PDF herunterladen
Am J Perinatol 2023; 40(04): 363-374
DOI: 10.1055/s-0041-1728823
Review Article

The Impact of Maternal Preeclampsia and Hyperglycemia on the Cardiovascular Health of the Offspring: A Systematic Review and Meta-analysis

Zahra Hoodbhoy 
1   Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
,
Nuruddin Mohammed
2   Department of Obstetrics and Gynecology, The Aga Khan University, Karachi, Pakistan
,
Karim Rizwan Nathani
3   Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
,
Saima Sattar
1   Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
,
Devyani Chowdhury
4   Nemours AI Dupont Children’s Hospital, Wilmington, Delaware
,
Shiraz Maskatia
5   Department of Paediatrics, Stanford University, Stanford, California
,
Seda Tierney
5   Department of Paediatrics, Stanford University, Stanford, California
,
Babar Hasan
1   Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
,
Jai K. Das
3   Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
› Institutsangaben
› Weitere Informationen
    Lizenzen und Reprints

Abstract

Objectives The objective of this review was to assess the impact of maternal preeclampsia or hyperglycemia on the body composition and cardiovascular health in the offspring.

Study Design We conducted a systematic review utilizing PubMed, EBSCO, CINAHLPlus, Cochrane Library, and Web of Science to include all studies assessing the impact of preeclampsia/eclampsia and/or gestational/pregestational diabetes mellitus on the health of the offspring (children <10 years of age). The health measures included anthropometry, cardiac dimensions and function, and vascular function. We performed a meta-analysis using Review Manager software and computed net risk ratio (RR) with 95% confidence interval (CI) for dichotomous data and mean difference (MD) with 95% CI for continuous data.

Results There were 6,376 studies in total, of which 45 were included in the review and 40 in the meta-analysis. The results demonstrated higher birth weight (MD: 0.12 kg; 95% CI: 0.06–0.18) and systolic and diastolic blood pressure (BP; MD: 5.98 mm Hg; 95% CI: 5.64–6.32 and MD: 3.27 mm Hg; 95% CI: 0.65–5.89, respectively) in the offspring of mothers with gestational diabetes compared to controls. In contrast, the offspring of mothers with preeclampsia had lower birth weight (MD: −0.41 kg; 95% CI: −0.7 to −0.11); however, they had increased systolic (MD: 2.2 mm Hg; 95% CI: 1.28–3.12) and diastolic BP (MD: 1.41 mm Hg; 95% CI: 0.3–2.52) compared to controls. There is lack of data to conduct a meta-analysis of cardiac morphology, functional, and vascular imaging parameters.

Conclusion These findings suggest that the in-utero milieu can have a permanent impact on the body composition and vascular health of the offspring. Future work warrants multicenter prospective studies to understand the mechanism and the actual effect of exposure to maternal hyperglycemia and high BP on the cardiovascular health of the offspring and long-term outcomes.

Key Points

  • Adverse in-utero exposures may have an impact on cardiovascular risk in children.

  • Maternal hyperglycemia/preeclampsia lead to changes in birthweight and BP.

  • Limited echocardiographic and vascular imaging data in these cohorts necessitates future work.

Keywords

hyperglycemia - preeclampsia - in-utero exposure - cardiovascular health - children - vascular health

