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Many studies have provided evidence for the hypothesis that size at birth is related to the risk of developing disease in later life. In particular, links are well established between reduced birthweight and increased risk of coronary heart disease, diabetes, hypertension and stroke in adulthood. These relationships are modified by patterns of postnatal growth. The most widely accepted mechanisms thought to underlie these relationships are those of fetal programming by nutritional stimuli or excess fetal glucocorticoid exposure. It is suggested that the fetus makes physiological adaptations in response to changes in its environment to prepare itself for postnatal life. These changes may include epigenetic modification of gene expression. Less clear at this time are the relevance of fetal programming phenomena to twins and preterm babies, and whether any of these effects can be reversed after birth. Much current active research in this field will be of direct relevance to future obstetric practice.

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BackgroundNeonatal hypoglycemia is common and a preventable cause of brain damage.Dextrose gel is used to reverse hypoglycemia in diabetics. However, there is little evidence for its use in babies. MethodWe enrolled 514 babies 35 to 42 weeks' gestation, < 48 hours, and at risk of hypoglycemia, to a randomized, double-blind placebo controlled trial to determine whether 40% dextrose gel massaged into the buccal mucosa is more effective than feeding alone in reversing hypoglycemia. Hypoglycemic babies were randomized to 40% dextrose gel 200 mg/kg (n= 118) or placebo (n= 119) and encouraged to feed.Primary outcome was treatment failure (blood glucose concentration <2·6 mmol/L) after two treatment attempts. FindingsDextrose gel reduced the frequency of treatment failure (16/118 (14%) in dextrose vs. 29/119 (24%) in placebo group, RR 0·57; 95% CI 0·33 to 0·98; p=0·04). Babies receiving dextrose gel were less likely to be admitted to intensive care for hypoglycemia, (16/118 (14%) vs. 30/119 (25%); RR 0.54 (0.31, 0.93); P=0.03), to receive formula feeds (median 7 vs. 10 feeds; median difference 2; 95% CI 0 to 4; p=0·04) and to be formula fed at two weeks (5/118 (4%) vs.15/119 (13%), RR 0·34; 95% CI 0·13 to 0·90; p=0·03). 3 InterpretationDextrose gel should be considered for first-line treatment for management of hypoglycemia in late preterm and term babies in the first 48 hours after birth.