Metabolic adaptation at birth

Evolution of Newborns' Urinary Metabolomic Profiles According to Age and Growth

Improving the management of neonatal diseases and prevention of chronic diseases in adulthood requires a better comprehension of the complex maturational processes associated with newborns' development. Urine-based metabolomic studies play a promising role in the fields of pediatrics and neonatology, relying on simple and noninvasive collection procedures while integrating a variety of factors such as genotype, nutritional state, lifestyle, and diseases. Here, we investigate the influence of age, weight, height, and gender on the urine metabolome during the first 4 months of life. Untargeted analysis of urine was carried out by ¹H-Nuclear Magnetic Resonance (NMR) spectroscopy for 90 newborns under 4 months of age, and free of metabolic, nephrologic, or urologic diseases. Supervised multivariate statistical analysis of the metabolic profiles revealed metabolites significantly associated with age, weight, and height, respectively. The tremendous growth occurring during the neonatal period is associated with specific modifications of newborns' metabolism. Conversely, gender appears to have no impact on the urine metabolome during early infancy. These results allow a deeper understanding of newborns' metabolic maturation and underline potential confounding factors in newborns' metabolomics studies. We emphasize the need to systematically and precisely report children age, height, and weight that impact urine metabolic profiles of infants.

Insulin resistance, glucagon-like peptide-1 and factors influencing glucose homeostasis in neonates

OBJECTIVES

To explore the relationships between postmenstrual age (PMA), insulin, C-peptide, glucagon and blood glucose concentrations (BGCs) in preterm and term neonates. To compare glucagon-like peptide-1 (GLP-1) concentrations in fed versus never-fed neonates.

DESIGN

Observational.

SETTING

Dunedin Hospital Neonatal Intensive Care Unit, New Zealand.

PATIENTS

Term or preterm euglycaemic neonates (102) receiving routine blood tests (343 samples).

INTERVENTIONS

None: plasma was obtained from surplus samples from routine clinical care.

MAIN OUTCOME MEASURES

Insulin, C-peptide, GLP-1 and glucagon concentrations were measured in temporal association with BGC.

RESULTS

Insulin and C-peptide concentrations were elevated in very preterm infants (PMA≤32 weeks) and decreased to term; this relationship persisted when BGCs were accounted for. Generalised linear mixed models showed that insulin:C-peptide ratio and insulin:BGC ratio decreased significantly with increasing PMA (p<0.001). GLP-1 increased following initial oral feeds regardless of PMA (p<0.001).

CONCLUSION

Preterm neonates exhibit insulin resistance in the absence of hyperglycaemia. Enteral feeds result in an increase in GLP-1. These factors are likely to contribute to the increased risk of hyperglycaemia in premature neonates (PMA<32 weeks).

The Successful Immediate Neonatal Transition to Extrauterine Life

Purpose:

To define and describe the processes underlying the successful neonatal transition to extrauterine life and methods to assess the transition.

Method:

Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, and Google Scholar were searched using a combination of the key words neonate, neonatal, newborn, transition, respiratory OR pulmonary, cardiac, metabolic, pH, umbilical cord, and assessment. Articles in English and German were reviewed. The final sample of articles consisted of one randomized controlled trial, 30 observational studies using human neonates, one observational study using rabbit pups, one secondary analysis, three systematic reviews, and 23 review articles.

Major Findings:

The pertinent findings in regard to normal events in the respiratory, cardiovascular, and metabolic transitions are reviewed and summarized. We address the underlying factors necessary for the transition to extrauterine life, specify the consequences of a successful transition, and review common assessment approaches.

Conclusion:

Available evidence indicates that the successful immediate transition to extrauterine life should be completed within 1–3 hr after birth, though some adaptive processes can fail as late as 24–48 hr after birth. Further research is necessary to identify a feasible, easily used, noninvasive method to assess the status of a neonate’s transition to extrauterine life.

Impact of transient period of metabolic adaptation on perinatal asphyxia in neonates with intrauterine growth retardation

INTRODUCTION

Temperature, glycemia and respiration make neonatal energy triangle (NET). In growth retardation (IUGR) neonates pathological metabolic adaptation exists in transient neonatal period.

AIM

The of this study was to examine the occurrence of pathological NET and check its impact on perinatal asphyxia during the transient period in IUGR neonates.

MATERIAL AND METHODS

One hundred and fifty-nine neonates with IUGR were classified into - early preterm, late preterm and term neonates. By the presence of hypothermia, hypoglycemia and hypoxia in the first hour after birth neonates were classified into: group of pathological NET, group of unstable NET and group of stable NET. We analyzed distribution per body mass, gestational age, type of IUGR, gender and the frequency of perinatal asphyxia between the groups.

RESULTS

The late preterm neonates were the most frequent in the group of pathological NET. Perinatal asphyxia was diagnosed in 52 (32.7%) neonates, with highest frequency in the group of pathological NET. Univariate binary logistic regression analysis showed that pathological NET in neonates with IUGR is significant predictor for perinatal asphyxia occurrence (OR = 8.57; CI = 4.05-18.12; p < 0.001 R² = 0.27).

CONCLUSION

Poor metabolic adaptation in neonates with IUGR in the first hour after birth is significant risk factor for the perinatal asphyxia.

Fetal Physiology and the Transition to Extrauterine Life

The physiology of the fetus is fundamentally different from the neonate, with both structural and functional distinctions. The fetus is well-adapted to the relatively hypoxemic intrauterine environment. The transition from intrauterine to extrauterine life requires rapid, complex, and well-orchestrated steps to ensure neonatal survival. This article explains the intrauterine physiology that allows the fetus to survive and then reviews the physiologic changes that occur during the transition to extrauterine life. Asphyxia fundamentally alters the physiology of transition and necessitates a thoughtful approach in the management of affected neonates.

Indices of Glucose Homeostasis in Cord Blood in Term and Preterm Newborns

OBJECTIVE

According to the thrifty phenotype hypothesis, intrauterine malnutrition has a role in the etiology of type 2 diabetes. This study was planned to determine the early alterations in indices of glucose homeostasis (glucose, insulin, and cortisol) in term and preterm newborns and the correlations of glucose, insulin, and cortisol levels with insulin resistance indices.

METHODS

A descriptive study comprising 35 term and 35 preterm newborns was carried out from December 2013 to June 2015. Venous cord blood was collected and plasma glucose was analyzed by the glucose oxidase-peroxidase method in an auto analyzer. Serum insulin and cortisol levels were assessed by the enzyme-linked immunosorbent assay. Homeostasis model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity check index and glucose insulin ratio were calculated to assess insulin resistance. The data on physical and metabolic parameters were analyzed using standard tests for statistical significance.

RESULTS

In term newborns, mean glucose and cortisol levels (83.6±17.4 mg/dL and 11.88±5.78 µg/dL, respectively) were significantly higher than those in preterm infants (70.4±15.8 mg/dL and 8.9±4.6 µg/dL, respectively). Insulin and HOMA-IR levels were found higher in preterm newborns (10.8±4.8 µIU/mL and 1.52±0.66, respectively) than in term newborns (7.9±2.7 µIU/mL and 1.19±0.29, respectively). Insulin was found to positively correlate with HOMA-IR, whereas cortisol was negatively correlated with HOMA-IR in both term and preterm newborns.

