Maternal smoking and increased risk of sudden infant death syndrome: a meta-analysis

Prenatal and postnatal factors associated with sudden infant death syndrome: an umbrella review of meta-analyses

BACKGROUND

Comprehensive quantitative evidence on the risk and protective factors for sudden infant death syndrome (SIDS) effects is lacking. We investigated the risk and protective factors related to SIDS.

METHODS

We conducted an umbrella review of meta-analyses of observational and interventional studies assessing SIDS-related factors. PubMed/MEDLINE, Embase, EBSCO, and Google Scholar were searched from inception until January 18, 2023. Data extraction, quality assessment, and certainty of evidence were assessed by using A Measurement Tool Assessment Systematic Reviews 2 following PRISMA guidelines. According to observational evidence, credibility was graded and classified by class and quality of evidence (CE; convincing, highly suggestive, suggestive, weak, or not significant). Our study protocol was registered with PROSPERO (CRD42023458696). The risk and protective factors related to SIDS are presented as equivalent odds ratios (eORs).

RESULTS

We identified eight original meta-analyses, including 152 original articles, covering 12 unique risk and protective factors for SIDS across 21 countries/regions and five continents. Several risk factors, including prenatal drug exposure [eOR = 7.84 (95% CI = 4.81-12.79), CE = highly suggestive], prenatal opioid exposure [9.55 (95% CI = 4.87-18.72), CE = suggestive], prenatal methadone exposure [9.52 (95% CI = 3.34-27.10), CE = weak], prenatal cocaine exposure [4.38 (95% CI = 1.95-9.86), CE = weak], prenatal maternal smoking [2.25 (95% CI = 1.95-2.60), CE = highly suggestive], postnatal maternal smoking [1.97 (95% CI = 1.75-2.22), CE = weak], bed sharing [2.89 (95% CI = 1.81-4.60), CE = weak], and infants found with heads covered by bedclothes after last sleep [11.01 (95% CI = 5.40-22.45), CE = suggestive], were identified. On the other hand, three protective factors, namely, breastfeeding [0.57 (95% CI = 0.39-0.83), CE = non-significant], supine sleeping position [0.48 (95% CI = 0.37-0.63), CE = suggestive], and pacifier use [0.44 (95% CI = 0.30-0.65), CE = weak], were also identified.

CONCLUSIONS

Based on the evidence, we propose several risk and protective factors for SIDS. This study suggests the need for further studies on SIDS-related factors supported by weak credibility, no association, or a lack of adequate research.

Neck Hair-Thread Tourniquet Syndrome by Co-sleeping With Family: A Case Report and Literature Review

Neck hair-thread tourniquet syndrome (NHTTS) is a rare condition that can be a pediatric emergency, occurring when a hair or thread becomes tightly wrapped around a body part, leading to vascular or tissue damage. NHTTS commonly affects infants and young children and can result in severe complications if not promptly diagnosed and treated. The unusual nature of this event, the diffuse petechial hemorrhage on the face, and the presentation of ligature marks extending around the neck led us to admit the child to the general pediatric ward for follow-up and further investigation of the possibility of non-accidental trauma. Co-sleeping is a common cultural practice in Japan where parents sleep in close proximity to their infants. This case report aims to raise awareness among pediatricians and parents about the possibility of NHTTS occurring in infants who co-sleep, particularly when a strand of hair becomes entangled around their neck, about the early detection and appropriate management of NHTTS. And we also summarize the reported NHTTS cases.

Dose-response association between maternal smoking during pregnancy and the risk of infant death: a nationwide, population-based, retrospective cohort study

BACKGROUND

Association of timing and intensity of maternal smoking during pregnancy with all-cause and cause-specific infant death remains inconclusive. We aimed to examine the dose-response association of maternal smoking during each of the three trimesters of pregnancy with all-cause and cause-specific infant death.

METHODS

In this nationwide, population-based, retrospective cohort study, data were extracted from the U.S. National Vital Statistics System, 2015-2019. We included mother-infant pairs after excluding twin or multiple births, newborns with gestation age <37 weeks and those with low birthweight, mothers aged <18 years or ≥50 years, mothers with pre-existing hypertension or diabetes, and those with missing values for variables of interest. Poisson regression models were used to examine the association of different intensities and doses of maternal smoking during each of the three trimesters of pregnancy with all-cause and cause-specific infant death attributed to congenital anomalies, preterm birth, other perinatal conditions, sudden unexpected infant death, and infection.

FINDINGS

A total of 13,524,204 mother-infant pairs were included in our analyses. Maternal smoking during the entire pregnancy was associated with infant all-cause death (relative risk [RR] 1.88, 95% confidence interval [95% CI] 1.79-1.97), cause-specific death due to preterm birth (1.57, 1.25-1.98), perinatal conditions excluding preterm birth (1.35, 1.10-1.65), sudden unexpected infant death (2.56, 2.40-2.73), and infection (1.51, 1.20-1.88). The risk of infant all-cause death (RR values from 1.80 to 2.15) and cause-specific infant death by preterm birth (RR values from 1.42 to 1.74), perinatal conditions excluding preterm birth (RR values from 1.46 to 1.53), sudden unexpected infant death (RR values from 2.37 to 3.04), and infection (RR values from 1.48 to 2.69) increased with the intensity of maternal cigarette use during the entire pregnancy from 1-5 to ≥11 cigarettes. Compared with mothers who smoked during their entire pregnancy, those who smoked in the first trimester and then quit smoking in the second or third trimesters of pregnancy had a reduced risk of infant all-cause death (0.71, 0.65-0.78) and sudden unexpected infant death (0.64, 0.57-0.72).

INTERPRETATION

There was a dose-response association of maternal cigarette use during each of the three trimesters of pregnancy with all-cause and cause-specific infant death. In addition, mothers who are smokers in the first trimester and then quit smoking in the subsequent two trimesters are at decreased risk of infant all-cause mortality and sudden unexpected infant death compared with those who smoked during the entire pregnancy. These findings suggest that there is no safe level of maternal smoking in any trimester of pregnancy and maternal smokers should stop smoking during pregnancy to improve the survival of infants.

FUNDING

Youth Team of Humanistic and Social Science and the Innovation Team of the "Climbing" Program of Shandong University (20820IFYT1902).

My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy

BACKGROUND

Most women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited.

AIM

This paper aims to explore Aboriginal women's experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received.

METHODS

Qualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed.

RESULTS

Major themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation.

CONCLUSION

This qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.

DNA methylation as a potential mediator of the association between prenatal tobacco and alcohol exposure and child neurodevelopment in a South African birth cohort

Prenatal tobacco exposure (PTE) and prenatal alcohol exposure (PAE) have been associated with an increased risk of delayed neurodevelopment in children as well as differential newborn DNA methylation (DNAm). However, the biological mechanisms connecting PTE and PAE, DNAm, and neurodevelopment are largely unknown. Here we aim to determine whether differential DNAm mediates the association between PTE and PAE and neurodevelopment at 6 (N = 112) and 24 months (N = 184) in children from the South African Drakenstein Child Health Study. PTE and PAE were assessed antenatally using urine cotinine measurements and the ASSIST questionnaire, respectively. Cord blood DNAm was measured using the EPIC and 450 K BeadChips. Neurodevelopment (cognitive, language, motor, adaptive behavior, socioemotional) was measured using the Bayley Scales of Infant and Toddler Development, Third Edition. We constructed methylation risk scores (MRS) for PTE and PAE and conducted causal mediation analysis (CMA) with these MRS as mediators. Next, we conducted a high-dimensional mediation analysis to identify individual CpG sites as potential mediators, followed by a CMA to estimate the average causal mediation effects (ACME) and total effect (TE). PTE and PAE were associated with neurodevelopment at 6 but not at 24 months. PTE MRS reached a prediction accuracy (R2) of 0.23 but did not significantly mediate the association between PTE and neurodevelopment. PAE MRS was not predictive of PAE (R2 = 0.006). For PTE, 31 CpG sites and eight CpG sites were identified as significant mediators (ACME and TE P < 0.05) for the cognitive and motor domains at 6 months, respectively. For PAE, 16 CpG sites and 1 CpG site were significant mediators for the motor and adaptive behavior domains at 6 months, respectively. Several of the associated genes, including MAD1L1, CAMTA1, and ALDH1A2 have been implicated in neurodevelopmental delay, suggesting that differential DNAm may partly explain the biological mechanisms underlying the relationship between PTE and PAE and child neurodevelopment.

