Journal of Perinatology (2014) 34, 100–104 & 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp

ORIGINAL ARTICLE IADPSG criteria for diagnosing gestational mellitus and predicting adverse outcomes

M Shang and L Lin

OBJECTIVE: To evaluate the International Association of Study Groups (IADPSG) criteria versus the American Diabetes Association (ADA) criteria for diagnosing mellitus (GDM) in China. STUDY DESIGN: Overall, 3083 women with a singleton pregnancy underwent a 75-g, 2-h oral tolerance test between 24 and 28 weeks of pregnancy, and both IADPSG and ADA criteria were used for GDM diagnosis. Adverse pregnancy outcomes (APOs), including , required Cesarean section, preeclampsia, macrosomia and low , were recorded and analyzed. RESULT: IADPSG and ADA criteria diagnosed 19.9% and 7.98% of women with GDM, respectively (Po0.001). IADPSG criteria has a stronger capacity of predicting APOs than ADA criteria (odds ratio (OR) ¼ 1.84, 95% confidence interval (CI): 1.52–2.25 for IADPSG, and OR ¼ 1.54, 95% CI: 1.16–2.05 for ADA). CONCLUSION: IADPSG criteria increase GDM diagnosis by almost twofold. GDM diagnosed by IADPSG criteria is more associated with APOs, although the economic impact needs further evaluation.

Journal of Perinatology (2014) 34, 100–104; doi:10.1038/jp.2013.143; published online 14 November 2013 Keywords: GDM; diagnosis; ; maternal and neonatal outcomes

INTRODUCTION HAPO study, the International Association of Diabetes and Gestational diabetes mellitus (GDM) is one of the most common Pregnancy Study Groups (IADPSG) recommended new GDM 6,14 medical complications during pregnancy and its prevalence diagnostic criteria in 2010. Since the recommendation, the appears to be increasing around the world, probably because of IADPSG criteria have been evaluated or validated worldwide, 8,15–17 the increase in the number of women of child-bearing age who but with controversies and inconsistencies. Whereas most 9,16 are overweight, of older age, and have sedentary lifestyles.1 studies have demonstrated a good association between GDM Recent randomized controlled trials2 and a blinded observational diagnosed based on the criteria and adverse pregnancy outcomes, 15 study3 have confirmed the association between maternal hyper- others have failed to show such an association. Moreover, these 16 glycemia and adverse pregnancy outcomes. There is mounting criteria have rarely been validated in an Asian population, evidence that treatment of even mild GDM reduces morbidity for especially in Chinese, who account for one-fifth of the world both the mother and baby.4 Therefore, clinical diagnosis of GDM, population. antepartum fetal surveillance and according interventions are Therefore, the aim of this prospective study was to evaluate the important to reduce perinatal morbidity and mortality associated IADPSG criteria, in parallel to the ADA criteria, and to determine with GDM. association between GDM and adverse pregnancy outcomes in However, the diagnostic criteria for GDM vary greatly worldwide Chinese pregnant women. among different countries or even different regions in the same country, although great effort has been invested to reach a 5–9 consensus over the past half century. Some diagnostic criteria MATERIALS AND METHODS 10 are based on that used in non-pregnant women, whereas others Study subjects that are based on data from pregnant women are simply defined Pregnant women who had their initial prenatal visit before 24 gestational mathematically (as being two s.d. above the mean), rather than on 11 weeks at the Antenatal Clinic of Beijing Friendship Hospital, Capital Medical data derived from the adverse pregnancy outcomes. To improve University, and were to receive and to deliver at the the quality of perinatal medicine, GDM values in the prediction of institution between January 2012 and March 2013 were consecutively adverse pregnancy outcome have been extensively assessed over enrolled for the study. We excluded women with before 28 the decades.12,13 Currently, the criteria recommended by the weeks’ gestation, those with multiple gestations confirmed by ultrasono- American Diabetes Association (ADA) and aimed to reduce graphy, those with a history of pre-gestational diabetes mellitus and those adverse pregnancy outcomes have generally been used world- without a documented GDM screening test result. In addition, pregnant wide as a ‘gold standard’. In 2002, the and Adverse women who were diagnosed with overt or pre-gestational diabetes 3 mellitus at the initial prenatal visit were also excluded. Pregnancy Outcomes (HAPO) study reported that the increase in The demographic and clinical characteristic such as maternal age, glucose levels close to but lower than that traditionally required height, weight, pre-pregnancy body mass index, parity, primary indications for the diagnosis of GDM were significantly associated with of Cesarean section such as breech presentation and previous Cesarean subsequent adverse pregnancy outcomes. Mainly based on the section, previous GDM history and complications such as induction of labor