CONCLUSION

Higher insulin levels and HOMA-IR values in the cord blood of preterm newborns support the theory of intrauterine origin of metabolic diseases.

The effects of therapeutic hypothermia on cerebral metabolism in neonates with hypoxic-ischemic encephalopathy: An in vivo 1H-MR spectroscopy study

Therapeutic hypothermia has emerged as the first empirically supported therapy for neuroprotection in neonates with hypoxic-ischemic encephalopathy (HIE). We used magnetic resonance spectroscopy ((1)H-MRS) to characterize the effects of hypothermia on energy metabolites, neurotransmitters, and antioxidants. Thirty-one neonates with HIE were studied during hypothermia and after rewarming. Metabolite concentrations (mmol/kg) were determined from the thalamus, basal ganglia, cortical grey matter, and cerebral white matter. In the thalamus, phosphocreatine concentrations were increased by 20% during hypothermia when compared to after rewarming (3.49 ± 0.88 vs. 2.90 ± 0.65, p < 0.001) while free creatine concentrations were reduced to a similar degree (3.00 ± 0.50 vs. 3.74 ± 0.85, p < 0.001). Glutamate (5.33 ± 0.82 vs. 6.32 ± 1.12, p < 0.001), aspartate (3.39 ± 0.66 vs. 3.87 ± 1.19, p < 0.05), and GABA (0.92 ± 0.36 vs. 1.19 ± 0.41, p < 0.05) were also reduced, while taurine (1.39 ± 0.52 vs. 0.79 ± 0.61, p < 0.001) and glutathione (2.23 ± 0.41 vs. 2.09 ± 0.33, p < 0.05) were increased. Similar patterns were observed in other brain regions. These findings support that hypothermia improves energy homeostasis by decreasing the availability of excitatory neurotransmitters, and thereby, cellular energy demand.

Hyperketonemia and ketosis increase the risk of complications in type 1 diabetes

Diets that boost ketone production are increasingly used for treating several neurological disorders. Elevation in ketones in most cases is considered favorable, as they provide energy and are efficient in fueling the body's energy needs. Despite all the benefits from ketones, the above normal elevation in the concentration of ketones in the circulation tend to illicit various pathological complications by activating injurious pathways leading to cellular damage. Recent literature demonstrates a plausible link between elevated levels of circulating ketones and oxidative stress, linking hyperketonemia to innumerable morbid conditions. Ketone bodies are produced by the oxidation of fatty acids in the liver as a source of alternative energy that generally occurs in glucose limiting conditions. Regulation of ketogenesis and ketolysis plays an important role in dictating ketone concentrations in the blood. Hyperketonemia is a condition with elevated blood levels of acetoacetate, 3-β-hydroxybutyrate, and acetone. Several physiological and pathological triggers, such as fasting, ketogenic diet, and diabetes cause an accumulation and elevation of circulating ketones. Complications of the brain, kidney, liver, and microvasculature were found to be elevated in diabetic patients who had elevated ketones compared to those diabetics with normal ketone levels. This review summarizes the mechanisms by which hyperketonemia and ketoacidosis cause an increase in redox imbalance and thereby increase the risk of morbidity and mortality in patients.

Prenatal Exposure to Bisphenol A Disrupts Mouse Fetal Liver Maturation in a Sex-Specific Manner

Bisphenol A (BPA) is one of the most prevalent endocrine disrupting chemicals in the environment. Developmental exposure to BPA is known to be associated with liver dysfunction and diseases, such as hepatic steatosis, liver tumors, metabolic syndrome, and altered hepatic gene expression, and DNA methylation profiles. However, the effects of BPA on rodent liver development are unknown. The present study was undertaken to address this important question using the mouse as an experimental model. Pregnant mice were exposed to BPA via diet from embryonic day 7.5 (E7.5) to E18.5. At E18.5, fetal livers were collected, and analyzed for changes in the expression of key hepatocyte maturation markers. We found the following significant alterations in BPA-exposed female but not male fetal livers: (a) levels of the mature hepatocyte markers, albumin and glycogen synthase proteins, were decreased (-65% and -40%, respectively); (b) levels of the immature hepatocyte marker, α-fetoprotein, were increased (+43%); (c) the level of C/EBP-α protein, the master transcription factor essential for hepatocyte maturation, was down-regulated (-50%); and (d) the level of PCNA protein (marker of proliferation) was elevated (+40%), while that of caspase-3 protein and activity (markers of apoptosis) was reduced (-40% and -55%, respectively), suggestive of a perturbed balance between cell proliferation and apoptosis in BPA-exposed female fetuses. Taken together, these findings demonstrate that prenatal exposure to BPA disrupts the mouse fetal liver maturation in a sex-specific manner, and suggest a fetal origin for BPA-induced hepatic dysfunction and diseases.

Common genetic and epigenetic syndromes

Cytogenetic anomalies should be considered in individuals with multiple congenital anomalies. DNA methylation analysis is the most sensitive initial test in evaluating for Prader-Willi and Angelman syndromes. The timely identification of cytogenetic anomalies allows for prompt initiation of early intervention services to maximize the potential of every individual as they grow older. Although many of these conditions are rare, keeping them in mind can have a profound impact on the clinical course of affected individuals. This article reviews some of the more common genetic syndromes.

Reliability of reagent strips for semi-quantitative measurement of glucosuria in a neonatal intensive care setting

BACKGROUND

Glucosuria in preterm infants is often measured using a visually readable reagent strip, e.g., when monitoring total parenteral nutrition or during sepsis or when treating with corticosteroids. However, the specific circumstances in a neonatal intensive care unit (NICU), such as the use of diapers and the high temperature in incubators, could affect its reliability.

OBJECTIVES

To evaluate the reliability of the semi-quantitative measurement of glucosuria under the specific circumstances of a NICU setting.

METHODS

Nine hundred assessments of artificially supplemented (contrived) urine samples, intended to simulate pathological specimens, were performed under the following varying conditions: environmental temperature (21°C and 34°C); different times of contact of the urine with the diaper; and using two different methods of collecting urine from the diaper. Each reagent strip was read independently by three observers. The test strips scores were categorized as 0, 1+, 2+, 3+, or 4+ in ascending degree of glucosuria.

RESULTS

Agreement was excellent under all the different conditions (temperature, weighted kappa (κ(w)) = 0.92; method of urine collection, κ(w) = 0.88; time, p = 0.266). Inter-observer reliability was very good (multi-rater κ = 0.81). The deviation between the different conditions was seldom larger than one category (2.9%). The reagent strip readings were concordant with the true urinary glucose concentrations in 79.0% of assessments. The discordance was never larger than one category.

CONCLUSION

The reliability of the semi-quantitative measurement of glucosuria in newborn infants using reagent strips is good, even under the conditions of a NICU. Changes in the rating of reagent strips of more than one category are most likely to be beyond measurement error.

