The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort

Maternal thyroid dysfunction and depressive symptoms during pregnancy and child behavioral and emotional problems - an ECHO multi-cohort investigation

BACKGROUND

Maternal thyroid dysfunction and maternal depression during pregnancy may increase the risk of child behavioral and emotional problems. We sought to investigate the independent and interactive associations of these two risk factors with child behavior problems.

METHODS

We combined data from four cohorts in the Environmental influences on Child Health Outcomes (ECHO) program (N = 949). Maternal thyroid function (thyroid-stimulating hormone [TSH], free thyroxine [fT4], thyroid peroxidase autoantibodies [TPO-Ab], fT4/TSH ratio) was measured predominantly during the first half of pregnancy. We harmonized maternal depression into a continuous measure of antepartum depressive symptomatology and a dichotomous measure reflecting (history of) clinical depression. Child internalizing and externalizing problems were harmonized to the T-score metric of the Child Behavior Checklist. We used multiple linear regression and random effects meta-analysis to assess the average relationship between each predictor and outcome, and the variability in these relationships across cohorts.

RESULTS

Across cohorts, antepartum depressive symptomatology was positively associated with both internalizing (meta B = 2.879, 95 % CI 1.87-3.89, p < .001) and externalizing problems (meta B = 1.683, 95 % CI 0.67-2.69, p = .001). None of the indicators of maternal thyroid function was associated with child behavior problems across cohorts. TPO-Ab concentrations were positively associated with child externalizing problems only in offspring of depressed mothers (meta B = 3.063, 95 % CI 0.73-5.40, p = .010).

CONCLUSIONS

This study supports the importance of maternal antepartum mental health for child behavior across diverse populations. However, we found little empirical evidence for an association between maternal thyroid function within the normal range during pregnancy and child behavioral problems.

Maternal polycystic ovarian syndrome and offspring psychopathology and neurodevelopment

Polycystic ovarian syndrome (PCOS) is a common female endocrinologic condition that affects both the metabolic and reproductive systems and is the most frequent cause of anovulatory infertility. It is also associated with a range of psychiatric outcomes in individuals, including bulimia nervosa, schizophrenia, bipolar disorder, depression, anxiety, and personality disorders. At the same time, evidence suggests that hyperandrogenism, the characteristic trait of PCOS, may impair fetal neurodevelopment. Epidemiological studies have linked maternal PCOS with a variety of behavioral and psychiatric conditions in offspring including autism spectrum disorder and attention deficit hyperactivity disorder. In this review, we explore evidence for potential underlying biological mechanisms that might explain these observed associations, discuss the complex interplay between genetics and various environmental factors across generations, and highlight avenues for future research.

Sociodemographic differences in parental hesitancy to the COVID-19 vaccine

OBJECTIVE(S)

To identify sociodemographic patterns in pediatric COVID-19 vaccination status and parental vaccine hesitancy reasons.

STUDY DESIGN

Cross-sectional survey data was collected from 5103 US parents of 6 month to 17-year-olds from the NIH Environmental influences on Child Health Outcomes (ECHO) study. We used chi-square tests to examine sociodemographic differences between vaccinated and unvaccinated children and between vaccine-hesitant and non-hesitant parents. We used risk ratios (RRs) from adjusted multivariable Poisson regressions to examine associations between sociodemographic characteristics and vaccine hesitancy reasons.

RESULTS

Less than half (41.7 %) of children had received at least one dose of the COVID-19 vaccine. Only 1 % of parents who were unsure or had no plans to vaccinate their children ("vaccine hesitant") cited resource barriers (e.g., transportation, cost). Instead, vaccine-hesitant parents reported concerns about side effects (general: 53.1 %; long-term: 56.2 %); believed their child did not need the vaccine due to low risk (33.7 %) or prior infection (21 %); perceived there was insufficient vaccine testing in children (24 %) and in racially/ethnically diverse populations (9.5 %); and lacked trust in healthcare provider recommendations (9 %). Vaccine-hesitant parents of Indigenous and Black children were less likely to report side effect concerns (general: RR 0.65-0.87; long-term: RR 0.55-0.66); higher-income and higher-educated vaccine-hesitant parents were ∼ 1.5-2 times more likely to say their child was at low risk.

CONCLUSION(S)

Safety concerns and perceived low risk influenced parental COVID-19 vaccination hesitancy, not resource barriers. Important sociodemographic differences can inform future approaches to public health campaigns to propel swift action during a public health crisis to help reduce disease burden and spread.

Neurobehavioral effects of gestational exposure to mixtures of non-persistent endocrine disruptors in preschool-aged children: The environmental influences on child health outcomes (ECHO) program

Exposures to phthalates and synthetic phenols are common among expectant mothers in the US. Previous studies on the neurotoxicity of these compounds have primarily assessed the effects of individual compounds on child behavior, but have not assessed potential combined effects of these substances. We assessed associations between prenatal exposure to a mixture of phthalates and phenols with behavioral problems among preschool-age children participating in the Environmental influences on Child Health Outcome (ECHO) Program. The study sample included 878 mother-child pairs from three cohorts with data on urinary concentrations of 10 phenols and 11 phthalate metabolites during pregnancy, along with caregiver reported Child Behavioral Checklist Ages 1½ to 5 (CBCL) data. Using covariate-adjusted weighted quantile sum (WQS) regression, we estimated associations between the phenol - phthalate mixture and CBCL behavioral scales T-scores. We fitted additional models stratified by sex due to previous reports of sex-specific associations. No statistically significant associations were observed in the overall sample when both male and female children were combined. However, in males, a quintile increase in the WQS index was associated with a 0.04 (95% CI: 0.00; 0.08) higher T-score of externalizing problems. The major contributors to this mixture effect were butylparaben (with a weight of 21%), benzophenone-3 (15%) and MCNP (11%). Conversely, in females, significant negative associations were observed between the WQS index with the total behavioral problems scale (beta = −0.05, 95% CI: −0.09; −0.01), externalizing problems (beta = −0.06, 95% CI = −0.10; −0.02) and internalizing problems (beta = −0.04, 95% CI: −0.08; −0.00).

