Maternal obesity and attention-related symptoms in the preterm offspring

Associations between maternal preconception and pregnancy adiposity and neuropsychiatric and behavioral outcomes in the offspring: A systematic review and meta-analysis

Maternal adiposity (overweight or obesity) has been associated with adverse perinatal outcomes, although the potential risks of long-term neuropsychiatric and behavioral outcomes in the offspring remain unclear. Using the PRISMA guidelines, we searched PubMed, EMBASE, Scopus, and Web of Science to identify studies on maternal adiposity and offspring neuropsychiatric outcomes. Inverse variance-weighted random-effects meta-analyses were used to pool effect estimates with 95 % confidence intervals (95 % CIs) from adjusted odds ratios (OR) and hazard ratios (HR). Estimates were computed separately for preconception and pregnancy maternal overweight and obesity, with outcomes stratified by the type of neuropsychiatric outcome. In our meta-analyses of 42 epidemiological studies involving 3,680,937 mother-offspring pairs, we found increased risks of ADHD [OR=1.57, 95 % CI: 1.42-1.74], autism spectrum disorder [OR=1.42, 95 % CI: 1.22-1.65], conduct disorder [OR=1.16, 95 % CI: 1.00-1.35], Psychotic disorder [HR=1.61, 95 % CI: 1.41-1.83], externalizing behaviors [OR=1.30, 95 % CI: 1.07-1.56] and peer relationship problems [OR=1.25, 95 % CI: 1.04-1.27] in the offspring of preconception obese mothers. Similar increased risks were found in the offspring of preconception overweight mothers and those exposed to maternal adiposity during pregnancy. However, no association was found with offspring mood, anxiety, personality, eating, sleep disorders or prosocial problems. Preconception weight management may mitigate such adverse effects in the offspring.

Maternal pre-pregnancy obesity and offspring hyperactivity-inattention symptoms at 5 years in preterm and term children: a multi-cohort analysis

The objective of this study was to determine the relationship between maternal pre-pregnancy body mass index (BMI) and child hyperactivity-inattention symptoms (HIS) at 5 years, including preterm and term-born children, and to determine whether this association varied with gestational age. Maternal pre-pregnancy BMI and offspring HIS were assessed in 10,898 participants born ≥ 33 weeks of gestation from the ELFE cohort and 2646 children born between 23 and 34 weeks from the EPIPAGE 2 cohort. Reported pre-pregnancy weight (kg) and measured height (m) were collected from mothers at inclusion and used to classify BMI (kg/m²). Child HIS were evaluated using the Strengths and Difficulties Questionnaire around 5 years of age. Logistic regression estimated odds ratios (OR) of a high HIS score (≥ 90th percentile) in the ELFE cohort and generalized estimated equations were used in EPIPAGE 2 to account for non-independence of multiple births. As a negative control, paternal BMI was also considered as an exposure of interest in sensitivity analyses. Maternal pre-pregnancy obesity and overweight were associated with child HIS at 5 years in ELFE (adjusted OR [aOR] for obesity 1.27 [1.06, 1.53]; overweight aOR 1.16 [1.00, 1.36]) and pre-pregnancy obesity was associated with high HIS scores in preterm infants of EPIPAGE 2 (aOR 1.48 [1.06, 2.08]). In ELFE, the magnitude of the association increased with decreasing gestational age (interaction p = 0.02). High maternal pre-pregnancy BMI is associated with greater likelihood of high HIS scores in both at-term and preterm children at 5 years of age.

Early Growth and Cognitive Development in Children Born Preterm: Relevance of Maternal Body Mass Index

OBJECTIVE

Maternal prepregnancy body mass index (BMI) represents a surrogate marker of fetal exposures to the maternal metabolism during pregnancy. Yet, it remains poorly understood whether this marker indicates risk of altered trajectories in postnatal growth and development in children born preterm. This study aimed to determine whether maternal prepregnancy BMI is associated with altered growth and development in children born preterm.

STUDY DESIGN

A retrospective cohort study evaluated prepregnancy BMI as the exposure for childhood outcomes using linear regression and mixed effects models. The 38 children included in this follow-up evaluation originally participated in a prospective, observational cohort study to determine longitudinal levels of lipid species in preterm human milk expressed by women who delivered prior to 32 weeks. Childhood outcomes in this study were anthropometric measures during hospitalization (n = 38), after discharge through 36 months (n = 34) and Bayley-III developmental scores through 18 months corrected age (n = 26).

