Maternal Diabetes Linked to Increased Childhood Epilepsy Risk

Maternal diabetes, whether type 1, type 2 or gestational, has been previously found to increase the risk of epilepsy in children. In this study, investigators conducted a large retrospective analysis of more than 2.1 million births in Ontario, Canada, and found that the risk of epilepsy in children of mothers with diabetes, especially type 2 or type 1 diabetes, was increased. Understanding these risks, managing glucose during pregnancy, monitoring children born to mothers with diabetes for symptoms and signs of epilepsy, and counseling families on the risks and management of epilepsy in children of mothers with diabetes can help clinicians provide the best possible care and outcomes for these patients.

Why It Matters

Examining the association between maternal diabetes and childhood epilepsy expands the possible consequences of maternal diabetes on her offspring during childhood. Epidemiological studies have found that epilepsy is more than just repeated seizures; it is a chronic condition affecting cognitive function, school performance, and overall quality of life. Children with epilepsy require long-term follow-up for recurrent seizures and potential adverse effects. Viewing the possible consequences of maternal diabetes and the potential need for prevention, screening, and follow-up for both mother and child during pregnancy and the postpartum period is therefore warranted.

From the prenatal medicine perspective, the goals of diabetes management in pregnancy are broadened to consider neurodevelopmental outcomes. Traditionally, goals for managing diabetes in pregnancy have focused on outcomes such as preeclampsia, cesarean delivery, fetal macrosomia, birth trauma, neonatal hypoglycemia, and stillbirth. Good glucose control in pregnant women with diabetes, however, may also reduce later neurologic vulnerability in children. Maternal metabolic health during pregnancy may impact the lifelong health of children.

This study identifies the critical maternal diabetes component that increases the risk of neurological complications in offspring and provides clinical implications for the healthcare system. All levels of prenatal care for women with diabetes need to be amended including early diabetes diagnosis, amendment of preconception and medical management of glycemia during pregnancy, and incorporation of more interdisciplinary health care providers from both medical and surgical disciplines. The health care reimbursement system and clinical pathways need to be revised to provide women with diabetes during pregnancy universal access to diabetes management education and nutrition counseling, continuous glucose monitoring, and follow-up with appropriate medical and/or surgical specialists. Diabetes management in pregnancy would no longer be viewed as a short-term, acute obstetric issue but rather an important concern for maternal and child health with effects persisting for years after birth.

While considerable attention has focused on long-term neurologic and developmental outcomes of children exposed prenatally to maternal diabetes, it may also be useful to consider the children’s postnatal development with attention to the need for more structured followup, particularly in the presence of additional perinatal risk factors. Children of diabetic mothers require the pediatrician, and their families, to have a clear understanding of the appropriate timing of neurologic and developmental screening tests, when seizure- related and developmental delay symptoms deserve particular concern, and when to refer a child for early intervention services or pediatric neurology evaluation. Timely referral for and initiation of such services, which have the potential to dramatically affect the outcome of children of diabetic mothers, is critical.

Consider should also be given to workforce planning and organisational issues that are required to support optimal care for women with diabetes during pregnancy and their infants. Stronger cooperation among a range of health care professionals and their staff including obstetricians, endocrinologists, diabetes educators, midwives, neonatologists, paediatricians and paediatric neurologists and their staff as well as shared protocols for care of women with pregestational and gestational diabetes, surveillance of infants at risk and improved communication between pregnancy management and child health services would be beneficial. It is very rare in the health system for maternal and paediatric health to be managed as an integrated program of care for two individuals as one clinical ‘case’. The focus to date has been on the long term outcomes for the fetus/infant and it is time to consider a more connected approach to the management of these women and children as they traverse the health system.

There are also significant equity and access concerns in the scope of work for a Diabetes in Pregnancy program. Diabetes in pregnancy is more common in disadvantaged communities and women in these communities face high rates of obesity and food insecurity as well as other health behaviors and health conditions including chronic stress. These same communities have significant barriers to receiving high quality preconception counseling and early prenatal care as well as access to affordable diabetes medications and glucometers, transportation to medical appointments, health literacy assistance and follow-up care post-delivery. After birth, there are significant barriers to access to pediatric specialists, developmental screening and early intervention programs for children most likely to be exposed to maternal metabolic risk, while least likely to receive timely developmental surveillance.

Reducing the potential long-term neurologic burden of maternal diabetes on children and their families will require more than good pregnancy care. Addressing this issue will need a strong public health and health care system, as well as community-based education and resources for healthy pregnant women. Adequate insurance coverage for all women and girls, and culturally competent diabetes care and prevention programs are also necessary. In addition, good continuity of care from preconception through early childhood is vital. Long-term health of children will depend on good policies related to diabetes prevention, maternal and child nutrition, and postpartum follow-up care for new mothers.

Maternal diabetes has been linked to increased risk of childhood epilepsy, illustrating how maternal health in pregnancy can affect brain development in the fetus and shape lifelong outcomes. By highlighting the critical period for brain health beginning in utero, and linking maternal metabolic health with childhood neurological health, these findings point to new opportunities for early prevention and intervention as well as improved, coordinated, and equitable health care for affected families.

Who It Affects

These findings are relevant to a number of groups of patients including pregnant women with diabetes (either pre-existing type 1 or type 2 diabetes or gestational diabetes) and their children, and consideration may need to be given to families with related parents and children. These findings further support early prenatal evaluation, good control of diabetes, adherence to recommended prenatal and postpartum evaluations for women with diabetes and their infants and appropriate follow-up of the child’s development. Children of mothers with diabetes and their families should also be aware of the early signs of seizures or developmental delays and seek early evaluation.