Impairments of hepatic gluconeogenesis and ketogenesis in PPARα-deficient neonatal mice

Peroxisome proliferator activated receptor-α (PPARα) is a master transcriptional regulator of hepatic metabolism and mediates the adaptive response to fasting. Here, we demonstrate the roles for PPARα in hepatic metabolic adaptations to birth. Like fasting, nutrient supply is abruptly altered at birth when a transplacental source of carbohydrates is replaced by a high-fat, low-carbohydrate milk diet. PPARα-knockout (KO) neonatal mice exhibit relative hypoglycemia due to impaired conversion of glycerol to glucose. Although hepatic expression of fatty acyl-CoA dehydrogenases is imparied in PPARα neonates, these animals exhibit normal blood acylcarnitine profiles. Furthermore, quantitative metabolic fate mapping of the medium-chain fatty acid [(13)C]octanoate in neonatal mouse livers revealed normal contribution of this fatty acid to the hepatic TCA cycle. Interestingly, octanoate-derived carbon labeled glucose uniquely in livers of PPARα-KO neonates. Relative hypoketonemia in newborn PPARα-KO animals could be mechanistically linked to a 50% decrease in de novo hepatic ketogenesis from labeled octanoate. Decreased ketogenesis was associated with diminished mRNA and protein abundance of the fate-committing ketogenic enzyme mitochondrial 3-hydroxymethylglutaryl-CoA synthase (HMGCS2) and decreased protein abundance of the ketogenic enzyme β-hydroxybutyrate dehydrogenase 1 (BDH1). Finally, hepatic triglyceride and free fatty acid concentrations were increased 6.9- and 2.7-fold, respectively, in suckling PPARα-KO neonates. Together, these findings indicate a primary defect of gluconeogenesis from glycerol and an important role for PPARα-dependent ketogenesis in the disposal of hepatic fatty acids during the neonatal period.

Diagnosis and management of hypotension in neonates

The diagnosis and management of hypotension in neonates is a frequently encountered issue in the intensive care setting. There is an ongoing debate as to the appropriateness of blood pressure monitoring as an indicator of organ perfusion and tissue hypoxia. These ultimately determine morbidity and mortality in the sick newborn. This article explores the methods available for the assessment of organ perfusion and speculates on other means that may become available in the future. Different modalities of treatment currently in use are discussed, with the aim of using information gained from perfusion monitoring techniques to determine the optimal choice of therapy.

High prevalence of severe circulatory complications with diazoxide in premature infants

BACKGROUND

Since diazoxide was approved for clinical use in Japan in 2008, its prescription for the treatment of infants with hyperinsulinemic hypoglycemia (HIH) has rapidly expanded. Concomitantly, reports of complications associated with diazoxide are increasing.

OBJECTIVES

To clarify the trends and problems associated with the treatment of infants with HIH, we planned a nationwide surveillance in Japan.

METHODS

Questionnaires were sent to 255 institutions belonging to the Japanese Neonatologist Association inquiring about neonatal cases of HIH from 2009 to 2011.

RESULTS

One hundred nineteen cases of neonates with transient HIH (THIH) related to perinatal problems and 15 cases with permanent HIH (PHIH; hypoglycemia persisting beyond a year) or genetic HIH were reported. Sixty-four infants (53.8%) with THIH were administered diazoxide, and the administration was completed within 3 months in 46 infants (71.9%). Fourteen of the PHIH or genetic cases were treated with diazoxide and 7 of them (50%) had hypoglycemia persisting beyond a year. Circulatory complications were reported in 15 infants, i.e. 10 with THIH and 5 with PHIH. Multiple regression analysis revealed that a younger gestational age at birth and higher maximum doses of diazoxide were significant risk factors for circulatory complications.

CONCLUSIONS

Diazoxide is widely prescribed for infants with HIH as a first-line medicine in Japan, but prophylactic diuretics are uncommon. Under these circumstances, a high prevalence of severe circulatory complications in very-low-birth-weight infants was reported.

Five steps to improve bedside breastfeeding care

Best postpartum breastfeeding practices must address the caloric needs of all infants, including vulnerable infants, while enabling long-term, exclusive breastfeeding. An adequate subsequent milk supply depends on early, frequent and effective colostrum removal. A combination of hand expression of colostrum, spoon-feeding and unrestricted breastfeeding provide more milk for infants and more stimulation for subsequent breast milk production. A sustainable, preventive practice model for low- and high-risk infants depends on elevating staff expertise and shifting the focus of lactation educators to address staff learning needs. We propose a five-step implementation program to achieve this.

Physiologic underpinnings for clinical problems in moderately preterm and late preterm infants

This article highlights some of the important developmental characteristics that underpin common problems seen in moderate and late preterm infants. Preterm birth is associated with an increased prevalence of clinical problems caused by functional immaturities in a wide variety of organ systems, acquired problems, and problems associated with inadequate monitoring and/or follow-up plans. There are variations in the degree of maturation among infants of similar gestational ages because the developmental process is nonlinear. Therefore, different organ systems mature at rates and trajectories that are specific to their functions. A better understanding of these principles can help guide optimal treatment strategies.

Differences in circulating carnitine status of preterm infants fed fortified human milk or preterm infant formula

OBJECTIVE

The aim of the study was to compare plasma carnitine profiles in fortified human milk (HM)-fed preterm infants or formula-fed preterm infants.

METHODS

Plasma acylcarnitine concentrations were determined in 20 formula-fed and 18 HM-fed preterm infants (birth weights between 1000 and 2200 g) by isotope dilution ESI MS/MS technique on study days 0, 14, and 28.

RESULTS

Concentrations of free carnitine (FC) and different acylcarnitines did not change during the 4 weeks of the study in infants fed HM. In contrast, in infants fed formula FC increased markedly (day 0: 29.989 [16.646] μmol/L, median [interquartile range], day 14: 43.972 [8.455], P < 0.05) along with increases of short-chain esters (C2 day 0: 5.300 [3.272], day 14: 6.773 [2.127], P < 0.05; C3 day 0: 0.070 [0.059], day 14: 0.110 [0.069], P < 0.05). In contrast, some medium-chain (C8:1, C12) and long-chain esters (C14, C16) decreased significantly in infant formula by day 14, whereas FC and C2 and C3 esters increased further by day 28 (FC: 47.672 [14.753], C2: 7.430 [4.688], C3: 0.107 [0.047]).

CONCLUSIONS

The altered carnitine ester profile likely reflects active involvement of the carnitine molecule in the buffering, metabolism, and elimination of nonphysiological acyl moieties.

Neonatal liver physiology

In the neonate, the liver is relatively immature and undergoes several changes in its functional capacity during the early postnatal period. The essential liver functions can be classified into three categories: metabolism, detoxification, and bile synthesis. In general, the immature liver function has limited consequences on the healthy term neonate. However, preterm neonates are particularly susceptible to the effects of the immature liver function placing them at risk of hypoglycemia, hyperbilirubinemia, cholestasis, bleeding, and impaired drug metabolism. An appreciation of the dynamic changes in liver function during the neonatal period is essential for successful management of neonates who require medical and surgical interventions. This review will focus on the neonatal liver function as well as the changes that the liver undergoes as it matures.

Audit of a clinical guideline for neonatal hypoglycaemia screening

AIM

This study aims to evaluate adherence to a clinical guideline for screening and prevention of neonatal hypoglycaemia on the post-natal wards.

METHODS

Retrospective chart review of 581 healthy term neonates born at a tertiary maternity hospital. Indications for hypoglycaemia screening included small for gestational age (SGA), infants of diabetic mothers (IDM; gestational, Type 1 or 2), symptomatic hypoglycaemia, macrosomia and wasted (undernourished) appearance. Outcomes were protocol entry and adherence with hypoglycaemia prevention strategies including early and frequent feeding and timely blood glucose measurement.

