Academic Achievement in Primary School in Offspring Born to Mothers With Type 1 Diabetes (the EPICOM Study): A Register-Based Prospective Cohort Study

Maternal type 1 diabetes, preterm birth, and risk of intellectual disability in the offspring: A nation-wide study in Sweden

OBJECTIVE

There are few data on long-term neurological or cognitive outcomes in the offspring of mothers with type 1 diabetes (T1D). The aims of this study were to examine if maternal T1D increases the risk of intellectual disability (ID) in the offspring, estimate the amount of mediation through preterm birth, and examine if the association was modified by maternal glycated hemoglobin (HbA1c).

DESIGN

Population-based cohort study using population-based data from several national registries in Sweden.

SETTING AND PARTICIPANTS

All offspring born alive in Sweden between the years 1998 and 2015.

MAIN OUTCOME MEASURE

The risk of ID was estimated through hazard ratios with 95% confidence intervals (HR, 95% CI) from Cox proportional hazard models, adjusting for potential confounding. Risks were also assessed in mediation analyses and in subgroups of term/preterm births, in relation to maternal HbA1c and by severity of ID.

RESULTS

In total, 1,406,441 offspring were included. In this cohort, 7,794 (0.57%) offspring were born to mothers with T1D. The risk of ID was increased in offspring of mothers with T1D (HR; 1.77, 1.43-2.20), of which 47% (95% CI: 34-100) was mediated through preterm birth. The HRs were not modified by HbA1c.

CONCLUSION

T1D in pregnancy is associated with moderately increased risks of ID in the offspring. The risk is largely mediated by preterm birth, in particular for moderate/severe cases of ID. There was no support for risk-modification by maternal HbA1c.

Maternal-fetal outcomes of pregnant women with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections during pregnancy - A Brazilian health care referral center cohort study

Objective

Pregnant women with type 1 diabetes (T1D) have an increased risk of maternal-fetal complications. Regarding treatment, continuous subcutaneous insulin infusion (CSII) has advantages compared to multiple daily injections (MDI), but data about the best option during pregnancy are limited. This study's aim was to compare maternal-fetal outcomes among T1D patients treated with CSII or MDI during pregnancy.

Subjects and methods

This study evaluated 174 pregnancies of T1D patients. Variables of interest were compared between the groups (CSII versus MDI), and logistic regression analysis was performed (p < 0.05).

Results

Of the 174 included pregnancies, CSII was used in 21.3% (37) and MDI were used in 78.7% (137). HbA1c values improved throughout gestation in both groups, with no difference in the first and third trimesters. The frequency of cesarean section was significantly higher in the CSII group [94.1 vs. 75.4%, p = 0.017], but there was no significant difference in the frequency of other complications, such as miscarriage, premature delivery and preeclampsia. The mean birth weight and occurrence of neonatal complications were also similar, except for the proportion of congenital malformations, which was significantly lower in the CSII group [2.9 vs. 15.6%, p = 0.048]. In regression analysis, the association of CSII with cesarean section and malformations lost significance after adjusting for HbA1c and other covariates of interest.

Conclusion

In this study, we observed a higher frequency of cesarean section and a lower occurrence of congenital malformations in the CSII group, but the adjusted results might indicate that these associations are influenced by glycemic control.

Long-term outcomes and potential mechanisms of offspring exposed to intrauterine hyperglycemia

Diabetes mellitus during pregnancy, which can be classified into pregestational diabetes and gestational diabetes, has become much more prevalent worldwide. Maternal diabetes fosters an intrauterine abnormal environment for fetus, which not only influences pregnancy outcomes, but also leads to fetal anomaly and development of diseases in later life, such as metabolic and cardiovascular diseases, neuropsychiatric outcomes, reproduction malformation, and immune dysfunction. The underlying mechanisms are comprehensive and ambiguous, which mainly focus on microbiota, inflammation, reactive oxygen species, cell viability, and epigenetics. This review concluded with the influence of intrauterine hyperglycemia on fetal structure development and organ function on later life and outlined potential mechanisms that underpin the development of diseases in adulthood. Maternal diabetes leaves an effect that continues generations after generations through gametes, thus more attention should be paid to the prevention and treatment of diabetes to rescue the pathological attacks of maternal diabetes from the offspring.

