Maternal pre-pregnancy risk drinking and toddler behavior problems: the Norwegian Mother and Child Cohort Study

Periconceptual and prenatal alcohol consumption and neurodevelopment at age two and five years

OBJECTIVE

Examine the association between alcohol consumption before and during pregnancy and neurodevelopmental outcomes in the offspring at two and five years.

STUDY DESIGN

Retrospective analysis of a prospective longitudinal cohort; SCOPE-BASELINE. Data on pre-conception and prenatal alcohol consumption were obtained at 15 weeks' gestation and categorised as abstinent, occasional-low (1-7units/week) and moderate-heavy (≥8units/week). Binge drinking was defined as ≥6 units/session. Outcome measures (Child Behaviour Checklist and Kaufman Brief Intelligence Test) were obtained at two and five years. Linear regression examined an alcohol consumption and Child Behaviour Checklist and Kaufman Brief Intelligence Test relationship, adjusting for several potential confounders.

RESULTS

Data on alcohol consumption was available for 1,507 women. Adjusted linear regression suggested few associations: pre-pregnancy occasional-low alcohol consumption was associated with lower log externalizing Child Behaviour Checklist scores (-0.264, 95% CI: -0.009, -0.520), while pre-pregnancy moderate-high levels of alcohol consumption was associated with lower Kaufman Brief Intelligence Test verbal standard scores (-0.034, 95% CI: -0.001, -0.068) and composite IQ scores (-0.028, 95% CI: -0.056, -0.0004) at five-years. In the first trimester, moderate-high levels of alcohol consumption was associated with lower internalizing Child Behaviour Checklist scores at two-years (-0.252, 95% CI: -0.074, -0.430). No significant associations were observed between number of binge episodes pre-pregnancy or binge drinking in the first trimester and Child Behaviour Checklist or Kaufman Brief Intelligence Test.

CONCLUSIONS

We did not find strong evidence of associations between pre-pregnancy and early pregnancy maternal alcohol consumption and adverse neurodevelopmental outcomes at age two and five years overall. Further research examining alcohol consumption (including binge drinking) beyond 15 weeks' gestation and subsequent neurodevelopmental outcomes is needed to examine the potential effect of alcohol consumption in later pregnancy.

An innovative postnatal risk assessment and corresponding care pathways in Preventive Child Healthcare

Aims

This study aims to evaluate the effectiveness of an innovative postnatal risk assessment (the postnatal Rotterdam Reproductive Risk Reduction checklist: R4U) and corresponding care pathways in Preventive Child Healthcare (PCHC), along with PCHC professional satisfaction.

Design

Four PCHC organizations located in three municipalities with a higher adverse perinatal outcome than the national average were selected for participation. The study concerns a historically controlled study design.

Methods

The study enrolled participants from September 2016 until December 2017. The historical cohort existed of children born in previous years from 2008 until 2016. The outcome measure was defined as catch‐up growth: more than 0.67 standard deviation score weight for height increase in the first 6 months of life. PCHC professional opinion was assessed with a digital survey.

Results

After the inclusion period, 1,953 children were included in the intervention cohort and 7,436 children in the historical cohort. Catch‐up growth was significantly less common in the intervention cohort; 14.9% versus 19.5% in the historical cohort (p < 0.001). A regression sensitivity analysis, using matching, showed an odds ratio of 0.957 (95% CI 0.938–0.976) for the intervention cohort. In the survey, 74 PCHC physicians and nurses participated; most of them were neutral concerning the benefits of the postnatal R4U.

Conclusion

This study shows that the implementation of a novel postnatal risk assessment including in PCHC is feasible and effective. Final efforts to ensure a widespread implementation should be taken.

Impact

PCHC offers a unique opportunity to recognize and address risk factors for growth and development in children and to implement care pathways. Effective and widely implemented risk assessments in antenatal and PCHC are scarce. To our knowledge, this kind of evidence‐based postnatal risk assessment has not been implemented in PCHC before and seizes the opportunity to prevent catch‐up growth and its long‐term effects.

