Does prenatal maternal stress impair cognitive development and alter temperament characteristics in toddlers with healthy birth outcomes?

Prenatal stress impacts foetal neurodevelopment: Temporal windows of gestational vulnerability

Prenatal maternal stressors ranging in severity from everyday occurrences/hassles to the experience of traumatic events negatively impact neurodevelopment, increasing the risk for the onset of psychopathology in the offspring. Notably, the timing of prenatal stress exposure plays a critical role in determining the nature and severity of subsequent neurodevelopmental outcomes. In this review, we evaluate the empirical evidence regarding temporal windows of heightened vulnerability to prenatal stress with respect to motor, cognitive, language, and behavioural development in both human and animal studies. We also explore potential temporal windows whereby several mechanisms may mediate prenatal stress-induced neurodevelopmental effects, namely, excessive hypothalamic-pituitary-adrenal axis activity, altered serotonin signalling and sympathetic-adrenal-medullary system, changes in placental function, immune system dysregulation, and alterations of the gut microbiota. While broadly defined developmental windows are apparent for specific psychopathological outcomes, inconsistencies arise when more complex cognitive and behavioural outcomes are considered. Novel approaches to track molecular markers reflective of the underlying aetiologies throughout gestation to identify tractable biomolecular signatures corresponding to critical vulnerability periods are urgently required.

The impact of maternal mood and economic stress during Covid-19 pandemic on infant behaviour: Findings from the cross-sectional UK Covid-19 New Mum Study

The UK Covid-19 New Mum Study (cross-sectional study) recorded maternal experience during the early stages of the pandemic. Our previous analyses showed that the pandemic and 2020 national lockdown negatively impacted maternal mental health. Here, we describe changes in infant behaviour (crying and fussiness) reported by the mother during the Covid-19 pandemic compared to beforehand, and test whether these changes are associated with maternal variables (mental health, coping, financial insecurity, income and household support). We included only responses of mothers whose infants were born before the pandemic started (n = 2,031). Composite scores for maternal mental health and coping were obtained using principal components analysis. Multivariable logistic regression analysis was used to test whether maternal mood and coping and household financial stresses were associated with changes in infant behaviour considered negative (becoming fussier, crying more). Adjusting for confounders, the odds of the infant being fussier and crying more increased by 52% (OR = 1.52, 95% CI = 1.35;1.72) and 64% (OR = 1.64, 95% CI = 1.38;1.95), respectively, if the mother experienced poorer mental health. If the mother coped better and had more time to focus on her health and interests, the odds of these outcomes decreased by 27% (OR = 0.73, 95% CI = 0.65;0.83) and 23% (OR = 0.77, 95% CI = 0.65;0.91), respectively. Mothers who reported that, during the lockdown, household chores were more equally divided 'to a high extent' had 40% (OR = 0.60, 95% CI = 0.39;0.92) lower odds of reporting that their babies became fussier. Reporting major/moderate impact on food expenses was associated with the infant crying more (OR = 2.52, 95% CI = 1.16;5.50). Our results are consistent with previous studies showing that maternal wellbeing plays a significant role in children's behavioural changes during lockdowns. We need strategies to improve mental health and enable women to develop the skills to maintain resilience and reassure their children in challenging times.

Association between esketamine interventions and postpartum depression and analgesia following cesarean delivery: a systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the efficacy and safety of the use of esketamine to reduce the risk for postpartum depression and pain after cesarean delivery.

DATA SOURCES

Literature searches were conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan fang from inception to August 2023.

STUDY ELIGIBILITY CRITERIA

The eligibility criteria were all randomized controlled trials of people who underwent a cesarean delivery and who were randomized to receive esketamine interventions irrespective of age or ethnicity. The outcomes that were assessed included the incidence of postpartum depression and the Edinburgh Postnatal Depression Scale score within 7 days and at 28 to 42 days after delivery, the pain score (visual analog scale or numerical rating scale, 0-10), the consumption of opioids, and intraoperative and postoperative adverse events.

METHODS

The Cochrane collaboration's tool was used for quality appraisal of the included studies. Statistical analysis of the data was performed using Review Manager 5.3 software, and the results were expressed as mean differences with 95% confidence intervals. Assessments were pooled using a random-effects or fixed-effects model. Study heterogeneity was assessed using the standard I2 statistic.

RESULTS

Among the 11 included randomized controlled trials that used the Edinburgh Postnatal Depression Scale for postpartum depression assessment, patients in esketamine group had a lower risk for postpartum depression within a week of surgery (risk ratio, 0.45; 95% confidence interval, 0.33-0.62). Intraoperative use of esketamine maintained a lower Edinburgh Postnatal Depression Scale score after surgery (mean difference, -1.64; 95% confidence interval, -2.14 to -1.14). Esketamine was associated with a beneficial effect in terms of the other outcomes, including a significant decline in pain score within 48 hours (mean difference, -0.71; 95% confidence interval, -0.89 to 0.52). Esketamine increased the risk for adverse neurologic and mental events during surgery without harming health, and there was no significant difference after delivery when compared with the control group.

CONCLUSION

Esketamine may reduce the risk for postpartum depression among patients who are undergoing cesarean delivery in the short term. In addition, as an adjunct to reduce analgesia, esketamine also effectively assists in pain management. Because of the lack of more high-quality evidence, we need more compelling evidence to confirm the value of esketamine in improving postpartum recovery.

Maternal perceived stress and infant behavior during the COVID-19 pandemic

BACKGROUND

Maternal stress has negative consequences on infant behavioral development, and COVID-19 presented uniquely stressful situations to mothers of infants born during the pandemic. We hypothesized that mothers with higher levels of perceived stress during the pandemic would report higher levels of infant regulatory problems including crying and interrupted sleep patterns.

METHODS

As part 6 sites of a longitudinal study, mothers of infants born during the pandemic completed the Perceived Stress Scale, the Brief Infant Sleep Questionnaire, and an Infant Crying survey at 6 (n = 433) and 12 (n = 344) months of infant age.

RESULTS

Maternal perceived stress, which remained consistent at 6 and 12 months of infant age, was significantly positively correlated with time taken to settle infants. Although maternal perceived stress was not correlated with uninterrupted sleep length, time taken to put the infant to sleep was correlated. Perceived stress was also correlated with the amount of infant crying and fussiness reported at 6 months.

CONCLUSIONS

Mothers who reported higher levels of perceived stress during the pandemic reported higher levels of regulatory problems, specifically at 6 months. Examining how varying levels of maternal stress and infant behaviors relate to overall infant developmental status over time is an important next step.

IMPACT

Women giving birth during the COVID-19 pandemic who reported higher levels of stress on the Perceived Stress Scale also reported higher levels of infant fussiness and crying at 6 months old, and more disruptive sleep patterns in their infants at 6 months and 12 months old. Sleeping problems and excessive crying in infancy are two regulatory problems that are known risk factors for emotional and behavioral issues in later childhood. This paper is one of the first studies highlighting the associations between maternal stress and infant behaviors during the COVID-19 pandemic.

Maternal mental health concerns during the COVID-19 pandemic in Iran: a content analysis study

BACKGROUND

As crises occur, attention to physical health usually becomes more than mental health, neglecting mental health, especially in some vulnerable groups such as pregnant women and new mothers, can have adverse consequences. Therefore, it is imperative to recognize and comprehend their mental health needs, particularly during critical situations such as the recent COVID-19 pandemic. The aim of this study was to explain the understanding and experience of mental health concerns faced by pregnant and postpartum women during this pandemic.

METHODS

This qualitative study was conducted from March 2021 to November 2021 in Iran. Data were collected using semi-structured in-depth interviews to understand mental health concerns in pregnancy and the postpartum period during the COVID-19 pandemic. Twenty-five purposefully retrieved and participated in the study. Due to the prevalence of coronavirus, most of the participants preferred tele interviews. When data saturation was achieved, the data were codified manually and analyzed using Graneheim and Lundman's approach 2004.

RESULTS

Based on the content analysis of the interviews, 2 main themes, 8 categories 23 subcategories were identified. The identified themes were as follows: (1) Maternal mental health threats and (2) Inadequate access to the required information.

CONCLUSION

The results of this study showed that the main concern and fear of pregnant and postpartum women in the COVID-19 pandemic was the fear of the possibility of death for themselves and/or their fetus/infant. The knowledge that was obtained from the understanding of pregnant women and new mothers about the mental health concerns during the COVID-19 pandemic can help managers in planning to improve and promote women's mental health, especially in critical situations.