Associations among positive child health measures in the environmental influences on child health outcomes (ECHO) cohort

PURPOSE

Effective measurement of positive child health is critical in improving public health. A proposed measure of positive health, a positive child health index (PCHI), is based on how many of 11 specific physical, developmental, and mental health conditions a child has (ranging from 0 to 11). Accepted measures of positive health, Patient-Reported Outcome Measurement Information System (PROMIS®) measures of global health, meaning and purpose, and life satisfaction, are based on child and caregiver perceptions.

METHODS

The sample comprised 3713 children aged 5 to 17 years from the NIH Environmental influences on Child Health Outcomes (ECHO) Cohort with data to calculate PCHI and at least 1 child- or caregiver-reported PROMIS measure. Linear regressions were performed to test the associations between each PROMIS measure T-score and the PCHI, adjusting for gestational age, child sex, child age, and maternal factors (age, education, income).

RESULTS

The PROMIS measure associated most strongly with PCHI was caregiver-reported global health, followed by child-reported global health. Caregiver-reported life satisfaction and child-reported meaning and purpose were higher for children with a PCHI = 0 compared with children with 3 or more health conditions but not when compared with children with only 1 or 2 conditions. Among children with 4 or more conditions, girls reported lower global health than boys. Sex differences were not found for caregiver-reported measures.

CONCLUSION

PROMIS measures and PCHI offer complementary information on positive child health. PROMIS measures are intended as measures of a person's perception of their health, whereas PCHI reflects a cumulative impact of chronic health conditions from the perspective of health care systems. Both viewpoints are informative in public health promotion.

A Latent Trait-based Measure as a Data Harmonization and Missing Data Solution Applied to the Environmental Influences on Child Health Outcomes Cohort

BACKGROUND

Collaborative research consortia provide an efficient method to increase sample size, enabling evaluation of subgroup heterogeneity and rare outcomes. In addition to missing data challenges faced by all cohort studies like nonresponse and attrition, collaborative studies have missing data due to differences in study design and measurement of the contributing studies.

METHODS

We extend ROSETTA, a latent variable method that creates common measures across datasets collecting the same latent constructs with only partial overlap in measures, to define a common measure of socioeconomic status (SES) across cohorts with varying indicators in the Environmental influences on Child Health Outcomes Cohort, a consortium of pregnancy and pediatric cohorts.

RESULTS

Starting with 52 indicators of prenatal SES from 39,372 participants across 53 cohorts, ROSETTA created three factors representing key domains of SES: income and education, insurance and poverty, and unemployment. At least one factor score was available for 34,528 participants and two factors were available for more participants than any single indicator. Factors fit the data well, had content validity, and were correlated with alternative measures of SES (for income and education factor, r = 0.40-0.89). Higher SES as measured by the factor scores was associated with lower odds of prenatal smoking: odds ratio income and education : 0.42 (95% confidence interval: 0.38, 0.45). Missing data were reduced compared with most methods, except for multiple imputation.

CONCLUSION

ROSETTA aids in pooled analysis of individual participant data by creating measures on a common scale and maximizing data in the presence of missing and mismatched measures.

Maternal Cardiometabolic Risk Factors in Pregnancy and Offspring Blood Pressure at Age 2 to 18 Years

Importance

Higher blood pressure in early life may signal cardiovascular disease over the life course, but determinants of blood pressure in early life are poorly understood.

Objective

To examine the association of maternal cardiometabolic risk factors during pregnancy with offspring blood pressure from age 2 to 18 years and explore whether the association is modified by offspring sex and race and ethnicity.

Design, Setting, and Participants

This cohort study analyzed data from the Environmental Influences on Child Health Outcomes program between January 1, 1994, and March 31, 2023. Three common maternal cardiometabolic risk factors during pregnancy were examined: prepregnancy obesity, gestational diabetes, and hypertensive disorders of pregnancy (HDP).

Exposure

Maternal cardiometabolic risk factors were retrieved and harmonized from medical records and questionnaires.

Main Outcomes and Measures

Offspring systolic blood pressure (SBP) and diastolic blood pressure (DBP) percentiles adjusted for age, sex, and height were calculated.

Results

Among 12 480 mother-offspring pairs (mean [SD] maternal age during pregnancy, 29.9 [6.4] years; 856 of 12 303 identifying as Asian [7.0%]; 1908 as Black [15.5%]; 2305 as Hispanic [18.7%]; 6522 as White [52.3%], and 712 as other [5.8%] race and ethnicity), at least 1 maternal cardiometabolic risk factor was present in 5537 (44.4%), with prepregnancy obesity being the most prevalent (3072 [24.6%]), followed by HDP (1693 [13.6%]) and gestational diabetes (805 [6.5%]). Offspring born to mothers with any cardiometabolic risk factors had higher SBP (4.88 percentile points; 95% CI, 3.97-5.82 percentile points) and higher DBP (1.90 percentile points; 95% CI, 1.15-2.64 percentile points) at their first blood pressure measurement, after adjusting for potential confounders, compared with their counterparts without any risk factors. Hypertensive disorders of pregnancy, alone or with either prepregnancy obesity or gestational diabetes, was significantly associated with higher offspring blood pressure. These associations were generally more significant among female compared with male offspring and among Black compared with other racial and ethnic groups. Among 6015 offspring who had 2 or more blood pressure measures, maternal cardiometabolic risk factors were associated with an increased rate of blood pressure change from age 2 to 18 years (SBP percentile, 0.5 [95% CI, 0.2-0.8] per year; DBP percentile, 0.7 [95% CI 0.5-1.0] per year).

Conclusions and Relevance

These findings suggest that protecting pregnant individuals from cardiometabolic risk factors may promote healthier blood pressure in the next generation.

Maternal vaginal and fecal microbiota in later pregnancy contribute to child fecal microbiota development in the ECHO cohort

There is growing interest in the use of microbial-seeding interventions to mitigate the impacts of prenatal antibiotics, C-section, and lack of breastfeeding on mother-child microbe sharing. However, the relative importance of maternal vaginal vs. fecal microbiota in this process is unclear. Analyzing 16S rRNA sequences from five US birth cohorts, we found that maternal vaginal and fecal microbiota became more similar as pregnancy progressed, and both niches influenced the child's fecal microbiota. The relative contribution of maternal vaginal microbiota increased when vaginal sampling occurred later in gestation. As children aged from birth to 5 years, their fecal microbiota increasingly resembled their mother's fecal microbiota as compared to vaginal microbiota. Patterns of sharing appeared to differ by prenatal antibiotic use, birth mode (C-section vs. vaginal), and breastfeeding. Our findings enhance understanding of niche-specific mother-child microbe sharing and may inform microbial-seeding interventions. Metagenomic studies are needed to identify specific shared strains.