Prenatal Carbamazepine Exposure and Academic Performance in Adolescents: A Population-Based Cohort Study

BACKGROUND AND OBJECTIVES

To investigate whether children born to mothers who used carbamazepine during pregnancy had worse academic performance in adolescence.

METHODS

This population-based cohort study included all live-born singletons in Denmark between 1996 and 2002 who participated in the national ninth-grade exit examination (n = 370,859). Those born to mothers with prescription of antiseizure medications other than carbamazepine during pregnancy were excluded. We examined the association of in utero exposure to maternal carbamazepine redeemed during pregnancy (n = 290) with academic performance of offspring, defined by the scores in Danish and mathematics in ninth-grade exit examination. We estimated mean z-score difference with linear regression adjusted for socioeconomic factors and potential indications, including epilepsy and medication for other psychiatric disorders. Additional analyses addressing confounding by indication included comparison between in utero exposed vs past exposed and between past exposed and never exposed. In utero exposure to valproate monotherapy was used as a positive control and in utero exposure to lamotrigine as a negative control.

RESULTS

At the age of 16.1 (SD 0.4) years, adolescents in utero exposed to maternal carbamazepine monotherapy had lower scores both in Danish and mathematics in ninth-grade exit examination (adjusted z-score difference, -0.14 [95% CI -0.24 to -0.05] and -0.17 [95% CI -0.28 to -0.07], respectively). In utero exposure to carbamazepine monotherapy was associated with lower scores than past exposure only (adjusted z-score difference, -0.24 [95% CI -0.41 to -0.06] for Danish and -0.25 [95% CI -0.44 to -0.06] for mathematics), while past exposure to carbamazepine was associated with minor decrease in offspring's academic performance (adjusted z-score difference, -0.02 [95% CI -0.09 to 0.06] for Danish and -0.07 [95% CI -0.16 to 0.01] for mathematics). The association was also observed for in utero exposure to valproate monotherapy, but not for in utero exposure to lamotrigine.

DISCUSSION

In utero exposure to carbamazepine was associated with poorer academic performance in adolescence, as represented by lower scores in ninth-grade exit examination in Danish and mathematics. Additional studies are needed to confirm these findings because of limitations in this study and variable findings in prior studies.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that academic performance, as reflected in ninth-grade exit examinations in Danish and mathematics, was worse among those exposed to carbamazepine monotherapy in utero, compared with those without in utero exposure to antiseizure medications.

Academic performance in adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations: A register-based, data linkage, cohort study

BACKGROUND

This is the first study to investigate the longitudinal association between prenatal and perinatal psychiatric hospitalizations and academic achievements in adolescent offspring.

METHODS

We conducted an administrative health data-based cohort study of 168, 528 mother-offspring pairs using linked data obtained from health and educational registries in New South Wales, Australia. Prenatal and perinatal maternal psychiatric diagnosis was measured by using ICD-10. The National Assessment Program for Literacy and Numeracy (NAPLAN) was used to assess the educational performance of the offspring. Logistic regression model was used to explore the association. Multivariate models were adjusted for maternal sociodemographic characteristics such as age at birth, marital status, educational status, and occupational status, maternal diabetes and chronic hypertension, maternal smoking during pregnancy, birth weight, and language spoken at home.

RESULTS

The findings show that after adjusting for important covariates adolescent offspring of mothers with prenatal and perinatal psychiatric hospitalizations were more likely to perform below the national minimum standard in all domains of academic performance at age 14 years, when compared with the offspring of mothers without such hospitalizations, with the highest odds for numeracy (OR = 2.88; 95% CI: 2.50-3.31) followed by reading (OR = 2.08; 95% CI: 1.81-2.38), spelling (OR = 1.74; 95% CI: 1.51-2.01), and writing (OR = 1.56; 95% CI: 1.34-1.80). There was significant gender interaction such that males were more likely to experience lower rates of academic performance than females in all academic domains. Lower academic achievements were observed among offspring of mothers with all major groupings of psychiatric disorders, with a higher risk for severe psychiatric disorders followed by mental disorders due to substance use or medical conditions.