RESULTS

Of 115 neonates screened for hypoglycaemia, 67 were IDM, 19 were SGA (including two both IDM and SGA), and two were macrosomic. One IDM and one SGA were not screened. Twenty-two neonates were screened for a reason not identifiable from the medical record, and 13 neonates were SGA by a definition different to the guideline definition, including five who were also IDM. Guideline adherence was variable. Few neonates (41 of 106, 39%) were fed in the first post-natal hour, and blood glucose measurement occurred later than recommended for 41 of 106 (39%) of neonates.

CONCLUSIONS

Most IDM and SGA neonates were screened. While guideline adherence overall was comparable with other studies, neonates were fed late. We recommend staff education about benefits of early (within the first hour) frequent breastfeeding for neonates at risk.

Neuroprotective potential of Bacopa monnieri and Bacoside A against dopamine receptor dysfunction in the cerebral cortex of neonatal hypoglycaemic rats

Neonatal hypoglycaemia initiates a series of events leading to neuronal death, even if glucose and glycogen stores return to normal. Disturbances in the cortical dopaminergic function affect memory and cognition. We recommend Bacopa monnieri extract or Bacoside A to treat neonatal hypoglycaemia. We investigated the alterations in dopaminergic functions by studying the Dopamine D1 and D2 receptor subtypes. Receptor-binding studies revealed a significant decrease (p < 0.001) in dopamine D1 receptor number in the hypoglycaemic condition, suggesting cognitive dysfunction. cAMP content was significantly (p < 0.001) downregulated in hypoglycaemic neonatal rats indicating the reduction in cell signalling of the dopamine D1 receptors. It is attributed to the deficits in spatial learning and memory. Hypoglycaemic neonatal rats treated with Bacopa extract alone and Bacoside A ameliorated the dopaminergic and cAMP imbalance as effectively as the glucose therapy. The upregulated Bax expression in the present study indicates the high cell death in hypoglycaemic neonatal rats. Enzyme assay of SOD confirmed cortical cell death due to free radical accumulation. The gene expression of SOD in the cortex was significantly downregulated (p < 0.001). Bacopa treatment showed a significant reversal in the altered gene expression parameters (p < 0.001) of Bax and SOD. Our results suggest that in the rat experimental model of neonatal hypoglycaemia, Bacopa extract improved alterations in D1, D2 receptor expression, cAMP signalling and cell death resulting from oxidative stress. This is an important area of study given the significant motor and cognitive impairment that may arise from neonatal hypoglycaemia if proper treatment is not implemented.

1H NMR derived metabolomic profile of neonatal asphyxia in umbilical cord serum: implications for hypoxic ischemic encephalopathy

Neonatal hypoxic ischemic encephalopathy (HIE) is a severe consequence of perinatal asphyxia (PA) that can result in life-long neurological disability. Disease mechanisms, including the role and interaction of individual metabolic pathways, remain unclear. As hypoxia is an acute condition, aerobic energy metabolism is central to global metabolic pathways, and these metabolites are detectable using 1H NMR spectroscopy, we hypothesized that characterizing the NMR-derived umbilical cord serum metabolome would offer insight into the consequences of PA that lead to HIE. Fifty-nine at-risk infants were enrolled, together with 1:1 matched healthy controls, and stratified by disease severity (n=25, HIE; n=34, non-HIE PA). Eighteen of 37 reproducibly detectable metabolites were significantly altered between study groups. Acetone, 3-hydroxybutyrate, succinate, and glycerol were significantly differentially altered in severe HIE. Multivariate data analysis revealed a metabolite profile associated with both asphyxia and HIE. Multiple-linear regression modeling using 4 metabolites (3-hydroxybutyrate, glycerol, O-phosphocholine, and succinate) predicted HIE severity with an adjusted R2 of 0.4. Altered ketones suggest that systemic metabolism may play a critical role in preventing neurological injury, while altered succinate provides a possible explanation for hypoxia-inducible factor 1-α (HIF-1α) stabilization in HI injury.

Feasibility of using ultrasound to measure preterm body composition and to assess macronutrient influences on tissue accretion rates

BACKGROUND AND AIMS

To assess ultrasound as a method for (i) measuring body composition (BC) of preterm infants and for (ii) assessing the influence of macronutrient intakes on tissue accretion rates.

METHODS

Preterm ultrasound studies of four anatomical sites were performed approximately every three weeks from birth to corrected-term age. Preterm measurements were compared to foetal reference data. Duplicate scans at each site were taken on a subset of infants to test the reproducibility of the method, assessed as the coefficient of variation (CV). The influence of measured macronutrient intakes on preterm BC was assessed by regression analysis.

RESULTS

Median (range) gestation and birth weight of 40 preterm infants were 27 (23-29) weeks and 1022 (480-1475) g, respectively. Accretion rates of adipose and muscle tissues were not uniform across the four sites. Relative to the foetus, preterm adipose tissue thickness was reduced at an equivalent (corrected) gestation, but towards term, a faster accretion rate of subcutaneous abdominal adipose and limb muscle tissue was evident. Timing of fortification (p=0.012), enteral carbohydrate intake (p=0.008) and the protein energy ratio of intakes (p=0.038) moderated the ratio of adipose to muscle tissue accretion over the four sites by -0.004, -0.048 and -0.042, respectively.

CONCLUSIONS

Ultrasound provides a non-invasive, portable method of assessing changes in subcutaneous adipose tissue and muscle accretion and appears sufficiently sensitive to detect influences of macronutrient intakes on accretion rates from birth. The method warrants further investigation as a bedside tool for measuring BC of preterm infants.

Impact of peripheral ketolytic deficiency on hepatic ketogenesis and gluconeogenesis during the transition to birth

Preservation of bioenergetic homeostasis during the transition from the carbohydrate-laden fetal diet to the high fat, low carbohydrate neonatal diet requires inductions of hepatic fatty acid oxidation, gluconeogenesis, and ketogenesis. Mice with loss-of-function mutation in the extrahepatic mitochondrial enzyme CoA transferase (succinyl-CoA:3-oxoacid CoA transferase, SCOT, encoded by nuclear Oxct1) cannot terminally oxidize ketone bodies and develop lethal hyperketonemic hypoglycemia within 48 h of birth. Here we use this model to demonstrate that loss of ketone body oxidation, an exclusively extrahepatic process, disrupts hepatic intermediary metabolic homeostasis after high fat mother's milk is ingested. Livers of SCOT-knock-out (SCOT-KO) neonates induce the expression of the genes encoding peroxisome proliferator-activated receptor γ co-activator-1a (PGC-1α), phosphoenolpyruvate carboxykinase (PEPCK), pyruvate carboxylase, and glucose-6-phosphatase, and the neonate's pools of gluconeogenic alanine and lactate are each diminished by 50%. NMR-based quantitative fate mapping of (13)C-labeled substrates revealed that livers of SCOT-KO newborn mice synthesize glucose from exogenously administered pyruvate. However, the contribution of exogenous pyruvate to the tricarboxylic acid cycle as acetyl-CoA is increased in SCOT-KO livers and is associated with diminished terminal oxidation of fatty acids. After mother's milk provokes hyperketonemia, livers of SCOT-KO mice diminish de novo hepatic β-hydroxybutyrate synthesis by 90%. Disruption of β-hydroxybutyrate production increases hepatic NAD(+)/NADH ratios 3-fold, oxidizing redox potential in liver but not skeletal muscle. Together, these results indicate that peripheral ketone body oxidation prevents hypoglycemia and supports hepatic metabolic homeostasis, which is critical for the maintenance of glycemia during the adaptation to birth.

