The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus Andrea Zacche Sa, Jose Roberto Silva Junior & Joao G. Alves To cite this article: Andrea Zacche Sa, Jose Roberto Silva Junior & Joao G. Alves (2015) Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus, The Journal of Maternal-Fetal & Neonatal Medicine, 28:14, 1687-1690, DOI: 10.3109/14767058.2014.964680 To link to this article: http://dx.doi.org/10.3109/14767058.2014.964680
Accepted author version posted online: 12 Sep 2014. Published online: 30 Sep 2014. Submit your article to this journal
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Date: 05 November 2015, At: 14:41
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(14): 1687–1690 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.964680
ORIGINAL ARTICLE
Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus Andrea Zacche Sa, Jose Roberto Silva Junior, and Joao G. Alves
Downloaded by [Central Michigan University] at 14:41 05 November 2015
Department of Pediatrics, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
Abstract
Keywords
Objective: To compare facial responses to basic tastes among newborns of women with and without gestational diabetes mellitus (GDM). Methods: Two-hundred and one healthy newborns, 100 from GDM women were studied at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Brazil. Basic tastes were evaluated through administration of glucose (25%), sodium chloride (1.4%), citric acid (25%) and quinine hydrochloride (25%); 0.2 ml of solution on the dorsal surface of the tongue. All newborns had their face videotaped and facial responses were coded according to the Baby Facial Action Coding System. The frequency of the facial action units was compared among newborns from mothers with and without GDM. Results: Facial responses to salt was more liking among newborns from GDM mothers as compared to controls; 33 (33%) versus 21 (21%), p ¼ 0.039). Facial responses to sweet, sour and bitter showed no differences among newborns from mothers with and without GDM. Facial expressions to basic tastes showed no differences among newborns from controlled and non- controlled GDM mothers. Conclusion: Newborns from GDM mothers seem to have a little more preference taste to salt. Further studies are needed to confirm this finding and to verify if these newborns responses to basic tastes remain life-long.
Diabetes, facial expression, gestational, taste perception
Introduction Food habits are established in fetal and early life and an unhealthy diet plays an important role in the development of chronic diseases in adult life, which are the main reasons of death worldwide [1,2]. Basic taste preferences to sweet, salt, sour, bitter and umami (savoury), are determinant factors in the development of food habits and track from infancy to adulthood [3,4]. Taste, smell and hemosensory irritation compose flavor to a major complex sense [5]. Children are first exposed to flavor during fetal life through the amniotic fluid ingestion [6]. It has been shown that amniotic fluid transmits food characteristics eaten by mother to the fetus [7,8]. There is evidence that fetal flavor exposure may influence food acceptance from the weaning to adulthood [9,10]. Flavor is also influenced by genetic and other environmental factors [11]. Influence of maternal diseases on food acceptance by the infant has been studied little. Gestational diabetes mellitus (GDM), the most common metabolic disease at pregnancy, may lead to a high level of glucose to
Address for correspondence: Dr. Joao G. Alves, PhD, Department of Pediatrics, Instituto de Medicina Integral Prof Fernando Figueira, Rua dsos Coelhos, 300, Boa Vista, Recife, 50070550, Brazil. E-mail: [email protected]
History Received 7 August 2014 Accepted 9 September 2014 Published online 30 September 2014
the fetus. Some studies had shown a correlation between maternal blood glucose levels and glucose amniotic fluid levels [12–14]. We hypothesized that higher levels of glucose in amniotic fluid of GDM women may alter newborn basic taste preferences. This study aims to compare preferences to basic taste among newborns from women with and without GDM.
Methods This cross-sectional study was developed at Instituto de Medicina Integral Prof. Fernando Figueira Hospital – IMIP (Recife, Brazil) from March 2012 to October 2013. This study was previously approved by IMIP Ethical Committee in Research and written informed consent was obtained. Two-hundred and one full-term newborns with Apgar score 47 at 5 min were studied, 101 from GDM women and 100 from women without GDM. GDM diagnosis was based on any degree of glucose intolerance with first recognition during pregnancy. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) criterion was adopted: fasting glucose 92 mg/dl, 1-h glucose 180, or 2-h glucose 153 [15]. All screen test for GDM were performed between 24th and 28th gestational weeks. Newborns with serious fetal malformations were excluded. The following biological and social maternal variables were
Downloaded by [Central Michigan University] at 14:41 05 November 2015
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A. Z. Sa et al.