RESULTS

In 38 children born prior to 32 weeks, higher maternal prepregnancy BMI was independently associated with higher preterm infant growth velocity during hospitalization, but not associated with in-hospital change in length or head circumference and/or postdischarge growth. In univariate linear regression models, higher maternal BMI was associated with lower cognitive scores at 18 months corrected age. This significant association remained in an adjusted model accounting for relevant influences on early childhood development.

CONCLUSION

Increasing maternal prepregnancy BMI may reflect risk of altered growth and cognitive development in children born preterm.

KEY POINTS

· Maternal BMI was associated with early preterm infant weight gain.. · Maternal BMI was not associated with postdischarge growth.. · Increased maternal BMI may be associated with lower cognitive function scores in offspring..

Cardiometabolic Pregnancy Complications in Association With Autism-Related Traits as Measured by the Social Responsiveness Scale in ECHO

Prior work has examined associations between cardiometabolic pregnancy complications and autism spectrum disorder (ASD) but not how these complications may relate to social communication traits more broadly. We addressed this question within the Environmental Influences on Child Health Outcomes program, with 6,778 participants from 40 cohorts conducted from 1998-2021 with information on ASD-related traits via the Social Responsiveness Scale. Four metabolic pregnancy complications were examined individually, and combined, in association with Social Responsiveness Scale scores, using crude and adjusted linear regression as well as quantile regression analyses. We also examined associations stratified by ASD diagnosis, and potential mediation by preterm birth and low birth weight, and modification by child sex and enriched risk of ASD. Increases in ASD-related traits were associated with obesity (β = 4.64, 95% confidence interval: 3.27, 6.01) and gestational diabetes (β = 5.21, 95% confidence interval: 2.41, 8.02), specifically, but not with hypertension or preeclampsia. Results among children without ASD were similar to main analyses, but weaker among ASD cases. There was not strong evidence for mediation or modification. Results suggest that common cardiometabolic pregnancy complications may influence child ASD-related traits, not only above a diagnostic threshold relevant to ASD but also across the population.

Behavioral and Cognitive Consequences of Obesity in Parents and Offspring in Female and Male Rats: Implications of Neuroinflammation and Neuromodulation

Obesity is a rapidly growing public health concern that can create a family-wise burden. This study was aimed to investigate behavioral, cognitive, neuroinflammatory, and neuromodulatory consequences of the diet and parental obesity. Female and male Wistar albino rats were fed on either an obesogenic or standard diet for 12 weeks, beginning with weaning. Thereafter, the animals were matched and allowed to mate. Pups born to obese or normal parents received either the diet or standard chow to the same age. The obesogenic diet and/or parental obesity increased the locomotor activity in both females and males. The diet exhibited anxiolytic-like and antidepressant-like properties, and impaired short-term object memory as well as spatial memory. Interestingly, the obesogenic diet resulted in neuroinflammation only in naïve animals, but not in the ones with parental obesity. BDNF, SIRT1, and p53 expressions were decreased, whereas RelN expression was increased in the brain with the diet, regardless of parental obesity. Multi-factor analyses demonstrated that the obesogenic diet is the prominent influencer of cognitive, neuroinflammatory, and neuromodulatory results while parental obesity has an effect on spatial memory, neuroinflammation, and hippocampal RelN and p53 expressions. Here, we provided supporting evidence for detrimental cognitive and neuroinflammatory consequences of early life consumption of the obesogenic diet which accompanies alterations in neuromodulatory factors. Surprisingly, the diet was found beneficial against anxiety-like and depression-like behaviors, and additionally, parental obesity was demonstrated to impair some aspects of cognitive performance which appears unrelated to neuroinflammation.

Associations between maternal pre-pregnancy body mass index and neonatal neurobehavior in infants born before 30 weeks gestation

OBJECTIVE

To examine the relationship between maternal pre-pregnancy body mass index (BMI) and neonatal neurobehavior in very premature infants.