Development of a Risk Score to Predict Sudden Infant Death Syndrome

Sudden Infant Death Syndrome (SIDS) is the third leading cause of death among infants younger than one year of age. Effective SIDS prediction models have yet to be developed. Hence, we developed a risk score for SIDS, testing contemporary factors including infant exposure to passive smoke, circumcision, and sleep position along with known risk factors based on 291 SIDS and 242 healthy control infants. The data were retrieved from death certificates, parent interviews, and medical records collected between 1989−1992, prior to the Back to Sleep Campaign. Multivariable logistic regression models were performed to develop a risk score model. Our finalized risk score model included: (i) breastfeeding duration (OR = 13.85, p < 0.001); (ii) family history of SIDS (OR = 4.31, p < 0.001); (iii) low birth weight (OR = 2.74, p = 0.003); (iv) exposure to passive smoking (OR = 2.64, p < 0.001); (v) maternal anemia during pregnancy (OR = 2.07, p = 0.03); and (vi) maternal age <25 years (OR = 1.77, p = 0.01). The area under the curve for the overall model was 0.79, and the sensitivity and specificity were 79% and 63%, respectively. Once this risk score is further validated it could ultimately help physicians identify the high risk infants and counsel parents about modifiable risk factors that are most predictive of SIDS.

Nicotine Exposure during Rodent Pregnancy Alters the Composition of Maternal Gut Microbiota and Abundance of Maternal and Amniotic Short Chain Fatty Acids

Tobacco smoking is the leading cause of preventable death. Numerous reports link smoking in pregnancy with serious adverse outcomes, such as miscarriage, stillbirth, prematurity, low birth weight, perinatal morbidity, and infant mortality. Corollaries of consuming nicotine in pregnancy, separate from smoking, are less explored, and the mechanisms of nicotine action on maternal–fetal communication are poorly understood. This study examined alterations in the maternal gut microbiome in response to nicotine exposure during pregnancy. We report that changes in the maternal gut microbiota milieu are an important intermediary that may mediate the prenatal nicotine exposure effects, affect gene expression, and alter fetal exposure to circulating short-chain fatty acids (SCFAs) and leptin during in utero development.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths has remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.

Unique effects of nicotine across the lifespan

Smoking remains the leading cause of preventable death in the United States. Although combustible cigarettes are largely being replaced by tobacco-free products, nicotine use continues to increase in vulnerable populations, including youth, adolescents, and pregnant women. Nicotine exerts unique effects on specific brain regions during distinct developmental periods due to the dynamic expression of nicotinic acetylcholine receptors (nAChRs) throughout the lifespan. Nicotine exposure is a health concern not only for adults but also has neurotoxic effects on the fetus, newborn, child, and adolescent. In this review, we aim to highlight the dynamic roles of nAChRs throughout gestation, adolescence, and adulthood. We also provide clinical and preclinical evidence of the neurodevelopmental, cognitive, and behavioral consequences of nicotine exposure at different developmental periods. This comprehensive review highlights unique effects of nicotine throughout the lifespan to help elucidate interventions and public health measures to protect sensitive populations from nicotine exposure.

European progress in working towards a tobacco-free generation

Children have the right to grow up free from the hazards associated with tobacco smoking. Tobacco smoke exposure can have detrimental effects on children's health and development, from before birth and beyond. As a result of effective tobacco control policies, European smoking rates are steadily decreasing among adults, as is the proportion of adolescents taking up smoking. Substantial variation however exists between countries, both in terms of smoking rates and regarding implementation, comprehensiveness and enforcement of policies to address smoking and second-hand smoke exposure. This is important because comprehensive tobacco control policies such as smoke-free legislation and tobacco taxation have extensively been shown to carry clear health benefits for both adults and children. Additional policies such as increasing the legal age to buy tobacco, reducing the number of outlets selling tobacco, banning tobacco display and advertising at the point-of-sale, and introducing plain packaging for tobacco products can help reduce smoking initiation by youth. At societal level, health professionals can play an important role in advocating for stronger policy measures, whereas they also clearly have a duty to address smoking and tobacco smoke exposure at the patient level. This includes providing cessation advise and referring to effective cessation services.Conclusion: Framing of tobacco exposure as a child right's issue and of comprehensive tobacco control as a tool to work towards the ultimate goal of reaching a tobacco-free generation can help accelerate European progress to curb the tobacco epidemic. What is Known: • Tobacco exposure is associated with a range of adverse health effects among babies and children. • Comprehensive tobacco control policies helped bring down smoking rates in Europe and benefit child health. What is New: • Protecting the rights and health of children provides a strong starting point for tobacco control advocacy. • The tobacco-free generation concept helps policy-makers set clear goals for protecting future generations from tobacco-associated harms.

Cigarette smoking cessation and mental health treatment receipt in a U.S national sample of pregnant women with mental illness

OBJECTIVES

To (1) compare the probability of cigarette smoking cessation for pregnant women with and without past-year mental illness by the trimester of pregnancy; and (2) examine the association between the receipt of past-year mental health treatment and prenatal cigarette smoking cessation among pregnant lifetime-smokers with mental illness.

METHODS

We conducted secondary analysis of data from the National Survey on Drug Use and Health (NSDUH) 2008-2014. The NSDUH included 2019 pregnant lifetime smokers aged 18-44 years, 528 of whom had a mental illness. We used multiple logistic regression to model the probability of prenatal cigarette smoking cessation.

RESULTS

Pregnant lifetime-smokers with mental illness had a lower rate of cigarette smoking cessation than women without mental illness (47.9% vs. 61.7%, p = 0.001). Compared to pregnant women without mental illness, pregnant women with mental illness had a significantly lower odds of smoking cessation in the first trimester (Adjusted Odds Ratio [AOR]: 0.34, 95% Confidence Interval [CI]: 0.18-0.66), but not in the second (AOR: 0.87, 95% CI: 0.46-1.63) and third trimesters (AOR: 0.94, 95% CI: 0.51-1.72). The likelihood of quitting smoking did not differ significantly for pregnant lifetime-smokers with mental illness who received and did not receive mental health treatment (AOR: 1.69, 95% CI: 0.87-3.28).

CONCLUSION

Pregnant lifetime-smokers with mental illness are less likely to quit smoking than those without mental illness; overall, pregnant women tended to quit smoking as they progressed in their pregnancy. The receipt of mental health treatment was not associated with quitting smoking. Mental health care providers need to screen for cigarette use among pregnant women and strengthen smoking cessation efforts.

CLINICAL RELEVANCE

Pregnancy presents a unique opportunity for mental health care providers to screen for cigarette use in women with mental illness and support their smoking cessation efforts.