CONCLUSION

In sum, maternal prenatal and perinatal psychiatric hospitalizations are associated with lower academic achievements in adolescent offspring, with a stronger effect on the academic performance of male offspring. Early intervention strategies that aim to enhance educational performance in the exposed offspring are needed.

Hyperglycemia in Pregnancy and Women's Health in the 21st Century

Hyperglycemia is the commonest medical condition affecting pregnancy and its incidence is increasing globally in parallel with the twin epidemics of diabetes and obesity. Both pre-pregnancy diabetes and gestational diabetes are associated with short term pregnancy complications, with the risk of immediate complications generally broadly rising with more severe hyperglycemia. In this article we firstly consider these risks and their optimal management during pregnancy and then broaden our scope to consider the long-term implications of hyperglycemia in pregnancy as it relates to overall maternal and offspring health in a life course perspective.

Validation of Danish registry-cases of type 1 diabetes in women giving live birth using a clinical cohort as gold standard

INTRODUCTION

The aim of this study was to validate type 1 diabetes in women giving live birth in the Danish national registries against a clinical cohort of confirmed cases (the Danish Diabetes Birth Registry [DDBR] cohort).

METHODS

National registries including diagnosis codes, redeemed prescriptions and background data were combined. Three main algorithms were constructed to define type 1 diabetes in women giving live birth: (1) Any diabetes diagnosis registered before delivery and before age of 30, (2) a specific type 1 diabetes diagnosis registered before delivery regardless of maternal age and (3) a 'preexisting type 1 diabetes in pregnancy' diagnosis registered before delivery. In additional sub-algorithms, we added information on anti-diabetic medicine and gestational diabetes diagnosis. We calculated positive predictive value (PPV) and completeness using the DDBR cohort as gold standard. Since DDBR included between 75 and 93% of women with confirmed type 1 diabetes giving live birth, we used quantitative bias analysis to assess the potential impact of missing data on PPV and completeness.

RESULTS

Main algorithm 2 had the highest PPV (77.4%) and shared the highest completeness (92.4%) with main algorithm 1. Information on anti-diabetic medicine and gestational diabetes increased PPV, on expense of completeness. All algorithms varied with PPV between 65.7 and 87.6% and completeness between 73.6 and 92.4%. The quantitative bias analysis indicated that PPV was underestimated, and completeness overestimated for all algorithms. For algorithm 2, corrected PPV was between 82.1 and 94.6% and corrected completeness between 84.7 and 91.2%.

CONCLUSIONS

The Danish national registries can identify type 1 diabetes in women giving live birth with a reasonably high accuracy. The registries are a valuable source for future comparative outcome studies and may also be suitable for monitoring prevalence and incidence of type 1 diabetes in women giving live birth.

Influence of Maternal Diabetes on the Risk of Neurodevelopmental Disorders in Offspring in the Prenatal and Postnatal Periods

BACKGROUND

This study aimed to evaluate the influence of maternal diabetes in the risk of neurodevelopmental disorders in offspring in the prenatal and postnatal periods.

METHODS

This cohort study included singleton gestational diabetes mellitus (GDM) pregnancies >22 weeks' gestation with live newborns between 1991 and 2008. The control group was randomly selected and matched (1:2) for maternal age, weeks of gestation and birth year. Cox regression models estimated the effect of GDM on the risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and maternal type 2 diabetes mellitus (T2DM). Moreover, interaction between maternal T2DM and GDM-ADHD relationship was evaluated.

RESULTS

Children (n=3,123) were included (1,073 GDM; 2,050 control group). The median follow-up was 18.2 years (interquartile range, 14.2 to 22.3) (n=323 with ADHD, n=36 with ASD, and n=275 from women who developed T2DM). GDM exposure was associated with ADHD (hazard ratio [HR]crude, 1.67; 95% confidence interval [CI], 1.33 to 2.07) (HRadjusted, 1.64; 95% CI, 1.31 to 2.05). This association remained significant regardless of the treatment (diet or insulin) and diagnosis after 26 weeks of gestation. Children of mothers who developed T2DM presented higher rates of ADHD (14.2 vs. 10%, P=0.029). However, no interaction was found when T2DM was included in the GDM and ADHD models (P>0.05). GDM was not associated with an increased risk of ASD (HRadjusted, 1.46; 95% CI, 0.74 to 2.84).