Association between prenatal maternal anxiety and/or stress and offspring's cognitive functioning: A meta-analysis

This meta-analysis examined the relationship between prenatal maternal stress and/or anxiety and the outcomes of children aged 3 months to 9 years. Of the 8754 studies published before June 2021 that were synthesized, 17 conducted in Western countries were included in the meta-analysis (Ntotal  = 23,307; Mmales 54%; Methnicity White 77%, Pacific 15%, African American/Black 10%, Middle Eastern 7%, Eastern 8%). Effect sizes ranged from -0.41 to 0.15. A weak negative association was found between prenatal stress and/or anxiety exposure and children's general intellectual development. Associations varied based on the type of exposure. Findings are limited to developed counties and cannot be generalized to low- and middle-income countries. Directions for maternal prenatal intervention and future studies are discussed.

The association between pregnancy-related anxiety and behavioral development in 18-month-old children: The mediating effects of parenting styles and breastfeeding methods

BACKGROUND

Pregnancy-related anxiety (PRA) is a distinct type of anxiety from general anxiety, affects many pregnant women, and is correlated with poor behavioral development in children. However, the mediation paths were unclear.

METHODS

A total of 2032 mother-infant pairs from the Ma'anshan Birth Cohort were included in the current study. Maternal PRA was assessed in the second and third trimesters. Children's behavioral development was evaluated at the age of 18 months. In addition, information on parenting styles and breastfeeding methods was obtained at postpartum. Multivariate regression and structural equation modeling were used to examine the associations between maternal PRA and children's behavioral development.

RESULTS

Significant intercorrelations were found between maternal PRA, the potential mediators (parenting styles and breastfeeding methods), and 18-month-old children's ASQ scores. Parenting styles played an intermediary role in the relationship between maternal PRA and children's behavioral development (β = 0.030, 95 % confidence interval: 0.017-0.051), and the mediating effect accounted for 29.1 % of the total effect. However, breastfeeding methods did not mediate the link between PRA and children's behavior.

LIMITATIONS

Depression and postpartum anxiety were not controlled for in our analysis, which left us unable to estimate the independent impact of PRA on children's behavior.

CONCLUSIONS

Parenting rather than breastfeeding is the mediating factor of behavioral problems in children caused by PRA.

Prenatal stressful life events increase the prevalence of postpartum depression: Evidence from prospective cohort studies

Postpartum depression (PPD) occurs frequently among postpartum women. Stressful life events (SLE) have gradually been recognized as risk factors for PPD. However, research on this topic has produced equivocal results. The purpose of this study was to explore whether women who experienced prenatal SLE had a higher prevalence of PPD. Electronic databases were systematically searched until October 2021. Only prospective cohort studies were included. Pooled prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated using random effects models. This meta-analysis included 17 studies involving 9822 individuals. Women who experienced prenatal SLE had a higher prevalence for PPD (PR = 1.82, 95%CI = 1.52-2.17). In subgroup analyses, a 112% and 78% higher prevalence of depressive disorders (PR = 2.12, 95%CI = 1.34-3.38) and depressive symptoms (PR = 1.78, 95%CI = 1.47-2.17) were detected in women who experienced prenatal SLE. The effect of SLE on PPD at postpartum different time points differed: PR = 3.25 (95%CI = 2.01-5.25) for ≤6 weeks, PR = 2.01 (95%CI = 1.53-2.65) for 7-12 weeks, PR = 1.17 (95%CI = 0.49-2.31) for >12 weeks. No obvious publication bias was detected. The findings support that prenatal SLE increase the prevalence of PPD. The effect of SLE on PPD tends to slightly decrease during the postpartum period. Furthermore, these findings highlight the importance of screening for PPD as early as possible, particularly among postpartum women who have experienced SLE.

The Single and Combined Effects of Prenatal Nonchemical Stressors and Lead Exposure on Neurodevelopmental Outcomes in Toddlers: Results from the CCREOH Environmental Epidemiologic Study in Suriname

The primary aim of this prospective study was to examine the single and combined effect of prenatal exposure to perceived stress, probable depression, and lead on toddlers' neurodevelopment using the Bayley Scales of Infant and Toddler Development, third edition. Data from 363 mother-toddler pairs enrolled in the Caribbean Consortium for Research in Environmental and Occupational Health prospective cohort study were analyzed. A prenatal lead exposure of ≥3.5 µg/dL was associated with significantly lower receptive (p = 0.008) and expressive (p = 0.006) communication scaled scores. Moderate and severe maternal prenatal probable depression scores were associated with significantly lower fine (p = 0.009) and gross (p = 0.009) motor scaled scores. However, a maternal report of prenatal stress was not associated with neurodevelopmental outcomes. After adjusting for maternal demographics, prenatal stress and lead exposure, prenatal probable depression remained predictive of the toddlers' gross motor scaled scores (β -0.13, 95% CI [-0.24--0.02]). Similarly, when adjusting for demographics, prenatal stress and probable depression, prenatal lead exposure remained a significant predictor of their receptive communication scaled scores (β -0.26, 95% CI [-0.49--0.02]). An analysis testing combined exposure to perceived stress, probable depression, and lead exposure, measured using a cumulative risk index, significantly predicted the child fine motor scaled scores after adjusting for other covariates (β -0.74, 95% CI: [-1.41--0.01]).

Prenatal maternal stress during the COVID-19 pandemic and infant regulatory capacity at 3 months: A longitudinal study

The COVID-19 pandemic is a global traumatic experience for citizens, especially during sensitive time windows of heightened plasticity such as pregnancy and neonatal life. Pandemic-related stress experienced by mothers during pregnancy may act as an early risk factor for infants' regulatory capacity development by altering maternal psychosocial well-being (e.g., increased anxiety, reduced social support) and caregiving environment (e.g., greater parenting stress, impaired mother-infant bonding). The aim of the present longitudinal study was to assess the consequences of pandemic-related prenatal stress on infants' regulatory capacity. A sample of 163 mother-infant dyads was enrolled at eight maternity units in northern Italy. They provided complete data about prenatal stress, perceived social support, postnatal anxiety symptoms, parenting stress, mother-infant bonding, and infants' regulatory capacity at 3 months of age. Women who experienced emotional stress and received partial social support during pregnancy reported higher anxious symptoms. Moreover, maternal postnatal anxiety was indirectly linked to the infants' regulatory capacity at 3 months, mediated by parenting stress and mother-infant bonding. Dedicated preventive interventions should be delivered to mothers and should be focused on protecting the mother-infant dyad from the detrimental effects of pandemic-related stress during the COVID-19 healthcare emergency.

Maternal Distress during Pregnancy and the Postpartum Period: Underlying Mechanisms and Child's Developmental Outcomes-A Narrative Review

Maternal mental health may be considered a determining factor influencing fetal and child development. An essential factor with potentially negative consequences for a child's psychophysiological development is the presence of maternal distress during pregnancy and the postpartum period. The review is organized and presented to explore and describe the effects of anxiety, stress, and depression in pregnancy and the postpartum period on adverse child developmental outcomes. The neurobiology of maternal distress and the transmission mechanisms at the molecular level to the fetus and child are noted. In addition, the paper discusses the findings of longitudinal studies in which early child development is monitored concerning the presence of maternal distress in pregnancy and the postpartum period. This topic gained importance in the COVID-19 pandemic context, during which a higher frequency of maternal psychological disorders was observed. The need for further interdisciplinary research on the relationship between maternal mental health and fetal/child development was highlighted, especially on the biological mechanisms underlying the transmission of maternal distress to the (unborn) child, to achieve positive developmental outcomes and improve maternal and child well-being.

Effects of Maternal and Child Lifetime Traumatic Stress Exposures, Infant Temperament, and Caregiving Quality on Preschoolers' Executive Functioning

We examined effects of maternal and child lifetime traumatic stress exposures, infant temperament, and caregiving quality on parent ratings of preschoolers' executive functioning (EF). Maternal lifetime trauma was associated with preschoolers' EF problems; this association was mediated by greater child trauma exposure. Infant temperament was associated with EF abilities, particularly among females. Among males, infant extraversion/surgency mediated the association of maternal lifetime trauma with poorer child EF. Caregiving quality was negatively associated with maternal and child trauma exposures but did not predict child EF. Findings have implications for interventions to identify children at risk for poor EF and optimize outcomes.