Parental tobacco and indoor secondhand smoking exposure and the risk of offspring under-five mortality in low- and middle-income countries

Children are vulnerable to exposure of secondhand smoking (SHS) which is a major preventable cause of disease and death. This study aimed to investigate the association between parental tobacco use or SHS exposure, respectively, and under-five mortality. Data were obtained from the nationally representative and population-based Demographic and Health Surveys in low- and middle-income countries (LMICs) between 2000 and 2018. Cox proportional hazard regression models with complex survey design were conducted to examine the adjusted associations between parental smoking and SHS exposure and child under-five mortality. In the pooled analysis of parental smoking, 437 322 children were included. Compared with children whose parents are not smoking, those whose father or both parents smoked any form of tobacco had higher risks of mortality (hazard ratio [HR] = 1.08, 95% confidence interval [CI] = 1.03-1.13; HR = 1.18, 95% CI = 1.06-1.32, respectively). In addition, parental using smokeless tobacco, smoking tobacco, and using smokeless tobacco and smoking tobacco simultaneously was significantly associated with child under-five mortality (HR = 1.07, 95% CI = 1.01-1.12; HR = 1.12, 95%CI = 1.04-1.21; and HR = 1.17, 95%CI = 1.06-1.30, respectively). In the pooled analysis of SHS exposure, 605 442 children were included, and weekly and daily SHS exposure were significantly associated with child under-five mortality (HR = 1.11, 95% CI = 1.03-1.20, and HR = 1.10, 95% CI = 1.06-1.15, respectively). The results were robust in most stratification analyses and sensitivity analyses. Parental tobacco use and indoor SHS exposure were associated with increased risk of under-five mortality in LMICs. Comprehensive tobacco control programs should be considered by policymakers in LMICs to promote smoke-free environments for children.

Community Pharmacist-Led Interventions to Improve Preconception and Pregnancy Health: A Systematic Review

Background: Community pharmacist-led interventions are effective in improving health outcomes; however, their impact in improving preconception and pregnancy health is not clear. This study evaluated the effectiveness of community pharmacist-led interventions which aimed to improve health outcomes of preconception and pregnant women. Methods: A systematic review of the literature, consistent with PRISMA guidelines, was performed. Five electronic databases were searched up to February 2021. Results: Four studies, three in pregnant women and one in preconception women, were identified. The studies focused on improving micronutrient status and smoking cessation. The studies increased knowledge about, and use of, iron supplements, and improved iron status and smoking cessation rates in pregnant women, while improving knowledge regarding, and increasing the use of, preconception folic acid. The studies were ranked as weak to moderate quality. Conclusion: This review provides preliminary evidence for the potential benefit of community pharmacist-led interventions to improve the health of women before and during pregnancy.

Development of a prenatal smoking cessation counseling scale for public health nurses in Japan

INTRODUCTION

This study aimed to develop a scale to measure prenatal smoking cessation counseling for Japanese public health nurses (PHNs).

METHODS

A cross-sectional study was conducted via an anonymous, self-administered questionnaire. The sample included 1933 PHNs working in 424 municipal health centers nationwide, which were randomly selected. We created the draft scale based on semi-structured interviews, previous studies, and preliminary survey. Additionally, we conducted back translation for English version of the draft scale to be applicable in English countries. The analytic strategy consisted of item analysis, exploratory factor analysis, and differentiation by 'known groups'.

RESULTS

A total of 550 responses (28.5%) were included in the analysis. Most of the respondents were female (98.2%) and the mean age was 37.5±9.37 years. In the exploratory factor analysis, two factors were extracted and the factor loadings for all items were greater than 0.40. The first factor with eleven items was named as 'basic counseling' and the second factor with seven items was named as 'advanced counseling'. The Cronbach's alpha of the scale was 0.918, and the cumulative contribution was 44.908%. Multiple comparisons by experience years working as a PHN revealed significant differences in the scale and two factors.

CONCLUSIONS

In this study, we initially developed the prenatal smoking cessation counseling scale for Japanese PHNs, and the reliability and validity of the scale were considered to be acceptable.

Identifying the Best Questions for Rapid Screening of Secondhand Smoke Exposure Among Children

INTRODUCTION

Many children suffer from secondhand smoke exposure (SHSe), which leads to a variety of negative health consequences. However, there is no consensus on how clinicians can best query parents for possible SHSe among children. We employed a data-driven approach to create an efficient screening tool for clinicians to quickly and correctly identify children at risk for SHSe.

METHODS

Survey data from mothers and biospecimens from children were ascertained from the Neurodevelopment and Improving Children's Health following Environmental Tobacco Smoke Exposure (NICHES) study. Included were mothers and their children whose saliva were assayed for cotinine (n = 351 pairs, mean child age = 5.6 years). Elastic net regression predicting SHSe, as indicated from cotinine concentration, was conducted on available smoking-related questions and cross-validated with 2015-2016 National Health and Nutrition Examination Survey (NHANES) data to select the most predictive items of SHSe among children (n = 1670, mean child age = 8.4 years).

RESULTS

Answering positively to at least one of the two final items ("During the past 30 days, did you smoke cigarettes at all?" and "Has anyone, including yourself, smoked tobacco in your home in the past 7 days?") showed area under the curve = .82, and good specificity (.88) and sensitivity (.74). These results were validated with similar items in the nationally representative NHANES sample, area under the curve = .82, specificity = .78, and sensitivity = .77.

CONCLUSIONS

Our data-driven approach identified and validated two items that may be useful as a screening tool for a speedy and accurate assessment of SHSe among children.

IMPLICATIONS

The current study used a rigorous data-driven approach to identify questions that could reliably predict SHSe among children. Using saliva cotinine concentration levels as a gold standard for determining SHSe, our analysis employing elastic net regression identified two questions that served as good classifier for distinguishing children who might be at risk for SHSe. The two items that we validated in the current study can be readily used by clinicians, such as pediatricians, as part of screening procedures to quickly identify whether children might be at risk for SHSe.

Health outcomes of smoking during pregnancy and the postpartum period: an umbrella review

BACKGROUND

Smoking during pregnancy (SDP) and the postpartum period has serious health outcomes for the mother and infant. Although some systematic reviews have shown the impact of maternal SDP on particular conditions, a systematic review examining the overall health outcomes has not been published. Hence, this paper aimed to conduct an umbrella review on this issue.

METHODS

A systematic review of systematic reviews (umbrella review) was conducted according to a protocol submitted to PROSPERO ( CRD42018086350 ). CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, CRD Database and HMIC databases were searched to include all studies published in English by 31 December 2017, except those focusing exclusively on low-income countries. Two researchers conducted the study selection and quality assessment independently.

RESULTS

The review included 64 studies analysing the relationship between maternal SDP and 46 health conditions. The highest increase in risks was found for sudden infant death syndrome, asthma, stillbirth, low birth weight and obesity amongst infants. The impact of SDP was associated with the number of cigarettes consumed. According to the causal link analysis, five mother-related and ten infant-related conditions had a causal link with SDP. In addition, some studies reported protective impacts of SDP on pre-eclampsia, hyperemesis gravidarum and skin defects on infants. The review identified important gaps in the literature regarding the dose-response association, exposure window, postnatal smoking.

CONCLUSIONS

The review shows that maternal SDP is not only associated with short-term health conditions (e.g. preterm birth, oral clefts) but also some which can have life-long detrimental impacts (e.g. obesity, intellectual impairment).

IMPLICATIONS

This umbrella review provides a comprehensive analysis of the overall health impacts of SDP. The study findings indicate that while estimating health and cost outcomes of SDP, long-term health impacts should be considered as well as short-term effects since studies not including the long-term outcomes would underestimate the magnitude of the issue. Also, interventions for pregnant women who smoke should consider the impact of reducing smoking due to health benefits on mothers and infants, and not solely cessation.

