Use of glucocorticoids during pregnancy and risk of attention-deficit/hyperactivity disorder in offspring: a nationwide Danish cohort study

Understanding the impact of non-shared unmeasured confounding on the sibling comparison analysis

BACKGROUND

The sibling comparison analysis is used to deal with unmeasured confounding. It has previously been shown that in the presence of non-shared unmeasured confounding, the sibling comparison analysis may introduce substantial bias depending on the sharedness of the unmeasured confounder and the sharedness of the exposure. We aimed to improve the awareness of this challenge of the sibling comparison analysis.

METHODS

First, we simulated sibling pairs with an exposure, a confounder and an outcome. We simulated sibling pairs with no effect of the exposure on the outcome and with positive confounding. For varying degrees of sharedness of the confounder and the exposure and for varying prevalence of the exposure, we calculated the sibling comparison odds ratio (OR). Second, we provided measures for sharedness of selected treatments based on Danish health data.

RESULTS

The confounded sibling comparison OR was visualized for varying degrees of sharedness of the confounder and the exposure and for varying prevalence of the exposure. The confounded sibling comparison OR was seen to increase with increasing sharedness of the exposure and the confounded sibling comparison OR decreased with an increasing prevalence of exposure. Measures for sharedness of treatments based on Danish health data showed that treatments of chronic diseases have the highest sharedness and treatments of non-chronic diseases have the lowest sharedness.

CONCLUSIONS

Researchers should be aware of the challenge regarding non-shared unmeasured confounding in the sibling comparison analysis, before applying the analysis in non-randomized studies. Otherwise, the sibling comparison analysis may lead to substantial bias.

Offspring neurodevelopmental outcomes born to parents with chronic inflammatory arthritis using antirheumatic therapies: A scoping review

INTRODUCTION

Most women with rheumatic diseases discontinue antirheumatic therapies in anticipation of, or during pregnancy due to concerns around medication safety and fetal wellbeing.

OBJECTIVE

We performed a scoping review of available evidence investigating the risks of adverse offspring neurodevelopmental outcomes amongst parents with chronic inflammatory arthritis, taking antirheumatic therapies during conception or pregnancy.

METHODS

We designed a scoping review protocol and search strategy a priori in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed an exhaustive search in Cochrane Library, Embase, Google Scholar, Medline, and Web of Science for relevant literature in January 2023. Articles needed to include offspring neurodevelopmental outcomes born to parents with CIA who took antirheumatic therapies during conception or pregnancy. Independent reviewers extracted data from eligible articles using a standard abstraction tool and performed critical appraisal of study quality.

RESULTS

Six studies were included for full data abstraction. Use of Nonsteroidal Anti-inflammatory Drugs, Tumor Necrosis Factor Alpha inhibitors, and exposure to methotrexate during early first trimester of pregnancy did not seem to increase risk for adverse offspring neurodevelopmental outcomes. Corticosteroid use during pregnancy seemed to pose an increased risk for attention deficit hyperactive disorders in offspring.

CONCLUSION

Use of some antirheumatic therapies during pregnancy may not be associated with adverse offspring neurodevelopmental outcomes. Further investigations are needed to elucidate if other confounding factors affect long term offspring health outcomes born to parents with chronic inflammatory arthritis.

Association of corticosteroid use and attention deficit/hyperactivity disorder in asthmatic children varies by age

OBJECTIVE

We aim to examine the impact of corticosteroids use on ADHD among children with asthma by administration routes.

METHODS

A population-based, cross-sectional analysis included pediatric patients ages 5-20 years old from the 2016 and 2019 Kids Inpatient Database (unweighted N = 111,702). ICD-10-CM codes were used to identify corticosteroids use, asthma, and ADHD cases. Survey logistic regression models with purposeful variable selection algorithms were built to examine the association between corticosteroids use, and ADHD by asthma severity and age. An inverse probability weighting (IPW) approach was used to help further control residual confounding.

RESULTS

Among children aged 5-11 years old, the odds of ADHD were significantly higher in children with moderate to severe asthma who used inhaled corticosteroids than nonusers (moderate asthma: adjusted odds ratios [aOR] 1.46, 95% confidence interval [CI] 1.14-2.44; severe asthma: aOR 1.61, 95% CI 1.18-2.21). Although oral corticosteroid use was not independently associated with ADHD in young children, combined use of inhaled and oral corticosteroid had almost 5 times higher odds of use among ADHD in children with severe asthma vs. nonusers (aOR 4.85, 95% CI 2.07 - 11.35). No associations were found between any corticosteroid use and ADHD among asthmatic children aged 12-20 years.

CONCLUSIONS

In this retrospective analysis, we found inhaled corticosteroids were positively associated with ADHD in younger children with moderate to severe asthma, but not in older children.

Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society

BACKGROUND

In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed.

OBJECTIVES

To establish recommendations on pregnancy in women with NMOSD.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments.

CONCLUSION

Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

Association of Attention Deficit/Hyperactivity Disorder With Events Occurring During Pregnancy and Perinatal Period

Background: The relationship of events occurring during pregnancy and perinatal period with attention deficit/hyperactivity disorder (ADHD) is not clear. Thus, the focus of the current study was to examine the effects of events occurring during pregnancy and perinatal period on ADHD.

Methods: A two-phase cross-sectional study was performed across 13 schools in Changsha and Yiyang cities from March to December, 2014. We preliminarily screened all students using CBCL and established the diagnosis using Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). A total of 3,418 questionnaires were effectively completed in this study.

