Infant of a Diabetic Mother (IDM) NEWBORN.pptx

Infant of a Diabetic Mother (IDM) refers to any newborn born to a mother with pre-existing diabetes mellitus (type 1 or type 2) or gestational diabetes mellitus (GDM). These infants are at increased risk for several metabolic, structural, and perinatal complications due to exposure to maternal hyperglycemia during pregnancy.


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🧬 Pathophysiology

Maternal hyperglycemia → fetal hyperglycemia → fetal pancreatic β-cell hyperplasia → fetal hyperinsulinemia.

Insulin acts as a growth factor, leading to macrosomia (except in long-standing diabetes with placental insufficiency → growth restriction).


Reference: Hay Jr, W.W., Nelson Textbook of Pediatrics, 22nd ed., 2024.


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⚖️ Clinical Features

1. Growth

Macrosomia (birth weight >90th percentile)

“Round, plump, cushingoid appearance”

Large shoulders and trunk → risk of shoulder dystocia


Intrauterine growth restriction (IUGR) may occur if there is maternal vascular disease.



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2. Metabolic Complications

Complication Mechanism Timing Notes

Hypoglycemia Persistent fetal hyperinsulinemia after birth Within 1–3 hours of birth Most common; glucose <45 mg/dL
Hypocalcemia ↓ PTH response 24–72 hours May cause jitteriness, seizures
Hypomagnesemia Maternal urinary loss Often accompanies hypocalcemia May worsen hypocalcemia
Polycythemia Chronic intrauterine hypoxia → ↑ EPO At birth Can cause hyperbilirubinemia
Hyperbilirubinemia Due to polycythemia and hepatic immaturity 2–3 days Indirect type



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3. Cardiac Complications

Hypertrophic cardiomyopathy (HCM):

Due to insulin-induced myocardial hypertrophy (esp. interventricular septum)

May cause outflow obstruction

Usually transient, resolving within months


Congenital heart defects: 5–10× higher risk

Common: VSD, transposition of great arteries (TGA)




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4. Other Congenital Anomalies

More common in pre-existing diabetes (esp. poor glycemic control during organogenesis)

Common defects:

Neural tube defects (e.g., caudal regression syndrome — pathognomonic)

Cardiac anomalies (VSD, TGA)

Renal and skeletal anomalies




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🩺 Management

At Birth

Immediate blood glucose monitoring (within 30 min of birth)

Early feeding (breast milk preferred)

IV glucose if:

Asymptomatic: <25–40 mg/dL (depending on age)

Symptomatic: <45 mg/dL


Monitor for electrolyte abnormalities


Ongoing Care

Monitor:

Glucose, calcium, magnesium, hematocrit, bilirubin

Cardiac function (echocardiography if murmur or respiratory distress)


Manage per AAP & ADA guidelines for neonatal hypoglycemia and infants of diabetic mothers.



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🧠 Prognosis

Most metabolic abnormalities resolve within days.

Long-term risk: Obesity, type 2 diabetes, metabolic syndrome in later life.



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📚 Key References

1. Nelson Textbook of Pediatrics, 22nd Edition, 2024.


2. American Academy of Pediatrics (AAP). Management of Infants of Diabetic Mothers, Pediatrics, 2022.


3. American Diabetes Association (ADA). Standards of Medical Care in Diabetes—2024.


4. Hay WW

1. Infant of Diabetic Mother Dr.Mohsen AL- Solaimani

2. Introduction: Women with diabetes in pregnancy (type 1, type 2, and gestational) are at increased risk for adverse pregnancy outcomes with higher fetal & neonatal mortality rate at all gestational ages, especially after 32 wk.

3. Incidence: Globally , the incidence of diabetes is increasing. The International Diabetic Federation estimated that approximately 16% of babies born in 2015 were exposed to hyperglycemia, approximately 85% due to GDM, approximately 7.5% due to PGDM (type 1 or type 2), and 7.4% due to other types of diabetes .

4. Pathophysiology: Maternal hyperglycemia → fetal hyperglycemia → hypertrophy and hyperplasia of the pancreatic islet β-cells → fetal hyperinsulinemia → ↑ hepatic glucose uptake and glycogen synthesis, accelerated lipogenesis with low free fatty acids, and augmented protein synthesis → macrosomia & visceromegally (except brain). In contrast, if diabetes is complicated by vascular disease, the newborn may be growth restricted , especially those born after 37 wk of gestation.