Factors associated with age of death in sudden unexpected infant death

Aim

This study aimed to systematically analyse the pregnancy, birth and demographic‐related factors associated with age of death in sudden unexpected infant death (SUID).

Methods

Data were analysed from the Centers for Disease Control and Prevention's Cohort Linked Birth/Infant Death data set (2011‐2013; 11 737 930 live births). SUID was defined as deaths from sudden infant death syndrome, ill‐defined causes, or accidental suffocation and strangulation in bed. There were 9668 SUID cases (7‐364 days; gestation >28 weeks; 0.82/1000 live births). The odds of death at different ages were compared to determine which variables significantly affect the SUID age of death.

Results

Forty‐three features indicated a significant change in age of death with two main patterns: (a) younger chronologic age at death was associated with maternal smoking and factors associated with lower socio‐economic status, and (b) older age was associated with low birthweight, prematurity and admission to the neonatal intensive care unit. However, when age was corrected for gestation, these factors were associated with younger age.

Conclusion

Factors that varied with age of death are well‐documented risk factors for SUID. The majority of these risk factors were associated with younger age at death after allowing for gestational age at birth.

Early Life Exposure to Nicotine: Postnatal Metabolic, Neurobehavioral and Respiratory Outcomes and the Development of Childhood Cancers

Cigarette smoking during pregnancy is associated with numerous obstetrical, fetal, and developmental complications, as well as an increased risk of adverse health consequences in the adult offspring. Nicotine replacement therapy and electronic nicotine delivery systems (e-cigarettes) have been developed as a pharmacotherapy for smoking cessation and are considered safer alternatives for women to smoke during pregnancy. The safety of nicotine replacement therapy use during pregnancy has been evaluated in a limited number of short-term human trials, but there is currently no information on the long-term effects of developmental nicotine exposure in humans. However, animal studies suggest that nicotine alone may be a key chemical responsible for many of the long-term effects associated with maternal cigarette smoking on the offspring and increases the risk of adverse neurobehavioral outcomes, dysmetabolism, respiratory illness, and cancer. This review will examine the long-term effects of fetal and neonatal nicotine exposure on postnatal health.

Investigating the effects of comprehensive smoke-free legislation on neonatal and infant mortality in Thailand using the synthetic control method

BACKGROUND

Almost all of the evidence on the benefits of smoke-free legislation on child health comes from evaluations in high-income countries. We investigated the effects of Thailand's 2010 comprehensive smoke-free legislation on neonatal and infant mortality.

METHODS

To overcome some of the methodological issues inherent to traditional quasi-experimental methods, we applied the novel synthetic control approach. Using 2001-2017 country-level panel data from the World Bank and Penn World datasets, we estimated the effects of smoke-free legislation as the difference between the outcome trends in Thailand versus those in a synthetic control country. The synthetic control country was composed of 'control' middle-income countries without comprehensive smoke-free legislation to recreate trends in Thailand in the 2001-2009 pre-legislation outcomes and covariates. We compared the legislation effects to 'placebo effects' obtained for each control country by fictitiously assuming that comprehensive smoke-free legislation was introduced there in 2010, similar to Thailand.

FINDINGS

Neonatal and infant mortality decreased by 2.9% and 2.8%/year respectively following smoke-free legislation, with an estimated 7463 infant deaths (including 4623 neonatal deaths) having been averted over eight years. The results were robust to different specifications of the control countries. Comparison with placebo effects indicated that the findings were unlikely to be attributable to factors other than the smoke-free legislation.

INTERPRETATION

Expanding comprehensive smoke-free policies to middle-income countries can support national efforts to achieve Sustainable Development Goal 3.2 for reducing preventable early-life deaths.

FUNDING

Netherlands Lung Foundation, HDRUK, Asthma UK center for Applied Research and NIHR Global Respiratory Health Unit (RESPIRE).

Factors Associated with Prenatal Smoking Cessation Interventions among Public Health Nurses in Japan

This study aimed to identify the factors associated with prenatal smoking cessation interventions based on the 5As model among public health nurses (PHNs) in Japan. A nationwide cross-sectional study was conducted from December 2019 to February 2020 via a self-administered questionnaire. The study subjects were 1988 PHNs working in 431 health centers of municipalities and special wards across the country. Of the 1988 questionnaires mailed, 521 responses (26.2%) were included in the analysis. Of the 521 responses, most of the respondents were female (98.1%) and the mean age was 37.5 years. There were statistically significant differences on age, work regions, experience years working as a PHN and smoking cessation training after becoming a PHN in implementing the 5As. Self-efficacy, professional development competency, research utilization competency, age and experience years working as a PHN were positively associated with the 5As. Social nicotine dependence was negatively associated with the 5As. Furthermore, self-efficacy mediated the relationship between the 5As and professional development competency, research utilization competency, social nicotine dependence, age and experience years working as a PHN. In the future, smoking cessation intervention training should be widely implemented to improve self-efficacy and prenatal smoking cessation interventions among Japanese PHNs.

Changes in parental smoking during pregnancy and risks of adverse birth outcomes and childhood overweight in Europe and North America: An individual participant data meta-analysis of 229,000 singleton births

BACKGROUND

Fetal smoke exposure is a common and key avoidable risk factor for birth complications and seems to influence later risk of overweight. It is unclear whether this increased risk is also present if mothers smoke during the first trimester only or reduce the number of cigarettes during pregnancy, or when only fathers smoke. We aimed to assess the associations of parental smoking during pregnancy, specifically of quitting or reducing smoking and maternal and paternal smoking combined, with preterm birth, small size for gestational age, and childhood overweight.

METHODS AND FINDINGS

We performed an individual participant data meta-analysis among 229,158 families from 28 pregnancy/birth cohorts from Europe and North America. All 28 cohorts had information on maternal smoking, and 16 also had information on paternal smoking. In total, 22 cohorts were population-based, with birth years ranging from 1991 to 2015. The mothers' median age was 30.0 years, and most mothers were medium or highly educated. We used multilevel binary logistic regression models adjusted for maternal and paternal sociodemographic and lifestyle-related characteristics. Compared with nonsmoking mothers, maternal first trimester smoking only was not associated with adverse birth outcomes but was associated with a higher risk of childhood overweight (odds ratio [OR] 1.17 [95% CI 1.02-1.35], P value = 0.030). Children from mothers who continued smoking during pregnancy had higher risks of preterm birth (OR 1.08 [95% CI 1.02-1.15], P value = 0.012), small size for gestational age (OR 2.15 [95% CI 2.07-2.23], P value < 0.001), and childhood overweight (OR 1.42 [95% CI 1.35-1.48], P value < 0.001). Mothers who reduced the number of cigarettes between the first and third trimester, without quitting, still had a higher risk of small size for gestational age. However, the corresponding risk estimates were smaller than for women who continued the same amount of cigarettes throughout pregnancy (OR 1.89 [95% CI 1.52-2.34] instead of OR 2.20 [95% CI 2.02-2.42] when reducing from 5-9 to ≤4 cigarettes/day; OR 2.79 [95% CI 2.39-3.25] and OR 1.93 [95% CI 1.46-2.57] instead of OR 2.95 [95% CI 2.75-3.15] when reducing from ≥10 to 5-9 and ≤4 cigarettes/day, respectively [P values < 0.001]). Reducing the number of cigarettes during pregnancy did not affect the risks of preterm birth and childhood overweight. Among nonsmoking mothers, paternal smoking was associated with childhood overweight (OR 1.21 [95% CI 1.16-1.27], P value < 0.001) but not with adverse birth outcomes. Limitations of this study include the self-report of parental smoking information and the possibility of residual confounding. As this study only included participants from Europe and North America, results need to be carefully interpreted regarding other populations.