STUDY DESIGN

Multi-center prospective observational study of 664 very preterm infants with 227 born to obese mothers. The NICU Network Neurobehavioral Scale (NNNS) assessed neurobehavior at NICU discharge.

RESULTS

Elevated BMI combined with infection increased the odds of having the most poorly regulated NNNS profile by 1.9 times per BMI SD. Infants born to mothers with elevated BMI in combination with: infection had poorer self-regulation, chorioamnionitis had increased asymmetrical reflexes, diabetes had poorer attention, and low SES required more handling.

CONCLUSION

Maternal pre-pregnancy BMI alone did not affect short-term neonatal neurobehavior in infants born before 30 weeks gestation. Infants born to mothers with elevated pre-pregnancy weight in addition to infections, diabetes, or socioeconomic adversity demonstrated increased risk of having the most poorly regulated NNNS profile and deficits in multiple domains.

Association of prenatal modifiable risk factors with attention-deficit hyperactivity disorder outcomes at age 10 and 15 in an extremely low gestational age cohort

Background

The increased risk of developing attention-deficit hyperactivity disorder (ADHD) in extremely preterm infants is well-documented. Better understanding of perinatal risk factors, particularly those that are modifiable, can inform prevention efforts.

Methods

We examined data from the Extremely Low Gestational Age Newborns (ELGAN) Study. Participants were screened for ADHD at age 10 with the Child Symptom Inventory-4 (N = 734) and assessed at age 15 with a structured diagnostic interview (MINI-KID) to evaluate for the diagnosis of ADHD (N = 575). We studied associations of pre-pregnancy maternal body mass index (BMI), pregestational and/or gestational diabetes, maternal smoking during pregnancy (MSDP), and hypertensive disorders of pregnancy (HDP) with 10-year and 15-year ADHD outcomes. Relative risks were calculated using Poisson regression models with robust error variance, adjusted for maternal age, maternal educational status, use of food stamps, public insurance status, marital status at birth, and family history of ADHD. We defined ADHD as a positive screen on the CSI-4 at age 10 and/or meeting DSM-5 criteria at age 15 on the MINI-KID. We evaluated the robustness of the associations to broadening or restricting the definition of ADHD. We limited the analysis to individuals with IQ ≥ 70 to decrease confounding by cognitive functioning. We evaluated interactions between maternal BMI and diabetes status. We assessed for mediation of risk increase by alterations in inflammatory or neurotrophic protein levels in the first week of life.

Results

Elevated maternal BMI and maternal diabetes were each associated with a 55-65% increase in risk of ADHD, with evidence of both additive and multiplicative interactions between the two exposures. MSDP and HDP were not associated with the risk of ADHD outcomes. There was some evidence for association of ADHD outcomes with high levels of inflammatory proteins or moderate levels of neurotrophic proteins, but there was no evidence that these mediated the risk associated with maternal BMI or diabetes.

Conclusion

Contrary to previous population-based studies, MSDP and HDP did not predict ADHD outcomes in this extremely preterm cohort, but elevated maternal pre-pregnancy BMI, maternal diabetes, and perinatal inflammatory markers were associated with increased risk of ADHD at age 10 and/or 15, with positive interaction between pre-pregnancy BMI and maternal diabetes.

Maternal pre-pregnancy overweight/obesity and the risk of attention-deficit/hyperactivity disorder in offspring: a systematic review, meta-analysis and quasi-experimental family-based study

BACKGROUND

Previous studies are inconclusive concerning the association between maternal pre-pregnancy overweight/obesity and risk of attention-deficit/hyperactivity disorder (ADHD) in offspring. We therefore conducted a systematic review and meta-analysis to clarify this association. To address the variation in confounding adjustment between studies, especially inadequate adjustment of unmeasured familial confounding in most studies, we further performed cousin and sibling comparisons in a nationwide population-based cohort in Sweden.

METHODS

We searched PubMed, Embase and PsycINFO during 1975-2018. We used random-effects models to calculate pooled risk ratios (RRs) with 95% confidence interval. In the population-based study, Cox proportional hazard models were used to calculate the unadjusted hazard ratios (HRs) and HRs adjusted for all confounders identified in previous studies. Stratified Cox models were applied to data on full cousins and full siblings to further control for unmeasured familial confounding.