CONCLUSION

Prenatal exposure to GDM increases the risk of ADHD in offspring, regardless of GDM treatment complexity. However, postnatal exposure to maternal T2DM was not related to the development of ADHD.

School performance in Danish children exposed to maternal type 1 diabetes in utero: A nationwide retrospective cohort study

BACKGROUND

Conflicting results have been reported concerning possible adverse effects on the cognitive function of offspring of mothers with type 1 diabetes (O-mT1D). Previous studies have included offspring of parents from the background population (O-BP), but not offspring of fathers with type 1 diabetes (O-fT1D) as the unexposed reference group.

METHODS AND FINDINGS

This is a population-based retrospective cohort study from 2010 to 2016. Nationally standardized school test scores (range, 1 to 100) were obtained for public school grades 2, 3, 4, 6, and 8 in O-mT1D and compared with those in O-fT1D and O-BP. Of the 622,073 included children, 2,144 were O-mT1D, and 3,474 were O-fT1D. Multiple linear regression models were used to compare outcomes, including the covariates offspring with type 1 diabetes, parity, number of siblings, offspring sex, smoking during pregnancy, parental age, and socioeconomic factors. Mean test scores were 54.2 (standard deviation, SD 24.8) in O-mT1D, 54.4 (SD 24.8) in O-fT1D, and 56.4 (SD 24.7) in O-BP. In adjusted analyses, the mean differences in test scores were -1.59 (95% CI -2.48 to -0.71, p < 0.001) between O-mT1D and O-BP and -0.78 (95% CI -1.48 to -0.08, p = 0.03) between O-fT1D and O-BP. No significant difference in the adjusted mean test scores was found between O-mT1D and O-fT1D (p = 0.16). The study's limitation was no access to measures of glycemic control during pregnancy.

CONCLUSIONS

O-mT1D achieved lower test scores than O-BP but similar test scores compared with O-fT1D. Glycemic control during pregnancy is essential to prevent various adverse pregnancy outcomes in women with type 1 diabetes. However, the present study reduces previous concerns regarding adverse effects of in utero hyperglycemia on offspring cognitive function.

Maternal smoking during pregnancy and poor academic performance in adolescent offspring: A registry data-based cohort study

BACKGROUND

Previous studies have suggested associations between maternal smoking during pregnancy (MSDP) and a range of adverse outcomes in offspring. However, evidence reporting adverse effects on poor academic performance in adolescence is scant.

METHODS

This register-based cohort study used linked data obtained from New South Wales (NSW) educational and health registries in Australia. MSDP was assessed using self-reports of smoking during pregnancy. Offspring's educational performance was assessed using the National Assessment Program for Literacy and numeracy (NAPLAN), when students were in grade 9 and approximately aged 14 years. We used multivariable logistic regression models to explore associations.

RESULTS

Adolescent offspring exposed to MSDP were at an increased risk of substandard academic performance in all domains, with the highest odds for spelling [OR, 3.12 (95%CI 2.98-3.26)] followed by writing [OR, 2.97 (95%CI 2.84-3.11)], reading [OR, 2.49 (95%CI 2.37-2.62)], and numeracy [OR, 2.43 (95%CI 2.30-2.58)]. In our sex-stratified analysis, MSDP displayed stronger effects on the academic performance of female offspring in all domains.

CONCLUSIONS

Our findings showed that MSDP was associated with an increased risk of reduced academic performance in adolescent offspring. The different effects of MSDP on the academic performance of male and female offspring is a new finding, which needs further investigation.

Academic Performance in Adolescents Born to Mothers With Gestational Diabetes-A National Danish Cohort Study

CONTEXT

The prevalence of gestational diabetes mellitus (GDM) is increasing, and intrauterine hyperglycemia is suspected to affect offspring cognitive function.