CONCLUSIONS

We observed that as compared to nonsmoking during pregnancy, quitting smoking in the first trimester is associated with the same risk of preterm birth and small size for gestational age, but with a higher risk of childhood overweight. Reducing the number of cigarettes, without quitting, has limited beneficial effects. Paternal smoking seems to be associated, independently of maternal smoking, with the risk of childhood overweight. Population strategies should focus on parental smoking prevention before or at the start, rather than during, pregnancy.

Description of Maternal Smoking Status Before and After Pregnancy: A Longitudinal, Community-Based Cohort Study

Background

Maternal smoking during pregnancy is a major risk for adverse perinatal outcomes, as well as children’s health status. Thus, it is important to describe maternal smoking status during pregnancy and child-rearing to devise better intervention strategies. However, there have been no longitudinal studies to describe the status. Thus, in this study, we aimed to describe maternal smoking status during pregnancy and child-rearing based on population-based maternal and child health information. Moreover, we explored the factors associated with maternal smoking relapse after delivery.

Methods

We performed a survey of 1,220 mothers in a Japanese rural area who responded to a questionnaire upon registration of their pregnancies. When their children received health checkups at 4, 18, and 36 months of age, maternal smoking status was also surveyed. We then performed multiple logistic regression analysis to explore factors associated with maternal smoking relapse after delivery.

Results

Ultimately, the total number of mothers with data available for longitudinal analysis was 727 (59.6%). At the time of pregnancy registration, there were 74 current smokers (10.2%) and 176 former smokers (24.2%). Among them, 59 (33.5%) relapsed after delivery. Under 28 years of maternal age at pregnancy registration (OR 2.6; 95% CI, 1.2–5.4) was associated with maternal smoking relapse after delivery.

Conclusions

Longitudinal analyses showed that about 60% of mothers who smoked before and after delivery failed smoking cessation. In addition, younger mothers were significantly likely to relapse smoking after delivery.

[In Utero Exposure to Maternal Smoking: Impact on the Child from Birth to Adulthood - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

INTRODUCTION

Smoking during pregnancy leads to fetal passive smoking. It is associated with several obstetrical complications and is a major modifiable factor of maternal and fetal morbidity. Long-term consequences also exist but are less well known to health professionals and in the general population.

METHODS

Consultation of the Medline® database.

RESULTS

Maternal smoking during pregnancy is associated in the offspring with sudden infant death syndrome (NP2), impaired lung function (NP2), lower respiratory infections and asthma (NP2), overweight and obesity (NP2), cancers (NP3), risk of tobacco use, nicotine dependence and early smoking initiation (NP2). Unadjusted analyses show associations between in utero tobacco exposure and cognitive deficits (NP3), impaired school performance (NP3) and behavioral disorders in children (NP2), which are in a large part explained by environmental factors. There is a cross-generational effect of smoking during pregnancy. For example, an increased risk of asthma is observed in the grandchildren of smoking women (NP4). The respective roles of ante- and post-natal smoking remain difficult to assess.

CONCLUSION

These results highlight the importance of prevention measures against tobacco use in the general population, as well as screening measures and support for smoking cessation before or at the beginning of the pregnancy.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.

Dual recombinase fate mapping reveals a transient cholinergic phenotype in multiple populations of developing glutamatergic neurons

Cholinergic transmission shapes the maturation of glutamatergic circuits, yet the developmental sources of acetylcholine have not been systematically explored. Here, we have used Cre-recombinase-mediated genetic labeling to identify and map both mature and developing CNS neurons that express choline acetyltransferase (ChAT). Correction of a significant problem with a widely used ChatCre transgenic line ensures that this map does not contain expression artifacts. ChatCre marks all known cholinergic systems in the adult brain, but also identifies several brain areas not usually regarded as cholinergic, including specific thalamic and hypothalamic neurons, the subiculum, the lateral parabrachial nucleus, the cuneate/gracilis nuclei, and the pontocerebellar system. This ChatCre fate map suggests transient developmental expression of a cholinergic phenotype in areas important for cognition, motor control, and respiration. We therefore examined expression of ChAT and the vesicular acetylcholine transporter in the embryonic and early postnatal brain to determine the developmental timing of this transient cholinergic phenotype, and found that it mirrored the establishment of relevant glutamatergic projection pathways. We then used an intersectional genetic strategy combining ChatCre with Vglut2Flp to show that these neurons adopt a glutamatergic fate in the adult brain. The transient cholinergic phenotype of these glutamatergic neurons suggests a homosynaptic source of acetylcholine for the maturation of developing glutamatergic synapses. These findings thus define critical windows during which specific glutamatergic circuits may be vulnerable to disruption by nicotine in utero, and suggest new mechanisms for pediatric disorders associated with maternal smoking, such as sudden infant death syndrome.

Concurrent prenatal drinking and smoking increases risk for SIDS: Safe Passage Study report

BACKGROUND

Sudden infant death syndrome (SIDS) is the leading cause of postneonatal mortality. Although the rate has plateaued, any unexpected death of an infant is a family tragedy thus finding causes and contributors to risk remains a major public health concern. The primary objective of this investigation was to determine patterns of drinking and smoking during pregnancy that increase risk of SIDS.

METHODS

The Safe Passage Study was a prospective, multi-center, observational study with 10,088 women, 11,892 pregnancies, and 12,029 fetuses, followed to 1-year post delivery. Subjects were from two sites in Cape Town, South Africa and five United States sites, including two American Indian Reservations. Group-based trajectory modeling was utilized to categorize patterns of drinking and smoking exposure during pregnancy.

FINDINGS

One-year outcome was ascertained in 94·2% infants, with 28 SIDS (2·43/1000) and 38 known causes of death (3·30/1000). The increase in relative risk for SIDS, adjusted for key demographic and clinical characteristics, was 11·79 (98·3% CI: 2·59-53·7, p < 0·001) in infants whose mothers reported both prenatal drinking and smoking beyond the first trimester, 3.95 (98·3% CI: 0·44-35·83, p = 0·14), for drinking only beyond the first trimester and 4·86 (95% CI: 0·97-24·27, p = 0·02) for smoking only beyond the first trimester as compared to those unexposed or reported quitting early in pregnancy.

INTERPRETATION

Infants prenatally exposed to both alcohol and cigarettes continuing beyond the first trimester have a substantially higher risk for SIDS compared to those unexposed, exposed to alcohol or cigarettes alone, or when mother reported quitting early in pregnancy. Given that prenatal drinking and smoking are modifiable risk factors, these results address a major global public health problem.

FUNDING

National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

Bedsharing and Breastfeeding: The Academy of Breastfeeding Medicine Protocol #6, Revision 2019

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Parental Smoking and Under-Five Child Mortality in Southeast Asia: Evidence from Demographic and Health Surveys

Smoking remains the main cause of preventable early death. However, little is known about the association between parental smoking and child mortality in under-fives in developing countries. This study assesses the association between parental smoking status, smoking amount and smoking frequency with child mortality in under-fives in four Southeast Asian countries (Cambodia, Indonesia, Lao People’s Democratic Republic and Timor Leste). We used the Demographic and Health Survey dataset. The information from couples consisting of fathers and mothers (n = 19,301 couples) in the same household were collected. Under-five child mortality was significantly associated with paternal smoking only (odds ratio (OR) = 1.25, 95% confidence interval (CI): 1.14–1.38), maternal smoking only (OR = 2.40, 95% CI: 1.61–3.59) and both parents smoking (OR = 2.60, 2.08–3.26). Paternal, maternal, both parents’ smoking amount and frequency were also assessed. The estimated association decreased after adjusting for covariates but remained highly significant for smoking in both parents, mothers who smoked 1–10 cigarettes/day, when both parents smoked > 20 cigarettes/day, and in mothers who smoked every day. Future behavioural changes and smoking cessation programmes should engage parents as a catalyst for the reduction of child mortality risk in LMICs in the SEA region.