Maternal-fetal stress and DNA methylation signatures in neonatal saliva: an epigenome-wide association study

BACKGROUND

Maternal stress before, during and after pregnancy has profound effects on the development and lifelong function of the infant's neurocognitive development. We hypothesized that the programming of the central nervous system (CNS), hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS) induced by prenatal stress (PS) is reflected in electrophysiological and epigenetic biomarkers. In this study, we aimed to find noninvasive epigenetic biomarkers of PS in the newborn salivary DNA.

RESULTS

A total of 728 pregnant women were screened for stress exposure using Cohen Perceived Stress Scale (PSS), 164 women were enrolled, and 114 dyads were analyzed. Prenatal Distress Questionnaire (PDQ) was also administered to assess specific pregnancy worries. Transabdominal fetal electrocardiograms (taECG) were recorded to derive coupling between maternal and fetal heart rates resulting in a 'Fetal Stress Index' (FSI). Upon delivery, we collected maternal hair strands for cortisol measurements and newborn's saliva for epigenetic analyses. DNA was extracted from saliva samples, and DNA methylation was measured using EPIC BeadChip array (850 k CpG sites). Linear regression was used to identify associations between PSS/PDQ/FSI/Cortisol and DNA methylation. We found epigenome-wide significant associations for 5 CpG with PDQ and cortisol at FDR < 5%. Three CpGs were annotated to genes (Illumina Gene annotation file): YAP1, TOMM20 and CSMD1, and two CpGs were located approximately lay at 50 kb from SSBP4 and SCAMP1. In addition, two differentiated methylation regions (DMR) related to maternal stress measures PDQ and cortisol were found: DAXX and ARL4D.

CONCLUSIONS

Genes annotated to these CpGs were found to be involved in secretion and transportation, nuclear signaling, Hippo signaling pathways, apoptosis, intracellular trafficking and neuronal signaling. Moreover, some CpGs are annotated to genes related to autism, post-traumatic stress disorder (PTSD) and schizophrenia. However, our results should be viewed as hypothesis generating until replicated in a larger sample. Early assessment of such noninvasive PS biomarkers will allow timelier detection of babies at risk and a more effective allocation of resources for early intervention programs to improve child development. A biomarker-guided early intervention strategy is the first step in the prevention of future health problems, reducing their personal and societal impact.

Behavioral Inhibition in the Second Year of Life Is Predicted by Prenatal Maternal Anxiety, Overprotective Parenting and Infant Temperament in Early Infancy

Background

Behavioral inhibition, characterized by shyness, fear and avoidance of novel stimuli, has been linked with internalizing personality traits in childhood, adolescence and early adulthood, and particularly later social anxiety disorder. Little is known about the relevance of potential prenatal precursors and early predictors for the development of inhibited behavior, such as infant vulnerability and family risk factors like parental anxiety and overprotection. Pregnancy-related anxiety has been associated with both infant temperament and maternal overprotective parenting. Thus, the aim of this study was investigating the predictive relevance of prenatal pregnancy-related anxiety for behavioral inhibition in toddlerhood, by considering the mediating role of maternal overprotection and infant distress to novelty.

Materials and Methods

As part of a longitudinal pregnancy cohort, behavioral inhibition at 24 months postpartum was assessed in N = 170 mother-child pairs. Maternal pregnancy-related anxiety was examined in the third trimester of pregnancy, and maternal overprotection and infant distress to novelty at 12 months postpartum.

Results

Mediation analysis with two parallel mediators showed that the significant direct effect of pregnancy-related anxiety on child behavioral inhibition was fully mediated by infant distress to novelty p < 0.001 and maternal overprotection (p < 0.05). The included variables explained 26% of variance in behavioral inhibition. A subsequent explorative mediation analysis with serial mediators further showed a significant positive association between distress to novelty and maternal overprotective parenting (p < 0.05).

Conclusion

Results indicate a predictive relevance of both infant and maternal factors for the development of behavioral inhibition in toddlerhood. Mothers who perceived more pregnancy-related anxiety showed more overprotective parenting and had infants with more distress to novelty. Further, mothers being more overprotective reported their child to be more inhibited in toddlerhood. Our findings also indicate the stability of reported infant distress to novelty as one aspect of later behavioral inhibition. Addressing specific forms of parental anxiety from pregnancy on and in interaction with child-related variables seems to be a promising approach for future studies and clinical interventions.

A Systematic Review of Vitamin D during Pregnancy and Postnatally and Symptoms of Depression in the Antenatal and Postpartum Period from Randomized Controlled Trials and Observational Studies

Depression is a common mood disorder associated with childbirth and is hypothesized to be affected by low vitamin D. This systematic review identified two randomized controlled trials (RCT) of vitamin D supplementation for the treatment or prevention of depressive symptoms in the perinatal period, as well as 18 observational studies of vitamin D exposure and depression in the antenatal and postnatal periods. Both RCTs claimed an improvement in depressive symptoms in the vitamin D group, although the sample sizes were too small to draw firm conclusions. The case-control and cohort studies had mixed findings and were limited by study quality. There were inconsistent results within the few studies with a more robust methodology or within samples restricted to women likely to have depression. The current evidence is inconclusive due to the poor quality and heterogeneity of studies, likely contributing to the contradictory findings. Given there are already numerous RCTs of prenatal vitamin D supplementation, we recommend adding an appropriate measure of depression in the perinatal period to assist in resolving the uncertainty.

Prenatal Exposure to a Climate-Related Disaster Results in Changes of the Placental Transcriptome and Infant Temperament

Maternal stress during pregnancy exerts long-term effects on the mental well-being of the offspring. However, the long-term effect of prenatal exposure on the offspring's mental status is only partially understood. The placenta plays a vital role in connecting the maternal side to the fetus, thereby serving as an important interface between maternal exposure and fetal development. Here, we profiled the placental transcriptome of women who were pregnant during a hurricane (Superstorm Sandy), which struck New York City in 2012. The offspring were followed longitudinally and their temperament was assessed during the first 6-12 months of age. The data identified a significant correlation between a Superstorm Sandy stress factor score and infant temperament. Further, analysis of the placental transcriptomes identified an enrichment of functional pathways related to inflammation, extracellular matrix integrity and sensory perception in the specimen from those infants with "Slow-to-Warm-up" temperament during the first year of life. Together, these findings provide initial evidence that maternal exposure to climate-related disasters results in altered placental transcriptome, which may be related to long-term emotional and behavioral consequences in children.

Effects of maternal psychological distress and perception of COVID-19 on prenatal attachment in a large sample of Italian pregnant women

BACKGROUND

Evidence concerning the impact of COVID-19-related stress exposure on prenatal attachment in pregnant women is unknown. In this study we sought to assess the effect of psychological distress and risk perception of COVID-19 on prenatal attachment in a Italian sample of pregnant women.

METHODS

1179 pregnant women completed an anonymous online survey and self-report questionnaires measuring socio-demographic and obstetric characteristics, psychological distress (STAI Form Y-1-2 and BDI-II), prenatal attachment (PAI) and risk perception of COVID-19. Data were collected from March 2020 to April 2020 referring to the national lockdown period.

RESULTS

After adjusting for the socio-demographic and obstetric factors in the multivariable analysis, we found out the state anxiety was shown to be a significant predictor (p < 0001) of prenatal attachment. Moreover, the COVID-19-risk perception positively moderate the relationship between trait anxiety and prenatal attachment (p=0008), indicating that when COVID-19-risk perception is high, the effects of trait anxiety on prenatal attachment is attenuated. The synergistic effect between STAI Form Y-1 and COVID-19-risk perception index on PAI is partially mediated by STAI Form Y-2 score.

CONCLUSIONS

Findings from this study showed that state anxiety related to COVID-19 outbreak in pregnant women may affect the prenatal attachment process of the expectant mother negatively. However, an adequate and functional perception of COVID-19 could enhance prenatal attachment. These results underline the importance of monitoring the prenatal attachment process and the mother's mental health during pandemics, to safeguard maternal and infant mental health.

Maternal stress during pregnancy and early childhood development

We estimate the impact of prenatal stress on early childhood development outcomes known as "middle years" or intermediate outcomes, which has not been studied previously. Using a unique measure of actual maternal stress induced by a large earthquake, we find that relative to children that were not exposed, in utero maternal stress reduces children's cognitive skills and socio-emotional problems by age 3, and that the effects are heterogeneous. The negative impacts on cognitive skills occur during the first trimester of pregnancy and are found among both low and high-income children, and boys and girls. The harmful effects on socio-emotional behaviors occur when stress is experienced in the last trimester of pregnancy.