Tulve N. A Systematic Review and Meta-Analysis Investigating the Relationship between Exposures to Chemical and Non-Chemical Stressors during Prenatal Development and Childhood Externalizing Behaviors

Childhood behavioral outcomes have been linked to low quality intrauterine environments caused by prenatal exposures to both chemical and non-chemical stressors. The effect(s) from the many stressors a child can be prenatally exposed to may be influenced by complex interactive relationships that are just beginning to be understood. Chemical stressors influence behavioral outcomes by affecting the monoamine oxidase A (MAOA) enzyme, which is involved in serotonin metabolism and the neuroendocrine response to stress. Non-chemical stressors, particularly those associated with violence, have been shown to influence and exacerbate the externalizing behavioral outcomes associated with low MAOA activity and slowed serotonin metabolism. The adverse developmental effects associated with high stress and maternal drug use during pregnancy are well documented. However, research examining the combined effects of other non-chemical and chemical stressors on development and childhood outcomes as a result of gestational exposures is scarce but is an expanding field. In this systematic review, we examined the extant literature to explore the interrelationships between exposures to chemical and non-chemical stressors (specifically stressful/traumatic experiences), MAOA characteristics, and childhood externalizing behaviors. We observed that exposures to chemical stressors (recreational drugs and environmental chemicals) are significantly related to externalizing behavioral outcomes in children. We also observed that existing literature examining the interactions between MAOA characteristics, exposures to chemical stressors, and traumatic experiences and their effects on behavioral outcomes is sparse. We propose that maternal stress and cortisol fluctuations during pregnancy may be an avenue to link these concepts. We recommend that future studies investigating childhood behaviors include chemical and non-chemical stressors as well as children’s inherent genetic characteristics to gain a holistic understanding of the relationship between prenatal exposures and childhood behavioral outcomes.

Maternal ethanol consumption before paternal fertilization: Stimulation of hypocretin neurogenesis and ethanol intake in zebrafish offspring

There are numerous clinical and pre-clinical studies showing that exposure of the embryo to ethanol markedly affects neuronal development and stimulates alcohol drinking and related behaviors. In rodents and zebrafish, our studies show that embryonic exposure to low-dose ethanol, in addition to increasing voluntary ethanol intake during adolescence, increases the density of hypothalamic hypocretin (hcrt) neurons, a neuropeptide known to regulate reward-related behaviors. The question addressed here in zebrafish is whether maternal ethanol intake before conception also affects neuronal and behavioral development, phenomena suggested by clinical reports but seldom investigated. To determine if preconception maternal ethanol consumption also affects these hcrt neurons and behavior in the offspring, we first standardized a method of measuring voluntary ethanol consumption in AB strain adult and larval zebrafish given gelatin meals containing 10% or 0.1% ethanol, respectively. We found the number of bites of gelatin to be an accurate measure of intake in adults and a strong predictor of blood ethanol levels, and also to be a reliable indicator of intake in larval zebrafish. We then used this feeding paradigm and live imaging to examine the effects of preconception maternal intake of 10% ethanol-gelatin compared to plain-gelatin for 14 days on neuronal development in the offspring. Whereas ethanol consumption by adult female HuC:GFP transgenic zebrafish had no impact on the number of differentiated HuC⁺ neurons at 28 h post-fertilization (hpf), preconception ethanol consumption by adult female hcrt:EGFP zebrafish significantly increased the number of hcrt neurons in the offspring, an effect observed at 28 hpf and confirmed at 6 and 12 days post-fertilization (dpf). This increase in hcrt neurons was primarily present on the left side of the brain, indicating asymmetry in ethanol's actions, and it was accompanied by behavioral changes in the offspring, including a significant increase in novelty-induced locomotor activity but not thigmotaxis measured at 6 dpf and also in voluntary consumption of 0.1% ethanol-gelatin at 12 dpf. Notably, these measures of ethanol intake and locomotor activity stimulated by preconception ethanol were strongly, positively correlated with the number of hcrt neurons. These findings demonstrate that preconception maternal ethanol consumption affects the brain and behavior of the offspring, producing effects similar to those caused by embryonic ethanol exposure, and they provide further evidence that the ethanol-induced increase in hcrt neurogenesis contributes to the behavioral disturbances caused by ethanol.