Department of and Gynecology, Beijing Friendship Hospital, Capital Medical University, Beijing, China. Correspondence: Dr L Lin, Department of Obstetrics and Gynecology, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China. E-mail: [email protected] Received 29 July 2013; revised 21 September 2013; accepted 7 October 2013; published online 14 November 2013 IADPSG criteria for diagnosing GDM M Shang and L Lin 101 and premature were recorded or calculated in a , macrosomia (defined as birth weightX4000 g) and low pre-designed case record form. The study was approved by the birth weight (LBW, defined as birth weightp2500 g). Institutional Ethics Committee of Beijing Friendship Hospital and written informed consent was obtained from each participant. Statistical analysis Categorical variables were reported as percentages or frequencies (%) and Screening, diagnosis and treatment of GDM continuous variables were reported using mean (±s.d.). Pearson’s w2-test, At the initial prenatal visit, the fasting plasma glucose was estimated for all or Fisher’s exact test, was used to compare the difference in categorical women. As recommended by the IADPSG criteria, 75-g oral glucose variables between or among different groups; the odds ratios (OR) and tolerance test (OGTT) was also performed at this visit for pregnant women 95% confidence intervals (CIs) were also calculated. The independent at higher risk, that is, those who were older than 25 years, obese (body sample t-test was used to compare the difference in the continuous 2 mass index430 or greater kg m À ), with a family history (first or second variables between groups. McNemar’s test was used to compare the degree-relatives) of diabetes mellitus, or a history of previous GDM or a prevalence of GDM diagnosed between the two criteria. All statistical 18 macrosomic infant. The women who were found to have diabetes analyses were performed using SPSS software package (SPSS, Chicago, IL, À 1 mellitus, using standard criteria (a fasting glucose level of 126 mg dl USA) version 11.5. A P-value of o0.05 was taken to signify statistical 1 -1 1 (7.0 mmol l À ) or higher, 2-h glucose level of 200 mg dl 11.1 (mmol l À ) significance. or higher, a random plasma glucose level 4200 mg dl À 1 (11.1 mmol l À 1) plus classical signs and symptoms of hyperglycemia), were diagnosed with 13 overt diabetes mellitus, not GDM. Women with overt diabetes were RESULTS excluded from this study. Women with fasting plasma glucose À 1 À 1 À 1 À 1 Prevalence of GDM diagnosed by IADPSG and ADA criteria X92 mg dl (X5.1 mmol l ) but 126 mg dl (o7.0 mmol l ) at the initial visit were diagnosed with GDM,14 and included in the study. Overall, 3629 pregnant women were enrolled for eligibility at the Then, at the 24–28 week visit, all women, except for those who were initial visit. Of them, 546 were excluded due to overt or pre- excluded, received universal screening for GDM by means of a 75-g, 2-h gestational diabetes mellitus (n ¼ 79), abortion before 28 gesta- OGTT. The standard protocols were used for the test. Briefly, after a 72-h no tional weeks (n ¼ 305), multiple pregnancy (n ¼ 45) and without a carbohydrate restriction and a 10-h overnight fast, 3 ml of venous plasma documented GDM screening test result (n ¼ 117). Thus, a total of samples were collected for the measurement of fasting, 1 and 2 h plasma 3083 women were recruited in the study and underwent a glucose levels. The plasma glucose levels were estimated by the glucose oxidase method (Beckman Coulter Instruments, Indianapolis, IN, USA), diagnostic 75-g/2-h OGTT at their 24–28 gestational weeks’ visits, and GDM was diagnosed according to the IADPSG and ADA criteria, including 67 women who were diagnosed with GDM at the initial respectively. Table 1 shows a comparison of the IADPSG and ADA visit based on the IADPSG criteria (Figure 1). diagnostic criteria.19 Of the 3083 women, 612 (19.9%) and 246 (7.98%) cases were The management of GDM was consistent with the standard clinical diagnosed with GDM, based on IADPSG and the ADA diagnostic practice, which consisted of dietary control and proper exercise, with criteria, respectively (Po0.001). By definition, all women diag- targets of fasting glucose level of 95 mg dl À 1 (o5.3 mmol l À 1) and 2-h À 1 À 1 nosed with GDM by the ADA criteria were also diagnosed with postprandial glucose level of 120 mg dl (o6.7 mmol l ). If these goals GDM by the IADPSG criteria. The 67 women who were diagnosed were still not attained, therapy was added according to the with GDM at the initial visit by the IADPSG criteria also met the guidelines of Committee on Technical Bulletins of the American College of Obstetricians and Gynecologists.20 ADA criteria for GDM. Fasting glucose concentrations during the 75-g/2-h OGTT at 24–28 weeks was abnormal in 384 (62.7%) of the 612 women and in 153 (62.2%) of the 246 women with GDM, Adverse pregnancy outcomes according to the IADPSG and ADA criteria, respectively (P ¼ 0.880). During the follow-up visits, clinical data and adverse pregnancy outcomes Accordingly, 2471 and 2837 cases were considered as healthy were recorded and compared among different groups. In the present pregnant women with normal glucose tolerance, based on the study, we included the adverse pregnancy outcomes that have been shown to be improved with the treatment of GDM in randomized IADPSG and ADA criteria, respectively (Figure 1). controlled trials or to be significantly associated with GDM in retrospective All women received prenatal care according to the standard studies.4,21 Namely, these adverse pregnancy outcomes were preterm clinical practice and delivered in our hospital. Maternal character- delivery (that is, delivery before 37 gestational weeks), requirement for istics according to the IADPSG and ADA criteria are shown in Cesarean section, preeclampsia (a disorder of widespread vascular Table 2. endothelial malfunction and vasospasm that occurs after 20 weeks’ gestation and can present as late as 4–6 weeks postpartum including mild preeclampsia, severe preeclampsia and ), neonatal Associations between GDM diagnosed by the IADPSG or ADA criteria and adverse pregnancy outcomes Overall, the pre-defined adverse pregnancy outcomes occurred in 1929 (62.6%) of the women, and diagnosis of GDM by the IADPSG Table 1. The IADPSG and the ADA criteria for diagnosis of gestational diabetes mellitus