A scoping review of adult NCD-relevant phenotypes measured in today's large child cohort studies

BACKGROUND

Child cohort studies are important resources that can inform strategies to prevent adult noncommunicable diseases (NCDs). Technological advances now enable direct measurement of NCD-relevant phenotypes at large scale. Across contemporary large child cohorts, we aimed to provide the first comprehensive map of NCD-relevant phenotype measurement and gaps.

METHODS

We included cohorts with >8000 child participants that were recruiting in whole or part after 2010 and measuring phenotypes relevant to ten high-burden NCDs. Our database and gray literature search identified 15 cohort studies for inclusion. Details on phenotype measurement (methods, age, location) are presented in an online, searchable inventory.

RESULTS

All 15 cohorts measure body size or composition. Most cohorts measure aspects of cardiovascular health (n = 10) and neurocognition (n = 9). Fewer measure musculoskeletal phenotypes (n = 6), pulmonary function (n = 6), vision (n = 6) and glucose (n = 4). Only two cohorts measure hearing or kidney function.

CONCLUSIONS

Today's childhood cohorts are not measuring some phenotypes important to global burden of disease, notably kidney function and hearing. Given the rarity of very large contemporary child cohorts, cross-cohort coordination will be required if all major NCD precursors are to be adequately represented for future benefit.

IMPACT

This scoping review provides a comprehensive overview of NCD-relevant phenotype measurement across large, modern child cohort studies. This review has identified measurement gaps in important areas that may obviate steps to prevent and detect NCDs with high global disease burden. Findings may inform planning of collaborative projects and future data collection to address measurement gaps for greatest future benefit.

Adolescent Social Media Use and Mental Health in the Environmental Influences on Child Health Outcomes Study

PURPOSE

Research on adolescent social media use focuses on negative mental health outcomes, with less attention on potential positive outcomes. The current study addresses this limitation by investigating associations between adolescent social media use and both psychological well-being and psychopathology.

METHODS

Three US-based pediatric cohort sites participating in the National Institutes of Health Environmental influences on Child Health Outcomes study contributed cross-sectional survey data. Adolescents (13-18 years) self-reported the time spent and type of (active, passive) social media use, and their psychological well-being (Patient-Reported Outcome Measurement Information System [PROMIS] Life Satisfaction and Meaning and Purpose), psychopathology (Strengths and Difficulties Questionnaire and PROMIS Depressive Symptoms), and peer relationship quality (PROMIS Peer Relationships). We estimated associations between social media use and 4 mental health groups aligned to the dual factor model of mental health (high well-being/low psychopathology; high well-being/high psychopathology; low well-being/low psychopathology; low well-being/high psychopathology), and tested interactions with peer relationships. Models were adjusted for age, sex, race, ethnicity, and family income.

RESULTS

Participants (N = 963) were sociodemographically diverse (22% income ≤130% federal poverty level; 42% adolescents of color). Elastic net regressions revealed more hours using social media increased the probability of being in the high psychopathology/low well-being group; adolescents with poor peer relationships spending ≥7 hours/day on social media had the greatest risk of poor mental health. Positive peer relationships were the strongest predictor of positive mental health.

DISCUSSION

Peer relationships were the most meaningful contribution to adolescent mental health, and quality of social media use had little influence.

Children's executive functioning and health behaviors across pediatric life stages and ecological contexts

Executive functioning (EF) has been linked to chronic disease risk in children. Health behaviors are thought to partially explain this association. The current cross-sectional study evaluated specific domains of EF and varied health behaviors in three pediatric life stages. Pediatric participants (early childhood n = 2074, Mage = 6.4 ± 0.9 y; middle childhood n = 3230, Mage = 9.6 ± 1.2 y; adolescence n = 1416, Mage = 15.2 ± 1.7 y) were part of the Environmental influences on Child Health Outcomes (ECHO) Program. They completed neurocognitive tasks measuring cognitive flexibility, behavioral inhibition, and working memory. Parent- and/or child-report measures of dietary intake, physical activity, sleep duration and quality, income, and positive parenting were also collected. Neighborhood crime and greenspace were calculated from publicly available census-tract level indices. After adjusting for study site, child body mass index, and demographics, working memory was related in the hypothesized direction to several dietary behaviors within all pediatric life stages. Working memory and cognitive flexibility were positively related to physical activity in middle childhood and adolescence. In adolescence, behavioral inhibition was positively related to physical activity and inversely related to sugar-sweetened beverage and total caloric intake. Associations with sleep were all non-significant. All significant associations reflected small effect sizes. Income, positive parenting, greenspace, and crime did not significantly influence any of the EF-health behavior associations. Findings highlight the need to consider EF domains, specific health behaviors, and developmental stage in creating intervention strategies that target EF to improve health behaviors. The small effect sizes reinforce the need for multi-tiered interventions to maximize health.

The role of prenatal maternal sex steroid hormones in weight and adiposity at birth and growth trajectories during infancy

OBJECTIVE

Intrauterine factors can impact fetal and child growth and may underlie the developmental origins of childhood obesity. Sex steroid hormone exposure during pregnancy is a plausible target because of the impact on placental vascularization, nutrient transportation, adipogenesis, and epigenetic modifications. In this study we assessed maternal sex steroid hormones in each trimester in relation to birthweight, neonatal adiposity, and infant growth trajectories, and evaluated sensitive windows of development.

METHODS

Participants from a prospective pregnancy cohort who delivered at term were included in the analysis (n = 252). Estrone, estradiol, and estriol, as well as total and free testosterone throughout gestation were assessed using high-performance liquid chromatography and tandem mass spectrometry. Path analyses were used to assess the direct associations of sex steroid hormones in each trimester with birth outcomes and infant growth trajectories (birth to 12 months) adjusting for covariates and considering moderation by sex.