Depression and Anxiety in Mothers Who Were Pregnant During the COVID-19 Outbreak in Northern Italy: The Role of Pandemic-Related Emotional Stress and Perceived Social Support

The COVID-19 pandemic is a collective trauma that is threatening citizens' mental health resulting in increased emotional stress, reduced social support, and heightened risk for affective symptoms. The present study aimed to investigate the effects of antenatal pandemic-related emotional stress and perceived social support on the symptoms of depression and anxiety of mothers who were pregnant during the initial COVID-19 outbreak in northern Italy. A sample of 281 mothers was enrolled at eight maternity units in the first hotspot region of the COVID-19 outbreak in northern Italy. Participants filled out online questionnaires assessing the direct or indirect exposure to the SARS-CoV-2 virus, pandemic-related stress, perceived social support, as well as symptoms of depression and anxiety. Depressive and anxious symptomatology was above clinical concern, respectively, in 26 and 32% of the respondents. Mothers who reported no exposure to SARS-CoV-2 during pregnancy and those who reported at least one direct or indirect exposure did not differ in terms of affective symptoms. Continuous scores and risk for severe depression and anxiety were positively associated with prenatal pandemic-related emotional stress and negatively linked with perceived social support during pregnancy. Women who become mothers during the COVID-19 emergency may be at high risk for affective problems. Dedicated preventive programs are needed to provide adequate preventive support and care for maternal mental health during and after the COVID-19 pandemic.

Cultivating mental health education in obstetrics and gynecology: a call to action

Mental health disorders are common and have a significantly negative impact on the health and well-being of women. For example, perinatal mental health disorders such as anxiety and depression are widely understood to be the most common complications of pregnancy and childbirth. Untreated mental health disorders are associated with significant obstetrical and psychiatric sequelae and have a long-lasting impact on neonatal and childhood outcomes. As front-line providers for women during times of elevated risk of psychiatric morbidity, such as pregnancy and postpartum, obstetricians and gynecologists are compelled to have familiarity with such disorders. Yet, a wide gap exists between the level of education in mental health disorders that obstetrician and gynecologist providers receive and the clinical need thereof. The objectives of this commentary are to describe the urgent need for mental health education for obstetricians and gynecologists providers and to introduce our vision for a concise, evidence-based and accessible set of digital educational materials designed to convey core concepts in women's reproductive mental health.

The effect of ketamine on preventing postpartum depression

Postpartum depression is a common disabling psychosocial disorder that could have adverse effects on the life of the mother, infant, and family. The present study was conducted to evaluate the effect of ketamine on preventing postpartum depression in women undergoing caesarian sections considering the relatively known positive effect of ketamine on major depression. The present double-blind, randomized clinical trial was conducted on 134 women undergoing scheduled caesarian sections. Participants were randomly allocated into two groups of control and intervention. To induce anesthesia, 1–2 mg/kg of body weight of Nesdonal and 0.5 mg/kg of body weight of ketamine were used in the intervention group, while only 3–5 mg/kg of body weight Nesdonal was administered in the control group. Data were gathered using the Edinburgh Postnatal Depression Scale (EPDS) in three stages: before the caesarian section and two and four weeks after the caesarian section. Data were analyzed using variance analysis with repeated measures and the Chi-square test. Results of the present study showed that the mean (± standard deviation) of the depression score in the intervention and control groups were 13.78±3.87 and 13.79±4.78(p = 0.98) before the caesarian section, 11.82±3.41 and 14.34±4.29 (p < 0.001) two weeks after and 10.84±3.48 and 13.09±3.79 (p = 0.001) four weeks after the caesarian section, respectively. Using ketamine in the induction of general anesthesia could be effective in preventing postpartum depression. However, further studies are required to strengthen these findings.

Is the Association between Postpartum Depression and Early Maternal-Infant Relationships Contextually Determined by Avoidant Coping in the Mother?

This study analyzes the moderating role of avoidant coping (in early pregnancy) in the relationship between postpartum depressive (PPD) symptoms and maternal perceptions about mother-baby relations and self-confidence. Participants were 116 low-risk obstetric mothers (mean age = 31.2 years, SD = 3.95, range 23-42) who received care and gave birth at a Spanish public hospital. Measurements were made at two points in time: at first trimester of pregnancy (maternal avoidance coping) and four months after childbirth (PPD and maternal perceptions). Avoidant coping was associated with the perception of the baby as irritable and unstable (p = 0.003), including irritability during lactation (p = 0.041). Interaction effects of avoidant coping and postpartum depression were observed on the perception of the baby as irritable (p = 0.031) and with easy temperament (p = 0.002). Regarding the mother's self-confidence, avoidant coping was related to a lack of security in caring for the baby (p < 0.001) and had a moderating effect between PPD and mother's self-confidence (i.e., lack of security in caring for the baby, p =0.027; general security, p = 0.007). Interaction effects showed that the use of avoidant coping in the mother exacerbated the impact of PPD on the early mother-infant relationship.

Measuring the Outcomes of Maternal COVID-19-related Prenatal Exposure (MOM-COPE): study protocol for a multicentric longitudinal project

INTRODUCTION

COVID-19 is a highly infectious respiratory disease that rapidly emerged as an unprecedented epidemic in Europe, with a primary hotspot in Northern Italy during the first months of 2020. Its high infection rate and rapid spread contribute to set the risk for relevant psychological stress in citizens. In this context, mother-infant health is at risk not only because of potential direct exposure to the virus but also due to high levels of stress experienced by mothers from conception to delivery. Prenatal stress exposure associates with less-than-optimal child developmental outcomes, and specific epigenetic mechanisms (eg, DNA methylation) may play a critical role in mediating this programming association.

METHODS AND ANALYSIS

We present the methodological protocol for a longitudinal, multicentric study on the behavioural and epigenetic effects of COVID-19-related prenatal stress in a cohort of mother-infant dyads in Northern Italy. The dyads will be enrolled at 10 facilities in Northern Italy. Saliva samples will be collected at birth to assess the methylation status of specific genes linked with stress regulation in mothers and newborns. Mothers will provide retrospective data on COVID-19-related stress during pregnancy. At 3, 6 and 12 months, mothers will provide data on child behavioural and socioemotional outcomes, their own psychological status (stress, depressive and anxious symptoms) and coping strategies. At 12 months, infants and mothers will be videotaped during semistructured interaction to assess maternal sensitivity and infant's relational functioning.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee (Pavia). Results will be published in peer-reviewed journals and presented at national and international scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04540029; Pre-results.

Associations of prenatal maternal stress with measures of cognition in 7.5-month-old infants

Studies have shown that prenatal stress can negatively impact neurodevelopment, but little is known about its effect on early cognitive development. We assessed the impact of prenatal stress on cognition in 152 7.5-month-old infants using Cohen's Perceived Stress Scale (PSS), maternal telomere length (MTL), and a Stressful Life Events (SLE) Scale. A visual recognition memory task consisting of nine blocks, each with one familiarization trial (two identical stimuli) followed by two test trials (one familiar stimulus, one novel), was administered. Outcomes assessed included: average time looking at stimuli (measure: processing speed), time to reach looking time criterion (measure: attention), and the proportion of time looking at the novel stimulus (measure: recognition memory). We examined the association of each stress measure with each outcome adjusted for infant age and sex, which of the two stimuli in each set was novel, household income, and maternal age, education, and IQ. Higher prenatal stress was associated with shorter looking durations [PSS (β = -1.6, 95% CI: -2.5, -0.58); SLE (β = 0.58, 95% CI: -0.08, 1.24); MTL (β = 1.81, 95% CI: 0.18, 3.44)] and longer time to reach criterion [PSS (β = 9.1, 95% CI: 1.6, 16.6); SLE (β = 12.2, 95% CI: 1.9, 24.1); MTL (β = -23.1, 95% CI: -45.3, -0.9)], suggesting that higher prenatal stress is associated with decreased visual attention in infancy.