Supplementary Material



Publikationsverlauf

Eingereicht: 22. Juli 2020

Angenommen: 02. März 2021

Artikel online veröffentlicht:
03. Mai 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Duffy TP, Burrow GN. Medical complications during pregnancy. WB Saunders; 1999
    Google Scholar
  • 2 Duley L. The global impact of pre-eclampsia and eclampsia. Paper presented at: Seminars in perinatology. Accessed 2009 at: https://www.sciencedirect.com/science/article/abs/pii/S0146000509000214
    PubMedGoogle Scholar
  • 3 Guariguata L, Linnenkamp U, Beagley J, Whiting DR, Cho NH. Global estimates of the prevalence of hyperglycaemia in pregnancy. Diabetes Res Clin Pract 2014; 103 (02) 176-185
    CrossrefPubMedGoogle Scholar
  • 4 Woelkers D, Barton J, von Dadelszen P, Sibai B. The revised 2013 ACOG definitions of hypertensive disorders of pregnancy significantly increase the diagnostic prevalence of preeclampsia. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health. 2015; 5 (01) 38
    PubMedGoogle Scholar
  • 5 Godfrey KM, Barker DJ. Fetal programming and adult health. Public Health Nutr 2001; 4 (2B, 2b): 611-624
    CrossrefPubMedGoogle Scholar
  • 6 Heindel JJ, Vandenberg LN. Developmental origins of health and disease: a paradigm for understanding disease cause and prevention. Curr Opin Pediatr 2015; 27 (02) 248-253
    CrossrefPubMedGoogle Scholar
  • 7 Balbus JM, Barouki R, Birnbaum LS. et al. Early-life prevention of non-communicable diseases. Lancet 2013; 381 (9860): 3-4
    CrossrefPubMedGoogle Scholar
  • 8 Rueda-Clausen CF, Morton JS, Davidge ST. Effects of hypoxia-induced intrauterine growth restriction on cardiopulmonary structure and function during adulthood. Cardiovasc Res 2009; 81 (04) 713-722
    CrossrefPubMedGoogle Scholar
  • 9 Lehtoranta L, Vuolteenaho O, Laine VJ. et al. Maternal hyperglycemia leads to fetal cardiac hyperplasia and dysfunction in a rat model. Am J Physiol Endocrinol Metab 2013; 305 (05) E611-E619
    CrossrefPubMedGoogle Scholar
  • 10 Vrachnis N, Antonakopoulos N, Iliodromiti Z. et al. Impact of maternal diabetes on epigenetic modifications leading to diseases in the offspring. Exp Diabetes Res 2012; 2012: 538474
    CrossrefPubMedGoogle Scholar
  • 11 Davis EF, Newton L, Lewandowski AJ. et al. Pre-eclampsia and offspring cardiovascular health: mechanistic insights from experimental studies. Clin Sci (Lond) 2012; 123 (02) 53-72
    CrossrefPubMedGoogle Scholar
  • 12 Himmelmann A, Svensson A, Hansson L. Relation of maternal blood pressure during pregnancy to birth weight and blood pressure in children. The Hypertension in Pregnancy Offspring Study. J Intern Med 1994; 235 (04) 347-352
    CrossrefPubMedGoogle Scholar
  • 13 Barker DJ. Adult consequences of fetal growth restriction. Clin Obstet Gynecol 2006; 49 (02) 270-283
    CrossrefPubMedGoogle Scholar
  • 14 Philipps LH, Santhakumaran S, Gale C. et al. The diabetic pregnancy and offspring BMI in childhood: a systematic review and meta-analysis. Diabetologia 2011; 54 (08) 1957-1966
    CrossrefPubMedGoogle Scholar
  • 15 Aceti A, Santhakumaran S, Logan KM. et al. The diabetic pregnancy and offspring blood pressure in childhood: a systematic review and meta-analysis. Diabetologia 2012; 55 (11) 3114-3127
    CrossrefPubMedGoogle Scholar
  • 16 Davis EF, Lazdam M, Lewandowski AJ. et al. Cardiovascular risk factors in children and young adults born to preeclamptic pregnancies: a systematic review. Pediatrics 2012; 129 (06) e1552-e1561
    CrossrefPubMedGoogle Scholar