OBJECTIVE

We assessed academic performance by grade point average (GPA) in children aged 15 to 16 years at compulsory school graduation, comparing offspring exposed to GDM (O-GDM) with offspring from the background population (O-BP).

METHODS

This register-based, cohort study comprised all singletons born in Denmark between 1994 and 2001 (O-GDM: n = 4286; O-BP: n = 501 045). Standardized and internationally comparable GPAs were compared in univariate and multivariable linear models. Main outcome measures included the adjusted mean difference in GPA. We also analyzed the probability of having a high GPA, a GPA below passing, and no GPA registered.

RESULTS

O-GDM had a GPA of 6.29 (SD 2.52), whereas O-BP had a GPA of 6.78 (SD 2.50). The adjusted mean difference was -0.36 (95% CI, -0.44 to -0.29), corresponding to a Cohen's D of 0.14. O-GDM had a lower probability of obtaining a high GPA (adjusted odds ratio [aOR] 0.68; 95% CI, 0.59 to 0.79), while their risk of obtaining a GPA below passing was similar to O-BP (aOR 1.20; 95% CI, 0.96 to 1.50). O-GDM had a higher risk of not having a GPA registered (aOR 1.38; 95% CI, 1.24 to 1.53).

CONCLUSION

Academic performance in O-GDM was marginally lower than in O-BP. However, this difference is unlikely to be of clinical importance.

The long-term metabolic and neurocognitive risks in offspring of women with type 1 diabetes mellitus

AIMS

Previous studies have evaluated long-term metabolic and neurocognitive outcomes in offspring of women with diabetes. However, many studies did not differentiate between different types of diabetes. We aimed to specifically evaluate both metabolic and neurocognitive outcomes in offspring of women with type 1 diabetes mellitus (OT1D).

METHODS

We conducted an extensive literature search on PubMed between February 2020 and September 2020. We performed a scoping review including 12 retrospective cohort studies, 15 prospective cohort studies, one case-control study and one cross-sectional study, comparing long-term metabolic and neurocognitive outcomes between OT1D and a control group.

RESULTS

OT1D had a higher body mass index and an increased risk for overweight and obesity compared to offspring of mothers without diabetes. A limited number of studies showed a higher risk for (pre)diabetes, higher rates of non-alcoholic fatty liver disease and metabolic syndrome in OT1D. Index offspring had in general similar intelligence and academic achievement as control children but a higher risk for attention deficit and hyperactivity disorders. Data were conflicting concerning the increased risk for autism spectrum disorders. There is limited evidence suggesting that female offspring have more often unfavorable metabolic parameters, while male offspring are more at risk for hyperactivity/impulsivity.

CONCLUSION

Maternal type 1 diabetes mellitus is associated with an increased risk of several metabolic complications and neurobehavioral disorders in the offspring. Increased attention for long-term complications in this population is needed. Further research is needed to evaluate whether improved glycemic control in pregnancy can reduce these long-term complications.

DNA Methylation Biomarkers of IQ Reduction are Associated with Long-term Lead Exposure in School Aged Children in Southern China

Although lead associated with intelligence decline in children has long been reported, studies combining intelligence determination, molecular mechanisms exploration, and biomarker screen are quite rare. In this study, based on 333 children aged 9-11, we determined the role of DNA methylation (DNAm) in the relationship of lead exposure with children's intelligence. DNAm was measured from children's blood DNA specimens, and mediation analysis was performed to identify DNAm biomarkers mediating the lead-intelligence relationship. We identified forty-three differentially methylated regions (DMRs), and two fragments (FAM50B1 and PTCHD3) significantly mediated the lead-intelligence relationship, with contribution rates of 30.36% (p = 0.010) and 60.36% (p < 0.001), respectively. In addition, blood lead levels (BLLs) lower than 100 μg/L still adversely affected children's IQs and DNAm of the two fragments. Our data suggests that DNAm mediates lead-associated cognitive delay in children and blood lead reference value for school-aged children (100 μg/L) should be revised, and the candidate biomarkers can be used in related neurological diseases in future.