Test IADPSG criteria (any one ADA criteria (at least two Screening 3629 of the cut-off values of the cut-off values below) below)a,b

Fasting X92 X95 3083 enrolled 546 excluded glucose (mg dl À 1) 1-h glucose X180 X180 (mg dl À 1) By ADA criteria By IADPSG criteria 2-h glucose X153 X155 (mg dl À 1) Abbreviations: ADA, American Diabetes Association; IADPSG, International 246 GDM 2837 normal 612 GDM 2471 normal Association of Diabetes and Pregnancy Study Groups. aThe ADA has recently endorsed the IADPSG criteria.19 Figure 1. The recruitment procedures and results of the study. ADA, b75-g OGTT was used in this study, so ADA criteria here referred to criteria the American Diabetes Association; GDM, gestational diabetes for 75-g OGTT. mellitus, IADPSG, International Association of Diabetes and Preg- nancy Study Groups.

& 2014 Nature America, Inc. Journal of Perinatology (2014), 100 – 104 IADPSG criteria for diagnosing GDM M Shang and L Lin 102 was associated with a significantly increased number (n ¼ 449) of (12.6% vs 8.6%, OR ¼ 1.54, 95% CI ¼ 1.03–2.29, w2 ¼ 4.554, women with adverse pregnancy outcomes, compared with that P ¼ 0.033) compared with those without GDM (Table 3). (n ¼ 174) for the ADA criteria (Table 3). According to the IADPSG criteria, women with GDM showed significantly higher percentages of overall adverse pregnancy DISCUSSION outcomes than those without GDM (73.4% vs 59.9%, OR ¼ 1.84, In the present study, an incidence rate of GDM of 19.9% was 95% CI ¼ 1.52–2.25, w2 ¼ 38.008, Po0.001). Specifically, women detected by the IADPSG criteria, whereas the rate was 7.98% for with GDM had significantly higher percentages of fetal macro- the ADA criteria, indicating that the IADPSG criteria increased the somia (13.1% vs 7.9%, OR ¼ 1.77, 95% CI ¼ 1.34–2.33, w2 ¼ 16.511, diagnostic yield for GDM by B12%, or by nearly twofold, Po0.001), higher percentage of requirement for Cesarean section compared with the ADA criteria. The incidence of GDM differs (54.9% vs 49.0%, OR ¼ 1.27, 95% CI ¼ 1.06–1.51, w2 ¼ 6.815, depending on the populations being screened and the diagnostic P ¼ 0.009) and lower percentage of LBW (3.8% vs 7.0%, criteria being used. It has been estimated that, if the IADPSG OR ¼ 0.52, 95% CI ¼ 0.33–0.80, w2 ¼ 8.841, P ¼ 0.003), and preterm criteria were applied to the HAPO cohort (that is, Caucasian delivery (6.2% vs 9.0%, OR ¼ 0.67, 95% CI ¼ 0.47–0.95, w2 ¼ 5.018, population in the USA), the incidence of GDM (including overt P ¼ 0.025), compared with those without GDM (Table 3). diabetes) would be increased from 3–5 to 17.8%.14,22 A recent According to the ADA criteria, women with GDM appeared to study by Agarwal et al.23 from the United Arab Emirates have a higher percentage of overall adverse pregnancy outcomes comparing IADPSG with ADA criteria also found a threefold than those without GDM (70.7% vs 61.1%, OR ¼ 1.54, 95% (37.7% vs 12.9%) increase with the newer criteria. It was noticed CI ¼ 1.16–2.05, w2 ¼ 8.935, P ¼ 0.003). Specifically, women with that the rates were higher in our study and the study by Agarwal GDM showed significantly higher percentages of fetal macrosomia et al.23, which was also consistent with the observation that GDM

Table 2. Maternal characteristics in women with or without gestational diabetes mellitus (GDM) according to the IADPSG and ADA criteria

Characteristics IADPSG criteria ADA criteria

GDM (N ¼ 612) Non-GDM (N ¼ 2471) GDM (N ¼ 246) Non-GDM (N ¼ 2837)

Average age (years) 30.1±3.6 28.9±3.5 30.4±3.6 29.8±3.6 (mean±s.d.) 39.64±1.54 39.42±2.00 39.52±1.49 39.12±1.55 Parity (n) 1.07±0.31 1.08±0.29 1.08±0.30 1.07±0.30 Primigravida (n (%)) 567 (92.6) 2245 (90.9) 224 (91.1) 2588 (91.2) Second pregnancy (n (%)) 43 (7.0) 207 (8.4) 22 (8.9) 228 (8.0) Third pregnancy (n (%)) 2 (0.3) 18 (0.7) 0 (0) 20 (0.7)) Fourth pregnancy (n (%)) 0 (0) 1 (0.0) 0 (0) 1 (0.0) Pre-gestational diabetes mellitus (n (%)) 4 (8.9) 16 (7.1) 1 (0.4) 20 (0.7) Pre-gestational BMI 22.3±3.1 21.9±2.8 22.2±3.2 22.0±2.9 Induction of labor (n (%)) 119 (19.4) 497 (20.1) 53 (21.5) 563 (19.8) Prior Cesarean section (n (%)) 21 (3.4) 76 (3.1) 9 (3.7) 88 (3.1) Breech presentation (n (%)) 19 (3.1) 55 (2.2) 6 (2.4) 68 (2.4) Treated with insulin (n (%)) 72 (11.4)a 0 (0) 37 (15.0)b 0 (0) Preterm premature rupture of membranes (n (%)) 122 (19.9) 490 (19.8) 48 (19.4) 564 (19.9) Abbreviations: ADA, American Diabetes Association; BMI, body mass index;GDM, gestational diabetes mellitus; IADPSG, International Association of Diabetes and Pregnancy Study Groups. aSignificant for GDM by IADPSG vs control groups (n ¼ 2471); bSignificant for GDM by ADA vs control group (n ¼ 2837).