Successful adaptation to ketosis by mice with tissue-specific deficiency of ketone body oxidation

During states of low carbohydrate intake, mammalian ketone body metabolism transfers energy substrates originally derived from fatty acyl chains within the liver to extrahepatic organs. We previously demonstrated that the mitochondrial enzyme coenzyme A (CoA) transferase [succinyl-CoA:3-oxoacid CoA transferase (SCOT), encoded by nuclear Oxct1] is required for oxidation of ketone bodies and that germline SCOT-knockout (KO) mice die within 48 h of birth because of hyperketonemic hypoglycemia. Here, we use novel transgenic and tissue-specific SCOT-KO mice to demonstrate that ketone bodies do not serve an obligate energetic role within highly ketolytic tissues during the ketogenic neonatal period or during starvation in the adult. Although transgene-mediated restoration of myocardial CoA transferase in germline SCOT-KO mice is insufficient to prevent lethal hyperketonemic hypoglycemia in the neonatal period, mice lacking CoA transferase selectively within neurons, cardiomyocytes, or skeletal myocytes are all viable as neonates. Like germline SCOT-KO neonatal mice, neonatal mice with neuronal CoA transferase deficiency exhibit increased cerebral glycolysis and glucose oxidation, and, while these neonatal mice exhibit modest hyperketonemia, they do not develop hypoglycemia. As adults, tissue-specific SCOT-KO mice tolerate starvation, exhibiting only modestly increased hyperketonemia. Finally, metabolic analysis of adult germline Oxct1(+/-) mice demonstrates that global diminution of ketone body oxidation yields hyperketonemia, but hypoglycemia emerges only during a protracted state of low carbohydrate intake. Together, these data suggest that, at the tissue level, ketone bodies are not a required energy substrate in the newborn period or during starvation, but rather that integrated ketone body metabolism mediates adaptation to ketogenic nutrient states.

Ketone body metabolism and cardiovascular disease

Ketone bodies are metabolized through evolutionarily conserved pathways that support bioenergetic homeostasis, particularly in brain, heart, and skeletal muscle when carbohydrates are in short supply. The metabolism of ketone bodies interfaces with the tricarboxylic acid cycle, β-oxidation of fatty acids, de novo lipogenesis, sterol biosynthesis, glucose metabolism, the mitochondrial electron transport chain, hormonal signaling, intracellular signal transduction pathways, and the microbiome. Here we review the mechanisms through which ketone bodies are metabolized and how their signals are transmitted. We focus on the roles this metabolic pathway may play in cardiovascular disease states, the bioenergetic benefits of myocardial ketone body oxidation, and prospective interactions among ketone body metabolism, obesity, metabolic syndrome, and atherosclerosis. Ketone body metabolism is noninvasively quantifiable in humans and is responsive to nutritional interventions. Therefore, further investigation of this pathway in disease models and in humans may ultimately yield tailored diagnostic strategies and therapies for specific pathological states.

In utero fuel homeostasis: Lessons for a clinician

Fetus exists in a complex, dynamic, and yet intriguing symbiosis with its mother as far as fuel metabolism is concerned. Though the dependence on maternal fuel is nearly complete to cater for its high requirement, the fetus is capable of some metabolism of its own. The first half of gestation is a period of maternal anabolism and storage whereas the second half results in exponential fetal growth where maternal stores are mobilized. Glucose is the primary substrate for energy production in the fetus though capable of utilizing alternate sources like lactate, ketoacids, amino acids, fatty acids, and glycogen as fuel under special circumstances. Key transporters like glucose transporters (GLUT) are responsible for preferential transfers, which are in turn regulated by complex interaction of maternal and fetal hormones. Amino acids are preferentially utilized for growth and essential fatty acids for development of brain and retina. Insulin, insulin like growth factors, glucagon, catecholamines, and letpin are the hormones implicated in this fascinating process. Hormonal regulation of metabolic substrate utilization and anabolism in the fetus is secondary to the supply of nutrient substrates. The knowledge of fuel homeostasis is crucial for a clinician caring for pregnant women and neonates to manage disorders of metabolism (diabetes), growth (intrauterine growth restriction), and transitional adaptation (hypoglycemia).

Breastfeeding and its impact on daily life in women with type 1 diabetes during the first six months after childbirth: a prospective cohort study

BACKGROUND

For mothers with diabetes, breastfeeding is a great challenge due to their struggle with potentially unstable blood glucose levels. This paper explores breastfeeding attitudes and impact of breastfeeding on the daily life of mothers with type 1 diabetes compared with non-diabetic mothers.

METHODS

We performed a prospective cohort study of 108 mothers with type 1 diabetes and a reference group of 104 mothers in the west of Sweden. Data were collected through medical records and structured telephone interviews at 2 and 6 months after childbirth.

RESULTS

Women in both the diabetes group and the reference group had high levels of confidence (84% and 93% respectively) in their breastfeeding capacity before childbirth, and 90% assessed breastfeeding as a positive and an important experience during the six months of follow-up. About 80% assessed breastfeeding as influencing daily life 'very much' or 'quite a lot' at 2 months as did 60% at 6 months, with no difference between the groups. In mothers with diabetes, the impact of breastfeeding on the priority of other duties decreased over time, as did feelings of time pressure and negative effects on patterns of sleep. Compared to the reference group, mothers with diabetes at 6 months remained more affected by disruptions in daily life and they felt more worried about their health both at 2 and 6 months after childbirth. For the reference group mothers' sensitivity to unexpected disruptions in daily routines decreased between 2 and 6 months after childbirth, and they expressed a greater need to organize their time than mothers with diabetes.

CONCLUSION

Mothers with diabetes type 1 express more worry for own health and are more sensitive to distruptions. To balance their everyday life and to reduce the risk of stress and illhealth they are therefor, compared to other mothers, likely to need additional professional and peer support.

Physiology of transition from intrauterine to extrauterine life

The transition from fetus to newborn is the most complex adaptation that occurs in human experience. Lung adaptation requires coordinated clearance of fetal lung fluid, surfactant secretion, and onset of consistent breathing. The cardiovascular response requires striking changes in blood flow, pressures, and pulmonary vasodilation. Energy metabolism and thermoregulation must be quickly controlled. The primary mediators that prepare the fetus for birth and support the multiorgan transition are cortisol and catecholamine. Abnormalities in adaptation are frequently found following preterm birth or cesarean delivery at term, and many of these infants need delivery room resuscitation to assist in this transition.

Gene expression in sheep carotid arteries: major changes with maturational development

BACKGROUND

With development from immature fetus to near-term fetus, newborn, and adult, the cerebral vasculature undergoes a number of fundamental changes. Although the near-term fetus is prepared for a transition from an intra- to extra-uterine existence, this is not necessarily the case with the premature fetus, which is more susceptible to cerebrovascular dysregulation. In this study, we tested the hypothesis that the profound developmental and age-related differences in cerebral blood flow are associated with significant underlying changes in gene expression.