An intervention in contraceptive counseling increased the knowledge about fertility and awareness of preconception health-a randomized controlled trial

Background: Reproductive life plan counseling (RLPC) is a tool to encourage women and men to reflect upon their reproduction, to avoid unintended pregnancies and negative health behavior that can threaten reproduction. The aim was to evaluate the effect of RLPC among women attending contraceptive counseling. Outcomes were knowledge about fertility and awareness of preconception health, use of contraception, and women's experience of RLPC. Material and methods: Swedish-speaking women, aged 20-40 years, were randomized to intervention group (IG) or control group (CG). Participants (n = 1,946) answered a questionnaire before and two months after (n = 1,198, 62%) the consultation. All women received standard contraceptive counseling, and the IG also received the RLPC, i.e. questions on reproductive intentions, information about fertility, and preconception health. Results: Women in the IG increased their knowledge about fertility: age and fertility, chances of getting pregnant, fecundity of an ovum, and chances of having a child with help of IVF. They also increased their awareness of factors affecting preconception health, such as to stop using tobacco, to refrain from alcohol, to be of normal weight, and to start with folic acid before a pregnancy. The most commonly used contraceptive method was combined oral contraceptives, followed by long-acting reversible contraception. Three out of four women (76%) in the IG stated that the RLPC should be part of the routine in contraceptive counseling. Conclusions: Knowledge about fertility and awareness of preconception health increased after the intervention. The RLPC can be recommended as a tool in contraceptive counseling.

Is the apparently protective effect of maternal nicotine replacement therapy (NRT) used in pregnancy on infant development explained by smoking cessation?: secondary analyses of a randomised controlled trial

OBJECTIVE

To investigate relationships between maternal smoking status in pregnancy and infant development. The largest randomised controlled trial of nicotine replacement therapy (NRT) for smoking cessation in pregnancy, the smoking, nicotine and pregnancy (SNAP) trial, found that at 1 month after randomisation, smoking cessation rates were doubled in the NRT group compared with the placebo group. At delivery, there was no significant difference in cessation rates between groups. Surprisingly, infants born to women randomised to NRT were more likely to have unimpaired development at 2 years. We hypothesised that this apparently protective effect was due to smoking cessation caused by NRT and so, investigate this relationship using the same cohort.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

Seven antenatal hospitals in the Midlands and North-West England.

PARTICIPANTS

Eight hundred and eighty-four pregnant smokers randomised to receive either NRT patches or visually-identical placebo in the SNAP trial. Participants' smoking behaviour were recorded at randomisation, 1 month after their target quit date and at delivery.

METHODS

Using logistic regression models, we investigated associations between participants' smoking measures and infant development (assessed using the Ages and Stages questionnaire) at 2 years.

MAIN OUTCOME MEASURES

2 year infant development.

RESULTS

Developmental impairment was reported for 12.7% of study 2 year olds. Maternal heaviness of smoking at randomisation (OR: 1.26, 95% CI: 0.82 to 1.96, p=0.091), validated smoking abstinence recorded at 1 month after a quit date (OR: 1.02, 95% CI: 0.60 to 1.74, p=0.914) and validated smoking abstinence recorded at both 1 month after a quit date and at the end of pregnancy (OR: 1.52, 95% CI: 0.81 to 2.85, p=0.795) were not independently associated with infant developmental impairment at 2 years.

CONCLUSION

We found no evidence that NRT treatment improved infants' developmental outcomes through smoking cessation.

TRIAL REGISTRATION NUMBER

CTA03057/0002/001-0001; Post-results.

Is the association between maternal alcohol consumption in pregnancy and pre-school child behavioural and emotional problems causal? Multiple approaches for controlling unmeasured confounding

BACKGROUND AND AIMS

Hazardous drinking (i.e. alcohol consumption that places drinkers at risk for adverse health outcomes) during pregnancy is associated with adverse child outcomes. To address whether the associations are causal, we aimed to estimate the effect of maternal hazardous drinking during the first trimester on offspring emotional and behavioural problems throughout the pre-school age. We adjusted for: (1) measured confounding (e.g. smoking), (2) familial risk factors by sibling control design and (3) non-shared environmental risk factors by using hazardous drinking the 3 months before pregnancy as an instrumental variable.

DESIGN

Prospective cohort study. Participants were recruited between 1999 and 2009 at ultrasound examination offered to all pregnant women in Norway. Data were collected during the 17th and the 30th weeks of gestation, and when the children were aged 1.5, 3 and 5 years.

SETTING

Norway, 1999-2015.

PARTICIPANTS

The sample consisted of 14 639 mothers with 25 744 offspring siblings from the Norwegian Mother and Child Cohort Study.

MEASUREMENTS

Respondents self-reported on: alcohol consumption, children's emotional problems (i.e. emotional reactive, anxiety/depression, somatic complaints) and children's behavioural problems (i.e. attention and aggressive behaviour) throughout pre-school age. We used longitudinal latent growth curve models to estimate the effect of maternal drinking during the first trimester on offspring emotional and behavioural problems.