  • 17 Andraweera PH, Lassi ZS. Cardiovascular risk factors in offspring of preeclamptic pregnancies—systematic review and meta-analysis. J Pediatr 2019; 208: 104-113.e6
    CrossrefPubMedGoogle Scholar
  • 18 Moher D, Shamseer L, Clarke M. et al; PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4 (01) 1
    CrossrefPubMedGoogle Scholar
  • 19 WHO. Definition of key terms. Published 2019. Accessed April 18, 2019 at: https://www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/
    PubMedGoogle Scholar
  • 20 AHRQ. Methods guide for effectiveness and comparative effectiveness reviews. Published 2013. Accessed December 1, 2018 at: https://effectivehealthcare.ahrq.gov/topics/cer-methods-guide/overview/
    PubMedGoogle Scholar
  • 21 Cochrane T. Review Manager (RevMan) 5.3. Copenhagen: The Nordic Cochrane Centre; 2008
    Google Scholar
  • 22 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21 (11) 1539-1558
    CrossrefPubMedGoogle Scholar
  • 23 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005; 5 (01) 13
    CrossrefPubMedGoogle Scholar
  • 24 Atabek ME, Çağan HH, Selver Eklioğlu B, Oran B. Absence of increase in carotid artery intima-media thickness in infants of diabetic mothers. J Clin Res Pediatr Endocrinol 2011; 3 (03) 144-148
    CrossrefPubMedGoogle Scholar
  • 25 Demiroren K, Cam L, Oran B. et al. Echocardiographic measurements in infants of diabetic mothers and macrosomic infants of nondiabetic mothers. J Perinat Med 2005; 33 (03) 232-235
    CrossrefPubMedGoogle Scholar
  • 26 Hăşmăşanu MG, Bolboacă SD, Matyas M, Zaharie GC. Clinical and echocardiographic findings in newborns of diabetic mothers. Acta Clin Croat 2015; 54 (04) 458-466
    PubMedGoogle Scholar
  • 27 Zablah JE, Gruber D, Stoffels G, Cabezas EG, Hayes DA. Subclinical decrease in myocardial function in asymptomatic infants of diabetic mothers: a tissue doppler study. Pediatr Cardiol 2017; 38 (04) 801-806
    CrossrefPubMedGoogle Scholar
  • 28 Antikainen L, Jääskeläinen J, Nordman H, Voutilainen R, Huopio H. Prepubertal children exposed to maternal gestational diabetes have latent low-grade inflammation. Horm Res Paediatr 2018; 90 (02) 109-115
    CrossrefPubMedGoogle Scholar
  • 29 Arslan D, Guvenc O, Cimen D, Ulu H, Oran B. Prolonged QT dispersion in the infants of diabetic mothers. Pediatr Cardiol 2014; 35 (06) 1052-1056
    CrossrefPubMedGoogle Scholar
  • 30 Baptiste-Roberts K, Nicholson WK, Wang N-Y, Brancati FL. Gestational diabetes and subsequent growth patterns of offspring: the National Collaborative Perinatal Project. Matern Child Health J 2012; 16 (01) 125-132
    CrossrefPubMedGoogle Scholar
  • 31 Berglund SK, García-Valdés L, Torres-Espinola FJ. et al; PREOBE team. Maternal, fetal and perinatal alterations associated with obesity, overweight and gestational diabetes: an observational cohort study (PREOBE). BMC Public Health 2016; 16 (01) 207
    CrossrefPubMedGoogle Scholar
  • 32 Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics 2005; 115 (03) e290-e296
    CrossrefPubMedGoogle Scholar
  • 33 Catalano PM, Farrell K, Thomas A. et al. Perinatal risk factors for childhood obesity and metabolic dysregulation. Am J Clin Nutr 2009; 90 (05) 1303-1313
    CrossrefPubMedGoogle Scholar
  • 34 Catalano PM, McIntyre HD, Cruickshank JK. et al; HAPO Study Cooperative Research Group. The hyperglycemia and adverse pregnancy outcome study: associations of GDM and obesity with pregnancy outcomes. Diabetes Care 2012; 35 (04) 780-786
    CrossrefPubMedGoogle Scholar