METHODS

With the use of oligonucleotide microarray and pathway analysis, we elucidated significant changes in the transcriptome with development in sheep carotid arteries.

RESULTS

As compared with adult, we demonstrate a U-shaped relationship of gene expression in major cerebrovascular network/pathways during early life, e.g., the level of gene expression in the premature fetus and newborn is considerably greater than that of the near-term fetus. Specifically, cell proliferation, growth, and assembly pathway genes were upregulated during early life. In turn, as compared with adult, mitogen-activated protein kinase-extracellular regulated kinase, actin cytoskeleton, and integrin-signaling pathways were downregulated during early life.

CONCLUSION

In cranial vascular smooth muscle, highly significant changes occur in important cellular and signaling pathways with maturational development.

Antenatal breast expression: a critical review of the literature

OBJECTIVE

to critically review literature related to the practice of antenatal breast expression (ABE) and the reasons for this practice.

METHOD

a critical review of available literature was undertaken by accessing Internet and library resources. Articles were to be documented in English. No restrictions were placed on dates due to the important historical background of this topic. Keywords used to refine the search included antenatal breast expression, colostrum, antenatal breast-feeding education and midwives and International Board Certified Lactation Consultants (IBCLC).

FINDINGS

the literature search discovered ABE has been performed historically to prepare breasts for breast-feeding postnatally. It is presently being taught to store colostrum to prevent neonatal hypoglycaemia or hasten production of Lactogenesis 2. Studies relating to nipple stimulation were also critically appraised due to concerns of premature labour.

CONCLUSIONS

the safety and efficacy of ABE has yet to be demonstrated. The three studies related to the benefits teaching of this skill were small in size with methodological flaws. Trials related to nipple stimulation were also found to have substantial limitations. The reasons for and physicality of performing ABE vs. nipple stimulation differed markedly. While recent teaching of ABE has been encouraged through available commentaries, case studies and policies (in view of the documented positive effects of early colostrum administration), the benefits of this practice are yet to be substantiated.

IMPLICATIONS FOR PRACTICE

large, credible RCTs are needed to confirm efficacy and safety of this technique. A survey exploring the prevalence of ABE practices is also indicated and to explore the information currently provided by midwives to women in their care.

Care of the infant of the diabetic mother

Gestational diabetes mellitus (GDM) from all causes of diabetes is the most common medical complication of pregnancy and is increasing in incidence, particularly as type 2 diabetes continues to increase worldwide. Despite advances in perinatal care, infants of diabetic mothers (IDMs) remain at risk for a multitude of physiologic, metabolic, and congenital complications such as preterm birth, macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, hypertrophic cardiomyopathy, and congenital anomalies, particularly of the central nervous system. Overt type 1 diabetes around conception produces marked risk of embryopathy (neural tube defects, cardiac defects, caudal regression syndrome), whereas later in gestation, severe and unstable type 1 maternal diabetes carries a higher risk of intrauterine growth restriction, asphyxia, and fetal death. IDMs born to mothers with type 2 diabetes are more commonly obese (macrosomic) with milder conditions of the common problems found in IDMs. IDMs from all causes of GDM also are predisposed to later-life risk of obesity, diabetes, and cardiovascular disease. Care of the IDM neonate needs to focus on ensuring adequate cardiorespiratory adaptation at birth, possible birth injuries, maintenance of normal glucose metabolism, and close observation for polycythemia, hyperbilirubinemia, and feeding intolerance.

The health implications of birth by Caesarean section

Since the first mention of fetal programming of adult health and disease, a plethora of programming events in early life has been suggested. These have included intrauterine and postnatal events, but limited attention has been given to the potential contribution of the birth process to normal physiology and long-term health. Over the last 30 years a growing number of studies have demonstrated that babies born at term by vaginal delivery (VD) have significantly different physiology at birth to those born by Caesarean section (CS), particularly when there has been no exposure to labour, i.e. pre-labour CS (PLCS). This literature is reviewed here and the processes involved in VD that might programme post-natal development are discussed. Some of the effects of CS are short term, but longer term problems are also apparent. We suggest that VD initiates important physiological trajectories and the absence of this stimulus in CS has implications for adult health. There are a number of factors that might plausibly contribute to this programming, one of which is the hormonal surge or "stress response" of VD. Given the increasing incidence of elective PLCS, an understanding of the effects of VD on normal development is crucial.

Lactate Effectively Covers Energy Demands during Neuronal Network Activity in Neonatal Hippocampal Slices

Although numerous experimental data indicate that lactate is efficiently used for energy by the mature brain, the direct measurements of energy metabolism parameters during neuronal network activity in early postnatal development have not been performed. Therefore, the role of lactate in the energy metabolism of neurons at this age remains unclear. In this study, we monitored field potentials and contents of oxygen and NAD(P)H in correlation with oxidative metabolism during intense network activity in the CA1 hippocampal region of neonatal brain slices. We show that in the presence of glucose, lactate is effectively utilized as an energy substrate, causing an augmentation of oxidative metabolism. Moreover, in the absence of glucose lactate is fully capable of maintaining synaptic function. Therefore, during network activity in neonatal slices, lactate can be an efficient energy substrate capable of sustaining and enhancing aerobic energy metabolism.

Extraordinary exposed in early motherhood - a qualitative study exploring experiences of mothers with type 1 diabetes

BACKGROUND

Women with type 1 diabetes face several challenges during pregnancy, childbirth and in relation to breastfeeding. It is therefore of utmost importance to consider their need for specific support, early postpartum as well as in daily life after discharge from maternity care. Few studies have investigated these aspects of healthcare. The aim of this study was to explore experiences after childbirth regarding breastfeeding, glycemic control, support and well-being in women with type 1 diabetes.

METHODS

A hermeneutic reflective life world research approach was used in this qualitative study. Data was gathered through audio-recorded focus group discussions and individual interviews with 23 women with type 1 diabetes, 6-24 months after childbirth. After verbatim transcription, the text was analyzed in order to identify themes of meaning and a conclusive interpretation of the explored phenomenon.

RESULTS

Experiences of extraordinary exposure challenged the women with type 1 diabetes in their transition to early motherhood. The exposure included a struggle with breastfeeding, although with a driving force to succeed. Everyday life was filled with uncertainty and unpredictability related to one's own unstable glycemic control and the women down-prioritized their own needs in favor of the child. A feeling of being disconnected from professional care further contributed to the experiences of extraordinary exposure.

CONCLUSION

In early motherhood women with type 1 diabetes have a great need for support in managing daily life postpartum, which requires contemporary approaches to overlap insufficient linkage between health care professionals in maternity and child health care, and diabetes care.