5. Specific disorders frequently encountered in the infant of a diabetic mother: All of these disorders/diseases occur in GDM, T1DM, and T2DM, with the exception of congenital malformations (does not occur in GDM because it presents after the first trimester). Fetal risk is significantly higher in mothers with T1DM and T2DM than mothers with GDM :

6. A. Disorders of growth: Macrosomia. Macrosomia is the classic presentation of the infant of a poorly controlled diabetic mother. After 20 weeks’ gestation, maternal hyperglycemia leads to macrosomia. Macrosomia occurs in >25% of diabetic pregnancies and plays a role in birth injuries. Fetal growth restriction. Mothers with renal, retinal, or cardiac diseases are more likely to have small for gestational age (SGA) or premature infants, poor fetal outcome, fetal distress, or fetal death.

7. Birth injuries : More common: Shoulder dystocia, brachial plexus injury, clavicle/ humerus fracture, perinatal asphyxia (difficult delivery, intrauterine hypoxia). Less common: Facial palsy, subdural hemorrhage, cephalohematoma .

8. Metabolic disorders : Hypoglycemia. Hypoglycemia is defined as a blood glucose level <45 mg/ dL in a preterm or term infant. Hypocalcemia. Hypocalcemia has varying definitions, but serum levels of <7 mg/ dL and ionized calcium levels <4 mg/ dL are considered to be hypocalcemic . Hypomagnesemia. A serum magnesium level <1.52 mg/ dL in any infant indicates hypomagnesemia.

9. Cardiorespiratory disorders : Perinatal asphyxia. Respiratory distress syndrome: . Most cases are the result of premature delivery, delayed maturation of pulmonary surfactant production, or delivery by elective cesarean section. Fetal lung maturity. Pulmonary surfactant production in the IDM is deficient or delayed .

10. Hematologic disorders: Hyperbilirubinemia . Bilirubin production is increased in the IDM. Polycythemia and hyperviscosity . The cause of polycythemia is unclear but may be related to increased levels of erythropoietin in the IDM and increased RBC production secondary to chronic intrauterine hypoxia in mothers with vascular disease. Renal venous thrombosis (RVT) is a rare complication. The most likely causes include hyperviscosity , hypotension, or disseminated intravascular coagulation.

11. Congenital malformations: occur more frequently in IDMs than in the general population. These malformations account for a significant portion of perinatal deaths. Risk of a major malformation is approximately 5% to 6% in mothers with hyperglycemia and 10% to 12% in mothers requiring insulin therapy.

12. Risk factors: The following factors or conditions may be associated with an increased risk for problems in IDMs Maternal class of diabetes : In gestational diabetes and class A diabetes controlled by diet alone, infants have few complications. Women with class A diabetes controlled with insulin and class B, C, and D diabetes are prone to deliver macrosomic infants if diabetes is inadequately controlled. Diabetic women with renal, retinal, cardiac, and vascular disease have the most severe fetal problems .

13. Hemoglobin A1c: To decrease perinatal morbidity and mortality, the diabetic woman should attempt to achieve good metabolic control before conception. Elevated hemoglobin A1c (normal <5.7%) levels during the first trimester appear to be associated with a higher incidence of congenital malformations Diabetic ketoacidosis. Pregnant women requiring insulin are apt to develop diabetic ketoacidosis

14. Preterm labor: Preterm delivery occurs more frequently in diabetic pregnancies. Premature onset of labor in a diabetic woman is a serious problem because of the increased likelihood of RDS in the fetus Immature fetal lung profile :. Medical indications for late preterm and early term deliveries include PGDM with vascular disease and PGDM or GDM that is poorly controlled. Infants delivered during the late preterm and early term have an increased rate of respiratory morbidity

15. Clinical presentation of the infant of a diabetic: During birth: the infant may be LGA or, if the mother has vascular disease, SGA After birth: hypoglycemia can present as lethargy, poor feeding, apnea, or jitteriness in the first 6 to 12 hour after birth. Jitteriness that occurs after 24 hours of age may be the result of hypocalcemia or hypomagnesemia. Signs of respiratory distress secondary to immature lungs, Cardiac disease and abdominal distension and delayed passage of meconium (small left colon syndrome).

16. Diagnostic testing of the infant of a diabetic mother : A. Laboratory studies. The following tests must be closely monitored in the IDM: Serum glucose levels: should be checked at delivery and may be needed frequently over the first 48 hours . Serum calcium levels : are often checked in the first day of life. If serum calcium levels are low, serum magnesium levels should be obtained because they may also be low The hematocrit is often checked at birth and again at 24 hours of life . Serum bilirubin levels should be checked as indicated by physical examination .