J Matern Fetal Neonatal Med, 2015; 28(14): 1687–1690
collected: age, weight, height, skin color, years of schooling, marital status and family income. Newborn variables studied were birth weight, gestational age and gender. Each newborn was tested within the first 2 h of life by the same researcher in an isolated room (at a temperature of 23 C). Newborn breastfed in the delivery room was always tested 1 h later; those not breastfed in the delivery room proceeded the test when they arrived at the mother’s room, usually during the first 30 min of life. Basic taste test followed the sequence: glucose (25%), sodium chloride (1.4%), citric acid (25%), and quinine hydrochloride (25%). An interval of 1 min between each tasting substance was followed. The solutions had a standard temperature of 37 C A 1-ml disposable syringe was used to apply 0.2 mL of solution on the dorsal surface of the tongue. All newborns were held upright facing forward during the test and had their face videotaped during 1-min with a digital camera (Sony HDRCX 350). The facial responses were coded into nine action units (AU) according to the Baby Facial Action Coding System [16]: A1 represents no distinct mouth action or sucking on the face (neutral facial response); A2 is A1 with a negative expression on the mid-face (disliking facial response); A3 is A1 with a negative expression on the mid-face and brows (disliking facial response); B1 represents the facial response of a pursing mouth (liking facial response); B2 is B1 with a negative expression on the mid-face (disliking facial response); B3 is B1 with a negative expression on the midface and brows (disliking facial response); C1 represents a mouth-gaping action (liking facial response); C2 is C1 with a negative expression on the mid-face (disliking facial response); and C3 is C1with a negative expression on the mid-face and brows (disliking facial response). Two trained professionals were unaware of the study aims including GDM status of the mother and watched the videotape recordings to classify facial responses. Reliability for scoring was 90% (p50.001).
The data were analyzed by SPSS software (SPSS, Inc., Chicago, IL). The frequency of the facial action units was compared among newborns from mothers with and without GDM. The chi-square test was used and significance was considered at p50.005.
Results We studied 201 infants, 101 children of mothers with GDM and 100 children of mothers without GDM. One newborn was excluded because he was nauseous and the test could not be performed. All newborns had Apgar 47 at 5 min and were considered healthy at the post-delivery neonatal evaluation at the end of the first week of life. GDM women had higher age, weight and income, as compared to non-GDM women. Newborns from GDM mothers had a lower gestational age and a mean Apgar score and a higher birth weight (Table 1). Facial responses to salt showed differences among newborns from GDM women; more neutral and less liking facial responses as compared to controls newborns (Table 2). Facial responses to sweet, sour and bitter showed no differences among newborns from mothers with and without GDM. Predominant facial responses to sweet were liking and to sour and bitter were disliking. Facial expressions to basic tastes showed no differences among newborns from mothers with controlled and noncontrolled GDM (Table 3).
Discussion Ours results pointed out some differences regarding facial responses to basic tastes among newborns from GDM women, a little more preference of taste to salt as compared to controls. Our hypothesis is that higher maternal glucose levels, increasing glucose concentration in amniotic fluid, could interfere on taste development during fetal life. It has been demonstrated that maternal diet during pregnancy and
Table 1. Some biological and social characteristics of women with and without gestational diabetes mellitus and their newborn. Gestational diabetes melitus Variable Maternal characteristics Age (years) Weight (kg) Height (cm) Body mass index (BMI) Glucose (mg/dl) Skin color: White Marital status: married Schooling (up to 8 years of studies) Family income (monthly US$) Gestational age (months) Vaginal delivery Neonatal characteristics Weight (kg) Male Gestational age (by Capurro) Apgar score at 50 (1): Student t-test with equal variances. (2): Pearson chi-square test. (3): Fisher exact test.