Obligate role for ketone body oxidation in neonatal metabolic homeostasis

To compensate for the energetic deficit elicited by reduced carbohydrate intake, mammals convert energy stored in ketone bodies to high energy phosphates. Ketone bodies provide fuel particularly to brain, heart, and skeletal muscle in states that include starvation, adherence to low carbohydrate diets, and the neonatal period. Here, we use novel Oxct1(-/-) mice, which lack the ketolytic enzyme succinyl-CoA:3-oxo-acid CoA-transferase (SCOT), to demonstrate that ketone body oxidation is required for postnatal survival in mice. Although Oxct1(-/-) mice exhibit normal prenatal development, all develop ketoacidosis, hypoglycemia, and reduced plasma lactate concentrations within the first 48 h of birth. In vivo oxidation of (13)C-labeled β-hydroxybutyrate in neonatal Oxct1(-/-) mice, measured using NMR, reveals intact oxidation to acetoacetate but no contribution of ketone bodies to the tricarboxylic acid cycle. Accumulation of acetoacetate yields a markedly reduced β-hydroxybutyrate:acetoacetate ratio of 1:3, compared with 3:1 in Oxct1(+) littermates. Frequent exogenous glucose administration to actively suckling Oxct1(-/-) mice delayed, but could not prevent, lethality. Brains of newborn SCOT-deficient mice demonstrate evidence of adaptive energy acquisition, with increased phosphorylation of AMP-activated protein kinase α, increased autophagy, and 2.4-fold increased in vivo oxidative metabolism of [(13)C]glucose. Furthermore, [(13)C]lactate oxidation is increased 1.7-fold in skeletal muscle of Oxct1(-/-) mice but not in brain. These results indicate the critical metabolic roles of ketone bodies in neonatal metabolism and suggest that distinct tissues exhibit specific metabolic responses to loss of ketone body oxidation.

Breastfeeding in women with type 1 diabetes: exploration of predictive factors

OBJECTIVE

To identify predictive factors for initiation and maintenance of breastfeeding with a focus on mothers with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This is a prospective observation survey, using a case-control design, comparing the outcomes of 108 mothers with type 1 diabetes with 104 mothers without diabetes that were matched for parity and gestational age. Mother and infant outcomes were collected from medical records and through telephone interviews 2 and 6 months after delivery. Predictive factors were calculated by logistic regression analyses.

RESULTS

Mothers with diabetes were less likely to partly or exclusively breastfeed their children at 2 months (OR 0.42 [95% CI 0.18-0.96], P = 0.041) and 6 months (0.50 [0.27-0.90], P = 0.022) than mothers without diabetes. On multivariable analysis, type 1 diabetes did not remain an independent predictive factor. Instead, higher education level and breastfeeding at discharge from hospital were predictive factors for breastfeeding at 2 months postpartum. These variables as well as delivery >37 weeks and early breastfeeding predicted breastfeeding 6 months postpartum.

CONCLUSIONS

Factors associated with maternal diabetes, such as problems with establishing breastfeeding in the early postpartum period, affects the likelihood of long-term breastfeeding.

Early transient hypoglycemia is associated with increased albumin nitration in the preterm infant

BACKGROUND

The clinical significance of early transient hypoglycemia (ETH), a frequent event in preterm newborns, is a highly controversial issue. In experimental models, hypoglycemia has been reported to cause oxidative stress. Among the reactive species, early generated peroxynitrite is responsible for protein nitration and lipid peroxidation, a process referred to as nitrative stress.

OBJECTIVES

The aim of the present study is to investigate whether ETH is associated with protein nitration in the preterm newborn.

METHODS

Using a novel highly sensitive ELISA, we quantified plasma nitroalbumin (PNA) as a marker of peroxynitrite generation in 72 preterm newborns (28-36 weeks), among which 25 had a glycemia level of <2.5 mmol/l during the first hour of life (H1).

RESULTS

PNA was significantly higher in ETH than in normoglycemic infants at H1 [median = 6.3 (3.8-8.8) vs. 3.4 ng/ml (2.1-5.1), p = 0.027] and at day 1 [median = 6.6 (5.6-15.3) vs. 3.9 ng/ml (2.3-4.6), p = 0.014]. PNA was inversely correlated with glycemia at H1 (r = -0.30, p = 0.01) and at day 1 (r = -0.63, p = 0.001). In ETH infants, lactatemia was inversely correlated with PNA. At day 1, PNA was higher in ETH infants treated by gavage than in those treated with intravenous dextrose [median = 8.9 ng/ml (7.1-10.4) vs. 4.4 ng/ml (2.6-5.7), p = 0.008].

CONCLUSIONS

These results indicate that ETH is associated with increased peroxynitrite generation resulting in systemic protein nitration in premature newborns. Treatment of ETH with intravenous dextrose is associated with lower PNA levels than gavage.

Infant feeding in the neonatal unit

Infants admitted to a neonatal unit (NNU) are frequently unable to feed by breast or bottle because of ill health or prematurity. These infants require nutritional support until they can start oral feeding. Breastfeeding is advocated for these infants, and mothers are frequently encouraged to express breast milk to be fed via the enteral tube. However, by discharge, breastfeeding rates tend to be low. Oral feeding requires careful management, and although practices may vary because of clinical need, some may be informed by unit norms. There is limited evidence for effective breastfeeding support in this environment and little exploration of the effect of routine feeding decisions. This study aimed to explore feeding decisions and considered how these might affect outcomes. The staff in the two large urban NNUs who participated in the feeding decisions were interviewed and the data were analysed using a theoretical framework. Feeding decisions were made mainly by the unit staff, with limited parental involvement. Subsequent management varied, with differences being related to staff experience and beliefs, unit norms, parent's expectations and physical constraints within the unit. The staff were overtly supportive of breastfeeding, but the need to monitor and quantify milk intake may undermine breastfeeding. Furthermore, feeding breastfed infants during the mothers' absence was controversial and provoked debate. There is a need for clear guidelines and increased parental involvement in feeding decisions. Routine practices within the system may discourage mothers from initiating and persisting with breastfeeding. A change in unit culture is required to fully support the parent's feeding choices.

Are we getting the best from breastfeeding?

Different breastfeeding methods (traditional ⁄ scheduled, demand or baby-led) influence lactation physiology by either supporting or interfering with the let-down reflex, by an autocrine effect in the breast, and indirectly via infant appetite. Postnatal breast morphological changes and neonatal osmoregulation are also susceptible to breastfeeding method. Feed length is important: short feeds from both breasts (employed in traditional methods) optimize breast morphological changes and neonatal osmoregulation, condition the let-down reflex, limit autocrine inhibition, stimulate the infant’s appetite and are associated with a plentiful supply of milk. However, the limited evidence available on prolonged feeds and those from only one breast (both often seen with the baby-led method), suggests interference with lactation because of a compromised let-down reflex and autocrine inhibition, resulting in a reduced milk supply.

CONCLUSION

Regular short feeds from both breasts encourage a plentiful milk supply and successful breastfeeding: these are best reflected by a modified traditional breastfeeding method.