Psychosocial adjustment of young offspring in the context of parental type 1 and type 2 diabetes: a systematic review

AIMS

To identify all available research on psychosocial outcomes in young people who have a parent with type 1 or type 2 diabetes.

METHODS

Embase, PsychInfo, Scopus, Web of Science, PubMed and ProQuest Social Sciences databases were searched according to a registered study protocol (PROSPERO CRD42019125301). Quality assessment, data extraction and data synthesis were carried out.

RESULTS

The initial search yielded 11 599 articles, 10 of which met the criteria for this review: six for type 1 diabetes and four for type 2 diabetes. Through thematic analysis, five categories emerged related to offspring psychosocial adjustment: offspring mental health, offspring physical health, offspring personal resources, parental illness characteristics and offspring caregiving. Overall, there were few studies focusing solely on the effects of parental type 1 and type 2 diabetes on young people. From the limited available research, there is weak evidence suggesting both parental types of diabetes can adversely impact young offspring. Illness-related variables were only explored in parental type 1 diabetes studies, while offspring caregiving was only examined in parental type 2 diabetes studies.

CONCLUSIONS

Research on the effects of parental diabetes on young people is scarce; however, there was weak evidence to suggest some young people are at risk of adverse psychosocial impacts. Given the rise in the incidence of diabetes globally, there is a pressing public health need to conduct more rigorously designed studies to ascertain the extent to which young people are at risk of mental and physical health problems and to identify risk and protective factors associated with youth adjustment in the context of parental diabetes.

Systemic endocrinopathies (thyroid conditions and diabetes): impact on postnatal life of the offspring

Fetal programming may influence childhood and adult life, determining the risk of specific diseases. During earlier stages of pregnancy, the transfer of maternal thyroid hormones to the fetus is vital for adequate neurologic development. The presence of severe maternal thyroid dysfunction, particularly severe iodine deficiency, is devastating, leading to irreversible neurologic sequelae. Moreover, mild maternal thyroid conditions, such as a mild-to-moderate iodine deficiency, may also lead to milder neurologic and behavioral conditions later during the life of the offspring. Maternal dysglycemia due to pregestational or gestational diabetes mellitus is another common situation in which fetal development encounters a hostile environment. Hyperglycemia in utero may trigger metabolic conditions in the offspring, including abnormalities of glucose tolerance and weight excess. Physicians assisting pregnant women have to be aware about these conditions, because they may go unnoticed if not properly screened. Because an early diagnosis and appropriate management may prevent most of the possible negative consequences for the progeny, the prevention, early diagnosis, and proper management of these endocrine conditions should be offered to all women undergoing pregnancy. Here, we comprehensively review the current evidence about the effects of maternal thyroid dysfunction and maternal dysglycemia on the cognitive function and carbohydrate metabolism in the offspring, two prevalent conditions of utmost importance for the child's health and development.

Neurocognitive and behavioural outcomes in offspring exposed to maternal pre-existing diabetes: a systematic review and meta-analysis

AIMS/HYPOTHESIS

We performed a systematic review and meta-analysis to determine whether exposure to maternal pre-existing diabetes in pregnancy is associated with neurocognitive or behavioural outcomes in offspring.

METHODS

We searched MEDLINE, EMBASE, PsychINFO, the Cochrane Database of Systematic Reviews and Scopus for studies that examined any neurocognitive or behavioural outcomes in offspring of mothers with pre-existing diabetes in pregnancy in accordance with a published protocol (PROSPERO CRD42018109038). Title and abstract review, full-text review and data extraction were performed independently and in duplicate. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of summary measures were performed using random-effects models.

RESULTS

Nineteen articles including at least 18,681 exposed and 2,856,688 control participants were identified for inclusion. Exposure to maternal pre-existing diabetes in pregnancy was associated with a lower pooled intelligence quotient in the offspring (pooled weighted mean difference -3.07 [95% CI -4.59, -1.55]; I2 = 0%) and an increased risk of autism spectrum disorders (effect estimate 1.98 [95% CI 1.46, 2.68]; I2 = 0%). There was also an increased risk of attention deficit/hyperactivity disorder (pooled HR 1.36 [95% CI 1.19, 1.55]; I2 = 0%), though this was based on only two studies. Although most studies were found to be high quality in terms of participant selection, in many studies, comparability of cohorts and adequacy of follow-up were sources of bias.