RESULTS

The associations between prenatal sex steroid hormones and fetal/infant growth varied by sex and timing of hormone exposure. First-trimester estrone was associated with higher birthweight z-scores (β = 0.37, 95% CI: 0.02, 0.73) and truncal skinfold thickness (TST) at birth (β = 0.94, 95% CI: 0.34, 1.54) in female infants. Third-trimester total testosterone was associated with higher TST at birth (β = 0.47, 95% CI: 0.03, 0.86) in both sexes. First-trimester estrone and estradiol and first- and third-trimester testosterone were associated with lower probabilities of high stable weight trajectory compared to low stable weight trajectory (Estrone: β = -3.87, 95% CI: -6.59, -1.16; Estradiol: β = -4.36, 95% CI: -7.62, -1.11; First-trimester testosterone: β = -3.53, 95% CI: -6.63, -0.43; Third-trimester testosterone: β = -3.67, 95% CI: -6.66, -0.69) during infancy in male infants.

CONCLUSIONS

We observed associations between prenatal sex steroid hormone exposure and birthweight, neonatal adiposity and infant growth that were sex and gestational timing dependent. Our findings suggest further investigation on additional mechanisms linking prenatal sex steroid exposure and fetal/postnatal growth is needed.

Child Opportunity Index at birth and asthma with recurrent exacerbations in the US ECHO program

BACKGROUND

Environmental exposures and social determinants likely influence specific childhood asthma phenotypes.

OBJECTIVE

We hypothesized that the Child Opportunity Index (COI) at birth, measuring multiple neighborhood opportunities, influences incidence rates (IRs) for asthma with recurrent exacerbations (ARE).

METHODS

We tested for COI associations with ARE IRs in 15,877 children born between 1990 and 2018 in the ECHO (Environmental Influences on Child Health Outcomes) program. Parent-reported race and ethnicity and other demographics were assessed as effect modifiers.

RESULTS

The IRs of ARE for children born in very low COI neighborhoods was higher (IR = 10.98; 95% CI: 9.71, 12.25) than for other COI categories. Rates for non-Hispanic Black (NHB) children were significantly higher than non-Hispanic White children in every COI category. The ARE IRs for children born in very low COI neighborhoods were several-fold higher for NHB and Hispanic Black children (IR = 15.30; 95% CI: 13.10, 17.49; and IR = 18.48; 95% CI: 8.80, 28.15, respectively) when compared to White children. Adjusting for individual-level characteristics, children born in very low COI neighborhoods demonstrated an ARE IR ratio of 1.26 (95% CI: 0.99, 1.59) with a higher incidence of cases among children ages 2 to 4 years and with a parental history of asthma.

CONCLUSIONS

Rates of ARE were higher among children born in under-resourced communities, and this relationship is strongest for young minoritized children with a parental history of asthma. Higher rates for NHB even in the highest COI categories suggest that risk associated with race persists regardless of social disadvantage.

Demographic Correlates of Autism: How Do Associations Compare Between Diagnosis and a Quantitative Trait Measure?

Prevalence of autism diagnosis has historically differed by demographic factors. Using data from 8224 participants drawn from the Environmental influences on Child Health Outcomes (ECHO) Program, we examined relationships between demographic factors and parent-reported autism-related traits as captured by the Social Responsiveness Scale (SRS; T score > 65) and compared these to relations with parent-reported clinician diagnosis of ASD, in generalized linear mixed effects regression analyses. Results suggested lower odds of autism diagnosis, but not of SRS T > 65, for non-Hispanic Black children (adjusted odds ratio [OR] = 0.76, 95% CI 0.55, 1.06) relative to non-Hispanic White children. Higher maternal education was associated with reduced odds of both outcomes (OR = 0.73, 95% CI 0.51, 1.05 for ASD autism diagnosis and 0.4, 95% CI 0.29, 0.55 for SRS score). In addition, results suggested a lower likelihood of autism diagnosis but a higher likelihood of an SRS score > 65 in Black girls. Findings suggest lower diagnostic recognition of autism in non-Hispanic Black children, despite a similar degree of SRS-assessed autism-related traits falling in the clinically elevated range. Further work is needed to address this disparity.

Depressive and anxiety symptoms during adolescence: The protective roles of adolescent and family assets within ECHO's diverse national population

To understand the factors that preserve mental health amongst a diverse population of adolescents, we examined links between neighborhood-level resources, adolescents' self-reported personal assets (low perceived stress, meaning and purpose, life satisfaction), parent-reported family assets (household income, maternal mental health) and adolescents' self-reported depressive and anxiety symptoms. Participants included a racially and ethnically diverse national sample of 4325 adolescents (10 - 21 years) from the Environmental influences on Child Health Outcomes (ECHO) program. Neighborhood-level resources were not directly associated with depressive or anxiety symptoms. However, higher levels of personal and family assets were related to lower levels of symptoms, regardless of neighborhood resources (ß's: -.09 to .55). Last, high neighborhood resources compensated for the absence of one asset - low perceived stress. For adolescents with levels of perceived stress that were just .17 SD above the sample mean, neighborhood resources were negatively associated with depressive symptoms. Findings did not vary across racial and ethnic groups. Results support the development of asset building endeavors that bolster positive child assets in adolescents and families to reduce mental health disparities. Implications for programs that seek to promote mental health amongst minoritized youth are discussed.

Comparison of Race-Neutral versus Race-Specific Spirometry Equations for Evaluation of Child Asthma

Rationale: Race-based estimates of pulmonary function in children could influence the evaluation of asthma in children from racial and ethnic minoritized backgrounds. Objectives: To determine if race-neutral (Global Lung Function Initiative [GLI]-Global) versus race-specific (GLI-Race-Specific) reference equations differentially impact spirometry evaluation of childhood asthma. Methods: The analysis included 8,719 children aged 5 to <12 years from 27 cohorts across the United States grouped by parent-reported race and ethnicity. We analyzed how the equations affected FEV1, FVC, and FEV1/FVC z-scores. We used multivariable logistic models to evaluate associations between z-scores calculated with different equations and asthma diagnosis, emergency department visits, and hospitalization. Measurements and Main Results: For Black children, the GLI-Global versus GLI-Race-Specific equations estimated significantly lower z-scores for FEV1 and FVC but similar values for FEV1/FVC, thus increasing the proportion of children classified with low FEV1 by 14%. Although both equations yielded strong inverse relationships between FEV1 and FEV1/FVC z-scores and asthma outcomes, these relationships varied across racial and ethnic groups (P < 0.05). For any given FEV1 or FEV1/FVC z-score, asthma diagnosis and emergency department visits were higher among Black and Hispanic than among White children (P < 0.05). For FEV1, GLI-Global equations estimated asthma outcomes that were more uniform across racial and ethnic groups. Conclusions: Parent-reported race and ethnicity influenced relationships between lung function and asthma outcomes. Our data show no advantage to race-specific equations for evaluating childhood asthma, and the potential for race-specific equations to obscure lung impairment in disadvantaged children strongly supports using race-neutral equations.