Maternal-Infant Bonding and Its Relationships with Maternal Depressive Symptoms, Stress and Anxiety in the Early Postpartum Period in a Polish Sample

A large body of literature indicates that there is a relationship between maternal psychological well-being and the early maternal-infant bond. However, this relationship is not fully understood, due to the different theoretical frameworks of maternal-infant bonding and different data collections points. Thus, the aim of this study was to examine the relationship between the maternal bond and the maternal psychological state including anxiety, stress, and maternal depressive symptoms. In this cohort study, 150 women who gave birth after 37 weeks of pregnancy completed the following self-reports 1-3 days post-delivery: Socio-demographic questionnaire, Postpartum Bonding Questionnaire (PBQ), Edinburgh Postpartum Depression Scale (EPDS), Postpartum Depression Screening Scale (PDSS), Generalized Anxiety Disorder Assessment (GAD-7), and Parental Stress Scale (PSS). The obtained results showed that the maternal level of stress, anxiety and postnatal depressive symptoms are significantly correlated with the maternal-infant bond in Polish mothers. In addition, regression analysis shows that postpartum depressive symptoms and maternal stress are significantly associated with the maternal-infant bonding process in the early postpartum period. This finding emphasizes the importance of identifying maternal mental state difficulties in the early postpartum period in order to provide interventions to help build healthy maternal-infant bonding.

Effectiveness of cognitive behavioural therapy for perinatal depression: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To systematically review the efficacy of cognitive behavioural therapy for improving mood in perinatal depression.

BACKGROUND

The impact of cognitive behavioural therapy on perinatal depression has been evaluated in various studies, but there is uncertainty about their impact.

DESIGN

Systematic review and meta-analysis.

METHODS

Nine electronic literature databases were searched to retrieve eligible randomised controlled trials: CNKI, VIP digital database, Chinese Wanfang database, the Cochrane library, PubMed, Web of science, EMBASE, PsycINFO, CINAHL from the inception of the databases up to 15 November 2019. The eligible studies were screened and extracted, and then, the methodological quality was evaluated independently by two researchers. The meta-analyst software (Rev Man 5.3) was used to conduct the meta-analysis. Checklist of Preferred Reporting Items for Systematic Reviews and Meta-analyses has been followed.

RESULTS

Thirteen RCTs with 966 participants were included. The results showed that the CBT group was superior to the usual care group in reducing depression symptoms of pregnant women after treatment immediately, and the difference was statistically significant. Similarly, at postpartum (<4 months), the results showed that the CBT group was superior to the usual care group in improving depression symptoms of pregnant women. However, there was no statistical difference at postpartum (>4 months).

CONCLUSIONS

Cognitive behavioural therapy can effectively relieve the symptoms of depression at short-term effect. However, its long-term effect need to be verified by further clinical studies.

RELEVANCE TO CLINICAL PRACTICE

This meta-analysis suggested that cognitive behavioural therapy should be considered as a complementary programme for patients with perinatal depression. Medical workers could apply cognitive behavioural therapy into daily routine cares for perinatal depression.

A randomized controlled pilot study of the effectiveness of magnolia tea on alleviating depression in postnatal women

The magnolia tea has been used in traditional oriental medicine for multiple purposes including sleep aid. Postpartum depression is a mental illness that adversely affects the health and well-being of many families with newborns. Given the known effectiveness and relative safety, herein we aimed to investigate whether magnolia tea has a palliative effect on postpartum depression. The qualified participants were randomly assigned to the intervention group or the control group. The participants in the intervention group drunk magnolia tea, while the control group received regular postpartum care only. The outcome variables including Postpartum Sleep Quality Scale (PSQS), Edinburgh Postnatal Depression Scale (EPDS), and Postpartum Fatigue Scale (PFS) were assessed and compared. In comparison with the control group, the intervention group demonstrated significant difference for physical-symptom-related sleep inefficiency (PSQS Factor 2) at 3 weeks post-test (t = -2.10, p = .03). The comparison results also revealed significant differences for PFS at both 3 weeks post-test (t = -2.02, p = .04) and 6 weeks post-test (t = -1.99, p = .04). Further, magnolia tea intervention significantly alleviated the symptoms of depression, reflected by the EPDS scores at 3 weeks post-test (t = -2.38, p = .02) and 6 weeks post-test (t = -2.13, p = .02). Our trial results suggested that drinking single-ingredient magnolia tea for a 3-week duration has positive effects on postpartum women. Magnolia tea is recommended as a supplementary approach to ameliorate sleep quality of postpartum women, while alleviating their symptoms of depression.

Influencing factors and correlation of anxiety, psychological stress sources, and psychological capital among women pregnant with a second child in Guangdong and Shandong Province

BACKGROUND

After the one-child policy has been effective for over 30 years, China implemented the universal two-child policy in 2015. The number of high-risk pregnant women had increased dramatically ever since, increasing negative health outcomes for both mothers and children. Our study aims to investigate the status of anxiety, psychological stress sources, and psychological capital among women pregnant with a second child, and to assess influencing factors and correlations, providing scientific basis for promoting women's health during pregnancy.

METHODS

We recruited 513 participants from maternity hospitals in Guangdong and Shandong Province. All participants completed the Zung Self-Rating Anxiety Scale (SAS), Pregnant women psychological stress sources questionnaire and the psychological capital questionnaire (PCQ-24).

RESULTS

The prevalence of anxiety of women pregnant with a second child was 27.5%. The score of psychological stress sources was 74.93 ± 16.07. The risk factors for the anxiety of the women pregnant with a second child included low education level of the husband, gender expectation and the sources of psychological stress of the pregnant woman. The risk factors for psychological stress were dissatisfaction of residence and unplanned pregnancy. The main factors influencing psychological capital were the participants' education level, whether they have learned antenatal care knowledge and satisfaction with the residence.

LIMITATIONS

All participants were recruited only from tertiary hospitals in Guangdong and Shandong province.

CONCLUSIONS

Anxiety and psychological stress is prevalent during pregnancy among women pregnant with a second child in Guangdong and Shandong. Psychological capital was a protective factor for anxiety.

Associations of antenatal maternal psychological distress with infant birth and development outcomes: Results from a South African birth cohort

BACKGROUND

Antenatal maternal psychological distress is common in low and middle-income countries (LMIC), but there is a dearth of research on its effect on birth and developmental outcomes in these settings, particularly in Sub-Saharan Africa. This study set out to identify risk factors for antenatal maternal psychological distress and determine whether antenatal maternal psychological distress was associated with infant birth and developmental outcomes, using data from the Drakenstein Child Health Study (DCHS), a birth cohort study in South Africa.

METHODS

Pregnant women were enrolled in the DCHS from primary care antenatal clinics. Antenatal maternal psychological distress was measured using the Self-Reporting Questionnaire 20-item (SRQ-20). A range of psychosocial measures, including maternal childhood trauma, depression, and posttraumatic stress disorder (PTSD) were administered. Birth outcomes, including premature birth, weight-for-age z-score and head circumference-for-age z-score, were measured using revised Fenton growth charts. The Bayley III Scales of Infant and Toddler Development was administered at 6 months of age to assess infant development outcomes, including cognitive, language, and motor domains in a subset of n=231. Associations of maternal antenatal psychological distress with psychosocial measures, and with infant birth and developmental outcomes were examined using linear regression models.

RESULTS

961 women were included in this analysis, with 197 (21%) reporting scores indicating the presence of psychological distress. Antenatal psychological distress was associated with maternal childhood trauma, antenatal depression, and PTSD, and inversely associated with partner support. No association was observed between antenatal maternal psychological distress and preterm birth or early developmental outcomes, but antenatal maternal psychological distress was associated with a smaller head circumference at birth (coefficient=-0.30, 95% CI: -0.49; -0.10).

CONCLUSION

Antenatal maternal psychological distress is common in LMIC settings and was found to be associated with key psychosocial measures during pregnancy, as well as with adverse birth outcomes, in our study population. These associations highlight the potential value of screening for antenatal maternal psychological distress as well as of developing targeted interventions.