Addressing Postpartum Smoking Relapse Among Low-Income Women: A Randomized Control Trial

PURPOSE

Smoking during pregnancy can have dire consequences for both the baby and mother. Low-income pregnant women smoke at particularly high rates. Among women who quit during pregnancy, postpartum relapse is high. This randomized control trial tested the effect of adding postpartum assistance to an existing smoking cessation program (First Breath) designed for low-income women.

METHODS

Of 185 study participants, 94 women were randomly assigned to the standard First Breath program (control) and 91 to an enhanced program. First Breath consisted of evidence-based smoking cessation counseling provided at every prenatal visit. The enhanced program included all First Breath services plus 4 in-home counseling visits (3 postpartum), 3 postpartum counseling calls, support to others in the home, and incentives (gift cards) totaling $100. The primary outcome was biochemically verified abstinence at 6 months postpartum.

RESULTS

Among the 98 women who completed the study, the abstinence rate among the intervention participants (n=41) was significantly greater than among the control participants (n=57) (36.6% vs 12.3%, respectively; P<0.01). Analyzed on an intent-to-treat basis, with those lost to follow-up assumed to be smoking, the abstinence rate among intervention subjects (n=91) was 16.5% vs 7.4% among control participants (n=94); P=0.07.

CONCLUSIONS

Extending smoking cessation interventions into the postpartum period may help address postpartum relapse.

Neurological Effects in the Offspring After Switching From Tobacco Cigarettes to E-Cigarettes During Pregnancy in a Mouse Model

Maternal smoking is currently a public health concern and has been associated with a number of complications in the offspring. E-cigarettes are gaining popularity as a “safer” alternative to tobacco cigarettes during pregnancy, however, there are a limited number of studies to suggest that it is actually “safe.” Balb/C female mice were exposed to ambient air (n = 8; Sham), or tobacco cigarette smoke (n = 8; SE) before gestation, during gestation and lactation. A third group was exposed to cigarette smoke before gestation followed by e-cigarette aerosols during gestation and lactation (n = 8; Switch). Male offspring (12-week old, n = 10–14/group) underwent behavioral assessments to investigate short-term memory, anxiety, and activity using the novel object recognition and elevated plus maze tests. Brains were collected at postnatal day (P)1, P20, and Week 13 for global DNA methylation, epigenetic gene expression, and neuronal cell counts. The offspring from mothers switching to e-cigarettes exhibited no change in exploration/activity but showed a decrease in global DNA methylation, Aurora Kinase (Aurk) A and AurkB gene expression and a reduction in neuronal cell numbers in the cornu ammonis 1 region of the dorsal hippocampus compared with the SE group. Continuous tobacco cigarette smoke exposure during pregnancy resulted in marked neurological deficits in the offspring. Switching to e-cigarettes during pregnancy reduced these neurological deficits compared with cigarette smoke exposure. However, neurological changes were still observed, so we therefore conclude that e-cigarette use during pregnancy is not advised.

Global trends in the extent of death scene investigation performed for sudden and unexpected death of infant (SUDI) cases: A systematic review

Sudden unexpected death of infants (SUDI) is the rapid and unexpected death of an infant aged less than 1year old. These deaths are referred for a medico-legal investigation to establish cause of death. National and regional protocols for the investigation of SUDI cases have been established in some countries and these typically include a death scene investigation component. However, there is a paucity of literature detailing the nature and extent of death scene investigation protocols. A systematic review was conducted to review the scope of death scene investigation of SUDI cases worldwide. Relevant articles (n=74) were identified by searching four literature databases, three discipline-specific journals, as well as each article's reference list, until saturation was reached. Of the 16 countries represented by the included articles, seven made specific reference to the standardised protocol used, which included photography, interviews and/or scene re-enactments. The remaining 54 studies appeared to include a subset of these analyses during death scene investigation, which varied between countries, and between SUDI admissions. This may be attributed to the differing socio-economic standings of countries, and the resources available. Only four studies were from developing countries, three of which originated from South Africa. Overall, where a standardised death scene investigation was performed, it added value to the post-mortem investigation; as such, death scene investigation should be encouraged in SUDI investigation. To this end, protocols should be established nationally, and contain core analyses, which could be expanded depending on the needs and resources of the country.

Maternal smoking and neurodevelopmental outcomes in infants <29 weeks gestation: a multicenter cohort study

OBJECTIVE

To compare neurodevelopmental outcomes of preterm infants at 18-21 months corrected age (CA) whose mothers smoked during pregnancy to those whose mothers did not smoke.

STUDY DESIGN

Preterm infants born at <29 weeks of gestation and evaluated at 18-21 months CA were included. Primary outcome was a composite outcome of death or neurodevelopmental impairment (NDI).

RESULTS

Of a total of 2760 infants, 699 met exclusion criteria. Of the remaining 2061 infants, 280 (13.6%) were exposed to maternal smoking and 1781 (86.4%) were not. The odds of the composite outcome of death or NDI (aOR 1.40; 95% CI: 1.03-1.91), NDI alone (aOR 1.43; 95% CI: 1.01-2.03), and Bayley-III motor score <85 (aOR 1.91; 95% CI: 1.31-2.81) were higher in exposed infants.

CONCLUSIONS

Exposure to maternal smoking was associated with adverse composite outcome of death or NDI, NDI alone and lower motor scores at 18-21 months CA.

Call to Action to Reduce Tobacco Use During Pregnancy

Tobacco use is a leading preventable cause of adverse maternal and child health outcomes. However, many women in the United States still report smoking during the third trimester of pregnancy. Smoking rates during pregnancy are particularly high among vulnerable women, such as those who experience mental illness, substance use disorder, homelessness, or interpersonal violence. The Tobacco Control Vaccine is a model based on population-level, evidence-based practices to reduce tobacco use. The four elements of the Tobacco Control Vaccine are access to treatment for tobacco dependence, smoke-free policies, increased tobacco taxes, and media campaigns. The purpose of this commentary is a call to action for health care providers to advocate for increased access to treatment for tobacco dependence; stay up-to-date on innovative, tailored treatment practices; and advocate for comprehensive, smoke-free policies, higher tobacco taxes, and media campaigns to help pregnant women quit smoking and avoid relapse in the postpartum period.

Models of care for neonatal abstinence syndrome: What works?

Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.

Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death

OBJECTIVES

Maternal smoking during pregnancy is an established risk factor for sudden unexpected infant death (SUID). Here, we aim to investigate the effects of maternal prepregnancy smoking, reduction during pregnancy, and smoking during pregnancy on SUID rates.

METHODS

We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2007-2011: 20 685 463 births and 19 127 SUIDs). SUID was defined as deaths at <1 year of age with International Classification of Diseases, 10th Revision codes R95 (sudden infant death syndrome), R99 (ill-defined or unknown cause), or W75 (accidental suffocation or strangulation in bed).

RESULTS

SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31-2.57) with any maternal smoking during pregnancy and increased twofold between no smoking and smoking 1 cigarette daily throughout pregnancy. For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 from 1 to 20 cigarettes; beyond 20 cigarettes, the relationship plateaued. Mothers who quit or reduced their smoking decreased their odds compared with those who continued smoking (reduced: aOR = 0.88, 95% CI 0.79-0.98; quit: aOR = 0.77, 95% CI 0.67-0.87). If we assume causality, 22% of SUIDs in the United States can be directly attributed to maternal smoking during pregnancy.