FINDINGS

Most associations were strongly reduced after controlling for both familial and measured environmental risk factors. After adjustment, exposed children were more emotionally reactive [β = 2.33; 95% confidence interval (CI) = 0.13-4.53] and had more somatic complaints (β = 1.93; 95% CI = 0.09-3.77) at age 3, but not at age 5. Exposed children were less aggressive than unexposed siblings at age 5 (β = -2.27; 95% CI = -4.02 to -0.52).

CONCLUSIONS

Children exposed to their mothers' hazardous drinking during the first trimester appear to be more emotionally reactive and have more somatic complaints at age 3, but not at age 5, and are less aggressive at age 5 compared with unexposed siblings.

Features and Associated Factors of the Behavioral Development of 24-month-old Children in Rural China: Follow-up Evaluation of a Randomized Controlled Trial

The aim of this study was to assess the risk factors associated with the behavioral development among 24-month-old children in rural northwestern China. A total of 657 children whose mothers had participated in a double-blinded, randomized, controlled trial of antenatal micronutrient supplementation in western China were followed until 24 months of age. Their mental, psychomotor, and behavioral development were assessed by the Bayley Scales of Infant Development. Multivariate logistic regression models were used to examine the factors associated with infant behavioral development. Six behavioral factors of infants were presented: activity, social adaptability, reactivity, endurance, concentration, and motor coordination. Further analysis demonstrated that maternal malnutrition, exposure to risk factors during pregnancy, and adverse birth outcomes negatively affected the behavioral development of children at 24 months, which is a common co-occurrence with cognitive and emotional problems. These results suggest that strategies to improve infant behavioral development should consider the maternal pregnancy status.

Postnatal screening and care for non-medical risk factors by preventive child healthcare in deprived and non-deprived neighbourhoods

Background

Children born in families with non-medical risk factors, such as deprivation, have higher odds of preterm birth (< 37 weeks of gestation) or being born small for gestational age (birth weight < 10th percentile). In addition, growing up they are at risk for growth and developmental problems. Preventive Child Healthcare (PCHC) monitors growth and development of babies and children. Early identification of children at risk could result in early interventions to prevent growth and developmental problems in later life. Therefore, we aimed to assess current practices in postnatal risk screening and care for non-medical risk factors and the collaboration with other healthcare professionals, in both deprived and non-deprived neighbourhoods in the Netherlands.

Methods

Eight out of ten invited PCHC organisations, from different areas in the Netherlands, consented to participate in this study. A questionnaire was designed and digitally distributed to professionals working at these organisations, where 370 physicians and nurses were employed. Data was collected between June and September 2016. Descriptive statistics, chi square tests and t-tests were applied.

Results

Eighty-nine questionnaires were eligible for analyses. Twenty percent of the respondents were working in a deprived neighbourhood and 70.8% of the respondents were employed as nurse. Most of them performed screening for non-medical risk factors in at least 50% of their consultations. PCHC professionals working in deprived neighbourhoods encountered significantly more often families with non-medical risk factors and experienced significantly more communication problems than their colleagues working in non-deprived neighbourhoods. 48.2% of the respondents were satisfied with the current form of postnatal risk screening in their organisation, whereas 41.2% felt a need for a structured postnatal risk assessment. Intensified collaboration is preferred with district-teams, general practitioners and midwifes, concerning clients with non-medical risk factors.

Conclusion

This study shows that postnatal screening for non-medical risk factors is part of current PCHC practice, regardless the neighbourhood status they are deployed. PCHC professionals consider screening for non-medical risk factors as their responsibility. Consequently, they felt a need for a structured postnatal risk assessment and for an intensified collaboration with other healthcare professionals.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3243-2) contains supplementary material, which is available to authorized users.

Sugar-Sweetened Beverage Consumption Is Adversely Associated with Childhood Attention Deficit/Hyperactivity Disorder

Attention deficit/hyperactivity disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Evidence of the negative effects of sugar-sweetened beverages (SSBs) on mental health has not been convincing, although a few studies have found an association between high SSB levels and attention problems in children. This study aimed to test the hypothesis that SSB consumption is associated with ADHD among children. Doctor-diagnosed ADHD cases (n = 173) and non-ADHD controls (n = 159) between age 4 to 15 were recruited. SSB consumption, socio-demographic and lifestyle characteristics of the children, as well as of their mothers' characteristics during pregnancy, were collected using a questionnaire. Blood lead levels and polymorphisms of two commonly verified dopaminergic-related genes (the D4 dopamine receptor gene DRD4 and the dopamine transporter gene DAT1) were also analyzed. There was a dose-response relationship between SSB consumption and ADHD. After covariates were adjusted, children who consumed SSBs at moderate levels and high levels had 1.36 and 3.69 odds, respectively, of having ADHD, compared with those who did not consume SSBs (p for trend < 0.05). Similar results were obtained when females were excluded. Our findings highlighted the adverse correlation between SSB consumption and ADHD and indicated a dose-response effect even after covariates were adjusted.