Table 3. Association of GDM diagnosed with IADPSG and ADA criteria and adverse pregnancy outcomes

Adverse pregnancy outcomes IADPSG criteria ADA criteria

GDM Non-GDM OR (95% CI) GDM Non-GDM OR (95% CI) (N ¼ 612) (N ¼ 2471) (N ¼ 246) (N ¼ 2837)

Macrosomia (n (%)) 80 (13.1)a 194 (7.9) 1.77 (1.34–2.33) 31 (12.6)b 243 (8.6) 1.54 (1.03–2.29) Cesarean section (n (%)) 336 (54.9)a 1211 (49.0) 1.27 (1.06–1.51) 136 (55.3) 1411 (49.7) 1.25 (0.96–1.62) Preeclampsia (n (%)) 44 (7.2) 140 (5.7) 1.29 (0.91–1.83) 17 (6.9) 167 (5.9) 1.19 (0.71–1.99)) Low body weight (n (%)) 23 (3.8)a 174 (7.0) 0.52 (0.33–0.80) 11 (4.5) 186 (6.6) 0.67 (0.36–1.24) Preterm delivery (n (%)) 38 (6.2)a 223 (9.0) 0.67 (0.47–0.95) 16 (6.5) 245 (8.6) 0.74 (0.44–1.24) Need for intravenous glucose 7 (1.1) 28 (1.1) 1.01 (0.44–2.32) 3 (1.2) 32 (1.1) 1.08 (0.33–3.56) treatment (n (%)) Total 449 (73.4)a 1480 (59.9) 1.84 (1.52–2.25) 174 (70.7) 1755 (61.1) 1.54 (1.16–2.05) Abbreviations: ADA, American Diabetes Association; CI, confidence interval; GDM, gestational diabetes mellitus; IADPSG, International Association of Diabetes and Pregnancy Study Groups; OR, odds ratio. aSignificant for GDM by IADPSG vs control groups (n ¼ 2471). bSignificant for GDM by ADA vs control group (n ¼ 2837).