CONCLUSIONS

These data support the need for smoking cessation before pregnancy. If no women smoked in pregnancy, SUID rates in the United States could be reduced substantially.

Differences in Prenatal Tobacco Exposure Patterns among 13 Race/Ethnic Groups in California

Prenatal tobacco exposure is a significant, preventable cause of childhood morbidity, yet little is known about exposure risks for many race/ethnic subpopulations. We studied active smoking and environmental tobacco smoke (ETS) exposure in a population-based cohort of 13 racially/ethnically diverse pregnant women: white, African American, Hispanic, Native American, including nine Asian/Pacific Islander subgroups: Chinese, Japanese, Korean, Filipino, Cambodian, Vietnamese, Laotian, Samoan, and Asian Indians (N = 3329). Using the major nicotine metabolite, cotinine, as an objective biomarker, we analyzed mid-pregnancy serum from prenatal screening banked in 1999–2002 from Southern California in an effort to understand differences in tobacco exposure patterns by race/ethnicity, as well as provide a baseline for future work to assess secular changes and longer-term health outcomes. Prevalence of active smoking (based on age- and race-specific cotinine cutpoints) was highest among African American, Samoan, Native Americans and whites (6.8–14.1%); and lowest among Filipinos, Chinese, Vietnamese and Asian Indians (0.3–1.0%). ETS exposure among non-smokers was highest among African Americans and Samoans, followed by Cambodians, Native Americans, Vietnamese and Koreans, and lowest among Filipinos, Japanese, whites, and Chinese. At least 75% of women had detectable cotinine. While for most groups, levels of active smoking corresponded with levels of ETS, divergent patterns were also found. For example, smoking prevalence among white women was among the highest, but the group’s ETS exposure was low among non-smokers; while Vietnamese women were unlikely to be active smokers, they experienced relatively high ETS exposure. Knowledge of race/ethnic differences may be useful in assessing disparities in health outcomes and creating successful tobacco interventions.

Sudden infant death and social justice: A syndemics approach

Sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) prevention has focused on modifying individual behavioural risk factors, especially bedsharing. Yet these deaths are most common among poor and marginalized people in wealthy countries, including U.S. Blacks, American Indians/Alaskan Natives, New Zealand Māori, Australian Aborigines, indigenous Canadians, and low-income British people. The United States now has the world's highest prevalence of SUID/SIDS, where even Whites' SIDS prevalence now approaches that of the Māori. Using public databases and the literature, we examine SUID/SIDS prevalence and the following risk factors in selected world populations: maternal smoking, preterm birth, alcohol use, poor prenatal care, sleep position, bedsharing, and formula feeding. Our findings suggest that risk factors cluster in high-prevalence populations, many are linked to poverty and discrimination and have independent effects on perinatal outcomes. Moreover, populations with the world's lowest rates of SUID/SIDS have low income-inequality or high relative wealth, yet have high to moderate rates of bedsharing. Employing syndemics theory, we suggest that disproportionately high prevalence of SUID/SIDS is primarily the result of socially driven, co-occurring epidemics that may act synergistically to amplify risk. SUID must be examined through the lens of structural inequity and the legacy of historical trauma. Emphasis on bedsharing may divert attention from risk reduction from structural interventions, breastfeeding, prenatal care, and tobacco cessation. Medical organizations play an important role in advocating for policies that address the root causes of infant mortality via poverty and discrimination interventions, tobacco control, and culturally appropriate support to families.

Oxidative stress and mitochondrial dysfunction in parafacial respiratory group induced by maternal cigarette smoke exposure in rat offspring

Cigarette smoke (CS) exposure negatively affects neurodevelopment. We established a CS exposure rat model to determine how maternal CS exposure induces oxidative stress and mitochondrial dysfunction in parafacial respiratory group (pFRG) essential to central chemoreceptive regulation of normal breathing. Pregnant rats were exposed to CS during gestational days 1-20, and the offspring were studied on postnatal day 2. Our data showed that maternal CS exposure resulted in elevated accumulation of ROS, which left a footprint on DNA and lipid with increases in 8-hydroxy-2'-deoxyguanosine and malondialdehyde contents. Furthermore, maternal CS exposure induced decreases in manganese superoxide dismutase, catalase and glutathione reductase activities as well as reduction in glutathione content in pFRG in the offspring. Moreover, maternal exposure to CS led to mitochondrial ultrastructure changes, mitochondrial swelling, reduction in ATP generation, loss of mitochondrial membrane potential and increase in mitochondrial DNA copy number. These findings suggest that maternal exposure to CS alters normal development of pFRG that is critical for normal respiratory control.

A survey of women who continue to smoke during pregnancy in Slovenia

INTRODUCTION

Smoking in pregnancy is unhealthy and can also have negative effects on the foetus. However, there are still some women who do not quit smoking during pregnancy. The aim of the study was to identify Slovenian women at risk who smoke during pregnancy.

METHODS

A quantative approach using an online survey was adopted. The study was conducted in May and June 2017, in Slovenia. A snowball sample was used. Participation in the survey was anonymous and voluntary, and 118 women who identified themselves as smokers participated in the study. Descriptive statistics was used to analyse the data.

RESULTS

More than half (66%) did not quit smoking during pregnancy. Women who continued to smoke during pregnancy were usually younger, less educated with a partner who smoked. Women who smoked more cigarettes per day before conception were less likely to refrain from smoking during pregnancy. The most common reason for not quitting smoking during pregnancy was failure in attempts to quit (37%).

CONCLUSIONS

Women who smoke need support to stop smoking before pregnancy or, at least, in the first trimester. Special groups for smoking cessation need to be created. Further and more extensive research is warranted in Slovenia to assess this issue.

The effects of sleeping position, maternal smoking and substance misuse on the ventilatory response to hypoxia in the newborn period

BACKGROUND

Maternal smoking, substance misuse in pregnancy and prone sleeping increase the risk of sudden infant death syndrome (SIDS). We examined the effect of maternal smoking, substance misuse and sleeping position on the newborn response to hypoxia.

METHODS

Infants born between 36 and 42 weeks of gestational age underwent respiratory monitoring in the prone and supine sleeping position before and during a hypoxic challenge. Minute ventilation (MV) and end-tidal carbon dioxide (ETCO₂) levels were assessed.

RESULTS

Sixty-three infants were studied: 22 controls, 23 whose mothers smoked and 18 whose mothers substance-misused and smoked. In the supine position, baseline MV was higher and ETCO₂ levels were lower in infants of substance-misusing mothers compared to controls (p = 0.015, p = 0.017, respectively). Infants of substance-misusing mothers had a lower baseline MV and higher ETCO₂ levels in the prone position (p = 0.005, p = 0.004, respectively). When prone, the rate of decline in minute ventilation in response to hypoxia was greater in infants whose mothers substance-misused and smoked compared to controls (p = 0.002) and infants of smoking mothers (p = 0.016).

CONCLUSION

The altered response to hypoxia in the prone position of infants whose mothers substance-misused and smoked in pregnancy may explain their increased vulnerability to SIDS.

