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Friday
Mar302012

"Big Healthy Babies"

The headline read: “Record Breaking Baby Born at Paoli Hospital” and then the abbreviated story of one mom’s birth of her extra-large child unfolded.

“Six-day-old Blake Alexander Ciarlone is the new biggest baby born at Paoli Hospital, according to available records dating back to 2002.

“Born to Allison and Daniel Ciarlone, he was 12 pounds nine ounces, beating the previous record, set last year, by two ounces.

“Blake is Allison and Daniel’s second child and follows the trend set by his 2-year-old brother, Landon James Matthew Ciarlone, who was born at 10 pounds 13 ounces. Both births were planned Cesarean sections because Allison was getting too big. Blake was born four days early, and his brother Landon was born two weeks early.”

I posted the story on my Navelgazing Midwife Facebook Page and surely made some comment or another about the mom having Gestational Diabetes. Often when these articles come out, there is a disclaimer inside the piece stating, “Gestational Diabetes can cause babies to be this large, but <mom’s last name> did not.” Or, “Baby Ciarlone was born healthy.” In this article, we get a hint about mom’s diet during the pregnancy, unusual in these stories.

“Both were pretty normal pregnancies, said Allison. She ate what she wanted, but it wasn’t anything excessive…. ‘I guess I just carry big babies,’ she said.”

Does she?

Here unfolds the discussion and I’ll answer the questions directed at me as we go along even though it becomes clear I didn’t answer during the discussion. These interjections will be in italics.

JT: Is it just me or are these stories getting more and more common?

KBH: They are! I have seen so many news articles and stories of babies 10lb+ lately who are obviously macrosomic, etc. and it's driving me nuts! Every single one, mom is "I guess I just make them big." Really, really wish people would wake up and realize that this is an issue!

CG: "big healthy baby" /sigh. Big doesn't mean healthy.

TWJ: But big doesn't necessarily mean unhealthy either. Just a thought.

SS-R: There's a difference between a "big, healthy baby" and a "macrosomic baby". Unfortunately, most news stories don't differentiate. I've seen a 10lb+ baby that was lean, stocky and long. Both parents were tall and stocky, with mom hovering around six feet tall and dad towering over her. Baby had great APGARS and perfect blood sugar. THAT is NOT the typical "biggest baby born" you see cropping up in the news.

HH: "Since she was measuring about 40 inches around (t)he waist at 36 weeks, her doctor “didn’t want to take any chances,” said Allison."

I am confused… I was almost 60 inches with my last. What's the big deal. (This was referring to: “Since she was measuring about 40 inches around he waist at 36 weeks, her doctor ‘didn’t want to take any chances,’ said Allison. They planned the cesarean section and were expecting another 10 pound baby, but were surprised by the extra two pounds.”)

Also, not to be rude, but she is a plus size momma. 40 inches isn't that big of a waist. Was she a size 5 before the pregnancy or something?

I can testify... I make big babies. My last was 9'13. I only gained 35 lbs and NO GD. Big can be healthy.

I wonder how much weight she gained.

NgM: It’s important to know that diet is not the only way to control GDM or IR. Sometimes it takes medications as well. I’ve known women to be meticulous with their diets and still have 10+ pound macrosomic babies because their pancreas needed more help than just the dietary changes. The diet certainly helps in these cases… imagine how large the babies would be without that help from mom… but the baby sometimes needs more help than even mom can offer.

KL-D: Is there any indication that this baby wasn't healthy?

NgM: A baby that big is, most assuredly, not healthy. ‎HH: There can be Insulin Resistance long before GDM and IR affects the size of babies, too. The GTT is an archaic screen/test, the best we have at the moment, but it doesn't catch all cases of IR (the lower limits catch some, however). ‎HH: They meant fundal height, not waist measurement.

TS: So, stupid question maybe for NGM-- if a mom is diagnosed with GDM or insulin resistance and is untreated aside from changing one's diet, is it possible to have a normal-sized baby?

NgM: No question is stupid! However, I’m not sure I understand this one totally. Let me try, though. If mom IS diagnosed with IR or GDM and changes her diet, is it possible to have a normal-weighted baby? Absolutely. If mom is diagnosed with IR or GDM and changes her diet, is it possible she might still have an LGA or macrosomic baby? Absolutely, because of the possibility of the pancreas needing more help than diet can offer… mom needing medications to help as well. Did I answer that right?