Healthcare providers (obstetricians, family physicians, midwives) managing pregnancies complicated by diabetes must be aware of the long-term risks to the child and advise women with diabetes accordingly. Endocrinologists, diabetes management and education professionals and providers of preconception counselling for women with diabetes are critical. Pediatricians and neonatologists managing the newborns of women with diabetes will have a greater understanding of the long-term risks to the child. Pediatric neurologists can also expect changes in their referral patterns due to increased recognition of the risk of seizure disorders in children of mothers with diabetes.

Health systems and payers: Health systems and hospitals will need to assess whether current systems of care for antenatal diabetes, neonatal hypoglycemia, and early childhood development and learning services can adequately serve the needs of mothers and children who have predisposition to neurodevelopmental disorders. Payers will need to determine whether to cover interventions, such as preconception care for women with hyperglycemia, continuous glucose monitoring for women with hyperglycemia during pregnancy and after delivery, and long-term follow-up of mother–child pairs. Public health systems and community-based organizations will need to consider how maternal metabolic health can be integrated into childhood neurologic-risk assessment and prevention efforts.

What Changes

• Clinical practice may broaden prenatal counseling to explicitly discuss longer-term neurodevelopmental risks associated with elevated blood sugar in pregnancy, encouraging preconception optimization and close monitoring throughout gestation.
• Newborn and pediatric care pathways should incorporate maternal diabetes history as a flag for earlier or more frequent developmental and neurologic follow-up so seizures or emerging neurodevelopmental issues are identified promptly.
• Health systems and payers may need to expand coverage for preconception care, diabetes education, and technologies such as continuous glucose monitoring during pregnancy to reduce risks that extend into childhood.
• Policy and equity efforts should target social determinants that limit access to high-quality prenatal diabetes care—addressing transportation, language services, insurance barriers, and community-based education to reduce disparities in outcomes.

Management of maternal diabetes is determined by several factors including the setting in which care is provided and the series of clinical decisions made along the way. Maternal diabetes is not a single disease entity, and hence the management approach for a woman with preexisting type 1 diabetes differs from that of a woman with preexisting type 2 diabetes or those who develop gestational diabetes. As with any medical condition, the goal is to strive for the best possible management while avoiding undue harm, all the while taking into account a patient’s preferences as well as the socioeconomic realities that impact her ability to achieve optimal management. Thus, there is an important role for shared decision-making, wherein intense monitoring of blood sugar and modifica- tion of her diabetes medications is warranted for some women, whereas more practical goals may need to be established for others. Incorporating considerations of social determinants of health and other patient-level barriers to optimal management will be crucial.

The message for pediatric clinicians is not a dire one. Infants of diabetic mothers (IDM) require careful metabolic monitoring for hypoglycemia at birth and subsequent developmental surveillance. Early identification of seizures and timely treatment is critical for optimal seizure control and development. Pediatricians must be aware of this condition and refer infants and children with risk factors to neurology, early intervention, and support and education for diabetic mothers and their children as indicated.

By providing a continuum of care for the woman with hyperglycemia and her newborn throughout the perinatal period, improved continuity between the obstetrics and pediatrics departments can be achieved. This can be facilitated by the accurate completion of birth records and the distribution of complete and accurate discharge summaries to all of a woman’s outpatient providers documenting her maternal diabetes diagnosis and any neonatal complications. Diabetes management education and social work support and resources should also be incorporated into the prenatal clinics to prepare the pregnant woman for management of her hyperglycemia.

Equity must be a top priority. Financial and logistial barriers to good preconception and prenatal diabetes care exist. Affordability of insulin and diabetes care supplies (such as glucometers, test strips, meters, insulin pumps and sensors, canulas) as well as access to in-person versus virtual diabetes education varies. Implementing policies and programs that pay for more comprehensive diabetes management in pregnancy, reimburse telemedicine and home glucose monitoring for pregnant women with diabetes, and support community health workers can help address these disparities and potentially reduce long-term neurologic sequelae in children.

Future clinical research is needed to translate these findings into preventive measures for clinical application. Studies are needed to elucidate the pathway, implementation, and degree to which tighter glycemic control before and during pregnancy might decrease long-term neurologic sequelae. In addition, studies are needed to delineate the approach to newborn monitoring and early intervention in the setting of maternal diabetes. The main message for clinicians is that optimal maternal metabolic control, careful newborn monitoring, and a low threshold for developmental follow-up are the keys to preventing CNS abnormalities in offspring exposed in utero to maternal diabetes.

Another way to look at this is to highlight the unknowns and discuss them cautiously with families. Simply because there is association does not mean there is causation, and it is likely that multiple factors will ultimately contribute to the neurologic development of a child, possibly including genetic predisposition, perinatal exposures, socioeconomic status, and the child’s postnatal environment. The challenge is to offer information that is realistic and cautious, yet provides guidance on steps that families can take to decrease potential harm.

This issue marks a significant shift in how perinatal medicine considers the consequences of maternal and pregnancy related conditions. While previously the focus of perinatal medicine has been on the health of mother and baby in the perinatal period, there is increasingly recognition that maternal health in pregnancy has long term effects on the health and cognitive development of the child which in turn can affect learning, education, health and well-being in adulthood and have broader societal benefits. As a result maternal diabetes and other medical conditions become an important area for research in obstetrics as well as an important area for maternal and child public health policy and practice.

References:

https://pubmed.ncbi.nlm.nih.gov/41633502/ https://pubmed.ncbi.nlm.nih.gov/41689071/