  • 35 Chandler-Laney PC, Bush NC, Granger WM, Rouse DJ, Mancuso MS, Gower BA. Overweight status and intrauterine exposure to gestational diabetes are associated with children's metabolic health. Pediatr Obes 2012; 7 (01) 44-52
    CrossrefPubMedGoogle Scholar
  • 36 Chang Y, Chen X, Zhang ZK. Intrauterine exposure to maternal diabetes is associated with adiposity in children at 6 years of age in China. Biomed Environ Sci 2015; 28 (02) 140-142
    PubMedGoogle Scholar
  • 37 Crume TL, Ogden L, West NA. et al. Association of exposure to diabetes in utero with adiposity and fat distribution in a multiethnic population of youth: the Exploring Perinatal Outcomes among Children (EPOCH) Study. Diabetologia 2011; 54 (01) 87-92
    CrossrefPubMedGoogle Scholar
  • 38 Gillman MW, Rifas-Shiman S, Berkey CS, Field AE, Colditz GA. Maternal gestational diabetes, birth weight, and adolescent obesity. Pediatrics 2003; 111 (03) e221-e226
    CrossrefPubMedGoogle Scholar
  • 39 Hillier TA, Pedula KL, Vesco KK, Oshiro CE, Ogasawara KK. Impact of maternal glucose and gestational weight gain on child obesity over the first decade of life in normal birth weight infants. Matern Child Health J 2016; 20 (08) 1559-1568
    CrossrefPubMedGoogle Scholar
  • 40 Hoodbhoy Z, Mohammed N, Aslam N. et al. Is the child at risk? Cardiovascular remodelling in children born to diabetic mothers. Cardiol Young 2019; 29 (04) 467-474
    CrossrefPubMedGoogle Scholar
  • 41 Kearney M, Perron J, Marc I, Weisnagel SJ, Tchernof A, Robitaille J. Association of prenatal exposure to gestational diabetes with offspring body composition and regional body fat distribution. Clin Obes 2018; 8 (02) 81-87
    CrossrefPubMedGoogle Scholar
  • 42 König AB, Junginger S, Reusch J, Louwen F, Badenhoop K. Gestational diabetes outcome in a single center study: higher BMI in children after six months. Horm Metab Res 2014; 46 (11) 804-809
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 43 Korraa A, Ezzat MH, Bastawy M, Aly H, El-Mazary A-A, Abd El-Aziz L. Cardiac troponin I levels and its relation to echocardiographic findings in infants of diabetic mothers. Ital J Pediatr 2012; 38 (01) 39
    CrossrefPubMedGoogle Scholar
  • 44 Krishnaveni GV, Veena SR, Hill JC, Kehoe S, Karat SC, Fall CH. Intrauterine exposure to maternal diabetes is associated with higher adiposity and insulin resistance and clustering of cardiovascular risk markers in Indian children. Diabetes Care 2010; 33 (02) 402-404
    CrossrefPubMedGoogle Scholar
  • 45 Logan KM, Emsley RJ, Jeffries S. et al. Development of early adiposity in infants of mothers with gestational diabetes mellitus. Diabetes Care 2016; 39 (06) 1045-1051
    CrossrefPubMedGoogle Scholar
  • 46 Mehta S, Nuamah I, Kalhan S. Altered diastolic function in infants of mothers with gestational diabetes: no relation to macrosomia. Pediatr Cardiol 1995; 16 (01) 24-27
    CrossrefPubMedGoogle Scholar
  • 47 Nehring I, Chmitorz A, Reulen H, von Kries R, Ensenauer R. Gestational diabetes predicts the risk of childhood overweight and abdominal circumference independent of maternal obesity. Diabet Med 2013; 30 (12) 1449-1456
    CrossrefPubMedGoogle Scholar
  • 48 Nilsson C, Carlsson A, Landin-Olsson M. Increased risk for overweight among Swedish children born to mothers with gestational diabetes mellitus. Pediatr Diabetes 2014; 15 (01) 57-66
    CrossrefPubMedGoogle Scholar
  • 49 Page KA, Romero A, Buchanan TA, Xiang AH. Gestational diabetes mellitus, maternal obesity, and adiposity in offspring. J Pediatr 2014; 164 (04) 807-810