We don’t talk about it enough, but it isn’t just diet… there is also a huge part of the puzzle with exercise. Exercise helps the pancreas metabolize the food in many different ways. Simplistically, it gives the pancreas more power to shoot out the insulin as well as burning some of the food through energy expenditure instead of it needing to be metabolized with insulin. If pregnant women walked for 15-20 minutes after each appropriately sized meal (and appropriate carbs!), it can make or break an IR/GDM experience.

AKS: TS, I believe the answer has to do with tight control of blood sugars, which is sometimes possible via diet and sometimes not.

Also, I have a friend who just had a 9 lb. 2 oz. 23 inch baby. Definitely no GD--she tested her blood sugar 4 times/day before the GTT, which she passed. Baby had heel sticks after birth, zero blood sugar problems. Maybe some women really do grow big healthy babies? They just don't make the news?

NgM: Depending on who you ask, 4000 grams (8lbs 13oz) or 4500 grams (9lbs 15oz) = LGA or macrosomic (two different definitions, by the way, but often used interchangeably), so 9lbs 2oz would barely fit one description and not the other one at all. I hardly waggle my eyebrows unless the baby is over 4500 grams. Unless mom is under about 5’5”.
Also, I’ve read in diabetic literature that testing four times a day is hardly adequate to determine how a person’s blood glucoses are doing in any 24 hour period. Even four times a day and the HgbA1c together won’t track the ups and downs that happen throughout the day. 10-12 times a day is a more accurate number of finger sticks needed.

This is why I’ve wished the three day continuous monitor might replace the Glucose Screen and GTT. The continuous monitor measures glucoses every 3-5 minutes for three days. Now that’s accurate! Here’s a great explanation about why the four times a day and the HgbA1c aren’t the most accurate ways to gauge BGs.

CS: This is the topic that had me hooked to NgM :) I ended up on her blog a few months ago for something entirely unrelated, and went to bed that night with a sigh of relief. I knew I had big babies and I always knew there was something not right. Hearing that IR can cause macrosomic babies was the light bulb I needed in this pregnancy. It makes sense. I'm 5'2, and both dads are 5'11 and under. So I always questioned where 9lb 2.5oz 23" and 9lb 5oz 24" babies came from. I hated hearing that I just made big babies, but it was a mantra I began to accept. My second son is huge. He's the size of his 4 year old brother. If I was going on just him, I'd agree I made big babies. But his brother normaled out quite quickly after birth. My first had a perfect APGAR, my second had a 7 and they took him to the nursery and his sugars were off. Add that with my dad's diabetes diagnosis at the beginning of this pregnancy, and the pouch around my middle that I can't get rid of, and I believe that I fit the category of IR macrosomic baby maker. Up until getting sick over a month ago, my diet was great. But I've gone off the diabetes lifestyle change as it was harder to maintain while battling chest infections with little sleep and raising my boys. I'm 24 weeks now, so I'm hoping to be healthy enough soon to regain my energy levels so I can change my lifestyle again and hopefully better my pregnancy, delivery, and my daughter's future. Thank you NgM for your logical and informative information on this subject. I wish you were able to reach more women on the subject.

Also, what was the test you recommended again? The one that tests 3 months worth opposed to the blood glucose level test? I'm going for the routine one next week and I don't suspect anything will come of it, but whether during pregnancy or after, I want to take that test just to see.

(Ps. I thought it was funny when my midwife asked if I wanted the glucose testing, I told her yes, but that I already changed my lifestyle based on the information I read on your blog. She smiled at me and nodded. She totally knew who you were and was supportive of the same information you speak of! Just thought it was cool that you are that well known up here in Canada too!)

NgM: Hilarious! And I’m flattered.

KDK: A1c is the more accurate test.

NgM: Yes, the Hemoglobin A1c is another measure of how a woman’s glucoses are doing, but it can only see from the point of the test backwards three months. Therefore, testing in pregnancy is good for observation, but not for diagnosing GDM. The reason the GD screen and GTT are done about 28 weeks is because that’s when the mechanism for pancreatic stress takes effect. While it seems gradual, it wouldn’t be surprising if it was a light switch reaction to the pancreas hitting its stress limit. Not diabetic one day and diabetic the next. Doubtful, but sometimes it’s easier to visualize what happens if you think of it that way.

But we know that Diabetes is a spectrum, it’s a ramping up of glucose in the blood because the pancreas gets more and more exhausted trying to keep up with metabolizing food intake. That’s why there can be tight control over food and exercise, but the pancreas still needing more help with medications because mom can only do so much. Diet and exercise are crucial… taking meds instead of changing the diet and exercising is inappropriate and probably pretty ineffective… but together, it can be awesome for the mom and baby.