Association Between Prenatal Antibiotic Exposure and Infant Wheeze Outcomes

AIM

This study examined the association between antibiotic exposure during pregnancy and the development of wheezing and cough during infancy.

METHODS

We analysed data from 12 cohorts in the Environmental influences on Child Health Outcomes Cohort Consortium. Outcomes during the first 18 months after birth included the presence of wheeze or dry cough and treatment or intervention for these symptoms, including medications, emergency room visits, and hospitalisations. We used generalised estimating equations and logistic models with adjustment for inverse propensity scores for exposure to antibiotics.

RESULTS

A total of 4721 pregnancies were included, resulting in 4779 infants. Overall, 1,701/4,721 (36%) individuals received antibiotics during pregnancy, and wheezing was reported in 1,214/4,779 (26%) infants. In adjusted analyses, prenatal antibiotics were not associated with a higher odds of wheeze (OR = 1.06; 95% CI 0.91, 1.24) or hospitalisations or emergency room visits for wheeze or dry cough. However, prenatal antibiotic exposure was associated with a higher odds of medication use for wheeze or dry cough (OR = 1.62; 95% CI 1.10, 2.38).

CONCLUSIONS

Prenatal antibiotic exposure may be associated with an increased odds of medication use for wheeze or dry cough during infancy but may not increase the risk of more severe events.

Racial and ethnic differences in prenatal exposure to environmental phenols and parabens in the ECHO Cohort

BACKGROUND

Research suggests racial/ethnic disparities in prenatal exposure to endocrine disrupting environmental phenols (EPs) in limited populations. However, no studies have investigated racial/ethnic disparities in prenatal EP exposure across the U.S.

OBJECTIVES

To estimate demographic differences in prenatal urinary EPs among participants in the Environmental influences on Child Health Outcomes (ECHO) Cohort.

METHODS

An analysis of 4006 pregnant ECHO participants was performed, with 7854 specimens collected from 1999-2020. Racial/ethnic identity was self-reported. Urinary levels of 2,4-dichlorophenol (2,4-DCP), 2,5-dichlorophenol (2,5-DCP), benzophenone-3 (BP-3), bisphenols A (BPA), F (BPF), and S (BPS), and methyl- (MePb), ethyl- (EtPb), propyl- (PrPb), and butyl- (BuPb) parabens were measured at one or more time points during pregnancy. Effect estimates were adjusted for age, pre-pregnancy body mass index, educational level, gestational age and season at urine collection, and ECHO cohort.

RESULTS

Participants were classified as Hispanic of any race (n = 1658), non-Hispanic White (n = 1478), non-Hispanic Black (n = 490), and non-Hispanic Other (n = 362), which included individuals of multiple races. Urinary 2,4-DCP and 2,5-DCP concentrations were 2- to 4-fold higher among Hispanic, non-Hispanic Black, and non-Hispanic Other participants relative to non-Hispanic White participants. MePb was ~2-fold higher among non-Hispanic Black (95% confidence interval (CI): 1.7-3.1) and non-Hispanic Other (95% CI: 1.5-2.8) participants. PrPb was similarly higher among non-Hispanic Black (95% CI: 1.7-3.7) and non-Hispanic Other (95% CI: 1.3-3.1) participants. EtPb was higher among non-Hispanic Black participants (3.1-fold; 95% CI 1.7-5.8). BP-3 was lower in Hispanic (0.7-fold; 95% CI: 0.5-0.9), non-Hispanic Black (0.4-fold; 95% CI: 0.3-0.5), and non-Hispanic Other (0.5-fold; 95% CI: 0.4-0.7) participants. Urinary BuPb, BPA, BPF, and BPS were similar across groups.

IMPACT STATEMENT

This multisite, observational cohort study investigated whether there are racial and ethnic differences in prenatal exposure to endocrine disrupting environmental phenols and parabens. Among 4006 participants from multiple U.S. cohorts who provided urine specimens during pregnancy, those who self-reported a racial and ethnic identity other than non-Hispanic White had higher urinary concentrations of 2,4-dichlorophenol, 2,5-dichlorophenol, methyl paraben, ethyl paraben, and propyl paraben and lower urinary concentrations of benzophenone-3 than those reporting as non-Hispanic White. These data show differences in prenatal concentrations of endocrine disrupting environmental phenols and parabens by racial and ethnic identity.

Prenatal exposure to environmental bisphenols over time and their association with childhood asthma, allergic rhinitis and atopic dermatitis in the ECHO consortium

Concerns persist about the potential impact of prenatal exposure to bisphenols (BP) and their replacement analogues on childhood asthma and allergies. Previous studies on single and small cohorts had limited statistical power, few investigated analogues BPF and BPS, and even fewer examined atopic outcomes. Our objective was to assess whether prenatal exposures to individual environmental bisphenols (BPA, BPF, BPS) influence risk of childhood asthma, allergic rhinitis, and atopic dermatitis. Data from the U.S. Environmental Influences on Child Health Outcomes (ECHO) consortium were harmonized on measures of prenatal urinary BPA, BPF and BPS and asthma and allergic rhinitis (ages 5-9 years) and atopic dermatitis (up to age 3 years) from 1905 mother-child pairs that were collected between 1998 and 2017. Across the 2012 federal ban of BPA from certain infant products, median BPA levels decreased from 1.11 ng/ml to 0.86 ng/ml; median BPF levels decreased from 0.51 ng/ml to 0.39 ng/ml; and median BPS levels increased from 0.23 ng/ml to 0.31 ng/ml (dilution adjusted; p < 0.001 for all three median comparisons). Prenatal measures of BPA, BPF, and BPS were unrelated to the risk of childhood asthma, allergic rhinitis, or atopic dermatitis in the total population. Modest sex-dependent effects were observed: only among girls, second tertile levels of BPF was associated with a reduced odds of asthma (odds ratio (OR) 0.27, 95% confidence interval (CI) 0.08, 0.93); a continuous index of prenatal BPS was associated with reduced odds of atopic dermatitis (OR 0.64, 95% CI 0.44, 0.93). The ongoing and changing patterns of exposure to bisphenols in the U.S. population require further study with additional attention to time windows of exposure and co-occurring social determinants of health, to continue to inform current policies and evaluate the importance of limiting exposure to BPA and its analogues on childhood asthma, allergic rhinitis, and atopic dermatitis.