Journal of Perinatology (2014), 100 – 104 & 2014 Nature America, Inc. IADPSG criteria for diagnosing GDM M Shang and L Lin 103 occurs more frequently in Asian women than Caucasian women.24 The diagnostic thresholds chosen in the IADPSG criteria are Furthermore, universal screening by 75-g OGTT was used in the arbitrary and will continue to miss a proportion of cases with present study, which, on one hand, will detect more women with abnormal glucose metabolism, and thus leave open the possibility GDM and thus might prevent or reduce the incidence of adverse of adverse pregnancy outcomes due to untreated GDM.14 pregnancy events, but on the other hand, will result in a Therefore, further studies are necessary to ascertain the substantial number of women receiving the 75-g OGTT test, and consequences and/or effects of the new criteria on the thus impose an increasing financial burden, compared with the incidence and outcomes of GDM. This is the first study that ADA criteria. evaluates the new IADPSG criteria to diagnose GDM and predict Pregnancy outcome is the key to determine the suitability of maternal and fetal outcomes in China. We confirmed that IADPSG diagnostic criteria for GDM. In the present study, GDM diagnosed criteria identified a group of women who would be classified as by the IADPSG criteria was associated with a significantly normal, but develop pregnancy outcomes resembling those in increased number of women with adverse maternal and neonatal women diagnosed with GDM by the ADA criteria. outcomes, compared with that diagnosed by the ADA criteria, and Therefore, the IADPSG criteria appears to be superior to the the IADPSG criteria has a stronger capacity of predicting adverse ADA criteria in the following aspects. First, the IADPSG criteria pregnancy outcomes than the ADA criteria (84.0% versus 54.0%). could identify more women with subsequent adverse pregnancy GDM is a well-established risk factor for fetal macrosomia,25 outcomes (84.0% vs 54.0%). Second, it is required that, in the which has been associated with an increased risk for obstetric IADPSG criteria, high-risk women be tested for overt diabetes problems and birth injury, adult obesity and glucose intolerance in mellitus and GDM at their initial prenatal visit, and those late adolescence and young adulthood.26 In the present study, the diagnosed with overt diabetes mellitus or GDM13 would receive incidence of macrosomia for women with GDM diagnosed by the a closer monitoring from early pregnancy. Third, universal IADPSG and the ADA criteria was increased by 77.0% and 54.0%, screening at 24–28 weeks gestation recommended in the IADPSG respectively, compared with non-GDM. There were more cases of criteria is more sensitive than selective screening generally macrosomia in the women with GDM than in those with normal adapted in the ADA criteria and more practical when a family glucose tolerance. These findings also suggest that GDM is mellitus cannot be reliably obtained.27 Finally, associated with macrosomia in the offspring even after glucose according to the IADPSG criteria, abnormality in the plasma control. This finding also suggests that even a mildly impaired glucose level (that is, above the cut-off values) at any one of the glucose tolerance is associated with macrosomia in the offspring, three time points in the OGTT is enough to make a diagnosis of and this group of pregnant women should receive close GDM. Based on this point, Agarwal et al.28 reported that the initial monitoring to reduce the potential adverse effects. fasting plasma glucose result can help decide if the pregnant Interestingly, there were fewer cases of LBW in the women with woman should continue with her OGTT, to relieve the economic GDM diagnosed by IADPSG criteria or ADA criteria. A possible burden of universal screening. Indeed, in the present study, explanation for this finding is that the moderate plasma glucose fasting glucose concentrations during the 75-g/2-h OGTT