Predictors of Postpartum Change in Alcohol Use in Norwegian Mothers

OBJECTIVE

This study examined the relationship between marital status, family size, and postpartum alcohol use from birth to 36 months postpartum, based on data from the Norwegian Mother and Child Cohort Study.

METHOD

Mothers' self-reported alcohol frequency and alcohol units per drinking occasion at 0-3 months, 4-6 months, 18 months, and 36 months postpartum were modeled using linear mixed models for repeated measures.

RESULTS

There was a strong main effect of time on alcohol use, with increases in alcohol use from childbirth to 36 months after childbirth. Adjusting for covariates, there were threeway interaction effects for Time × Family Structure × Family Size for alcohol units and alcohol frequency, indicating that a change in alcohol use varied as a function of family structure and family size. Single mothers had a lower increase in frequency of alcohol use but a steeper increase in the number of alcohol units. However, this effect was less pronounced with increasing family size.

CONCLUSIONS

The patterns of findings are consistent with a differential opportunity perspective on alcohol use.

Maternal heavy alcohol use and toddler behavior problems: a fixed effects regression analysis

Using data from the longitudinal Norwegian Mother and Child Cohort Study, the aims of the current study were to examine associations between postnatal maternal heavy alcohol use and toddler behavior problems, taking both observed and unobserved confounding factors into account by employing fixed effects regression models. Postnatal maternal heavy alcohol use (defined as drinking alcohol 4 or more times a week, or drinking 7 units or more per alcohol use episode) and toddler internalizing and externalizing behavior problems were assessed when the toddlers were aged 18 and 36 months. Maternal psychopathology, civil status and negative life events last year were included as time-variant covariates. Maternal heavy alcohol use was associated with toddler internalizing and externalizing behavior problems (p < 0.001) in the population when examined with generalized estimating equation models. The associations disappeared when observed and unobserved sources of confounding were taken into account in the fixed effects models [(p = 0.909 for externalizing behaviors (b = 0.002, SE = 0.021), p = 0.928 for internalizing behaviors (b = 0.002, SE = 0.023)], with an even further reduction of the estimates with the inclusion of time-variant confounders. No causal effect was found between postnatal maternal heavy alcohol use and toddler behavior problems. Increased levels of behavior problems among toddlers of heavy drinking mothers should therefore be attributed to other adverse characteristics associated with these mothers, toddlers and families. This should be taken into account when interventions aimed at at-risk families identified by maternal heavy alcohol use are planned and conducted.

Genetic epidemiology and insights into interactive genetic and environmental effects in autism spectrum disorders

Understanding the pathogenesis of neurodevelopmental disorders has proven to be challenging. Using autism spectrum disorder (ASD) as a paradigmatic neurodevelopmental disorder, this article reviews the existing literature on the etiological substrates of ASD and explores how genetic epidemiology approaches including gene-environment interactions (G×E) can play a role in identifying factors associated with ASD etiology. New genetic and bioinformatics strategies have yielded important clues to ASD genetic substrates. The next steps for understanding ASD pathogenesis require significant effort to focus on how genes and environment interact with one another in typical development and its perturbations. Along with larger sample sizes, future study designs should include sample ascertainment that is epidemiologic and population-based to capture the entire ASD spectrum with both categorical and dimensional phenotypic characterization; environmental measurements with accuracy, validity, and biomarkers; statistical methods to address population stratification, multiple comparisons, and G×E of rare variants; animal models to test hypotheses; and new methods to broaden the capacity to search for G×E, including genome-wide and environment-wide association studies, precise estimation of heritability using dense genetic markers, and consideration of G×E both as the disease cause and a disease course modifier. Although examination of G×E appears to be a daunting task, tremendous recent progress in gene discovery has opened new horizons for advancing our understanding of the role of G×E in the pathogenesis of ASD and ultimately identifying the causes, treatments, and even preventive measures for ASD and other neurodevelopmental disorders.