Yes (n ¼ 101) Range (Mean ± SD) n (%)
No (n ¼ 100) Range (Mean ± SD) n (%)
p value
17 to 42 (30.75 ± 6.19) 65 to 96 (84.82 ± 15.90) 1.46 to 1.73 (1.63 ± 0.07) 19.9 to 32.2 (26.8 ± 4.7) 75 to 106 (94.0 ± 16.1) 28 (28.0%) 92 (92.0%) 24 (24.0%) 548.0 ± 321.3 37 to 42 (38.34 ± 1.07) 43 (43.0%)
16 to 40 (24.72 ± 5.61) 62 to 88 (75.91 ± 15.10) 1.45 to 1.72 (1.63 ± 0.08) 19.1 to 30.8 (25.2 ± 4.9) 69 to 88 (79.1 ± 6.1) 29 (29.0%) 80 (80.0%) 30 (30.0%) 451.0 ± 291.5 37 to 41 (38.61 ± 4.08) 76 (76.0%)
p(1)50.001* p(1)50.001* p(1) ¼ 0.802 p(1)50.01* p(1)50.001* p(2) ¼ 0.888 p(2) ¼ 0.014* p(2) ¼ 0.632 p(1)50.001* p(1) ¼ 0.522 p(2)50.001*
3035 to 4150 (3390 ± 501) 47 (47.0) 37 to 42 (38.06 ± 3.79) 9.23 ± 0.62
2985 to 3880 (3223 ± 448) 49 (49.5)(4) 37 to 41 (39.06 ± 1.10) 9.53 ± 0.56
p(1) ¼ 0.014* p(2) ¼ 0.725 p(1) ¼ 0.012* p(1)50.001*
Facial responses
DOI: 10.3109/14767058.2014.964680
Table 2. Facial responses of newborn of mother with and without gestational diabetes mellitus. Gestational diabetes mellitus Yes
Downloaded by [Central Michigan University] at 14:41 05 November 2015
Facial responses Total Sweet Like (A1) Neutral (B1) Salt Like (A1 + A2) Neutral (B1 + B2) Sour Like (A1 + A2) Neutral (B1 + B2) Dislike (B3 + C2 + C3) Bitter Like (A1) Neutral (B1 + B2) Dislike (B3 + C1 + C2 + C3)
No
N
%
N
%
p value
100
100.0
100
100.0
95 5
95.0 5.0
94 6
94.0 6.0
p(1) ¼ 0.756
34 66
33.3 1.0
21 79
20.0 1.0
p(1) ¼ 0.040
3 14 83
3.0 14.0 83.0
1 17 82
1.0 17.0 82.0
p(2) ¼ 0.560
1 13 86
2.0 13.0 86.0
1 18 82
1.0 18.0 81.0
p(2) ¼ 0.435
(1): Pearson Chi-square test. (2): Fisher exact test. Table 3. Facial responses of newborn of mothers with controlled and not controlled gestational diabetes mellitus. Controlled gestational diabetes mellitus Yes
No
Facial responses
N
%
N
%
p value
Total Sweet Like (A1) Neutral (B1) Salt Like (A1 + A2) Neutral (B1 + B2) Sour Like (A1) Neutral (B1 + B2) Dislike (B3 + C2 + C3) Bitter Like (A1) Neutral (B1 + B2) Dislike (B3 + C1 + C2 + C3)
33
33.0
67
67.0
32 1
97.0 3.0
62 5
92.5 7.5
p(1) ¼ 0.661
5 28
15.1 84.8
16 51
23.9 76.1
p(1) ¼ 0.314
2 4 27
6.0 12.1 82.0
1 10 56
1.5 15.0 83.6
p(2) ¼ 0.512
1 3 29
3.0 9.1 87.9
– 10 57
– 14.9 85.1
p(2) ¼ 0.318
(1): Pearson Chi-square test. (2): Fisher exact test.
