Is there evidence that multiple deliveries increase the risk of childhood obesity and stress on the fetus?

Multiple Gestations: Impact on Fetal Stress and Childhood Obesity Risk

Multiple gestations are associated with increased fetal stress and may contribute to adverse outcomes including childhood obesity, primarily due to higher rates of preterm birth, growth restriction, and placental complications. 1

Fetal Stress in Multiple Gestations

Physiological Stressors

• Multiple gestations have significantly higher rates of preterm birth (53.1% for monochorionic twins vs. 44.9% for dichorionic twins), which is a major source of fetal stress 1
• Monochorionic twins face additional unique stressors including unequal placental sharing and vascular communications that can lead to twin-to-twin transfusion syndrome (TTTS) 1
• Velamentous cord insertion occurs in up to 22% of monochorionic twins, increasing the risk of small for gestational age, growth restriction, and intrauterine fetal demise 1

Growth-Related Stress

• Multiple gestations show asymmetric growth patterns compared to singletons, with constraints becoming evident around 32 weeks' gestation 1
• Nearly 40% of twins would be classified as small for gestational age based on singleton growth standards 1
• Discordant growth between twins can indicate placental insufficiency, creating additional metabolic stress on the smaller fetus 1

Link to Childhood Obesity

Metabolic Programming

• Fetal stress from multiple gestations may contribute to altered metabolic programming, potentially increasing the risk for childhood obesity 1
• Clustering of multiple risk factors in childhood, including those potentially related to fetal stress, is associated with accelerated atherosclerotic processes and future cardiovascular disease 1

Postpartum Weight Retention and Family Environment

• Mothers of multiples face greater challenges with postpartum weight management, which can influence the home environment and childhood obesity risk 1
• Postpartum weight retention carries significant risks to maternal and child health, including increased risk of obesity in subsequent pregnancies 1
• Mothers with multiples experience more significant barriers to healthy lifestyle maintenance, including:
  • Sleep deprivation, which is associated with postpartum weight retention 1
  • Decreased physical activity levels that remain lower than pre-pregnancy levels 1
  • Reduced healthy dietary behaviors marked by decreased fruit and vegetable intake 1

Specific Risks by Type of Multiple Gestation

Monochorionic Twins

• Higher perinatal mortality compared to dichorionic twins 1
• Increased risk of congenital cardiac anomalies (2% in uncomplicated monochorionic twins, 5% in cases of TTTS) 1
• Greater risk of fetal growth restriction due to placental sharing issues 1

Dichorionic Twins and Higher-Order Multiples

• While generally lower risk than monochorionic twins, still have significantly higher rates of preterm birth and growth restriction compared to singletons 1
• Higher rates of gestational diabetes and preeclampsia, which can contribute to fetal stress 1

Prevention Strategies

Prenatal Care Recommendations

• More frequent monitoring is recommended for multiple gestations (every 3-4 weeks for uncomplicated dichorionic twins) 1
• Closer surveillance is warranted if there is discordance in fetal size or amniotic fluid 1
• Avoid activity restriction for multiple gestations, as evidence shows it does not improve outcomes and may be harmful 1

Postpartum Interventions

• Targeted interventions combining diet and physical activity have shown efficacy in reducing postpartum weight retention, which may benefit childhood obesity prevention 1
• Addressing barriers to childcare, scheduling, and accessibility can increase engagement in postpartum health programs from 38% to 82% 1

Common Pitfalls in Management

• Relying on singleton growth standards for multiple gestations can lead to misclassification of fetal growth 1
• Routine inpatient hospitalization and activity restriction for multiple gestations is not recommended and may be harmful 1
• Overlooking the importance of cord insertion assessment, which is critical in monochorionic twins 1
• Failing to provide adequate support for mothers of multiples during the postpartum period, when lifestyle challenges are significant 1

While direct evidence specifically linking multiple gestations to childhood obesity is limited, the physiological stress experienced by fetuses in multiple gestations, combined with the unique challenges faced by families with multiples, creates a plausible pathway for increased obesity risk that warrants attention in clinical practice.