RESULTS

Eight cohorts with a total of 784 804 mother-child pairs were included in the meta-analysis. Maternal overweight [RRoverweight = 1.31 (1.25-1.38), I2 = 6.80%] and obesity [RRobesity = 1.92 (1.84-2.00), I2 = 0.00%] were both associated with an increased risk of ADHD in offspring. In the population-based cohort of 971 501 individuals born between 1992 and 2004, unadjusted Cox models revealed similar associations [HRoverweight = 1.30 (1.28-1.34), HRobesity = 1.92 (1.87-1.98)]. These associations gradually attenuated towards the null when adjusted for measured confounders [HRoverweight = 1.21 (1.19-1.25), HRobesity = 1.60 (1.55-1.65)], unmeasured factors shared by cousins [HRoverweight = 1.10 (0.98-1.23), HRobesity = 1.44 (1.22-1.70)] and unmeasured factors shared by siblings [HRoverweight = 1.01 (0.92-1.11), HRobesity = 1.10 (0.94-1.27)].

CONCLUSION

Pre-pregnancy overweight/obesity is associated with an increased risk of ADHD in offspring. The observed association is largely due to unmeasured familial confounding.

Parental Weight Status and Offspring Behavioral Problems and Psychiatric Symptoms

OBJECTIVES

To assess relations of prepregnancy maternal and paternal obesity with offspring behavioral problems and psychiatric symptoms at 7-8 years in the Upstate KIDS study, a prospective cohort study.

STUDY DESIGN

Maternal body mass index (BMI) was calculated from prepregnancy height and weight provided in vital records or self-report at 4 months postpartum. Mothers reported paternal height and weight. At 7-8 years, mothers indicated if their children had been diagnosed with ADHD or anxiety (n = 1915). Additionally, children's behavior was measured with the Strengths and Difficulties Questionnaire at 7 years of age (n = 1386) and the Vanderbilt ADHD Diagnostic Parent Rating Scale at 8 years of age (n = 1484). Based on Strengths and Difficulties Questionnaire scores, we identified children with borderline behavioral problems. Adjusted risk ratios (aRR) and 95% CIs were estimated with robust multivariable Poisson regression.

RESULTS

Compared with children of mothers with a BMI of <25, children whose mothers had BMI 25-30, 30-35, and ≥35 kg/m2 had higher risks of reported ADHD (aRR, 1.14, 95% CI, 0.78-1.69; aRR, 1.96, 95% CI, 1.29-2.98; and aRR, 1.82, 95% CI,1.21-2.74, respectively). Risks of hyperactivity problems identified by the Strengths and Difficulties Questionnaire and a positive screen for inattentive or hyperactive/impulsive behavior with the Vanderbilt ADHD Diagnostic Parent Rating Scale were also higher with increasing maternal prepregnancy BMI. Paternal BMI was not associated with child outcomes.

CONCLUSIONS

Our findings suggest that maternal, rather than paternal, obesity is associated with maternal report of child ADHD diagnosis and inattentive or hyperactivity problems. Further research is needed to understand how maternal obesity might influence these behavioral changes during or after pregnancy.

Early life antecedents of positive child health among 10-year-old children born extremely preterm

BACKGROUND

To identify modifiable antecedents during pre-pregnancy and pregnancy windows associated with a positive child health at 10 years of age.

METHODS

Data on 889 children enrolled in the Extremely Low Gestational Age Newborn (ELGAN) study in 2002-2004 were analyzed for associations between potentially modifiable maternal antecedents during pre-pregnancy and pregnancy time windows and a previously described positive child health index (PCHI) score at 10 years of age. Stratification by race was also investigated for associations with investigated antecedents.

RESULTS

Factors associated with higher PCHI (more positive health) included greater gestational age, birth weight, multiple gestation, and medical interventions, including assisted reproduction and cervical cerclage. Factors associated with lower PCHI included correlates of lower socioeconomic status, pre-pregnancy chronic medical disorders in the mother such as pre-pregnancy body mass index (BMI), and maternal asthma. When stratified by race, variation in significant results was observed.