breastfeeding period plays an important role on taste development interfering on food acceptance of offspring life-long. However influences of maternal diseases during pregnancy on taste development has not been adequately studied. To our best knowledge, it is the first time that a study searched for basic taste preferences in newborn from GDM women. As expected GDM mothers were older, heavier and had more Cesarean deliveries. Their newborns were also heavier, had both lower gestational age and Apgar score, but all were born at term and had high vitality (Apgar ¼ 9). It has been demonstrated through facial responses that newborns have a preference of taste to sweet, indifference to salt and dislike of sour and bitter [17]. These data support a
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beginning of taste development during uterus life. Taste development during the first months of life undergoes a phase of predilection for salt and maintenance of sweet preference [10]. Salt avidity develops later (2–6 months of life) and is more complex and less understood as compared to sweet preference. However, some studies have shown that high sweet stimulus can anticipate salt preference [18]. Our data corroborate to these findings which have suggested that sweet and salt have a close and related development. We can speculate that a sweet stimulus during fetal life may anticipate this development phase of salt predilection. Further studies with prospective designs could contribute to a better knowledge on taste development. It has been demonstrated that fetus oral stimulus through swallow of the amniotic fluid, especially in later pregnancy, play an important role in taste development [9,10]. However, it is not known if blood levels of some substances as glucose may influence taste development. As GDM provides both higher glucose on blood and amniotic fluid, we could not identify the specific role of each one of them on neonatal taste preferences. Even few studies had assessed glucose levels in the amniotic fluid of GDM women have demonstrated higher glucose levels in amniotic fluid [14]. We could not have this data in our study because it is an invasive technique, but we also compared the facial responses to basic tastes among controlled and non-controlled GDM women and no differences were observed. However, we have a few numbers of controlled GDM women which may not allow any conclusions. The method employed to measure taste changes in newborn, facial responses to basic tastes may not have the proper accuracy at this age, especially related to sweet taste which is the predominant preference at this age. This test has no qualitative responses, only quantitative answers based on upper and middle face, lips and mouth movements. Furthermore, we made this test during their first 2 h of life and it could be early to detect facial changes to sweet. However, this method has been validated as applied at this time of life. Anyway we intend to follow these infants until weaning to verify solid sweet and salt acceptances. Our study has strengths. Although there are studies about the different facial reactions in newborns in response to the four basic tastes, no one has compared these reactions in infants born from GDM mothers. We also performed a study with a large number of participating subjects. A validated method and recommended standards were used; newborn facial responses to basic tastes followed the standards of FACS adapted to the baby, the Baby FACS [16]. This standard instrument allows comparisons among different studies. Our study has some limitations. Although we have performed a valid test to verify taste preferences to basic tastes during neonatal period, this method may carry some degree of subjectivity in the interpretation of images, especially in those with mild facial changes. We used a single concentration of glucose in the solution offered to the newborn. The use of solutions with different concentrations could have greater sensitivity for detecting the presence of minor changes in taste differentiation to sweet in these
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infants. However, we used the standard solution recommended by other studies and also validated [16]. We also could not detect glucose levels in the amniotic fluid. However, this approach is invasive and can cause maternal or fetal damage.
Conclusion We detected some changes in facial responses to primary tastes among newborns from mothers with GDM, a little more preference to salt taste. This finding seems to indicate that maternal higher glucose levels may influence taste development during fetal life. Further studies are needed to confirm this finding in neonatal period and verify if it influences lifelong on food acceptance in the offspring of GDM mothers.
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Declaration of interest The authors report no declarations of interest.
References 1. Harris G. Development of taste and food preferences in children. Curr Opin Clin Nutr Metab Care 2007;11:315–19. 2. Willett WC, Stampfer MJ. Current evidence on healthy eating. Ann Rev Publ Health 2013;34:77–95. 3. Schwartz C, Issanchou S, Nicklaus S. Developmental changes in the acceptance of the five basic tastes in the first year of life. Br J Nutr 2009;102:1375–85. 4. Robinson S, Ntani G, Simmonds S, et al.; Hertfordshire Cohort Study Group. Type of milk feeding in infancy and health behaviours in adult life: findings from the Hertfordshire Cohort Study. Br J Nutr 2013;109:1114–22.
