstrate habituation decreases with advancing gestational age.11 In our series we did not observe this pattern in either IDM or control subjects, probably because we initiated tests later in pregnancy, at 35 weeks GA. At this gestational age, most fetuses have achieved sufficient CNS maturity to be capable of habituation.10,11 In a previous study8 we showed that normal fetuses over 38 weeks GA habituated more rapidly when successive habituation tests were performed at intervals of 48 hours, which indicates that memory and learning capacity exist in the prenatal period. Van Heteren et al12 demonstrated this learning capacity on repeating habituation tests at 10 minutes and 24 hours. The use of a longer interval, 1 week, in this study probably explains why we did not observe this effect. The observed differences in habituation abilities between the diabetic and nondiabetic groups suggest a difference in CNS function, which has been postulated to be the consequence of delayed maturation of the CNS in IDM. This hypothesis is supported by Mulder et al,13 who found a delay in the appearance of body activity in fetuses of diabetic mothers. The quality of spontaneous body movements in these infants was also reported to be altered,14 as well as their response to vibroacoustic stimulation.15 Fetal behavioral studies also support the hypothesis that neurologic alterations 495
observed in IDM are due to maturational delay.16,17 Neurologic study of IDM during childhood would allow us to confirm this hypothesis and clarify whether or not these neurologic alterations persist later in life. In our study, less than two thirds of the IDM showed habituation capacity, and those who did required significantly increased vibroacoustic stimulation compared with newborn control subjects who were not exposed to this type of intrauterine stimulation. The difficulties detected before birth in IDM persisted after birth. The lack of response to the vibroacoustic stimulus of some newborns in both groups may result from secretions in the auditive conduct, to the proximity of delivery and to the acoustic superstimulation that all newborns receive after birth. This lack of response has been considered to be physiological.8 There are not longitudinal studies of either habituation or perinatal neurologic development against which we could compare our results. In addition there are only a few reports evaluating neurologic states in IDM. Our results are consistent with DeRegnier et al,18 who observed impaired auditory recognition memory in IDM at 1 year of age by use of objective electrophysiological techniques. Visual impairments19 and cross-modal recognition memory20 have also been described in IDM. Maternal blood glucose was not measured at the time of habituation testing. However, difficulties with habituation persisted in the IDM group in the neonatal period, suggesting that occasional elevations of maternal glycemia did not explain our findings. We found that high levels of maternal HbA1c in any of the 3 trimesters of pregnancy significantly correlated with impaired habituation. This correlation could not be demonstrated in the prenatal study, probably because of the very high proportion of fetuses that did not habituate during both the first and second tests. Cognitive and motor neurologic alterations that can be present in diabetic patients were related to either hyperglycemia or hypoglycemia.21 Rizzo et al22 found a correlation between second- and third-trimester maternal glycemia levels and behavior in newborns of DM. They reported a correlation between maternal beta-hydroxybutyrate levels and child neurologic development evaluated at ages 2 to 6 and 9 years. The frequency of major psychomotor alterations in children of diabetic mothers at the end of adolescence is not higher than that of the general population. However, in adolescents of DM, the lowest indexes of psychomotor and cognitive development were associated with worse maternal metabolic control.23 The evaluating presentation of hippocampal neurogenesis has changed the concept of brain plasticity24 and attracted considerable attention because of its role in cognitive functions such as learning and memory.25 The hippocampus is injured in both hypoxia-ischemia and perinatal iron deficiency, which are comorbidities in infants of diabetic mothers and intrauterine growth restricted infants.26 Siddappa et al27 suggest that impaired auditory recognition memory found in IDM may be related with brain iron deficits, which would adversely affect hippocampus function in the perinatal period. 496
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Previous studies performed with a streptozotocin model of type 1 diabetes suggested that DM is associated with lower neuronal production, proliferation, and survival.28 Stranahan et al29 demonstrated that, in both insulin-deficient rats and insulin-resistant mice, diabetes impairs hippocampus-dependent memory, perforant path synaptic plasticity and adult neurogenesis, and adrenal steroid corticosterone contributes to these adverse effects. These results may shed light on causes of diabetic neuropathology and provide an explanation for the memory deficiencies seen in some adult patients with diabetes. The effect of maternal diabetes on fetal neurogenesis at the hippocampus level could be related with impaired habituation ability that we have found in babies from diabetic mothers.