SS-R: At 60, my mother has no signs of IR or Diabetes, she had four babies ranging from 9lbs even to 9lbs 15.5ozs. Diabetes in all its forms is virtually unheard of in our family at all, in fact. MOST babies born on my mother's side of the family are between 9 & 10 pounds (big, but generally not considered macrosomic). I think we need to be careful to distinguish between the two. There is such a thing as big and healthy, and I think we are going to be seeing more and more of it as people are eating better during pregnancy, as humans get taller with each generation, as smoking decreases- both during pregnancy and prior to it. There are a lot of things known to contribute to SGA babies, even in a good-sized baby, those things- or the lack of them- can cause a variation of a few ounces one way or the other, and when you are talking about people with a family or genetic disposition to babies that are on the upper end of that size bell curve, a few ounces can make a big difference.

That said, I am not one of the people who believe that all big babies are healthy, or that GD doesn't exist. I simply think we need to be cautious not to be diagnosing mothers and babies with medical conditions based on a single factor and without access to their medical information.

S: as I pointed out in my previous comment (and if someone could link the blog post where NgM discusses this in full) I kind of have a triple threat against me. I may have self-diagnosed, but it's not affecting my life. It's a lifestyle change that really is a billion times better for me. Diabetes can hit anyone at any time, regardless of genetics (although usually they do play a part). I would rather change my lifestyle now and possibly have a smaller baby (less traumatic birth) and possibly avoid becoming full-fledged diabetic later in life. Some women obviously make big babies. Genetics is great like that. But, the 3 strikes were that I had one child who was born large but who normalized after birth (i.e. he wasn't that high in the percentiles, but rather quite normal), diabetes runs in my family with my dad being diagnosed quite recently, and I've had recent weight gain (mainly in waist area). One thing on that list doesn't necessarily mean IR. It doesn't mean that it's not IR either, but I firmly believe that with each checkmark on the list, the chances are increased immensely. I think more needs to be studied on this to help more women. Diabetes is awful on its own, but to know what it does to your heart and the rest of your systems is enough to want to avoid it at all costs. I don't ever think that NgM is throwing everyone under the big babies = undiagnosed IR or worse bus. But I do think that her way of thinking could change the face of pregnancy and even diabetes as we know it for the world over.

LA: Seems to me that generalizations do one thing: hurt mom and babies (yeah, generalizing about generalizations).

There are big healthy babies. There are big unhealthy babies. There are small healthy babies. There are small unhealthy babies. ...There are many in between.

Lumping Mommas and babies into predetermined risk categories based on generalizations and assumptions is killing maternity care in the US. It ties everyone's hands. I don't understand why providers perpetuate one size fits all care. Who benefits? Not me. Not my kids. Lazy, CYA based medicine. Hmmm. There ya go.

I have 10-11 lb babies. In nearly 15 years of having babies I have never shows signs of or tested remotely positive for diabetes or IR (not GD bullshit, real diabetes). I have no family history of diabetes. I have children who have remained in the 90th + percentile to off the charts into their teens.

I grow big, healthy, strong babies and they grow into big, healthy, strong kids. My family has lots of big, healthy long lived adults.

Maybe those providing maternity care need some diversity training and lessons on genetics.

NgM: The size of your babies alone puts you at risk for future diabetes and unless you stay active and normal-weighted, you could very well end up with diabetes, too. It’s great you’ve avoided it so far, but I find it incredibly difficult to believe your babies were that big without any IR issues going on. But, that’s part of your argument, right? That I (and other providers) lump you in with the others… so ‘round and ‘round we go.

SS-R: C- I was in no way directing my comment at you. I was speaking about how quick some people are to call every large baby unhealthy when ALL they know is birth weight. In fact, I would be MORE inclined to give credence to your strong sense that something was off than to the medical professionals that told you everything was fine. If you were my friend and you were telling me this, I would PUSH you to fight for answers and to trust your gut.

I also think that IR does need to be taken into account, especially given the rise we are seeing in PCOS and related issues being diagnosed, and more attention needs to be paid to nutritional counseling prior to and during pregnancy than simply the 'weigh and shame' routine that many moms encounter.

CS: I think the problem is simply the testing for GD doesn't screen for IR which can cause problems much the same. To know that and to see big babies being born and to hear statements like "She ate everything she wanted" (which usually equates to salt and sugars... not many people make that statement when referring to copious amounts of fruits and vegetables and steak), you can't help but wonder. I don't think she is throwing this mom or anyone else under the bus, but raising an important topic of concern. How many babies are born that big where it is genetics? Are they still truly healthy or is there lower APGARS, messed up blood sugars, or even outside of just birth, what are the risks in the future? And if it's genetics, can diet and exercise (assuming there is no true GD that requires insulin) bring the size of the baby into normal parameters to minimize the risks? Or does genetics truly determine that the baby will be large no matter what (and presumably healthy)? In which case how can screening be done accurately to risk out women who do have undiagnosed IR? Can studies be done to prove the risks associated with living a lifestyle that creates a larger baby in that case?