Results: History of threatened abortion (TA) [odds ratio (OR): 1.707 (1.201–2.426)] (vs. No-TA) and neonatal asphyxia (NA) [OR: 2.497(1.225–5.09)] (vs. health) showed a positive association with ADHD. On subgroup analysis, TA [OR: 2.216 (1.458–3.369)] (vs. No-TA) was a risk factor for ADHD without comorbidity; instrumental delivery [OR: 2.748 (1.057–7.142)] (vs. natural birth) and NA [OR: 2.789 (1.222–6.361)] (vs. health) were risk factors for ADHD in the subgroup of ADHD with comorbidity; TA (vs. no-TA) and NA (vs. health) were risk factors for ADHD among male students [ORs: 2.232 (1.439–3.462) and 2.808 (1.115–7.068), respectively], while low birth weight (LBW) (vs. normal birth weight) was a risk factor [OR: 2.054 (1.063–3.967)] for ADHD among female students.

Conclusion: TA was a risk factor for ADHD in the absence of comorbid conditions; instrumental delivery and NA were risk factors for ADHD in the subgroup of ADHD with comorbidity; TA and NA were risk factors for ADHD among male students. LBW was a risk factor for ADHD among female students.

Early environmental risk factors for neurodevelopmental disorders - a systematic review of twin and sibling studies

While neurodevelopmental disorders (NDDs) are highly heritable, several environmental risk factors have also been suggested. However, the role of familial confounding is unclear. To shed more light on this, we reviewed the evidence from twin and sibling studies. A systematic review was performed on case control and cohort studies including a twin or sibling within-pair comparison of neurodevelopmental outcomes, with environmental exposures until the sixth birthday. From 7,315 screened abstracts, 140 eligible articles were identified. After adjustment for familial confounding advanced paternal age, low birth weight, birth defects, and perinatal hypoxia and respiratory stress were associated with autism spectrum disorder (ASD), and low birth weight, gestational age and family income were associated with attention-deficit/hyperactivity disorder (ADHD), categorically and dimensionally. Several previously suspected factors, including pregnancy-related factors, were deemed due to familial confounding. Most studies were conducted in North America and Scandinavia, pointing to a global research bias. Moreover, most studies focused on ASD and ADHD. This genetically informed review showed evidence for a range of environmental factors of potential casual significance in NDDs, but also points to a critical need of more genetically informed studies of good quality in the quest of the environmental causes of NDDs.

Neuromyelitis optica spectrum disorders and pregnancy: therapeutic considerations

Neuromyelitis optica spectrum disorders (NMOSD) are a type of neurological autoimmune disease characterized by attacks of CNS inflammation that are often severe and predominantly affect the spinal cord and optic nerve. The majority of individuals with NMOSD are women, many of whom are of childbearing age. Although NMOSD are rare, several small retrospective studies and case reports have indicated that pregnancy can worsen disease activity and might contribute to disease onset. NMOSD disease activity seems to negatively affect pregnancy outcomes. Moreover, some of the current NMOSD treatments are known to pose risks to the developing fetus and only limited safety data are available for others. Here, we review published studies regarding the relationship between pregnancy outcomes and NMOSD disease activity. We also assess the risks associated with using disease-modifying therapies for NMOSD during the course of pregnancy and breastfeeding. On the basis of the available evidence, we offer recommendations regarding the use of these therapies in the course of pregnancy planning in individuals with NMOSD.

Maternal and fetal outcomes in pregnancies with long-term corticosteroid use

PURPOSE

Long-term corticosteroids are administered in pregnant patients with an array of autoimmune and inflammatory disorders. Our objective is to determine whether long-term corticosteroid use is associated with increased maternal and neonatal adverse outcomes.

MATERIALS AND METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project-national Inpatient Sample from the USA. All pregnant patients on long-term corticosteroids were identified using International Classification of Disease-9 coding from 2003 to 2015. The effect of long-term corticosteroid use on maternal and neonatal outcomes was evaluated using multivariate logistic regression.

RESULTS

Out of the 10,491,798 births included in our study, 3999 were among women with long-term use of steroids, for an overall prevalence of 38 per 100,000 births. There was a steady increase in chronic steroid use from 2 to 81 per 100,000 births over the 13-year study period (p < .0001). Women on long-term steroids were more likely to have pregnancies complicated by preeclampsia, 1.72 (1.30-2.29) and were at greater risk of preterm premature rupture of membranes, 1.63 (1.01-2.44), pyelonephritis, 4.81 (1.18-19.61), and venous thromboembolisms, 2.50 (1.32-4.73). Neonates born from mothers on long-term steroids were more likely to suffer from prematurity, 1.51 (1.13-2.05), and lower weight for gestational age, 2.10 (1.34-3.30).

CONCLUSION

Long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy to minimize complications.

The Hypothalamic-Pituitary-Adrenal Axis and the Fetus

Glucocorticoids (GCs), cortisol in humans, influence multiple essential maturational events during gestation. In the human fetus, fetal hypothalamic-pituitary-adrenal (HPA) axis function, fetal adrenal steroidogenesis, placental 11β- hydroxysteroid dehydrogenase type 2 activity, maternal cortisol concentrations, and environmental factors impact fetal cortisol exposure. The beneficial effects of synthetic glucocorticoids (sGCs), such as dexamethasone and betamethasone, on fetal lung maturation have significantly shifted the management of preterm labor and threatened preterm birth. Accumulating evidence suggests that exposure to sGCs in utero at critical developmental stages can alter the function of organ systems and that these effects may have sequelae that extend into adult life. Maternal stress and environmental influences may also impact fetal GC exposure. This article explores the vulnerability of the fetal HPA axis to endogenous GCs and exogenous sGCs.