J Matern Fetal Neonatal Med, 2015; 28(14): 1687–1690
5. Small DM, Prescott J. Odor/taste integration and the perception of flavor. Exp Brain Res 2005;166:345–57. 6. Mennella JA, Johnson A, Beauchamp GK. Garlic ingestion by pregnant women alters the odour of amniotic fluid. Chem Senses 1995;20:207–9. 7. Hauser GH, Chitayat D, Berns L, et al. Peculiar odours in newborns and maternal prenatal ingestion of spicy food. Eur J Pediatr 1985; 144:403. 8. Schaal B, Marlier L, Soussignan R. Human foetuses learn odours from their pregnant mother’s diet. Chem Senses 2000;25:729–37. 9. Mennella JA, Jagnow CP, Beauchamp GK. Prenatal and postnatal flavor learning by human infants. Pediatrics 2001;107:E88. 10. Beauchamp GK, Mennella JA. Flavor perception in human infants: development and functional significance. Digestion 2011;83:1–6. 11. Cooke L, Fildea A. The impact of flavour exposure in utero and during milk feeding on food acceptance at weaning and beyond. Appetite 2011;57:808–11. 12. Dashe JS, Nathan L, McIntire DD, Leveno KJ. Correlation between amniotic fluid glucose concentration and amniotic fluid volume in pregnancy complicated by diabetes. Obstet Gynecol 2000;182: 901–4. 13. Kainer F, Weiss PA, Hu¨ttner U, et al. Levels of amniotic fluid insulin and profiles of maternal blood glucose in pregnant women with diabetes type-1. Early Hum Dev 1997;49:97–105. 14. Rinala SG, Dryfhout VL, Lambers DS. Correlation of glucose concentrations in maternal serum and amniotic fluid in high-risk pregnancies. AJOG 2009;200:e43–4. 15. Metzger BE, Gabbe SG, Persson B, et al. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–82. 16. Zhang L, Li H-qi. Taste development in Chinese newborns. World J Pediatr 2007;3:203–8. 17. Rosenstein D, Oster H. Differential facial responses to four basic tastes in newborns. Child Dev 1988;59:1555–68. 18. Menella JA. Ontogeny of taste preferences: basic biology and implications for health. Am J Clin Nutr 2014;99:704S–11S.
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus Andrea Zacche Sa, Jose Roberto Silva Junior & Joao G. Alves To cite this article: Andrea Zacche Sa, Jose Roberto Silva Junior & Joao G. Alves (2015) Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus, The Journal of Maternal-Fetal & Neonatal Medicine, 28:14, 1687-1690, DOI: 10.3109/14767058.2014.964680 To link to this article: http://dx.doi.org/10.3109/14767058.2014.964680
Accepted author version posted online: 12 Sep 2014. Published online: 30 Sep 2014. Submit your article to this journal
Article views: 31
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [Central Michigan University]
Date: 05 November 2015, At: 14:41
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(14): 1687–1690 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.964680
ORIGINAL ARTICLE
Facial responses to basic tastes in the newborns of women with gestational diabetes mellitus Andrea Zacche Sa, Jose Roberto Silva Junior, and Joao G. Alves
Downloaded by [Central Michigan University] at 14:41 05 November 2015
Department of Pediatrics, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
Abstract
Keywords
Objective: To compare facial responses to basic tastes among newborns of women with and without gestational diabetes mellitus (GDM). Methods: Two-hundred and one healthy newborns, 100 from GDM women were studied at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Brazil. Basic tastes were evaluated through administration of glucose (25%), sodium chloride (1.4%), citric acid (25%) and quinine hydrochloride (25%); 0.2 ml of solution on the dorsal surface of the tongue. All newborns had their face videotaped and facial responses were coded according to the Baby Facial Action Coding System. The frequency of the facial action units was compared among newborns from mothers with and without GDM. Results: Facial responses to salt was more liking among newborns from GDM mothers as compared to controls; 33 (33%) versus 21 (21%), p ¼ 0.039). Facial responses to sweet, sour and bitter showed no differences among newborns from mothers with and without GDM. Facial expressions to basic tastes showed no differences among newborns from controlled and non- controlled GDM mothers. Conclusion: Newborns from GDM mothers seem to have a little more preference taste to salt. Further studies are needed to confirm this finding and to verify if these newborns responses to basic tastes remain life-long.