Co-occurring Psychopathology in Children With and Without Autism Spectrum Disorder (ASD): Differences by Sex in the ECHO Cohorts

PURPOSE

Our goals were to: 1) examine the occurrence of behavioral and emotional symptoms in children on the autism spectrum in a large national sample, stratifying by sex, and 2) evaluate whether children with increased autism-related social communication deficits also experience more behavioral and emotional problems.

METHODS

 Participants (n = 7,998) were from 37 cohorts from the Environmental influences on Child Health Outcomes (ECHO) Program. Cross-sectional information on demographic factors, parent-report of an ASD diagnosis by clinician, Social Responsiveness Scale (SRS) scores, and Child Behavior Checklist (CBCL) scores were obtained for children aged 2.5-18 years by surveys. We examined mean differences in CBCL Total Problems and DSM-oriented subscale scores by autism diagnosis and by child sex. Analyses using logistic regression were conducted to examine whether autism was associated with higher CBCL scores. We further examined if these relationships differed by child age category (< 6 years, 6-11 years, 12 + years). The relationships between SRS score and CBCL total and subscale scores were examined using quantile regression models, with analyses adjusted for child sex and age.

RESULTS

 In ECHO, 553 youth were reported by a parent to have a clinician diagnosis of autism spectrum disorder (ASD) (432 [78%] boys and 121 [22%] girls). Youth on the spectrum had higher mean CBCL raw scores on Total Problems and all DSM-oriented subscales compared to those not on the spectrum (all p < 0.0001). Analyses adjusted for sex and stratified by age group indicated that higher odds of autism diagnosis were associated with total, depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD) scales in the top 30% of the CBCL score distribution. Autistic girls were more likely to have parent-reported depression and anxiety compared to autistic boys. In quantile regression analyses, we observed evidence of stronger associations between SRS and CBCL for those in higher quantiles of CBCL total problems scale score (beta representing 1-unit change in SRS associated with 1-unit increase in CBCL total problems scale score), among children in the 70-90th percentile (β = 1.60, p < 0.01), or top 10th percentile (β = 2.43, p < 0.01) of the CBCL total problems scale score distribution. Similar findings were seen for the DSM-oriented depression, anxiety, and ADHD subscales.

CONCLUSION

 Results from this large national sample suggest increased behavioral and emotional problems among autistic children compared to non-autistic children throughout early life. Among children on the spectrum this may warrant increased monitoring for co-occurring behavioral and emotional problems.

Combining developmental and sleep health measures for autism spectrum disorder screening: an ECHO study

BACKGROUND

Sleep problems are reported for up to 80% of autistic individuals. We examined whether parsimonious sets of items derived from the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R) and the Brief Infant Sleep Questionnaire (BISQ) are superior to the standard M-CHAT-R in predicting subsequent autism spectrum disorder (ASD) diagnoses.

METHODS

Participants from 11 Environmental influences on Child Health Outcomes (ECHO) cohorts were included. We performed logistic LASSO regression models with 10-fold cross-validation to identify whether a combination of items derived from the M-CHAT-R and BISQ are superior to the standard M-CHAT-R in predicting ASD diagnoses.

RESULTS

The final sample comprised 1552 children. The standard M-CHAT-R had a sensitivity of 44% (95% CI: 34, 55), specificity of 92% (95% CI: 91, 94), and AUROC of 0.726 (95% CI: 0.663, 0.790). A higher proportion of children with ASD had difficulty falling asleep or resisted bedtime during infancy/toddlerhood. However, LASSO models revealed parental reports of sleep problems did not improve the accuracy of the M-CHAT-R in predicting ASD diagnosis.

CONCLUSION

While children with ASD had higher rates of sleep problems during infancy/toddlerhood, there was no improvement in ASD developmental screening through the incorporation of parent-report sleep metrics.

IMPACT

Parental-reported sleep problems are common in autism spectrum disorder (ASD). We investigated whether the inclusion of parental-reports of infant/toddler sleep patterns enhanced the effectiveness of developmental screening for autism. We reported higher rates of difficulty falling asleep and resisting bedtime during infancy and toddlerhood among children later diagnosed with ASD; however, we did not find an improvement in ASD developmental screening through the incorporation of parent-report sleep metrics. In our sample, the standard M-CHAT-R had a sensitivity of 39% among children of mothers with government insurance compared with a sensitivity of 53% among children of mothers with employer-based insurance.

Prenatal exposure to phthalates and phthalate replacements in relation to chorionic plate surface vasculature at delivery

Pregnant people are ubiquitously exposed to endocrine-disrupting phthalates through consumer products and food. The placenta may be particularly vulnerable to the adverse effects of phthalates, with evidence from animal models suggesting impacts on placental development and vascularization. We translate this research to humans, examining gestational exposure to phthalates and phthalate replacements in relation to novel markers of chorionic plate surface vascularization. Phthalate and phthalate replacement metabolites were measured in first trimester urine from pregnant participants in the Understanding Pregnancy Signals and Infant Development (UPSIDE) cohort (n = 154). At delivery, placentae underwent specialized 2D and 3D digital imaging to quantify chorionic plate surface vasculature. Using weighted quantile g-computation mixtures methods as well as multivariable linear regression models examining individual metabolites, we evaluated associations with overall chorionic plate surface area and five chorionic plate surface vascular measures, adjusting for covariates. We additionally examined interactions with placental sex. Exposure to a phthalate mixture was associated with longer total arterial arc length (β = 9.64 cm; 95%CI: 1.68, 17.59), shorter mean arterial arc length (β = -0.07 cm; 95%CI: -0.14, -0.01), and more arterial branch points (β = 5.77; 95%CI: 1.56, 9.98), but not chorionic plate surface area. In models considering individual metabolites and their molar sums, results were strongest for the metabolites of Di-isobutyl phthalate (DiBP), Di-isononyl phthalate (DiNP), and Di(2-ethylhexyl) phthalate (DEHP). Associations with metabolites of phthalate replacements tended to be in the same direction but weaker. Few sex differences were observed. Gestational phthalate exposure may be associated with alterations in placental chorionic plate surface vasculature characterized by more branching and shorter segments. These alterations may have implications for placental perfusion and suggest a placental mechanism by which phthalates may impact fetal development.