Effect of smoking cessation intervention for pregnant smokers

This study retrospectively evaluated the effect of smoking cessation intervention in pregnant women with smoking.A total of 176 pregnant smokers were included in this study. Ninety-five participants received smoking cessation intervention plus physical activity, and were assigned into a treatment group. Eighty-one participants underwent physical activity only, and were assigned into a control group. Primary outcomes included the number of participants quit smoking, daily cigarettes consumption, and quit attempts. The secondary outcomes included infant outcomes. All primary outcomes were measured after 12-week treatment and at delivery. Secondary outcomes were measured at delivery only.After 12-week treatment, participants in the treatment group did not significantly reduce the number of participants quit smoking; decrease daily cigarettes consumption, and quit attempts in pregnant smokers, compared with subjects in the control group. At delivery, the comparison also did not show significant differences in the number of participants quit smoking, decreasing daily cigarettes consumption, and quitting attempts in pregnant smokers, as well as all infant outcomes between 2 groups.The results of this retrospective study did not found that smoking cessation intervention may help to quit smoking for pregnant smokers.

Maternal E-Cigarette Exposure Results in Cognitive and Epigenetic Alterations in Offspring in a Mouse Model

Electronic cigarette (e-cigarette) use is on the rise worldwide and is particularly attractive to young people and as a smoking substitute by pregnant woman. There is a perception in pregnant women and women of child-bearing age that the use of e-cigarettes (vaping) is safer than smoking tobacco cigarettes during pregnancy. However, there is little evidence to support this perception. Here, we examined the offspring from mouse dams that had been exposed during and after pregnancy to ambient air (sham) ( n = 8), e-cigarette aerosols with nicotine ( n = 8), or e-cigarette aerosols without nicotine ( n = 8). Offspring underwent cognitive testing at 12 weeks of age and epigenetic testing of brain tissues at 1 day, 20 days, and 13 weeks after birth. The findings showed deficits in short-term memory, reduced anxiety, and hyperactivity in offspring following maternal e-cigarette exposure using the novel object recognition and elevated plus maze tests. In addition, global DNA methylation was increased in the brains of offspring soon after birth. Using a quantitative-PCR array specific to chromatin modification enzymes on genomic DNA and histones,13 key genes were identified to be significantly altered in the offspring brains from the e-cigarette groups compared to the nonexposed groups. The changes to genes Aurka, Aurkb, Aurkc, Kdm5c, Kdm6b, Dnmt3a, Dnmt3b, and Atf2, all associated with modulating neurological activity, were validated using RT-qPCR. In conclusion, in a mouse model, maternal exposure to e-cigarette aerosols resulted in both cognitive and epigenetic changes in offspring. This suggests that the use of e-cigarettes during pregnancy may have hitherto undetected neurological consequences on newborns.

Substance use in pregnancy: The medical challenge

Substance use contributes significantly to the global burden of disease. Growing numbers of women use nicotine, alcohol, and illicit substances. Women are the most vulnerable to problematic substance use in their reproductive years. The first 1000 days of life, starting at conception, have been established as a critical window of time for long-term health and development. Substance use in pregnancy is associated with negative pregnancy and child health outcomes. The impact of antenatal substance use on these outcomes needs to be considered within a challenging and complex context. This review provides an overview of the current literature on the impact of substances on pregnancy and child outcomes as well as the evidence and guidelines on screening and interventions for women using substances during pregnancy.

A systematic review exploring the relationship between infection and sudden unexpected death between 2000 and 2016: A forensic perspective

Death due to infectious diseases is a major health concern worldwide. This is of particular concern in developing countries where poor-socio economic status and a lack of healthcare resources contribute to the high burden of disease. In some cases death due to infection can be acute and aggressive, and death may occur without a diagnosis whilst the person is still alive. These deaths may ultimately lead to a medico-legal autopsy being performed. There are various mechanisms by which sudden death due to infection may occur. In addition, there are many risk factors associated with sudden death due to infection, which differ between infants and older individuals. However, it is unclear which pathogens and risk factors are most frequently associated with sudden death due to infection. Therefore a systematic review of articles and case reports published between 1 January 2000 and 30 June 2016 was undertaken in order to (1) explore the relationship between pathogens and their causative role and (2) identify the relationship between predisposing and/or risk factors associated with sudden death due to infection. Major databases were searched and after critical appraisal 143 articles were identified. It was found that respiratory infections and deaths involving bacterial pathogens were most commonly associated with these deaths. In addition the most common risk factors in infants were exposure to tobacco smoke and co-sleeping. In adults the most common risk factors were co-morbid conditions and illnesses. This information aids in a better understanding of these deaths and highlights the need for more research in this field, particularly in developing countries.

A Context-Aware Indoor Air Quality System for Sudden Infant Death Syndrome Prevention

Context-aware monitoring systems designed for e-Health solutions and ambient assisted living (AAL) play an important role in today's personalized health-care services. The majority of these systems are intended for the monitoring of patients' vital signs by means of bio-sensors. At present, there are very few systems that monitor environmental conditions and air quality in the homes of users. A home's environmental conditions can have a significant influence on the state of the health of its residents. Monitoring the environment is the key to preventing possible diseases caused by conditions that do not favor health. This paper presents a context-aware system that monitors air quality to prevent a specific health problem at home. The aim of this system is to reduce the incidence of the Sudden Infant Death Syndrome, which is triggered mainly by environmental factors. In the conducted case study, the system monitored the state of the neonate and the quality of air while it was asleep. The designed proposal is characterized by its low cost and non-intrusive nature. The results are promising.

Examining characteristics associated with quitting smoking during pregnancy and relapse postpartum

INTRODUCTION

Smoking during pregnancy is a significant public health concern that can cause adverse health outcomes for both the mother and fetus. Studies have shown only 40% of women quit smoking during pregnancy, with more than half relapsing within 6months, and up to 90% relapsing within one year. This study investigates differences in demographics and smoking-related symptomatology between pregnant smokers and pregnant quitters, as well as factors associated with postpartum relapse.

METHODS

Data on pregnant smokers and pregnant quitters were obtained from two separate parent studies. Data on smoking demographics and smoking-related symptomatology were collected at screening visits.

RESULTS

Compared to pregnant smokers, pregnant quitters had more favorable smoking characteristics (e.g., smoked fewer cigarettes per day, reported higher motivation for abstinence and less dependency). They also had more favorable relationship characteristics (e.g., were more likely to be married, less likely to have a significant other who smokes) and had less reproductive liability (e.g., fewer pregnancies, fewer children). In terms of symptomatology, pregnant quitters reported more positive affect, negative affect, physical symptoms and withdrawal but less craving. Predictors of postpartum relapse included increased maternal age, having a significant other who smokes and an increased likelihood of returning to smoking after pregnancy (self-reported prior to delivery).

CONCLUSIONS

Several demographics and smoking-related symptomatology were significantly different between pregnant quitters and pregnant smokers. In addition, multiple factors predicting postpartum relapse were identified. This information can inform personalized interventions for high risk pregnant smokers and pregnant quitters at risk for postpartum relapse.

Risky Behaviors of Mothers with Infants on Sudden Infant Death Syndrome in Turkey

PURPOSE

Sudden infant death syndrome is the most common cause of death during the post-neonatal period. Factors such as sleeping position, bed sharing, pillow use, smoking during pregnancy and the breastfeeding period constitute risk factors for sudden infant death syndrome. This study aims to identify the risky behaviors of mothers with infants that may put their children at risk for sudden infant death syndrome.

DESIGN AND METHODS

This is a cross-sectional, descriptive study. Data were collected using a questionnaire that was developed by the researchers. The questionnaire was filled out by 456 mothers who applied to the family health center between October 2014 and January 2015.

RESULTS

The greatest risk factor is the infant's sleeping position. A total of 77.9% of the mothers put their babies in bed in a non-supine position; 65.8% used a pillow when they put their babies in bed, 52.9% used a soft mattress, and 28.5% shared their beds with their babies. Prone sleeping was more likely to occur when smoke was present in the home or a pillow was used.

CONCLUSION

Nurses should notify families of the risky behaviors that can cause sudden infant death syndrome and plan appropriate nursing care.