    CrossrefPubMedGoogle Scholar
  • 50 Pham MT, Brubaker K, Pruett K, Caughey AB. Risk of childhood obesity in the toddler offspring of mothers with gestational diabetes. Obstet Gynecol 2013; 121 (05) 976-982
    CrossrefPubMedGoogle Scholar
  • 51 Retnakaran R, Ye C, Hanley A. et al. Effect of maternal gestational diabetes on the cardiovascular risk factor profile of infants at 1 year of age. Nutr Metab Cardiovasc Dis 2013; 23 (12) 1175-1181
    CrossrefPubMedGoogle Scholar
  • 52 Tam WH, Ma RCW, Yang X. et al. Glucose intolerance and cardiometabolic risk in children exposed to maternal gestational diabetes mellitus in utero. Pediatrics 2008; 122 (06) 1229-1234
    CrossrefPubMedGoogle Scholar
  • 53 Tam WH, Ma RCW, Ozaki R. et al. In utero exposure to maternal hyperglycemia increases childhood cardiometabolic risk in offspring. Diabetes Care 2017; 40 (05) 679-686
    CrossrefPubMedGoogle Scholar
  • 54 Vohr BR, McGarvey ST. Growth patterns of large-for-gestational-age and appropriate-for-gestational-age infants of gestational diabetic mothers and control mothers at age 1 year. Diabetes Care 1997; 20 (07) 1066-1072
    CrossrefPubMedGoogle Scholar
  • 55 Al-Biltagi M, Tolba OARE, Rowisha MA, Mahfouz Ael-S, Elewa MA. Speckle tracking and myocardial tissue imaging in infant of diabetic mother with gestational and pregestational diabetes. Pediatr Cardiol 2015; 36 (02) 445-453
    CrossrefPubMedGoogle Scholar
  • 56 Åman J, Hansson U, Östlund I, Wall K, Persson B. Increased fat mass and cardiac septal hypertrophy in newborn infants of mothers with well-controlled diabetes during pregnancy. Neonatology 2011; 100 (02) 147-154
    CrossrefPubMedGoogle Scholar
  • 57 Boerschmann H, Pflüger M, Henneberger L, Ziegler A-G, Hummel S. Prevalence and predictors of overweight and insulin resistance in offspring of mothers with gestational diabetes mellitus. Diabetes Care 2010; 33 (08) 1845-1849
    CrossrefPubMedGoogle Scholar
  • 58 Fugelseth D, Ramstad HB, Kvehaugen AS, Nestaas E, Støylen A, Staff AC. Myocardial function in offspring 5-8years after pregnancy complicated by preeclampsia. Early Hum Dev 2011; 87 (08) 531-535
    CrossrefPubMedGoogle Scholar
  • 59 Hakanen T, Saha MT, Salo MK. et al. Mothers with gestational diabetes are more likely to give birth to children who experience early weight problems. Acta Paediatr 2016; 105 (10) 1166-1172
    CrossrefPubMedGoogle Scholar
  • 60 Kozák-Bárány A, Jokinen E, Kero P, Tuominen J, Rönnemaa T, Välimäki I. Impaired left ventricular diastolic function in newborn infants of mothers with pregestational or gestational diabetes with good glycemic control. Early Hum Dev 2004; 77 (1-2): 13-22
    CrossrefPubMedGoogle Scholar
  • 61 Lawlor DA, Fraser A, Lindsay RS. et al. Association of existing diabetes, gestational diabetes and glycosuria in pregnancy with macrosomia and offspring body mass index, waist and fat mass in later childhood: findings from a prospective pregnancy cohort. Diabetologia 2010; 53 (01) 89-97
    CrossrefPubMedGoogle Scholar
  • 62 Mutlu K, Karadas U, Yozgat Y. et al. Echocardiographic evaluation of cardiac functions in newborns of mildly preeclamptic pregnant women within postnatal 24-48 hours. J Obstet Gynaecol 2018; 38 (01) 16-21
    CrossrefPubMedGoogle Scholar
  • 63 Palti H, Rothschild E. Blood pressure and growth at 6 years of age among offsprings of mothers with hypertension of pregnancy. Early Hum Dev 1989; 19 (04) 263-269
    CrossrefPubMedGoogle Scholar