17. Radiologic studies: are not necessary unless there is evidence of cardiac, respiratory, gastrointestinal, or skeletal problems . Electrocardiography and echocardiography: should be performed if hypertrophic cardiomyopathy or a cardiac malformation is suspected

18. Management of the infant of a diabetic mother : Initial evaluation: A physical examination should be performed, paying particular attention to the heart, kidneys, lungs, and extremities. Look for any evidence of birth trauma and closely look for any major or minor malformations. Continuing evaluation. Over the first several hours after delivery, the infant should be screened for hypoglycemia and assessed for signs of respiratory distress. During the first 48 hours, observe for signs of jaundice .

19. Metabolic management : Hypoglycemia: AAP recommends screening for late preterm and term IDM/ LGA infants and has specific guidelines for management of hypoglycemia in those groups. The Pediatric Endocrine Society has published new recommendations for hypoglycemia in neonates

20. Persistent hypoglycemia . Continue IV glucose and increase the rate of IV glucose to 16 to 20 mg/kg/min. Rates >20 mg/kg/min are usually not helpful . Diazoxide . First treatment of choice for persistent/pathologic hypoglycemia . Octreotide . A long-acting analog of somatostatin ; starting dose is 2 to 10 mcg/kg/d subcutaneously divided every 6–12 hoursor by continuous IV infusion. Glucagon . Used if the infant has good glycogen stores. It converts stores of glycogen to glucose. Usually it is only given in temporary situations ( eg , waiting for IV/central line access, waiting for surgery, used with octreotide in short-term stabilization of infants with hyperinsulinemia ). Lower dose of 0.02 to 0.30 mg/kg/dose IV may work. PES recommends using a 0.5- to 1.0-mg dose (independent of weight) IV, IM, or subcutaneously

21. Nifedipine reduces glucose tolerance and insulin secretion. It has been used in some infants, but because of severe hypotension and lack of longterm experience , it is not used often. Sirolimus has been used in a few infants unresponsive to high doses of diazoxide and octreotide with promising results. Medications for endocrine deficiency disorders. GH should be used if there is a GH deficiency. Epinephrine can be used in epinephrine deficiency.Zinc protamine glucagon is indicated for infants with glucagon deficiency . Steroid if Congenital hypopituitarism suspected. Pancreatic surgery.

22. Hypocalcemia: Calcium therapy. Symptomatic infants should receive 10% calcium gluconate intravenously. The infusion should be given slowly to prevent cardiac arrhythmias The hypocalcemia should respond in 3 to 4 days; until then, serum calcium levels should be monitored every 12 to 24 hours. Magnesium maintenance therapy. Magnesium is usually added to intravenous fluids or given orally as magnesium sulfate.

23. Management of cardiorespiratory problems: Perinatal asphyxia. Close observation for fetal distress should continue throughout labor and delivery Respiratory distress. Management of respiratory distress depends on the etiology. RDS, TTN, and other conditions are more common in the IDM. Provide oxygen and ventilator support as needed initially. Treatment depends on the etiology. Hypertrophic cardiomyopathy associated with DM is self-limited and usually resolves within 6 months. Therapy includes possible mechanical ventilation, maintenance fluids, and correction of hypoglycemia and hypomagnesemia; if medication is necessary, the treatment of choice is short-acting β-blockers ( esmolol , propranolol ). Diuretics are not necessary unless there is fluid overload. If pulmonary hypertension is present, inhaled nitric oxide should be considered.

24. Hematologic management : Hyperbilirubinemia : Phototherapy and exchange transfusion for infants with hyperbilirubinemia Polycythemia: Observation and/or fluids and/or partial exchange transfusion depending on the hematocrit and clinical symptoms Renal venous thrombosis: Treatment consists of appropriate fluid management and close monitoring of electrolytes and renal status.

25. Management of morphologic and functional problems : Macrosomia and birth injury : Fractures of the extremities should be treated with immobilization. Brachial plexus injuries are usually treated with physical therapy involving range-of-motion and strengthening exercises or possible reconstruction surgery if not resolved. . Congenital malformations. If a gross malformation is discovered, a specialist should be consulted.

26. Prognosis: Less morbidity and mortality occur with adequate control during the diabetic pregnancy. . The increased risk of subsequent diabetes in the infants of these women is at least 10 times greater than in the general population, suggesting the need for lifelong follow-up.