REFERENCES 1. Dandel ER, Schwartz JH, Jessell TM. Cellular mechanisms of learning and the bilogical basis of individuality. Principles of Neural Science. Fourth Ed. McGraw-Hill; 2000:1248-79. 2. Morokuma S, Fukushima K, Kkawai N, Tomonaga M, Satoh S, Nakano H. Fetal habituation correlates with functional brain development. Behav Brain Res 2004; 153:459-63. 3. Leader LR, Baillie P. The changes in fetal habituation patterns due to a decrease inspired maternal oxygen. Br J Obstet Gynecol 1988;95:664-8. 4. Duarte JM, Oses JP, Rodrigues RJ, Cunha RA. Modification of purinergic signaling in the hippocampus of streptozotocin-induced diabetic rats. Neuroscience 2007;149:382-91. 5. Gonzalez Gonzalez NL, Ramírez O, Mozas J, Melchor JC, Armas H, García Hernández JA, et al. Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus. Acta Obstet Gynecol Scand 2007;87:43-9. 6. Ornoy A. Growth and neurodevelopmental outcome of children born to mothers with pregestational and gestational diabetes. Pediatr Endocrinol Rev 2005; 2:104-113. 7. Dahlaquist G, Kallen B. School marks for Swedish children shoes mothers had diabetes during pregnancy: a population based study. Diabelología 2007;50:1826-31. 8. González González NL, Suárez MN, Pérez Piñero B, Armas H, Doménech E. Persistent of fetal memory into neonatal life. Acta Obstet Gynecol Scand 2006; 85;1032-6. 9. James DK, Spencer CJ, Stepsis BW. Fetal learning: a prospective randomized controlled study. Ultrasound Obstet Gynecol 2002;20:431-8. 10. Doherty NN, Hepper PH. Habituation in fetuses of diabetic mothers. Early Hum Dev 2000;59:85-93. 11. Groome LJ, Singh KP, Burgard SL, Neely CL, Deason MA. Motor responsivity during habituation testing of normal human fetuses. J Perinatal Med 1995;23:159-66. 12. Van Heteren CF, Boekkooi PF, Jongsma HW, Nijhuis JG. Fetal learning and memory. Lancet 2000;356:1169-70. 13. Mulder EH, O’Brien MJ, Lems YL, Visser GH, Prechtl HF. Body and breathing movements in near-term fetuses and newborn infants of type-1 diabetic women. Early Hum Dev 1990;24:131-52. 14. Kainer F, Prechtl HF, Engele H, Einspieler C. Assessment of the quality of general movements in fetuses and infants of women with type-1 diabetes mellitus. Early Hum Dev 1997;50:13-25. 15. Allen CL, Kisilevsky BS. Fetal behaviour in diabetic and non-diabetic women: an exploratory study. Dev Psycobiol 1999;35:69-80. 16. Mulder EH, Visser GH, Bekedam DJ, Prechtl HF. Emergence of behavioural states in fetuses of type-1 diabetic women. Early Hum Dev 1987;15:231-51. 17. González González NL, Váquez P, Jimenez A, Caballero A, Parache J. Estados de comportamiento intrautero en los hijos de madres con diabetes tipo I. Prog Obstet Gynecol 2001;9:368-74. 18. DeRegnier RA, Nelson CA, Thomas KM, Wewerka S, Georgieff MK. Neurophysiologic evaluation of auditory recognition memory in healthy newborn infants and infants of diabetic mothers. J Pediatr 2000;37:777-84. 19. DeRegnier RAO, Georgieff MK, Nelson CA. Visual event-related brain potentials in 4 month old infants at risk for neurodevelopmental impairments. Dev Psychobiol 1997;30:11-28. 20. Nelson CA, Wewerka SS, Borscheid AJ, DeRegnier RA, Georgieff MK. Electrophysiologic evidence of impaired cross-modal recognition memory in 8 month-old infants of diabetic mothers. J Pediatr 2003;142:575-82. 21. Wessels AM, Scheltens P, Barkhof F, Heine RJ. Hyperglycaemia as a deter-
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minant of cognitive decline in patients with type 1 diabetes. Eur J Pharmacol 2008;585:88-96. 22. Rizzo T, Freinkel N, Metzger BE, Hatcher R, Burns J, Barglow P. Correlations between antepartum maternal metabolism and newborn behavior. Am J Obstet Gynecol 1990;163:1458-64. 23. Rizzo T, Mettger Burns WJ, Burns K. Correlations between antepartum maternal metabolism and child intelligence. N Engl J Med 1991;325:911-6. 24. Waddell J, Shors TJ. Neurogenesis, learning and associative strength. Eur J Neurosci 2008;2:3020-8. 25. Becker S, Wojtowicz JM. A model of hippocampal neurogenesis in memory and mood disorders. TICS 2007;11:70-6.