at 24–28 level is reasonable for fetal growth and that mild hyperglycemia weeks was abnormal in 384 (62.7%) women, indicating that may be beneficial for some with growth restriction to gain almost two-thirds of women can be diagnosed with GDM by the normal weight. This notion can be indirectly supported by the fasting glucose levels without further OGTT. finding on the positive association between GDM and macrosomia There are a few concerns with application of the IADPSG criteria. observed in the present study. This phenomenon also reminds us The first one is over-diagnosis of GDM. However, this is not the that diet control should be controlled in an adequate extent and case due to the stronger association between the adverse that lowering the target of controlled plasma glucose levels might pregnancy outcomes with GDM as diagnosed by the IADPSG be associated with LBW. criteria, compared with the ADA criteria. The second concern is the An unexpected result was that the incidence of preterm costs. Compared with the ADA criteria that have been widely used delivery was not elevated in GDM women, by both the IADPSG as a ‘gold standard’, the IADPSG criteria use lower cut-off values and ADA criteria. While the increased risk of macrosomia is well- for glucose levels at fasting and 2 h and require abnormality only recognized in association with GDM, the 33.0% decrease in the at single time point, which would impose a potential economic risk of preterm delivery in women with GDM diagnosed by the impact. Therefore, further randomized clinical trials are needed to IADPSG criteria observed in the present study was contrary to that determine the short- and long-term cost-effectiveness, optimal in the HAPO study, which showed an association between treatment targets and strategies in terms of plasma glucose increasing maternal glucose levels and prematurity.3 There are levels.29 In addition, there is a room to modify the criteria as multiple causes for preterm delivery including premature rupture described above, to reduce the costs. of membranes, previa, intrauterine infection and cervical In conclusion, application of the IADPSG criteria increases the incompetence that threaten the safety of the mother or the . diagnoses of GDM in pregnant women by almost twofold In women with overt diabetes mellitus and/or GDM and whose in China, compared with the ADA criteria. GDM diagnosed hyperglycemia is not well controlled, the incidence of preterm by the IADPSG criteria appears to be more associated with delivery might be elevated mainly because of complications with adverse pregnancy outcomes. Therefore, the IADPSG criteria are early onset of severe preeclampsia or premature rupture of suitable in China but the economic impact needs to be further membranes. However, in the present study, women with overt evaluated. diabetes mellitus were excluded, and all women were carefully monitored and glucose levels were well controlled. The incidence of preeclampsia and premature rupture of membranes were similar between GDM and non-GDM according to both the ADA CONFLICT OF INTEREST criteria and the IADPSG criteria. Therefore, GDM was no longer The authors declare no conflict of interest. predictive of preterm delivery. Other adverse outcomes such as preeclampsia and neonatal hypoglycemia were similar between GDM and the non-GDM ACKNOWLEDGEMENTS group by both sets of criteria. A possible explanation for this This work was supported by a grant from Capital Medical University (Grant No# 12JL- finding is that more attention and management provided to L02). We thank all the colleagues who took care of the pregnant women included in women diagnosed with GDM may have successfully reduced the our study, and Medjaden Bioscience Limited for assisting in the preparation of this risk of preeclampsia and neonatal hypoglycemia. manuscript.

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Journal of Perinatology (2014), 100 – 104 & 2014 Nature America, Inc.