Transitory hypothermia as early prognostic factor in term newborns with intrauterine growth retardation

Introduction. According to numerous researches, transitory hypothermia is a part of the neonatological energetic triangle and represents a significant prognostic factor within morbidity and mortality in newborns with intrauterine growth retardation (IUGR), that are, due to their characteristics, more inclined to transitory hypothermia. Objective. The aim of the study was an analysis of frequency of transitory hypothermia in term newborns with IUGR, as well as an analysis of frequency of the most frequent pathological conditions typical of IUGR newborns depending on the presence of transitory hypothermia after birth (hypoglycaemia, perinatal asphyxia, hyperbilirubinaemia and hypocalcaemia). Methods. The study included 143 term newborns with IUGR treated at the Neonatology Ward of the Gynaecology- Obstetrics Clinic ?Narodni front?, Belgrade. The newborns were divided into two groups: the one with registered transitory hypothermia - the observed group, and the one without transitory hypothermia - the control group. The data analysis included the analysis of the frequency of transitory hypothermia depending on gestation and body mass, as well as the analysis of pathological conditions (perinatal asphyxia, hypoglycaemia, hypocalcaemia, hyperbilirubinaemia) depending on the presence of hypothermia.The analysis was done by statistical tests of analytic and descriptive statistics. Results. In morbidity structure dominate hypothermia (65.03%), hypoglycaemia (43.36%), perinatal asphyxia (37.76%), hyperbilirubinaemia (30.77%), hypocalcaemia (25.17%). There were 93 newborns in the observed group, and 50 in the control one. Mean value of the measured body temperature was 35.9?C. 20 newborns (32.26%) had moderate hypothermia, and 73 newborns (67.74%) had mild hypothermia. In the observed group, average gestation was 39.0 weeks, and 39.6 (p<0.01) in the control group. Average body mass at birth in the whole group was 2339 g: 2214 g in the observed and 2571 g in the control group. The frequency of hypoglycaemia in the observed group was 53.8%, and 24% in the control group (p<0.01). In the observed group, the frequency of pH<7.25 was 38.71%, and 14% in the control group (p<0.05). The frequency of hyperbilirubinaemia was 38.71% in the observed group, and 16% in the control group (p<0.01). The frequency of hypocalcaemia was 32.26% in the observed, and 12% in the control group (p<0.01). Conclusion. Transitory hypothermia in the first ten hours of life represents a significant risk factor for deepening hypoglycaemia, asphyxia, hyperbilirubinaemia and hypocalcaemia in term newborns with IUGR.

Delivery by Caesarean section, rather than vaginal delivery, promotes hepatic steatosis in piglets

There has been a marked increase in the number of babies born by elective CS (Caesarean section). Following CS, the lack of normal stimuli that occur at birth alters the thermogeneic response, but any effects on hepatic metabolism have not been identified. In the present study, we compared the effect of delivery on hepatic metabolism in piglets, born either by CS or VD (vaginal delivery) and fed by TPN (total parenteral nutrition), by measuring lipid metabolism and enzyme activity coupled with metabolomic and genomic approaches. Hepatic lipid in the CS piglets at 7 days post-partum was in excess of 5 mg/g of liver consistent with hepatic steatosis, whereas in the VD piglets the amount of lipid was markedly lower (3 mg/g of liver) and below the threshold for a diagnosis of steatosis. Metabolomic analysis indicated that CS resulted in higher hepatic glycerol and lower glycerol phosphate dehydrogenase activity, suggesting that CS causes a decrease in hepatic gluconeogenesis from glycerol. CS also resulted in altered cholesterol handling and gene expression, despite the same dietary intake for 7 days post-partum. Furthermore, the CS piglets had a lower expression of interferon-responsive genes, but a higher expression of markers of immature hepatocytes. In conclusion, the results suggest that VD promotes normal liver maturation and hepatic metabolism, thereby reducing the accumulation of hepatic lipid.

Neonatal management and long-term sequelae

Intrauterine or fetal growth restriction is best defined by using customised birth weight percentiles based upon the growth potential for an individual infant. Growth restriction in utero may be classified as asymmetric or symmetric depending upon the duration of the process. Asymmetric growth restriction is caused by placental insufficiency, maternal hypertensive conditions, long-standing maternal diabetes, smoking, living at altitude or multiple gestation. Symmetric growth restriction may be due to congenital infections, chromosomal or other abnormalities, fetal alcohol syndrome, low socioeconomic status or be constitutional. The underlying cause of growth restriction often predicts the potential adverse effects on the foetus and newborn and later effects in childhood and adulthood. With placental insufficiency, there may be chronic or acute on chronic fetal hypoxia with birth asphyxia and hypothermia, neonatal hypoglycaemia, polycythaemia and coagulopathy. Management is directed at prevention or early treatment of these conditions. In contrast, symmetrically growth-restricted infants should be examined carefully to look for congenital infections and malformations that may need specific interventions. Infants with constitutional short stature generally do not need any specific management. Feeding of growth-restricted infants is important to overcome deficiencies incurred in utero. Most infants show catch-up growth although about 10% do not. Those with excessive catch-up growth may be at greatest risk of developing insulin resistance in adulthood leading to diabetes, obesity and heart disease. The so-called fetal origins of disease may actually have a postnatal onset related more to excessive weight gain in infancy. There is still controversy over the indications for growth hormone treatment in growth-restricted infants who remain of short stature in early childhood. Intrauterine growth restriction is also associated with a five- to seven-fold increased risk of cerebral palsy probably due to chronic placental insufficiency.

Alpha-ketoglutarate protects the liver of piglets exposed during prenatal life to chronic excess of dexamethasone from metabolic and structural changes

Glucocorticoids play a role in the origin of the features of the metabolic diseases. Alpha-ketoglutarate (AKG) is defined as glutamine homologue and derivative, conditionally an essential amino acid. In the liver, glutamine serves as a precursor for ureagenesis, gluconeogenesis and acute phase protein synthesis The aim of the study was to determine the effect of AKG administered to piglets prenatally exposed to dexamethasone, on the structure of the liver and its metabolic function. Sows were administered with dexamethasone (3 mg/sow/48 h) from day 70 of pregnancy to the parturition, and then after the birth, the piglets were divided into the group administered with AKG (0.4 g/kg body weight) or physiological saline. Biochemical markers, lysozyme and ceruloplasmin serum activities, concentrations of selected free amino acids, macro- and microelements and histomorphometry of the liver tissue were determined. The total cholesterol concentrations in the sows and their newborns from the Dex groups were higher by 72% and 64%, respectively, compared with the control groups. Triacylglycerol concentration was higher by 50% in sows from the Dex group and 55% in the new-born piglets. Alpha-ketoglutarate administered to the piglets after prenatal influence of dexamethasone lowered the total cholesterol concentration by 40%, and enhanced aspartate by 41%, serine by 76%, glutamate by 105%, glutamine by 36%, glycine by 53% and arginine by 105%, as well as methionine and cystathionine, but increased the sulphur concentration compared with the control (p < 0.01). Intracellular space D decreased after AKG administration in comparison with the piglets from Dex/Control group not treated with AKG. Postnatal administration of AKG had a protective effect on liver structure, and lowered the total cholesterol concentration in piglets prenatally exposed to dexamethasone, and also influenced selected macro- and microelement serum concentrations and amino acids plasma concentration.

Offspring of diabetic pregnancy: short-term outcomes

In spite of clinicians apparently appreciating the risks of maternal diabetes to the baby, babies of mothers with diabetes are still at increased risk compared to those of non-diabetic women. The rate of prematurity in infants of diabetic mothers is five times that of the general population. Women with pre-gestational diabetes give birth to larger babies. In a recent study, half were above the 90th centile for weight. The postnatal management of these babies continues to give cause for concern. In a recent UK study, over half of all infants of diabetic mothers were admitted to a neonatal unit. One-third of these were at term. This admission rate is three times the UK average and examination of cases showed that two-thirds of admissions were unnecessary. It is likely that a high maternal blood glucose concentration is the most important factor causing this increased risk. Babies of women with type 1 and type 2 DM have similar complication rates. Tighter preconceptional glycaemic control as well as during the pregnancy is likely to be important in improving outcome for the babies of diabetic mothers.