Diabetes, facial expression, gestational, taste perception
Introduction Food habits are established in fetal and early life and an unhealthy diet plays an important role in the development of chronic diseases in adult life, which are the main reasons of death worldwide [1,2]. Basic taste preferences to sweet, salt, sour, bitter and umami (savoury), are determinant factors in the development of food habits and track from infancy to adulthood [3,4]. Taste, smell and hemosensory irritation compose flavor to a major complex sense [5]. Children are first exposed to flavor during fetal life through the amniotic fluid ingestion [6]. It has been shown that amniotic fluid transmits food characteristics eaten by mother to the fetus [7,8]. There is evidence that fetal flavor exposure may influence food acceptance from the weaning to adulthood [9,10]. Flavor is also influenced by genetic and other environmental factors [11]. Influence of maternal diseases on food acceptance by the infant has been studied little. Gestational diabetes mellitus (GDM), the most common metabolic disease at pregnancy, may lead to a high level of glucose to
Address for correspondence: Dr. Joao G. Alves, PhD, Department of Pediatrics, Instituto de Medicina Integral Prof Fernando Figueira, Rua dsos Coelhos, 300, Boa Vista, Recife, 50070550, Brazil. E-mail: [email protected]
History Received 7 August 2014 Accepted 9 September 2014 Published online 30 September 2014
the fetus. Some studies had shown a correlation between maternal blood glucose levels and glucose amniotic fluid levels [12–14]. We hypothesized that higher levels of glucose in amniotic fluid of GDM women may alter newborn basic taste preferences. This study aims to compare preferences to basic taste among newborns from women with and without GDM.
Methods This cross-sectional study was developed at Instituto de Medicina Integral Prof. Fernando Figueira Hospital – IMIP (Recife, Brazil) from March 2012 to October 2013. This study was previously approved by IMIP Ethical Committee in Research and written informed consent was obtained. Two-hundred and one full-term newborns with Apgar score 47 at 5 min were studied, 101 from GDM women and 100 from women without GDM. GDM diagnosis was based on any degree of glucose intolerance with first recognition during pregnancy. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) criterion was adopted: fasting glucose 92 mg/dl, 1-h glucose 180, or 2-h glucose 153 [15]. All screen test for GDM were performed between 24th and 28th gestational weeks. Newborns with serious fetal malformations were excluded. The following biological and social maternal variables were
Downloaded by [Central Michigan University] at 14:41 05 November 2015
1688
A. Z. Sa et al.
J Matern Fetal Neonatal Med, 2015; 28(14): 1687–1690
collected: age, weight, height, skin color, years of schooling, marital status and family income. Newborn variables studied were birth weight, gestational age and gender. Each newborn was tested within the first 2 h of life by the same researcher in an isolated room (at a temperature of 23 C). Newborn breastfed in the delivery room was always tested 1 h later; those not breastfed in the delivery room proceeded the test when they arrived at the mother’s room, usually during the first 30 min of life. Basic taste test followed the sequence: glucose (25%), sodium chloride (1.4%), citric acid (25%), and quinine hydrochloride (25%). An interval of 1 min between each tasting substance was followed. The solutions had a standard temperature of 37 C A 1-ml disposable syringe was used to apply 0.2 mL of solution on the dorsal surface of the tongue. All newborns were held upright facing forward during the test and had their face videotaped during 1-min with a digital camera (Sony HDRCX 350). The facial responses were coded into nine action units (AU) according to the Baby Facial Action Coding System [16]: A1 represents no distinct mouth action or sucking on the face (neutral facial response); A2 is A1 with a negative expression on the mid-face (disliking facial response); A3 is A1 with a negative expression on the mid-face and brows (disliking facial response); B1 represents the facial response of a pursing mouth (liking facial response); B2 is B1 with a negative expression on the mid-face (disliking facial response); B3 is B1 with a negative expression on the midface and brows (disliking facial response); C1 represents a mouth-gaping action (liking facial response); C2 is C1 with a negative expression on the mid-face (disliking facial response); and C3 is C1with a negative expression on the mid-face and brows (disliking facial response). Two trained professionals were unaware of the study aims including GDM status of the mother and watched the videotape recordings to classify facial responses. Reliability for scoring was 90% (p50.001).
The data were analyzed by SPSS software (SPSS, Inc., Chicago, IL). The frequency of the facial action units was compared among newborns from mothers with and without GDM. The chi-square test was used and significance was considered at p50.005.
Results We studied 201 infants, 101 children of mothers with GDM and 100 children of mothers without GDM. One newborn was excluded because he was nauseous and the test could not be performed. All newborns had Apgar 47 at 5 min and were considered healthy at the post-delivery neonatal evaluation at the end of the first week of life. GDM women had higher age, weight and income, as compared to non-GDM women. Newborns from GDM mothers had a lower gestational age and a mean Apgar score and a higher birth weight (Table 1). Facial responses to salt showed differences among newborns from GDM women; more neutral and less liking facial responses as compared to controls newborns (Table 2). Facial responses to sweet, sour and bitter showed no differences among newborns from mothers with and without GDM. Predominant facial responses to sweet were liking and to sour and bitter were disliking. Facial expressions to basic tastes showed no differences among newborns from mothers with controlled and noncontrolled GDM (Table 3).