Associations of prenatal urinary melamine, melamine analogues, and aromatic amines with gestational duration and fetal growth in the ECHO Cohort

Melamine, its analogues, and aromatic amines (AAs) were commonly detected in a previous study of pregnant women in the Environmental influences on Child Health Outcomes (ECHO) Cohort. While these chemicals have identified toxicities, little is known about their influences on fetal development. We measured these chemicals in gestational urine samples in 3 ECHO cohort sites to assess associations with birth outcomes (n = 1,231). We estimated beta coefficients and 95% confidence intervals (CIs) using adjusted linear mixed models with continuous dilution-standardized concentrations (log2 transformed and scaled by interquartile range, IQR) or binary indicators for detection. As secondary analyses, we repeated analyses using categorical outcomes. Forty-one of 45 analytes were detected in at least one sample, with > 95 % detection of melamine, cyanuric acid, ammelide, and aniline. Higher melamine concentration was associated with longer gestational age (β^ per IQR increase of log2-transformed: 0.082 [95 % CI: -0.012, 0.177]; 2nd vs 1st tertile: 0.173 [-0.048, 0.394]; 3rd vs 1st tertile: 0.186 [-0.035, 0.407]). Similarly in secondary analyses using categorical outcomes, an IQR increase in log2(melamine) was associated with 1.22 [0.99, 1.50] higher odds of post-term (>40 & ≤42 weeks) as compared to full-term (≥38 & ≤40 weeks). Several AAs were associated with birthweight and gestational length, with the direction of associations varying by AA. Some stronger associations were observed in females. Our findings suggest melamine and its analogs and AAs may influence gestational length and birthweight.

A descriptive examination of rurality in the Environmental influences on Child Health Outcomes Cohort: Implications, illustrations, and future directions

PURPOSE

The Environmental influences on Child Health Outcomes (ECHO) Cohort has enrolled over 60,000 children to examine how early environmental factors (broadly defined) are associated with key child health outcomes. The ECHO Cohort may be well-positioned to contribute to our understanding of rural environments and contexts, which has implications for rural health disparities research. The present study examined the outcome of child obesity to not only illustrate the suitability of ECHO Cohort data for these purposes but also determine how various definitions of rural and urban populations impact the presentation of findings and their interpretation.

METHODS

This analysis uses data from children in the ECHO Cohort study who had residential address information between January 2010 and October 2023, including a subset who also had height and weight data. Several rural-urban classification schemes were examined with and without collapsing into binary rural/urban groupings (ie, the Rural-Urban Continuum Codes, 2010 Rural-Urban Commuting Area [RUCA] Codes, and Urban Influence Codes).

FINDINGS

Various rural/urban definitions and classification schemes produce similar obesity prevalence (17%) when collapsed into binary categories (rural vs urban) and for urban participants in general. When all categories within a classification scheme are examined, however, the rural child obesity prevalence ranges from 5.8% to 24%.

CONCLUSIONS

Collapsing rural-urban classification schemes into binary groupings erases nuance and context needed for interpreting findings, ultimately impacting health disparities research. Future work should leverage both individual- and community-level datasets to provide context, and all categories of classification schemes should be used when examining rural populations.

Affective symptoms in pregnancy are associated with the vaginal microbiome

BACKGROUND

Composition of the vaginal microbiome in pregnancy is associated with adverse maternal, obstetric, and child health outcomes. Therefore, identifying sources of individual differences in the vaginal microbiome is of considerable clinical and public health interest. The current study tested the hypothesis that vaginal microbiome composition during pregnancy is associated with an individual's experience of affective symptoms and stress exposure.

METHODS

Data were based on a prospective longitudinal study of a medically healthy community sample of 275 mother-infant pairs. Affective symptoms and stress exposure and select measures of associated biomarkers (diurnal salivary cortisol, serum measures of sex hormones) were collected at each trimester; self-report, clinical, and medical records were used to collect detailed data on socio-demographic factors and health behavior, including diet and sleep. Vaginal microbiome samples were collected in the third trimester (34-40 weeks) and characterized by 16S rRNA sequencing. Identified taxa were clustered into three community clusters (CC1-3) based on dissimilarity of vaginal microbiota composition.

RESULTS

Results indicate that depressive symptoms during pregnancy were reliably associated with individual taxa and CC3 in the third trimester. Prediction of functional potential from 16S taxonomy revealed a differential abundance of metabolic pathways in CC1-3 and individual taxa, including biosynthetic pathways for serotonin and dopamine. We did not find robust evidence linking symptom- and stress-related biomarkers and CCs.

CONCLUSIONS

Our results provide further evidence of how prenatal psychological distress during pregnancy alters the maternal-fetal microbiome ecosystem that may be important for understanding maternal and child health outcomes.