Association of prenatal maternal perceived stress with a sexually dimorphic measure of cognition in 4.5-month-old infants

Maternal prenatal stress can adversely impact subsequent child neurodevelopment, but little is known about its effect on cognitive development in infancy. This analysis of 107 infants from a prospective birth cohort assessed whether prenatal stress disrupts sexually dimorphic performance typically observed on a physical reasoning task. Maternal stress was assessed at 8-14 and 33-37 gestational weeks using the Perceived Stress Scale. Stress was defined as: low (scores below the median at both times), medium (scores above the median at one of the two times), and high (scores above the median at both times). At 4.5 months infants saw videos of two events: one impossible and the other possible. In the impossible event a box was placed against a wall without support underneath. In the possible event the box was placed against the wall, supported by the floor. Looking time at each event was recorded via infrared eye-tracking. Previous literature has shown that, at 4.5 months of age, girls typically look significantly longer at the impossible than at the possible event, suggesting that they expect the unsupported box to fall and are surprised when it does not. Boys tend to look equally at the two events suggesting that they do not share this expectation. This sex difference was replicated in the current study. General linear models stratified by sex and adjusted for household income, maternal education, mother's age at birth, infant's age at exam, and order of event presentation revealed that girls whose mothers reported high perceived stress during pregnancy had shorter looking time differences between the impossible and possible events than girls whose mothers reported low perceived stress (β = -7.1; 95% CI: -12.0, -2.2 s; p = 0.006). Similar to boys, girls in the highest stress category spent about the same amount of time looking at each event. For boys, there were no significant looking time differences by maternal stress level. This finding suggests prenatal stress is associated with a delay in the development of physical reasoning in girls.

Cohort profile: the Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) cohort, a prospective preterm birth cohort in New York City

PURPOSE

The Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) longitudinal preterm birth cohort studies the impact of the NICU exposome on early-life development. NICU-HEALTH collects multiple biospecimens, complex observational and survey data and comprehensive multisystem outcome assessments to allow measurement of the impact of modifiable environmental exposures during the preterm period on neurodevelopmental, pulmonary and growth outcomes.

PARTICIPANTS

Moderately preterm infants without genetic or congenital anomalies and their mothers are recruited from an urban academic medical centre level IV NICU in New York City, New York, USA. Recruitment began in 2011 and continues through multiple enrolment phases to the present with goal enrolment of 400 infants. Follow-up includes daily data collection throughout the NICU stay and six follow-up visits in the first 2 years. Study retention is 77% to date, with the oldest patients turning age 8 in 2019.

FINDINGS TO DATE

NICU-HEALTH has already contributed significantly to our understanding of phthalate exposure in the NICU. Phase I produced the first evidence of the clinical impact of phthalate exposure in the NICU population. Further study identified specific sources of exposure to clinically relevant phthalate mixtures in the NICU.

FUTURE PLANS

Follow-up from age 3 to 12 is co-ordinated through integration with the Environmental Influences on Child Health Outcomes (ECHO) programme. The NICU-HEALTH cohort will generate a wealth of biomarker, clinical and outcome data from which future studies of the impact of early-life chemical and non-chemical environmental exposures can benefit. Findings from study of this cohort and other collaborating environmental health cohorts will likely translate into improvements in the hospital environment for infant development.

TRIAL REGISTRATION NUMBERS

This observational cohort is registered with ClinicalTrials.gov (NCT01420029 and NCT01963065).

Maternal and Neonatal Hair Cortisol Levels Are Associated with Infant Neurodevelopment at Six Months of Age

Background: Maternal stress during pregnancy can affect fetal development during certain sensitive periods. Objective: To longitudinally assess maternal hair cortisol levels during pregnancy, and the postpartum along with neonatal hair cortisol levels that could be associated with infant neurodevelopment at six months of age. Methods: A sample of 41 pregnant women longitudinally assessed during the first, second, and third trimester and the postpartum, along with their 41 full-term neonates participated in this study. Hair cortisol levels were assessed from participants. Infant neurodevelopment was assessed by means of the Bayley Scale of Infants Development, Third Edition at age six months. Results: Maternal hair cortisol levels in the first and second trimester accounted for 24% and 23%, respectively, of variance of infant gross motor development (p < 0.05). Maternal hair cortisol levels during the postpartum accounted for 31% of variance of infant cognitive development (p < 0.05), and 25% of variance of infant gross motor development (p < 0.05). Neonatal hair cortisol levels accounted for 28% of variance of infant gross motor development (p < 0.05). Conclusions: The preconception and prenatal time are sensitive periods related to infant neurodevelopment along with the cortisol levels surrounding the fetus while in the womb. Pregnant women could be assessed for hair cortisol levels while attending a prenatal appointment.

Characteristics and changes in the mental health indicators of expecting parents in a couple-based parenting support program in Japan

Postpartum depression is a serious problem not only for mothers, but also for their children and families. Evidence is scarce on the effectiveness of couple-targeted antenatal interventions aimed at preventing postpartum depression in Asia. Therefore, we implemented an antenatal parenting support program from Australia ("empathy program") at three sites in Japan, and assessed the characteristics of participating couples and changes in their mental health indicators before and after the program (during pregnancy and 6 weeks postpartum, respectively). In this program, participant couples discussed concerns during pregnancy and a "difficult day" scenario with other same-gender participants and then with their own partners. In total, 100 couples attended the program. Among 60 participating mothers, 20% screened positive for maternal depression symptoms (defined as an Edinburgh Postnatal Depression Scale greater than 9). Changes in paternal empathy and maternal antenatal Edinburgh Postnatal Depression Scale score were significantly associated with maternal postpartum Edinburgh Postnatal Depression Scale score in multivariable analyses. Our results indicate that a key in preventing postpartum depression is paternal involvement and long-term support from antenatal phase.

Prenatal stress and elevated seizure susceptibility: Molecular inheritable changes

Stressful episodes are common during early-life and may have a wide range of negative effects on both physical and mental status of the offspring. In addition to various neurobehavioral complications induced by prenatal stress (PS), seizure is a common complication with no fully explained cause. In this study, the association between PS and seizure susceptibility was reviewed focusing on sex differences and various underlying mechanisms. The role of drugs in the initiation of seizure and the effects of PS on the nervous system that prone the brain for seizure, especially the hypothalamic-pituitary-adrenal (HPA) axis, are also discussed in detail by reviewing the papers studying the effect of PS on glutamatergic, gamma-aminobutyric acid (GABA)ergic, and adrenergic systems in the context of seizure and epilepsy. Finally, epigenetic changes in epilepsy are described, and the underlying mechanisms of this change are expanded. As the effects of PS may be life-lasting, it is possible to prevent future psychiatric and behavioral disorders including epilepsy by preventing avoidable PS risk factors.

Potential Risk Factors of Developmental Cognitive Delay in the First Two Years of Life

BACKGROUND

The first two years of life constitute a critical period of rapid change. The events during this phase prepare the child for subsequent developmental competency.

AIM

To determine the potential risk factors that affect an infant's cognitive development in the first two years of life in a sample of Egyptian infants.

SUBJECTS AND METHODS

A cross-sectional comparative study included 655 male and female infants. Their age ranged from 3 - 24 months. Bayley Scales of Infant and Toddler Development (Bayley III) were used for cognitive assessment. Perinatal and nutritional data were recorded. Levels of serum Zinc, Copper, Iron, vitamin B12 and complete blood count (CBC) were assessed in a subsample of 193 infants.

RESULTS

Infants having below the average cognitive composite score (CCS) represented 38.47% of the whole sample. The risk of having a low average (CCS) was determined by multiple factors. Poor maternal education and low family income were the most significant social risk factors (OR = 2.19, p = 0.0003; OR = 1.64, p = 0.002 respectively). Prematurity and complicated labor represented significant perinatal risks (OR = 1.22, p = 0.005; OR = 2.39, p =0.001respectively). Bottle feeding versus breastfeeding in the first six months of life was the most significant nutritional predictor of low average (CCS) (OR = 1.79, p = 0.001). Infants with low average (CCS) had significantly lower levels of serum zinc and vitamin B12 than those with average scores.

CONCLUSION

Multiple factors appear to interact affecting the early cognitive development of Egyptian infants. Prematurity, complicated labour, poor maternal education, low family income and micronutrient deficiency are the main risk factors. Studying these factors is of great value in directing governmental intervention efforts.

The children of Superstorm Sandy: Maternal prenatal depression blunts offspring electrodermal activity

We set out to examine the relations between prenatal exposure to the natural disaster Superstorm Sandy, maternal depression, and offspring electrodermal activity (EDA). EDA was measured via skin conductance response (SCR) magnitude in 198 children (M = 42.54 months, SD = 12.76) during a startle paradigm. In keeping with prior research, we expected prenatal depression to be associated with hyporeactive EDA and prenatal stress to be associated with hyperreactive EDA. SCR magnitude was lower in children prenatally exposed to depression alone, when compared to Superstorm Sandy, and controls. SCR magnitude of children prenatally exposed to both maternal depression and the storm was lower than that of all other groups. Our results emphasize the influence of maternal prenatal mental health, support targeted risk assessment for children who experienced an adverse prenatal environment, and highlight the need for a deeper understanding of the interactions between maternal mood and stress on the developing child.

