Fatty Acid Ethyl Esters in Meconium of Infants of Diabetic Mothers: a Pilot Trial
Conditions: Infants of Diabetic Mothers
Sponsor: University of Oklahoma

 
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Fatty Acid Ethyl Esters in Meconium of Infants of Diabetic Mothers: 
A Pilot Trial 
 
 
 
 
 
 
 
NCT02308735 
 
 
Document Approved 24 March 2017 
 
Submitted: 22 December 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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RESEARCH PROTOCOL OUTLINE 
 
Title of Project:  Fatty Acid Ethyl Esters in Meconium of Infants of Diabetic 
Mothers: a Pilot Trial 
 
Principal Investigator:  Doug Dannaway, MD, Department of Pediatrics 
 
Co-Investigators:  Marvin Williams, DO; Department of Obstetrics and 
Gynecology, Division of Maternal Fetal Medicine; 
Katherine Arnold, MD, Department of Obstetrics and 
Gynecology; Kimberly Ernst, MD, Department of 
Pediatrics, Section of Neonatal-Perinatal Medicine 
 
Abstract 
 
Gestational diabetes mellitus (GDM) affects as many as 14% of women in 
the United States. Furthermore, the number of pregnant women with 
pregestational diabetes mellitus (PGDM) is also increasing, mainly due to 
an increase in the diagnosis of non-insulin dependent diabetes mellitus. A 
recent study demonstrated that 1.3% of pregnancies are now complicated 
by PGDM and that PGDM now comprises 21% of the diabetes that 
complicate gestations, which represents a two fold increase since 1999. 
One notable side effect of diabetes is an elevation of endogenous ethanol 
production, which in turn may result in a rise in fetal production of fatty 
acid ethyl ester (FAEE). FAEE found in meconium have been utilized as a 
marker of prenatal ethanol exposure.  Therefore, FAEE elevation could 
call into question maternal claims of abstinence from alcohol during 
pregnancy. This study seeks to determine if meconium FAEE levels in the 
newborns of abstinent women with various classifications of diabetes 
mellitus are increased when compared to non-diabetic, abstaining 
controls.   
 
 
 
A. Specific Aims 
 
Hypothesis:  The levels of ethanol metabolites found in fetal meconium of 
teetotalling pregnant women with diabetes mellitus (both gestational and 
pre-gestational) will be greater than that found in teetotalling women 
without diabetes mellitus.    
 
Objectives: 1) To compare meconium FAEE levels and profiles in the 
infants of four groups of abstinent pregnant women: women with 
pregestational diabetes mellitus (PGDM); women with gestational diabetes 

 
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mellitus (GDM) with only an abnormal glucose tolerance test (White’s 
Class A1); women with GDM with fasting hyperglycemia requiring 
treatment with oral hypoglycemic or insulin therapy (White’s Class A2); 
and non-diabetic controls. 
 
 
 
B.  Background and Significance 
 
For over a decade, meconium FAEEs have been used as a biomarker of 
fetal ethanol exposure. FAEEs are formed by the esterification of ethanol 
with free fatty acids.  Once formed in the fetus, FAEEs do not cross the 
placenta and are therefore valid markers of circulating fetal ethanol. The 
availability of this biomarker has allowed epidemiologic prognostication of 
prenatal alcohol exposure and for identification of potentially at-risk social 
situations. Increased meconium FAEE levels have also been correlated 
with poorer neurodevelopmental outcomes in children exposed to ethanol 
in utero. 
 
While maternal consumption of ethanol is the most obvious and direct 
explanation of elevated FAEEs in meconium, it is not the only possible 
mechanism for this finding.  For example, it has been noted that FAEEs 
occur naturally in certain olive oils; this could explain the elevated levels of 
meconium FAEEs found in the children born into reportedly-abstinent 
mothers.  Also, there are medications that may include ethanol as part of 
their preparations. Additionally, one must remember that ethanol is a 
normal by-product of human intestinal microflora metabolism. While 
normal maternal metabolism is unlikely to raise FAEE levels to any 
significant degree, increased endogenous ethanol production has been 
noted in patients suffering from metabolic disorders, hepatitis, cirrhosis, 
and, most notably, diabetes mellitus. 
 
Gestational diabetes mellitus (GDM) affects as many as 14% of women in 
the United States. Furthermore, the number of pregnant women with 
pregestational diabetes mellitus (PGDM) is also increasing, mainly due to 
an increase in the diagnosis of non-insulin dependent diabetes mellitus. A 
recent study showed that 1.3% of pregnancies are now complicated by 
PGDM and that PGDM now comprises 21% of the diabetes that 
complicate gestations, up from 10% in 1999. 
 
It is theoretically possible that infants of diabetic mothers may have 
elevated levels of FAEE in their meconium despite maternal abstinence 
from alcohol intake.  However, there is no available literature directly 
studying this potential phenomenon. 
 
Also, the meconium FAEE screen is susceptible to false positive results; a 
newer method of detecting in utero ethanol exposure has been developed. 

 
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This method looks at the concentration of an ethanol by-product, 
phosphatidylethanol, on newborn dried blood spots (e.g., the ones taken 
for newborn screening).  
 
C.  Preliminary Studies/Progress Report   
 
Dr. Dannaway is a board-certified neonatal-perinatal medicine specialist 
with a publication history in the area of fetal alcohol spectrum disorder. 
Dr. Williams is a board-certified maternal-fetal medicine specialist, and Dr. 
Arnold is a resident in obstetrics and gynecology.  Both have an avid 
interest in the fetal effects of maternal diabetes. 
Dr. Ernst is a board-certified neonatal-perinatal medicine specialist with a 
master’s degree in medical informatics. 
 