So many questions, so many theories, and I think everyone just wants happy, healthy babies in the end. But I'm happy that someone is asking these questions and getting people talking about it. I'm kind of ill right now and heading to bed, but I'll try to find the link to NgM's blog entry on this. She does mention the 3 strikes rule instead of just focusing solely on the big baby aspect. Like I said, I have 3 strikes against me. It doesn't mean I have IR or will most certainly develop GD or DM, but it does light a fire under my bum to make some needed changes in my life. Do I need pop? Nope. Do I need 4+ teas with 2tsp of sugar every day? Nope. Do I need more exercise? Certainly. Living the lifestyle like I have diabetes isn't limiting at all. In fact I never felt better and I'm sure I was increasing my quality of life as well as my life expectancy. Even if the testing comes back that I'm not even IR and even if I just do make big babies, I'll still be thankful for the motivation to change my life and my habits as it can only be making my life better:)

MM: I had diet-controlled GD with my first pregnancy - my sugar control was spot on and I delivered a healthy 9lb 7oz boy. I figured he was big due the GD but my second, with absolutely no GD was 9lb exactly. My last, again with absolutely no GD, was born at 37 weeks, perfectly healthy weighing 7lb. By his due date he was 9lb. I've come to the conclusion that I do just make big healthy babies. They stay big til about 6 months, and then they even out to average size.

NgM:This was a great conversation, ladies… thanks for exploring it more in-depth. It certainly is one of my favorite topics.

References (5)

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    Sometimes I will even keep a few specific blog posts open in my browser for days – this post is one of them. I appreciate you taking the time and effort to share your thoughts with us.
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    - Navelgazing Midwife Blog - "Big Healthy Babies"
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    - Navelgazing Midwife Blog - "Big Healthy Babies"

Reader Comments (10)

Can a mom then have a less than large baby...more average because of smoking or high blood pressure, but still have sugar problems herself? That is what I think is likely with some. I just have a hard time believing, with my horrible diet in past pregnancies, that I didn't have issues (failing first GD tests...). Babes were in a range from 6lb 12 oz (failed the 1 hour in that one) and 8 lbs 6 oz (failed the one hour, then passed the 3 hour but had a 42 on the last hour...42). So, there's something weird. This time I did pass the 1 hour, and walked like a crazy woman so far. Also, midwife now says she thinks baby feels like a mid 7lb baby...will be interesting. Not exactly great on diet though, better with balance but still love carbs inappropriately.

March 30, 2012 | Unregistered CommenterDawn

"There are big healthy babies. There are big unhealthy babies. There are small healthy babies. There are small unhealthy babies. ...There are many in between.

Lumping Mommas and babies into predetermined risk categories based on generalizations and assumptions is killing maternity care in the US. It ties everyone's hands. I don't understand why providers perpetuate one size fits all care. "

This is what I would say to sum up my thoughts. I know my own situations are just that, situations, but I have big babyies. Not HUGE, but 9 lbs 15 oz was my biggest. Another was over 9, 2 more over 8 and a half and one normal(he's still my 5th percentile child-so I actually wonder if he's the abnormal one). I am 115-120 lbs, 5'5.5", my husband is small too. No history of diabetes on my side. My Aunts and cousins all have babies about the same size as mine. I had a third degree tear with my first, but that's it and no problems with the repair or afterwards. No problems with my other ones...pushed for 1.5 hours with my first and about 5-10 min with my other ones. Never tested positive for GD, eat healthy(mostly fresh fruits and vedgies). I think my big babies are just genetic.

I think if we only go by weight alone, it's not an accurate indicator for GD. Most babies I've seen working as a nurse that are over 9lbs have been fine. The shoulder dystocia babies I've been involved with have all been between 6-9 lbs. That said, I have only helped a handful of babies over 10.

good post, though...with some great discussion

March 30, 2012 | Unregistered CommenterRachel

Not that they don't happen, but I've never seen a shoulder dystocia in a baby under 10+ pounds.