Differential Effects of Stress Exposures, Caregiving Quality, and Temperament in Early Life on Working Memory versus Inhibitory Control in Preschool-Aged Children

We examined the roles of maternal and child lifetime stress exposures, infant temperament (orienting/regulation, surgency/extraversion), and maternal caregiving during infancy and preschool on preschoolers' working memory and inhibitory control in a sociodemographically diverse pregnancy cohort. Working memory was predicted by infant orienting/regulation, with differential effects by the level of maternal cognitive support in infancy; maternal lifetime stress exposures exerted independent negative effects on working memory. Inhibitory control was positively associated with maternal emotionally supportive behaviors in infancy, which mediated the effects of maternal lifetime stress exposures on inhibitory control. These findings have implications for interventions designed to optimize child executive functioning.

Infant Temperament: Repercussions of Superstorm Sandy-Related Maternal Stress

This study recruited a prospective cohort of 380 pregnant women before, during, or after Superstorm Sandy in 2012 to examine the association between disaster-related pre- and post-natal maternal stress and offspring temperament at 6 months-old. Mothers prospectively reported stressful experiences during the storm and rated their child's temperament 6 months postpartum. Results indicated that length of time without phone or electricity and financial loss was associated with offspring negative affect, whereas financial loss and threat of death or injury was associated with emotion dysregulation. Furthermore, offspring born before the storm had greater negative affect and lower emotion regulation than those born after the storm. Given the probable increase in the occurrence of natural disasters due to climate change in recent years (McCarthy, Intergovernmental Panel on Climate Change, Climate change 2001: impacts, adaptation, and vulnerability: contribution of Working Group II to the third assessment report of the Intergovernmental Panel on Climate Change, Cambridge University Press, Cambridge, 2001), our results highlight the necessity of education and planning to help ameliorate any potential consequences on the developing infant.

Prenatal stress and child development: A scoping review of research in low- and middle-income countries

INTRODUCTION

Past research has shown relationships between stress during pregnancy, and related psychosocial health measures such as anxiety and depressive symptoms, with infant, child, and adult outcomes. However, most research is from high-income countries. We conducted a scoping review to identify research studies on prenatal stress and outcomes of the pregnancy or offspring in low- and middle-income countries (LMICs), and to synthesize the stress measures and outcomes assessed, the findings observed, and directions for future research.

METHODS

We searched PubMed, Scopus, and PsycINFO for English-language abstracts published from Jan 1960-Jan 2017. Search terms were related to stress and psychosocial health; pregnancy; infant or child development; and LMICs.

RESULTS

48 articles were identified. Sixty percent of studies were in upper-middle, 25% in lower-middle, and 15% in low income countries. Most studies used questionnaires, either existing or tailor-made, to assess stress. Eight assessed cortisol. Most studies (n = 31) assessed infant outcomes at birth, particularly gestational age or preterm birth (n = 22, 12 showing significant relationships), and birthweight (n = 21, 14 showing significant relationships). Five studies analyzed outcomes later in infancy such as temperament and motor development, all showing significant results; and nine in childhood such as behavioral development, asthma, and physical growth, with eight showing significant results.

CONCLUSIONS

Results highlight the importance of prenatal stress on infant and child outcomes in LMICs. Methods used in high-income countries are successfully employed in LMICs, but tailored tools remain necessary. Careful assessment of covariates is needed to foster analyses of interactive effects and pathways. Studies including longer-term follow-up should be prioritized.

The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants

The biological embedding of early life stress exposure may result in life-long neurodevelopmental impairment in preterm infants. Infants hospitalized in the neonatal intensive care unit are exposed to significant experiential, environmental, and physiologic stressors over the course of their extended hospitalization. Stress exposure during the sensitive period of brain development may alter biological processes, including functioning of the immune system, the autonomic nervous system, and the hypothalamic-pituitary-adrenal axis as well as gene expression. These alterations may subsequently affect brain structure and function. Changes to these processes may mediate the relationship between neonatal stress exposure and neurodevelopment in preterm infants and represent potential therapeutic targets to improve long-term outcomes. The purpose of this paper is to introduce a conceptual model, based on published research, that describes the mechanisms mediating stress exposure and neurodevelopment impairment in preterm infants and to provide the theoretical foundation on which to base future descriptive research, intervention studies, and clinical care.

Omega-3 fatty acid addition during pregnancy

BACKGROUND

Higher intakes of foods containing omega-3 long-chain polyunsaturated fatty acids (LCPUFA), such as fish, during pregnancy have been associated with longer gestations and improved perinatal outcomes. This is an update of a review that was first published in 2006.

OBJECTIVES

To assess the effects of omega-3 LCPUFA, as supplements or as dietary additions, during pregnancy on maternal, perinatal, and neonatal outcomes and longer-term outcomes for mother and child.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (16 August 2018), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing omega-3 fatty acids (as supplements or as foods, stand-alone interventions, or with a co-intervention) during pregnancy with placebo or no omega-3, and studies or study arms directly comparing omega-3 LCPUFA doses or types. Trials published in abstract form were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias in trials and assessed quality of evidence for prespecified birth/infant, maternal, child/adult and health service outcomes using the GRADE approach.

MAIN RESULTS

In this update, we included 70 RCTs (involving 19,927 women at low, mixed or high risk of poor pregnancy outcomes) which compared omega-3 LCPUFA interventions (supplements and food) compared with placebo or no omega-3. Overall study-level risk of bias was mixed, with selection and performance bias mostly at low risk, but there was high risk of attrition bias in some trials. Most trials were conducted in upper-middle or high-income countries; and nearly half the trials included women at increased/high risk for factors which might increase the risk of adverse maternal and birth outcomes.Preterm birth < 37 weeks (13.4% versus 11.9%; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.81 to 0.97; 26 RCTs, 10,304 participants; high-quality evidence) and early preterm birth < 34 weeks (4.6% versus 2.7%; RR 0.58, 95% CI 0.44 to 0.77; 9 RCTs, 5204 participants; high-quality evidence) were both lower in women who received omega-3 LCPUFA compared with no omega-3. Prolonged gestation > 42 weeks was probably increased from 1.6% to 2.6% in women who received omega-3 LCPUFA compared with no omega-3 (RR 1.61 95% CI 1.11 to 2.33; 5141 participants; 6 RCTs; moderate-quality evidence).For infants, there was a possibly reduced risk of perinatal death (RR 0.75, 95% CI 0.54 to 1.03; 10 RCTs, 7416 participants; moderate-quality evidence: 62/3715 versus 83/3701 infants) and possibly fewer neonatal care admissions (RR 0.92, 95% CI 0.83 to 1.03; 9 RCTs, 6920 participants; moderate-quality evidence - 483/3475 infants versus 519/3445 infants). There was a reduced risk of low birthweight (LBW) babies (15.6% versus 14%; RR 0.90, 95% CI 0.82 to 0.99; 15 trials, 8449 participants; high-quality evidence); but a possible small increase in large-for-gestational age (LGA) babies (RR 1.15, 95% CI 0.97 to 1.36; 6 RCTs, 3722 participants; moderate-quality evidence, for omega-3 LCPUFA compared with no omega-3. Little or no difference in small-for-gestational age or intrauterine growth restriction (RR 1.01, 95% CI 0.90 to 1.13; 8 RCTs, 6907 participants; moderate-quality evidence) was seen.For the maternal outcomes, there is insufficient evidence to determine the effects of omega-3 on induction post-term (average RR 0.82, 95% CI 0.22 to 2.98; 3 trials, 2900 participants; low-quality evidence), maternal serious adverse events (RR 1.04, 95% CI 0.40 to 2.72; 2 trials, 2690 participants; low-quality evidence), maternal admission to intensive care (RR 0.56, 95% CI 0.12 to 2.63; 2 trials, 2458 participants; low-quality evidence), or postnatal depression (average RR 0.99, 95% CI 0.56 to 1.77; 2 trials, 2431 participants; low-quality evidence). Mean gestational length was greater in women who received omega-3 LCPUFA (mean difference (MD) 1.67 days, 95% CI 0.95 to 2.39; 41 trials, 12,517 participants; moderate-quality evidence), and pre-eclampsia may possibly be reduced with omega-3 LCPUFA (RR 0.84, 95% CI 0.69 to 1.01; 20 trials, 8306 participants; low-quality evidence).For the child/adult outcomes, very few differences between antenatal omega-3 LCPUFA supplementation and no omega-3 were observed in cognition, IQ, vision, other neurodevelopment and growth outcomes, language and behaviour (mostly low-quality to very low-quality evidence). The effect of omega-3 LCPUFA on body mass index at 19 years (MD 0, 95% CI -0.83 to 0.83; 1 trial, 243 participants; very low-quality evidence) was uncertain. No data were reported for development of diabetes in the children of study participants.