 
 
D.  Research Design and Methods 
 
This will be a pilot study, the data from which may be used in the 
development of a larger, multicenter study. 
 
Researchers will approach four groups of pregnant women at 24-28 
weeks when they present for routine obstetrical out-patient appointments: 
 
1. Those with PGDM 
2. Those with White’s Class A1 GDM 
3. Those with White’s Class A2 GDM 
4. Non-diabetic controls 
 
Patients who complete their prenatal glucose screening from 24-28 weeks 
will be recruited once their results have been received or confirmed unless 
they have been designated type 1 or 2 diabetic. Patients who have type 1 
or type 2 can be recruited any time after 24 weeks. 
 
The medical records of these women will be examined to determine self-
reporting of any alcohol or other drug usage while pregnant; women who 
report any illicit drug use (or ethanol use) while pregnant will not be 
eligible for this study. A routine urine drug screen will further confirm this 
finding.   Women who have not reported alcohol use during their 
pregnancy will be questioned regarding medication usage while pregnant, 
as some medications do contain small amounts of ethanol.  Women who 
are judged to have not consumed alcohol during their pregnancies 
(intentionally or incidentally) would then be included in the study. 
 
Demographic information about the mother would also be collected (age, 
parity, length of pregnancy), as would the mother’s most recent 
glycosylated hemoglobin level; additionally, a glycosylated hemoglobin 

 
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level will be drawn on our presumptive controls (to allow for covert 
gestational diabetes mellitus). This lab draw would be added to the 
mother’s routine lab studies and would not require an additional 
venipuncture, unless no other laboratory work would be needed at the 
time, in which case an extra venipuncture would be necessary. 
 
A second urine drug screen will be performed on the mother upon her 
admission to OUHSC for the delivery of her baby. If both screens are 
negative and the baby does not meet any of the exclusion criteria, the 
baby will be enrolled in the study. 
 
The initial meconium from each baby of the recruited mothers will be 
gathered. Approximately 1 g of meconium will be collected, frozen, and 
evaluated for fatty acid ethyl ester analysis at the United States Drug 
Testing Laboratories, Inc. We will also be sending a dried blood spot 
either from the placenta after delivery or from the baby which will be 
collected at the time of the baby’s scheduled newborn screen.  This dried 
blood spot will be evaluated for phospatidylethanol, an ethanol by-product.   
 
Upon determination of eligibility and signing of the consent form, each 
enrolled mother will be compensated $25.  Upon confirmation of a second 
negative urine drug screen and successful enrollment of their baby into 
the study, the mother would be awarded an additional $25. 
 
E.  Statistical Methods   
 
This is a pilot study and will not be powered to strengthen any conclusion.  
The four groups will be compared to each other utilizing an analysis of 
variance with a multiple comparisons procedure. The diabetic group and 
control group will be compared via t-test. 
 
F.  Gender/Minority/Pediatric Inclusion for Research 
 
Women and minorities will not be specifically excluded from this research 
protocol.  The recruitment forms will be printed only in English. 
 
 
 
 
 
 
 
 
 
 
 
G.  Human Participants 
 
1. Women seen in the low-risk and high-risk obstetrical clinics at the 
University of Oklahoma Health Sciences Center will be eligible for 
this study, as will their babies. 
2.  We will be seeking to enlist a total of 60 infants in this study (10 in each 
diabetic category, and 30 non-diabetic controls). The expected age 
range of the mothers approached will be approximately 16 years – 
45 years of age. 
3.  Inclusion criteria (understood to include only abstemious women): 

 
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a). Pregnant women expected to deliver between 37 and 41 weeks 
gestation (controls), and their babies 
 
b). Pregnant women expected to deliver between 37 and 41 weeks 
gestation who have class A1 diabetes mellitus, and their babies 
 
c). Pregnant women expected to deliver between 37 and 41 weeks 
gestation who have class A2 diabetes mellitus, and their babies 
 
d). Pregnant women expected to deliver between 37 and 41 weeks 
gestation who were diagnosed with diabetes mellitus prior to their 
pregnancy, and their babies. 
4.  Exclusion criteria:  
a). Babies whose mothers self-reported any alcohol or any illicit 
drug use during their pregnancy 
b). Babies whose mothers had a positive drug screen at any point 
during their pregnancy 
c). Babies whose mothers suffered a placental abruption during 
their pregnancy. 
d). Babies whose mothers had inadequate prenatal care (defined 
as <3 prenatal clinic visits prior to admission for delivery) 
e). Non-English-speaking mothers 
f). Babies who pass meconium in utero. 
g). Babies born with multiple congenital anomalies or abdominal 
wall defects. 
5.  Each participant will be de-identified and assigned a number based on 
their sequence of enrollment and the particular arm of the study 
that their clinical status would ascribe them. This information would 
be kept on a password-protected database. 
6. Information obtained during this pilot study would be used as the basis 
upon which to request funding for a larger-scale study.  The study 
would enable the researchers to determine if maternal diabetes 
mellitus increases the chances of having babies who have elevated 
levels of FAEEs in their meconium.   This information could alter 
the approaches that physicians and epidemiologists take toward 
this finding. 
7. The information that could be obtained from this study far outweighs the 
negligible risk of accidental release of protected medical 
information. 
 
 
 
 
H.  Data and Safety Monitoring Plan  
 
Adverse events, should they occur, will be reported to the IRB in a timely 
fashion. 
 
I.  Literature Cited 
 
 

 
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