CONCLUSIONS/INTERPRETATION

There is evidence to suggest that in utero exposure to maternal pre-existing diabetes is associated with some adverse neurocognitive and behavioural outcomes. It remains unclear what the role of perinatal factors is and the degree to which other environmental factors contribute to these findings.

Intergenerational Effects of Health Issues Among Women of Childbearing Age: a Review of the Recent Literature

PURPOSE OF REVIEW

This review summarizes the latest scientific evidence, primarily from systematic reviews/meta-analyses and large cohort studies, on the impact of health issues among women of childbearing age and their effect on their offspring during pregnancy and from birth to adulthood.

RECENT FINDINGS

Women of childbearing age with overweight/obesity, diabetes, and hypertension prior to pregnancy are at increased risk for adverse outcomes during pregnancy, such as excessive gestational weight gain, gestational diabetes mellitus, and hypertensive disorders of pregnancy. These adverse outcomes could complicate delivery and put their offspring at risk of developing overweight/obesity, diabetes, and hypertension (i.e., intergenerational transmission of health issues). Interventions should target women of childbearing age, especially those who wish to conceive, in order to possibly stop the transmission of women's health issues to the offspring and favor a healthy pregnancy from the start. This could be one of the best strategies to promote both maternal and child health.

Management of Preexisting Diabetes in Pregnancy: A Review

IMPORTANCE

The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes.

OBSERVATIONS

Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated.

CONCLUSIONS AND RELEVANCE

Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.

Associations of Prenatal and Child Sugar Intake With Child Cognition

INTRODUCTION

Sugar consumption among Americans is above recommended limits, and excess sugar intake may influence cognition. The aim of this study was to examine associations of pregnancy and offspring sugar consumption (sucrose, fructose) with child cognition. Additionally, associations of maternal and child consumption of sugar-sweetened beverages (SSBs), other beverages (diet soda, juice), and fruit with child cognition were examined.

METHODS

Among 1,234 mother-child pairs enrolled 1999-2002 in Project Viva, a pre-birth cohort, in 2017 diet was assessed during pregnancy and early childhood, and cognitive outcomes in early and mid-childhood (median ages 3.3 and 7.7 years). Analyses used linear regression models adjusted for maternal and child characteristics.

RESULTS

Maternal sucrose consumption (mean 49.8 grams/day [SD=12.9]) was inversely associated with mid-childhood Kaufman Brief Intelligence Test (KBIT-II) non-verbal scores (-1.5 points per 15 grams/day, 95% CI= -2.8, -0.2). Additionally, maternal SSB consumption was inversely associated with mid-childhood cognition, and diet soda was inversely associated with early and mid-childhood cognition scores. Early childhood consumption of SSBs was inversely associated with mid-childhood KBIT-II verbal scores (-2.4 points per serving/day, 95% CI= -4.3, -0.5) while fruit consumption was associated with higher cognitive scores in early and mid-childhood. Maternal and child fructose and juice consumption were not associated with cognition. After adjusting for multiple comparisons, the association between maternal diet soda consumption and mid-childhood KBIT-II verbal scores remained significant.

CONCLUSIONS

Sugar consumption, especially from SSBs, during pregnancy and childhood, and maternal diet soda consumption may adversely impact child cognition, while child fruit consumption may lead to improvements. Interventions and policies that promote healthier diets may prevent adverse effects on childhood cognition.

Assessment of Attention Deficits in Adolescent Offspring Exposed to Maternal Type 1 Diabetes

OBJECTIVE

The aim of this study was to examine the potential association between intrauterine exposure to maternal diabetes and attention deficits in the offspring.

RESEARCH DESIGN AND METHODS

Adolescent offspring of a prospectively followed cohort of women with type 1 diabetes (n = 269) and a control group from the background population (n = 293) participated in a follow-up assessment in 2012-2013. We used scores from Conners Continuous Performance Test II to assess attention and based on a principal component analysis we evaluated scores on five different attention factors: focused attention, vigilance, hyperactivity/impulsivity, sustained attention and response style.