March 30, 2012 | Registered CommenterNavelgazing Midwife

Dawn: There are tons of variables... of course smoking could affect things. I smoked through my first pregnancy and Tristan was 9lbs 4oz. I used to (smugly) say, "Think how big he would have been if I didn't smoke!" What an ass I was. I didn't smoke pregnant with Meghann and she was 10lbs 6oz. I didn't smoke and walked my butt off in Germany while pregnant with Aimee (we didn't have a car) and she was 8lbs 13.5oz. Imagine if I'd have known what I know now, not being smug (again) about passing the GTTs each time even though I weighed over 200/250/280 (or so)... I wonder what normal-weighted babies I could have had. I wish I knew then what I know now about a LOT of topics, but this is one that haunts me.

Oh, and important to remember, too, that some of the sickest babies of diabetic moms are extremely small. Not all babies of GDM moms are huge.

March 30, 2012 | Registered CommenterNavelgazing Midwife

So, I'm curious now. I have PCOS and was diagnosed as IR years ago. To conceive my first baby, I took metformin. It worked perfectly and I conceived within 6 weeks of starting it! I was told to stop taking it while pregnant. I was 260 lbs at my first prenatal appt (I'm 5'10") and 287 lbs at the birth. My daughter was 7 lbs 9 oz, was born at 39 weeks and very healthy. 2 years later, I get pregnant with my second child, and get my endocrinologist to agree to let me take metformin while pregnant (I had been taking it since I weaned my daughter at 6 months old). I weighed 200 lbs at the beginning of the pregnancy and 241 lbs at the birth. I continue taking the metformin throughout the pregnancy, and give birth to a 7 lb 0 oz son at 38 weeks. They tested his sugar shortly after birth and it was normal. I have continued the metformin since. My A1C levels are almost always 5. My FPG is 98. I should also mention that I had untreated hypothyroidism (T3/T4 about 0.03) during first pregnancy, but treated during second (euthyroid during second due to treatment).
So, was I just lucky that I had a normal sized baby during my first pregnancy? DId my untreated hypothyroidism have an effect? I ate a crappy diet during my first pregnancy, but was more active. I ate a little better during my second, but wasn't very active at all (with the exception of chasing my 2 year old). I also gained a lot more weight during the second pregnancy, even though I was on the metformin (although I think this may be due to the fact that I lost 30 lbs in the months prior to conceiving him). I guess I am wondering if GD/IR always equals LGA or macrosomia. What's the distribution of fetal size among mom's with GD/IR? Are most babies born to GD/IR moms normal sized, with some small and some large? Thanks for your feedback!

March 30, 2012 | Unregistered CommenterJen B

I had a shoulder dystocia with an 8lb 4 oz. baby. Just saying.

March 30, 2012 | Unregistered Commenterchingona

Oh, I know they happen! I just said I hadn't ever seen one.

Jen B: There are so many variables in women that picking out THE ONE that might have changed things is virtually impossible. Who knows if it was the gaining less weight... the Metformin pre-pregnancy... that you were younger... very hard to say. And yes, I would say most babies of IR/GDM moms are not have enormous size. I don't know any percentage, though. Would be an interesting study.

March 31, 2012 | Registered CommenterNavelgazing Midwife

I had GD with my pregnancy last year. I never knew of any IR prior to my pregnancy and diabetes is the one thing that doesn't run in my family. When I was diagnosed with GD, they initially had me test my BS 4 times a day (fasting, then 2 hrs after meals). After a few weeks, my numbers were so well controlled with diet, they told me I could just test 2x/day (fasting, then after 1 meal). I was relieved! But now I wonder if that might have been a bad idea since if testing 4x/day doesn't give an adequate picture of your blood sugars, 2x/day certainly doesn't!

Due to the GD, I was induced with Cervadil at 40 weeks 6 days and gave birth (naturally and unmedicated except for that Cervidil) to a 7 lb 5 oz baby boy who had perfect sugar readings. His APGARs were 9's. No big baby for me, thankfully.

Having GD in this pregnancy was definitely a wake-up call. I now know that my body is probably prone to IR and that I need to make changes even when I'm not pregnant so that I don't develop full blown diabetes down the road.

March 31, 2012 | Unregistered CommenterKate

Just to be pedantic: they're Apgar scores, not APGAR scores. It's not an acronym; it's the surname of the doctor who devised them in 1952 (Dr Virginia Apgar).
Great blog (nitpicking proofreading notwithstanding!)!

April 3, 2012 | Unregistered CommenterAnna

Anna, Dr. Apgar did invent the Apgars but it also is an acronym:

Appearance, Pulse, Grimace, Activity, Respiration

So APGAR is also a correct term when you are looking at it as an acronym. Many hospitals assign the scores to the individual letters. It just conveniently works that way! (haha, okay, someone tried really hard to find words that made it work out I suppose... )

October 20, 2012 | Unregistered CommenterMarisa

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