Discussion Ours results pointed out some differences regarding facial responses to basic tastes among newborns from GDM women, a little more preference of taste to salt as compared to controls. Our hypothesis is that higher maternal glucose levels, increasing glucose concentration in amniotic fluid, could interfere on taste development during fetal life. It has been demonstrated that maternal diet during pregnancy and
Table 1. Some biological and social characteristics of women with and without gestational diabetes mellitus and their newborn. Gestational diabetes melitus Variable Maternal characteristics Age (years) Weight (kg) Height (cm) Body mass index (BMI) Glucose (mg/dl) Skin color: White Marital status: married Schooling (up to 8 years of studies) Family income (monthly US$) Gestational age (months) Vaginal delivery Neonatal characteristics Weight (kg) Male Gestational age (by Capurro) Apgar score at 50 (1): Student t-test with equal variances. (2): Pearson chi-square test. (3): Fisher exact test.
Yes (n ¼ 101) Range (Mean ± SD) n (%)
No (n ¼ 100) Range (Mean ± SD) n (%)
p value
17 to 42 (30.75 ± 6.19) 65 to 96 (84.82 ± 15.90) 1.46 to 1.73 (1.63 ± 0.07) 19.9 to 32.2 (26.8 ± 4.7) 75 to 106 (94.0 ± 16.1) 28 (28.0%) 92 (92.0%) 24 (24.0%) 548.0 ± 321.3 37 to 42 (38.34 ± 1.07) 43 (43.0%)
16 to 40 (24.72 ± 5.61) 62 to 88 (75.91 ± 15.10) 1.45 to 1.72 (1.63 ± 0.08) 19.1 to 30.8 (25.2 ± 4.9) 69 to 88 (79.1 ± 6.1) 29 (29.0%) 80 (80.0%) 30 (30.0%) 451.0 ± 291.5 37 to 41 (38.61 ± 4.08) 76 (76.0%)
p(1)50.001* p(1)50.001* p(1) ¼ 0.802 p(1)50.01* p(1)50.001* p(2) ¼ 0.888 p(2) ¼ 0.014* p(2) ¼ 0.632 p(1)50.001* p(1) ¼ 0.522 p(2)50.001*
3035 to 4150 (3390 ± 501) 47 (47.0) 37 to 42 (38.06 ± 3.79) 9.23 ± 0.62
2985 to 3880 (3223 ± 448) 49 (49.5)(4) 37 to 41 (39.06 ± 1.10) 9.53 ± 0.56
p(1) ¼ 0.014* p(2) ¼ 0.725 p(1) ¼ 0.012* p(1)50.001*
Facial responses
DOI: 10.3109/14767058.2014.964680
Table 2. Facial responses of newborn of mother with and without gestational diabetes mellitus. Gestational diabetes mellitus Yes
Downloaded by [Central Michigan University] at 14:41 05 November 2015
Facial responses Total Sweet Like (A1) Neutral (B1) Salt Like (A1 + A2) Neutral (B1 + B2) Sour Like (A1 + A2) Neutral (B1 + B2) Dislike (B3 + C2 + C3) Bitter Like (A1) Neutral (B1 + B2) Dislike (B3 + C1 + C2 + C3)
No
N
%
N
%
p value
100
100.0
100
100.0
95 5
95.0 5.0
94 6
94.0 6.0
p(1) ¼ 0.756
34 66
33.3 1.0
21 79
20.0 1.0
p(1) ¼ 0.040
3 14 83
3.0 14.0 83.0
1 17 82
1.0 17.0 82.0
p(2) ¼ 0.560
1 13 86
2.0 13.0 86.0
1 18 82
1.0 18.0 81.0
p(2) ¼ 0.435
(1): Pearson Chi-square test. (2): Fisher exact test. Table 3. Facial responses of newborn of mothers with controlled and not controlled gestational diabetes mellitus. Controlled gestational diabetes mellitus Yes
No
Facial responses
N
%
N
%
p value
Total Sweet Like (A1) Neutral (B1) Salt Like (A1 + A2) Neutral (B1 + B2) Sour Like (A1) Neutral (B1 + B2) Dislike (B3 + C2 + C3) Bitter Like (A1) Neutral (B1 + B2) Dislike (B3 + C1 + C2 + C3)
33
33.0
67
67.0
32 1
97.0 3.0
62 5
92.5 7.5
p(1) ¼ 0.661
5 28
15.1 84.8
16 51
23.9 76.1
p(1) ¼ 0.314
2 4 27
6.0 12.1 82.0
1 10 56
1.5 15.0 83.6
p(2) ¼ 0.512
1 3 29
3.0 9.1 87.9
– 10 57
– 14.9 85.1
p(2) ¼ 0.318
(1): Pearson Chi-square test. (2): Fisher exact test.