  • 64 Staley JR, Bradley J, Silverwood RJ. et al. Associations of blood pressure in pregnancy with offspring blood pressure trajectories during childhood and adolescence: findings from a prospective study. J Am Heart Assoc 2015; 4 (05) e001422
    CrossrefPubMedGoogle Scholar
  • 65 Wen X, Triche EW, Hogan JW, Shenassa ED, Buka SL. Prenatal factors for childhood blood pressure mediated by intrauterine and/or childhood growth?. Pediatrics 2011; 127 (03) e713-e721
    CrossrefPubMedGoogle Scholar
  • 66 Byberg KK, Øymar K, Eide GE, Forman MR, Júlíusson PB. Exposure to preeclampsia in utero affects growth from birth to late childhood dependent on child's sex and severity of exposure: Follow-up of a nested case-control study. PLoS One 2017; 12 (05) e0176627
    CrossrefPubMedGoogle Scholar
  • 67 Geelhoed JJ, Fraser A, Tilling K. et al. Preeclampsia and gestational hypertension are associated with childhood blood pressure independently of family adiposity measures: the Avon Longitudinal Study of Parents and Children. Circulation 2010; 122 (12) 1192-1199
    CrossrefPubMedGoogle Scholar
  • 68 Lawlor DA, Macdonald-Wallis C, Fraser A. et al. Cardiovascular biomarkers and vascular function during childhood in the offspring of mothers with hypertensive disorders of pregnancy: findings from the Avon Longitudinal Study of Parents and Children. Eur Heart J 2012; 33 (03) 335-345
    CrossrefPubMedGoogle Scholar
  • 69 Bank W. The World by Income and Region. Accessed July 7, 2020 at: http://datatopics.worldbank.org/world-development-indicators/the-world-by-income-and-region.html
    PubMedGoogle Scholar
  • 70 Smith CJ, Ryckman KK, Barnabei VM. et al. The impact of birth weight on cardiovascular disease risk in the Women's Health Initiative. Nutr Metab Cardiovasc Dis 2016; 26 (03) 239-245
    CrossrefPubMedGoogle Scholar
  • 71 Johnsson IW, Haglund B, Ahlsson F, Gustafsson J. A high birth weight is associated with increased risk of type 2 diabetes and obesity. Pediatr Obes 2015; 10 (02) 77-83
    CrossrefPubMedGoogle Scholar
  • 72 Szostak-Węgierek D, Szamotulska K. Fetal development and risk of cardiovascular diseases and diabetes type 2 in adult life. Med Wieku Rozwoj 2011; 15 (03) 203-215
    PubMedGoogle Scholar
  • 73 Fan ZT, Yang HX, Gao XL, Lintu H, Sun WJ. Pregnancy outcome in gestational diabetes. Int J Gynaecol Obstet 2006; 94 (01) 12-16
    CrossrefPubMedGoogle Scholar
  • 74 Xiong X, Demianczuk NN, Saunders LD, Wang F-L, Fraser WD. Impact of preeclampsia and gestational hypertension on birth weight by gestational age. Am J Epidemiol 2002; 155 (03) 203-209
    CrossrefPubMedGoogle Scholar
  • 75 West NA, Crume TL, Maligie MA, Dabelea D. Cardiovascular risk factors in children exposed to maternal diabetes in utero. Diabetologia 2011; 54 (03) 504-507
    CrossrefPubMedGoogle Scholar
  • 76 Constans J, Conri C. Circulating markers of endothelial function in cardiovascular disease. Clin Chim Acta 2006; 368 (1-2): 33-47
    CrossrefPubMedGoogle Scholar
  • 77 Ettehad D, Emdin CA, Kiran A. et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016; 387 (10022): 957-967
    CrossrefPubMedGoogle Scholar
  • 78 Moodley S, Arunamata A, Stauffer KJ. et al. Maternal arterial stiffness and fetal cardiovascular physiology in diabetic pregnancy. Ultrasound Obstet Gynecol 2018; 52 (05) 654-661
    CrossrefPubMedGoogle Scholar
  • 79 Dawid G, Horodnicka-Jozwa A, Czeszynska M. et al. 78 a prospective echocardiography evaluation in infants of diabetic mothers during the first year of life. Pediatr Res 2005; 58 (02) 367-367
    CrossrefPubMedGoogle Scholar