26. Rao R, Tkac I, Townsend EL, Ennis K, Gruetter R, Georgieff MK. Perinatal iron deficiency predisposes the developing rat hippocampus to greater injury from mild to moderate hypoxia-ischemia. J Cereb Blood Flow Metab 2007;27:729-40. 27. Sidappa AM, Georgieff MK, Weweka S, Worwa C, Nelson CA, DeRegnier RA. Iron deficiency alters auditory recognition memory in newborn infants of diabetic mothers. Pediatr Res 2004;55:1034-41. 28. Zhang WJ, Tan YF, Vranic M, Wojtowicz JM. Impairment of hippocampal neurogenesis in streptozotocin treated diabetic rats. Acta Neurol Scand 2008;117:205-10. 29. Stranahan AM, Arumugam TV, Cutler RG, Lee K, Egan JM, Mattson MP. Diabetes impairs hippocampal function through glucocorticoid-mediated effects on new and mature neurons. Nat Neurosci 2008;11:309-17.
50 Years Ago in The Journal of Pediatrics HEMANGIOMA
WITH
THROMBOCYTOPENIA
Dargeon HW, Adiao AC, Pack GT. J Pediatr 1959;54:285-95
In 1940, Kasabach and Merritt were the first to report the association of a “capillary hemangioma” with profound thrombocytopenia.1 This association is re-addressed in Dargeon’s article almost 20 years later, in which the cases of 14 patients with “hemangiomas” and thrombocytopenia were reviewed. Critical observations were noted: most lesions occurred in early infancy; splenectomy, although performed in half the patients, was not effective; steroids helped in some cases; and irradiation was successful in half the patients. It was not until 1982 that a classification system was proposed for vascular anomalies,2 and not until 1997 that tumors called Kaposiform hemangioendotheliomas and tufted angiomas were identified as the “hemangiomas” that caused profound thrombocytopenia.3 For many “vascular anomaly specialists,” the patients identified in Dargeon’s paper had a spectrum of vascular anomalies (tumors, malformations, congenital hemangiomas) and not the more common infantile hemangioma. Fifty years later, we have made some progress. Steroids are used for the treatment of hemangiomas and other vascular tumors with varying response, but other therapies such as vincristine and anti-angiogenic agents are beginning to be studied in clinical trials verses retrospective case reports.4 The genetic and biologic characteristics of these anomalies are being investigated with vigor. Organizations such as the International Society for the Study of Vascular Anomalies (ISSVA) and patient support groups have helped with the new interest in this expanding field. Currently, the proper care of patients with vascular anomalies requires the expertise of multiple medical specialists with clinical acumen in surgery, radiology, dermatology, hematology, oncology, pathology, neurology, cardiology, gastroenterology, and basic sciences. This comprehensive multidisciplinary approach offers the best opportunity for proper diagnosis, management, and scientific progress in this field. Denise M. Adams, MD Associate Professor of Pediatrics Medical Director of the Hemangioma and Vascular Malformations Center Inpatient Clinical Director Cincinnati Children’s Hospital Medical Center University of Cincinnati Cincinnati, Ohio 10.1016/j.jpeds.2008.09.045
REFERENCES 1. Kasabach H, Merritt K. Capillary hemangioma with extensive purpura: report of a case. Am J Dis Child 1940;59:1063-70. 2. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982;69:412-22. 3. Sarkar M, Mulliken JB, et al. Thrombocytopenic coagulopathy (Kasabach-Merritt phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma. Plast Reconstr Surg 1997;100:1377-86. 4. Adams DM, Wentzel MS. The role of the hematologist/oncologist in the care of patients with vascular anomalies. Pediatr Clin North Am 55:339-55 2008.
Fetal and Neonatal Habituation in Infants of Diabetic Mothers
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