breastfeeding period plays an important role on taste development interfering on food acceptance of offspring life-long. However influences of maternal diseases during pregnancy on taste development has not been adequately studied. To our best knowledge, it is the first time that a study searched for basic taste preferences in newborn from GDM women. As expected GDM mothers were older, heavier and had more Cesarean deliveries. Their newborns were also heavier, had both lower gestational age and Apgar score, but all were born at term and had high vitality (Apgar ¼ 9). It has been demonstrated through facial responses that newborns have a preference of taste to sweet, indifference to salt and dislike of sour and bitter [17]. These data support a
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beginning of taste development during uterus life. Taste development during the first months of life undergoes a phase of predilection for salt and maintenance of sweet preference [10]. Salt avidity develops later (2–6 months of life) and is more complex and less understood as compared to sweet preference. However, some studies have shown that high sweet stimulus can anticipate salt preference [18]. Our data corroborate to these findings which have suggested that sweet and salt have a close and related development. We can speculate that a sweet stimulus during fetal life may anticipate this development phase of salt predilection. Further studies with prospective designs could contribute to a better knowledge on taste development. It has been demonstrated that fetus oral stimulus through swallow of the amniotic fluid, especially in later pregnancy, play an important role in taste development [9,10]. However, it is not known if blood levels of some substances as glucose may influence taste development. As GDM provides both higher glucose on blood and amniotic fluid, we could not identify the specific role of each one of them on neonatal taste preferences. Even few studies had assessed glucose levels in the amniotic fluid of GDM women have demonstrated higher glucose levels in amniotic fluid [14]. We could not have this data in our study because it is an invasive technique, but we also compared the facial responses to basic tastes among controlled and non-controlled GDM women and no differences were observed. However, we have a few numbers of controlled GDM women which may not allow any conclusions. The method employed to measure taste changes in newborn, facial responses to basic tastes may not have the proper accuracy at this age, especially related to sweet taste which is the predominant preference at this age. This test has no qualitative responses, only quantitative answers based on upper and middle face, lips and mouth movements. Furthermore, we made this test during their first 2 h of life and it could be early to detect facial changes to sweet. However, this method has been validated as applied at this time of life. Anyway we intend to follow these infants until weaning to verify solid sweet and salt acceptances. Our study has strengths. Although there are studies about the different facial reactions in newborns in response to the four basic tastes, no one has compared these reactions in infants born from GDM mothers. We also performed a study with a large number of participating subjects. A validated method and recommended standards were used; newborn facial responses to basic tastes followed the standards of FACS adapted to the baby, the Baby FACS [16]. This standard instrument allows comparisons among different studies. Our study has some limitations. Although we have performed a valid test to verify taste preferences to basic tastes during neonatal period, this method may carry some degree of subjectivity in the interpretation of images, especially in those with mild facial changes. We used a single concentration of glucose in the solution offered to the newborn. The use of solutions with different concentrations could have greater sensitivity for detecting the presence of minor changes in taste differentiation to sweet in these
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infants. However, we used the standard solution recommended by other studies and also validated [16]. We also could not detect glucose levels in the amniotic fluid. However, this approach is invasive and can cause maternal or fetal damage.
Conclusion We detected some changes in facial responses to primary tastes among newborns from mothers with GDM, a little more preference to salt taste. This finding seems to indicate that maternal higher glucose levels may influence taste development during fetal life. Further studies are needed to confirm this finding in neonatal period and verify if it influences lifelong on food acceptance in the offspring of GDM mothers.
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Declaration of interest The authors report no declarations of interest.
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