CONCLUSIONS

Among children born extremely preterm, medical interventions and higher socioeconomic status were associated with improved PCHI, while chronic illness and high BMI in the mother is associated with lower PCHI at 10 years of age. Knowledge of such antecedent factors could inform efforts to develop interventions that promote positive child health outcomes in future pregnancies.

Maternal Overweight, Inflammation and Neurological Consequences for the Preterm Child: Results of the ELGAN Study

Maternal overweight and obesity are prenatal risk factors for obstetrical complications, preterm birth, neonatal morbidity as well as cognitive and behavioural developmental disorders in children. Paediatric morbidity and mortality as well as child development disorders are significantly associated with maternal obesity. Particularly in the neurodevelopmental and psychiatric area, it is becoming increasingly clear that, in children of mothers with an increased body mass index (BMI), there is a high correlation with childhood cognitive disabilities, attention disorders, and diseases on the autistic spectrum. The ELGAN (Extremely Low Gestational Age Newborn) study is a multicentre study which has been supported since 2000 by the National Institutes of Health (NIH) and whose objective is to research predictors for neonatal brain damage and neurological-cognitive sequelae in premature infants. The areas of focus are the connection between maternal overweight and obesity and pregnancy complications, APGAR scores and systemic inflammatory markers. In this overview, our aim is to summarise the work in this area and discuss it critically on the basis of current literature. We will examine the hypothesis whether maternal overweight and obesity in terms of a chronic inflammatory state is associated with neonatal inflammation which in turn is associated with an unfavourable development prognosis.

Considerations for Preterm Human Milk Feedings When Caring for Mothers Who Are Overweight or Obese

BACKGROUND

Mother's milk is the recommended source of nutrition for all newborns. Preterm infants may be further compromised by maternal factors that impede successful lactation and alter milk composition.

PURPOSE

To review and summarize the state of the science regarding implications of maternal overweight and obesity on successful lactation and associated alterations in preterm mother's milk composition.

METHODS/SEARCH STRATEGY

PubMed, EMBASE, and Web of Science searches were performed using relevant key words to identify references addressing maternal overweight or obesity, prematurity, human milk, and lactation.

FINDINGS/RESULTS

In the United States, more than half of women enter pregnancy with an overweight or obese body mass index. These women have increased risk of adverse pregnancy outcomes and obstetric complications that can undermine successful initiation and continuation of lactation, including preterm birth. Maternal overweight and obesity are also associated with alterations in mother's milk composition.

IMPLICATIONS FOR PRACTICE

Mother-preterm infant dyads affected by maternal overweight and obesity are at risk for barriers to initiation and continuation of lactation. Support for early initiation of milk expression is needed. Continued support, especially during the first weeks of lactation, can facilitate sustained milk production.

IMPLICATIONS FOR RESEARCH

Considerable knowledge gaps remain in this area of human milk science. Future research is needed to facilitate more comprehensive understanding of differences in milk composition associated with maternal overweight and obesity and their impact on clinical outcomes in the preterm infant.

The maternal prepregnancy body mass index and the risk of attention deficit hyperactivity disorder among children and adolescents: a systematic review and meta-analysis

Background

Attention deficit hyperactivity disorder (ADHD) symptoms have a major impact on individuals, families, and society. Therefore identification risk factors of ADHD are a public health priority.

Purpose

This is meta-analysis evaluated the association between maternal prepregnancy body mass index and the risk of ADHD among the resulting offspring.

Methods

The search identified studies published through December 2018 in the PubMed, Web of Science, and Scopus databases. The odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CI) extracted from eligible studies were used as the common measure of association among studies.

Results

A significant association was found between overweight women and the risk of ADHD among children with the pooled HR and OR estimates (HR, 1.27 and 95% CI, 1.17–1.37; OR, 1.28 and 95% CI, 1.15–1.40, respectively). This association was significant between obese women and the risk of ADHD among children and adolescents with the pooled estimates of HR and OR (HR, 1.65 and 95% CI, 1.55–1.76; OR, 1.42 and 95% CI, 1.23–1.61).

Conclusion

The current epidemiological studies present sufficient evidence that prepregnancy overweight and obesity are significantly associated with an increased risk of ADHD among children and adolescents. These findings provide a new approach to preventing ADHD by controlling weight gain in the prenatal period, which should be considered by policymakers.