RESULTS

A higher frequency of the exposed offspring had a parent/self-reported use of Attention Deficit Hyperactivity Disorder (ADHD) medication compared to the control group (2.2% vs. 0.0%, p = 0.01). Clinical significant differences between adolescents exposed to maternal diabetes and unexposed controls were not found in either single scores on Conners Continuous Performance Test or on any of the five attention factors identified.

CONCLUSIONS

Exposure to maternal type 1 diabetes did not seem to increase the risk of attention deficits in the adolescent offspring. However, a higher self-reported use of ADHD medication in the exposed group could suggest a difference in attention not revealed by the applied test.

Long-term Cognitive Implications of Intrauterine Hyperglycemia in Adolescent Offspring of Women With Type 1 Diabetes (the EPICOM Study)

OBJECTIVE

Exposure to maternal diabetes in utero may have a negative impact on the developing brain. The objective was to examine long-term cognitive consequences of intrauterine hyperglycemia in adolescent offspring of women with type 1 diabetes and to ascertain a possible association with maternal HbA1c.

RESEARCH DESIGN AND METHODS

Offspring of a prospectively followed cohort of women with type 1 diabetes (n = 277) participated in a follow-up examination at the age of 13-19 years. A control group from the background population was identified (n = 301). Cognitive function was evaluated using Reynolds Intellectual Assessment Scales and classified into indices of composite intelligence, verbal and nonverbal intelligence, and composite memory. Frequencies of reading and writing problems and attendance to classes for children with learning difficulties were assessed.

RESULTS

Offspring of women with type 1 diabetes scored lower in all normalized and standardized intelligence indices compared with controls: composite intelligence (95.7 vs. 100, P = 0.001), verbal intelligence (96.2 vs. 100, P = 0.004), nonverbal intelligence (96.4 vs. 100, P = 0.008), and composite memory (95.7 vs. 100, P = 0.001). A higher frequency of diabetes-exposed offspring had parent-reported learning difficulties in primary school. Differences between groups remained after adjustment for confounders and potential mediators. We found no direct association between maternal HbA1c and offspring cognitive function in the exposed group.

CONCLUSIONS

Adolescent offspring of women with type 1 diabetes had lower cognitive function compared with a control group, also after adjustment for confounders and potential mediators. These differences may reflect direct harmful effects of maternal diabetes on neurodevelopment in the offspring.

Maternal Diabetes and Cognitive Performance in the Offspring: A Systematic Review and Meta-Analysis

Objective

Diabetes during gestation is one of the most common pregnancy complications associated with adverse health effects for the mother and the child. Maternal diabetes has been proposed to negatively affect the cognitive abilities of the child, but experimental research assessing its impact is conflicting. The main aim of our study was to compare the cognitive function in children of diabetic and healthy pregnant women.

Methods

A systematic review and meta-analysis was conducted through a literature search using different electronic databases from the index date to January 31, 2015. We included studies that assessed the cognitive abilities in children (up to 14 years) of diabetic and non-diabetic mothers using standardized and validated neuropsychological tests.

Results

Of 7,698 references reviewed, 12 studies involving 6,140 infants met our inclusion criteria and contributed to meta-analysis. A random effect model was used to compute the standardized mean differences and 95% confidence interval (CI) were calculated. Infants (1–2 years) of diabetic mothers had significantly lower scores of mental and psychomotor development compared to control infants. The effect size for mental development was -0.41 (95% CI -0.59, -0.24; p<0.0001) and for psychomotor development was -0.31 (95% CI -0.55, -0.07; p = 0.0125) with non-significant heterogeneity. Diabetes during pregnancy could be associated with decreased intelligence quotient scores in school-age children, although studies showed significant heterogeneity.

Conclusion

The association between maternal diabetes and deleterious effects on mental/psychomotor development and overall intellectual function in the offspring must be taken with caution. Results are based on observational cohorts and a direct causal influence of intrauterine hyperglycemia remains uncertain. Therefore, more trials that include larger populations are warranted to elucidate whether gestational diabetes mellitus (GDM) has a negative impact on offspring central nervous system (CNS).