AUTHORS' CONCLUSIONS

In the overall analysis, preterm birth < 37 weeks and early preterm birth < 34 weeks were reduced in women receiving omega-3 LCPUFA compared with no omega-3. There was a possibly reduced risk of perinatal death and of neonatal care admission, a reduced risk of LBW babies; and possibly a small increased risk of LGA babies with omega-3 LCPUFA.For our GRADE quality assessments, we assessed most of the important perinatal outcomes as high-quality (e.g. preterm birth) or moderate-quality evidence (e.g. perinatal death). For the other outcome domains (maternal, child/adult and health service outcomes) GRADE ratings ranged from moderate to very low, with over half rated as low. Reasons for downgrading across the domain were mostly due to design limitations and imprecision.Omega-3 LCPUFA supplementation during pregnancy is an effective strategy for reducing the incidence of preterm birth, although it probably increases the incidence of post-term pregnancies. More studies comparing omega-3 LCPUFA and placebo (to establish causality in relation to preterm birth) are not needed at this stage. A further 23 ongoing trials are still to report on over 5000 women, so no more RCTs are needed that compare omega-3 LCPUFA against placebo or no intervention. However, further follow-up of completed trials is needed to assess longer-term outcomes for mother and child, to improve understanding of metabolic, growth and neurodevelopment pathways in particular, and to establish if, and how, outcomes vary by different types of omega-3 LCPUFA, timing and doses; or by characteristics of women.

A Meta-Analysis of Maternal Prenatal Depression and Anxiety on Child Socioemotional Development

OBJECTIVE

Observed associations between maternal prenatal stress and children's socioemotional development have varied widely in the literature. The objective of the current study was to provide a synthesis of studies examining maternal prenatal anxiety and depression and the socioemotional development of their children.

METHOD

Eligible studies through to February 2018 were identified using a comprehensive search strategy. Included studies examined the association between maternal prenatal depression or anxiety and the future development of their children's socioemotional development (eg, difficult temperament, behavioral dysregulation) up to 18 years later. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean effect sizes and test for potential moderators.

RESULTS

A total of 71 studies met full inclusion criteria for data analysis. The weighted average effect size for the association between prenatal stress and child socioemotional problems was as follows: odds ratio (OR) = 1.66 (95% CI = 1.54-1.79). Effect sizes were stronger for depression (OR = 1.79; 95% CI = 1.61-1.99) compared to anxiety (OR = 1.50; 95% CI = 1.36-1.64). Moderator analyses indicated that effect sizes were stronger when depression was more severe and when socio-demographic risk was heightened.

CONCLUSION

Findings suggest that maternal prenatal stress is associated with offspring socioemotional development, with the effect size for prenatal depression being more robust than for anxiety. Mitigating stress and mental health difficulties in mothers during pregnancy may be an effective strategy for reducing offspring behavioral difficulties, especially in groups with social disadvantage and greater severity of mental health difficulties.

Secure attachment style appears to compensate for the effect of prenatal maternal distress regarding difficult infant temperament development

Objective: Secure attachment style is a known protective factor regarding psychopathological development. The infant's attachment style, which is developed during the first two years of life, is therefore considered a moderating factor on the association between prenatal maternal distress and child temperament development which has repeatedly been reported in previous studies. Method: In this longitudinal study on a new sample of 51 mother-child-dyads, reported maternal distress and maternal empathy were assessed during pregnancy. Infant temperament and motor development were assessed at 12 months, while additionally controlling for the infant's attachment style as a postnatal factor. Results: Infants with secure attachment style whose mothers had experienced higher prenatal distress showed slightly better gross motor development at the age of 12 months. No association could be found between prenatal maternal distress and infant temperament. Conclusions: The results support the view that secure attachment style in children is a protective factor and softens the effects of prenatal maternal distress on difficult temperament development.

Perinatal nutrition interventions and post-partum depressive symptoms

BACKGROUND

Postpartum depression (PPD) is the most prevalent mood disorder associated with childbirth. No single cause of PPD has been identified, however the increased risk of nutritional deficiencies incurred through the high nutritional requirements of pregnancy may play a role in the pathology of depressive symptoms. Three nutritional interventions have drawn particular interest as possible non-invasive and cost-effective prevention and/or treatment strategies for PPD; omega-3 (n-3) long chain polyunsaturated fatty acids (LCPUFA), vitamin D and overall diet.

METHODS

We searched for meta-analyses of randomised controlled trials (RCT's) of nutritional interventions during the perinatal period with PPD as an outcome, and checked for any trials published subsequently to the meta-analyses.

RESULTS

Fish oil: Eleven RCT's of prenatal fish oil supplementation RCT's show null and positive effects on PPD symptoms. Vitamin D: no relevant RCT's were identified, however seven observational studies of maternal vitamin D levels with PPD outcomes showed inconsistent associations. Diet: Two Australian RCT's with dietary advice interventions in pregnancy had a positive and null result on PPD.

LIMITATIONS

With the exception of fish oil, few RCT's with nutritional interventions during pregnancy assess PPD.

CONCLUSIONS

Further research is needed to determine whether nutritional intervention strategies during pregnancy can protect against symptoms of PPD. Given the prevalence of PPD and ease of administering PPD measures, we recommend future prenatal nutritional RCT's include PPD as an outcome.

The Relations Between Maternal Prenatal Anxiety or Stress and Child's Early Negative Reactivity or Self-Regulation: A Systematic Review

In the present review, we examine the association between maternal prenatal stress or anxiety and children's early negative reactivity or self-regulation. The review includes 32 studies that focus on pregnancy-related anxiety, state or trait anxiety, perceived stress, and stressful life events in relation to child's crying, temperament, or behavior during the first 2 years of life. We searched four electronic databases and 32 studies were selected based on the inclusion criteria. Twenty-three studies found an association between maternal prenatal anxiety or stress and a child's negative reactivity or self-regulation, and typically the effect sizes varied from low to moderate. The association was found regardless of the form of prenatal stress or anxiety and the trimester in which the prenatal stress or anxiety was measured. In conclusion, several forms of prenatal anxiety and stress may increase the risk of emotional and self-regulatory difficulties during the first 2 years of life.

Prenatal phthalate exposures and child temperament at 12 and 24 months

INTRODUCTION

Gestational phthalate exposures have been adversely associated with attention, externalizing, and internalizing behaviors in childhood. Early childhood temperament may be a marker of later behavioral patterns. We therefore sought to determine whether gestational phthalate exposures were associated with infant and toddler temperament.

METHODS

The Mount Sinai Children's Environmental Health Study is a prospective cohort study of children born between May 1998 and July 2001 in New York City (N=404). Phthalate metabolites were measured in spot urine samples collected from pregnant women in their third trimester. Child temperament was assessed by parental report at 12-months using the Infant Behavior Questionnaire (IBQ) (N=204) and at 24-months using the Toddler Behavior Assessment Questionnaire (TBAQ) (N=279). We used multiple linear regression to evaluate associations between urinary phthalate metabolites and eleven temperament domains.

RESULTS

Phthalate biomarker concentrations were weakly associated with lower gross motor activity levels as well as higher duration of orienting at the 12-month assessment. Mono(3-carboxypropyl) phthalate (MCPP), monobenzyl phthalate (MBzP) and the sum of metabolites of di(2-ethylhexyl) phthalate (∑DEHP) were associated with lower levels of smiling and laughing at 12 months. At 24-months, social fear and lower pleasure was linked to higher concentrations of MCPP and MBzP, and higher ∑DEHP was weakly associated with increased anger levels at 24-months.

CONCLUSIONS

Though we observed some weak associations between biomarkers of prenatal exposure to phthalates and temperament at 12- and 24-months, overall phthalates biomarkers were not strongly associated with alterations in temperament.