Extending the Environmental influences on Child Health Outcomes (ECHO) Cohort through 2030: Rationale and study protocol

Early life environmental exposures, even those experienced before conception, can shape health and disease trajectories across the lifespan. Optimizing the detection of the constellation of exposure effects on a broad range of child health outcomes across development requires considerable sample size, transdisciplinary expertise, and developmentally sensitive and dimensional measurement. To address this, the National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) Cohort Study is an observational longitudinal pediatric cohort study. In the first phase from 2016-2023, the ECHO Program built a robust platform for investigating prenatal and early life environmental exposures on child health outcomes. Now, the ECHO Program is extending longitudinal follow-up of existing ECHO participants <21 years of age and recruiting and following new pregnant participants <20 weeks gestation and their offspring through 2030. Participants will be enrolled at 72 Cohort Study Sites across all 50 US states, the District of Columbia, and Puerto Rico. Exposure assessments span the biological, chemical/physical, lifestyle, and social environment; child health outcomes focus on five broad domains: pre-, peri-, postnatal; airways; obesity; neurodevelopment; and positive health, or one's physical, mental, and social well-being. Data and biospecimens will be collected annually through August 2030, with an expected total sample size of 60,000 children and their caregivers. The ECHO Cohort Study represents the largest national longitudinal study of children's health in the US. Here, we describe the ECHO Cohort "Cycle 2" observational study arm and the ECHO Cohort Protocol version 3.0 (ECP v3.0), which delineates the data elements, measures, and biospecimens that all ECHO Cycle 2 Cohort Study Sites will collect and analyze.

The influence of early childhood education and care on the relation between early-life social adversity and children's mental health in the environmental influences for Child Health Outcomes Program

Early adversity increases risk for child mental health difficulties. Stressors in the home environment (e.g., parental mental illness, household socioeconomic challenges) may be particularly impactful. Attending out-of-home childcare may buffer or magnify negative effects of such exposures. Using a longitudinal observational design, we leveraged data from the NIH Environmental influences on Child Health Outcomes Program to test whether number of hours in childcare, defined as 1) any type of nonparental care and 2) center-based care specifically, was associated with child mental health, including via buffering or magnifying associations between early exposure to psychosocial and socioeconomic risks (age 0-3 years) and later internalizing and externalizing symptoms (age 3-5.5 years), in a diverse sample of N = 2,024 parent-child dyads. In linear regression models, childcare participation was not associated with mental health outcomes, nor did we observe an impact of childcare attendance on associations between risk exposures and symptoms. Psychosocial and socioeconomic risks had interactive effects on internalizing and externalizing symptoms. Overall, the findings did not indicate that childcare attendance positively or negatively influenced child mental health and suggested that psychosocial and socioeconomic adversity may need to be considered as separate exposures to understand child mental health risk in early life.

Redlining in New York City: impacts on particulate matter exposure during pregnancy and birth outcomes

BACKGROUND

Evidence suggests historical redlining shaped the built environment and health outcomes in urban areas. Only a handful of studies have examined redlining's association with air pollution and adverse birth outcomes in New York City (NYC). Additionally, no NYC-specific studies have examined the impact of redlining on birth weight.

METHODS

This longitudinal cohort study analysed data from the National Institute of Health Environmental Influences on Child Health Outcomes Programme to investigate the extent to which maternal residence in a historically redlined neighbourhood is associated with fine particulate matter (PM2.5) exposure during pregnancy using multivariable regression models. Additionally, we examined how maternal residence in a historically redlined neighbourhood during pregnancy influenced birth weight z-score, preterm birth and low birth weight.

RESULTS

Our air pollution model showed that living in a historically redlined census tract or an ungraded census tract was associated with increased PM2.5 exposure during pregnancy. We also found living in a historically redlined census tract or an ungraded census tract was associated with a lower birth weight z-score. This finding remained significant when controlling for individual and census tract-level race, ethnicity and income. When we controlled PM2.5 in our models assessing the relationship between redlining grade and birth outcome, our results did not change.

DISCUSSION

Our study supports the literature linking redlining to contemporary outcomes. However, our research in ungraded tracts suggests redlining alone is insufficient to fully explain inequality in birth outcomes and PM2.5 levels today.

The Promise and Challenges of Integrating Biological and Prevention Sciences: A Community-Engaged Model for the Next Generation of Translational Research

Beginning with the successful sequencing of the human genome two decades ago, the possibility of developing personalized health interventions based on one's biology has captured the imagination of researchers, medical providers, and individuals seeking health care services. However, the application of a personalized medicine approach to emotional and behavioral health has lagged behind the development of personalized approaches for physical health conditions. There is potential value in developing improved methods for integrating biological science with prevention science to identify risk and protective mechanisms that have biological underpinnings, and then applying that knowledge to inform prevention and intervention services for emotional and behavioral health. This report represents the work of a task force appointed by the Board of the Society for Prevention Research to explore challenges and recommendations for the integration of biological and prevention sciences. We present the state of the science and barriers to progress in integrating the two approaches, followed by recommended strategies that would promote the responsible integration of biological and prevention sciences. Recommendations are grounded in Community-Based Participatory Research approaches, with the goal of centering equity in future research aimed at integrating the two disciplines to ultimately improve the well-being of those who have disproportionately experienced or are at risk for experiencing emotional and behavioral problems.

In utero exposure to per - and polyfluoroalkyl substances (PFAS) associates with altered human infant T helper cell development

Background

Environmental exposures to chemical toxicants during gestation and infancy can dysregulate multiple developmental processes, causing lifelong effects. There is compelling evidence of PFAS-associated immunotoxicity in adults and children. However, the effect of developmental PFAS exposure on infant T-cell immunity is unreported, and, if present, could be implicated in immune-related health outcomes.

Objectives

We seek to model longitudinal changes in CD4+ T-cell subpopulations from birth through 12 months and their association with in-utero PFAS exposure and postnatal CD4+ T-cell frequencies and functions.

Methods

Maternal-infant dyads were recruited as part of the UPSIDE-ECHO cohort during the first trimester between 2015 and 2019 in Rochester, New York; dyads were followed through the infant's first birthday. Maternal PFAS concentrations (PFOS, PFOA, PFNA, and PFHXS) were quantified in serum during the second trimester using high-performance liquid chromatography and tandem mass spectrometry. Infant lymphocyte frequencies were assessed at birth, 6- and 12-months using mass cytometry and high-dimensional clustering methods. Linear mixed-effects models were employed to analyze the relationship between maternal PFAS concentrations and CD4+ T-cell subpopulations (n=200). All models included a PFAS and age interaction and were adjusted for parity, infant sex, and pre-pregnancy body mass index.

Results

In-utero PFAS exposure correlated with multiple CD4+ T-cell subpopulations in infants. The greatest effect sizes were seen in T-follicular helper (Tfh) and T-helper 2 (Th2) cells at 12 months. A log 2 -unit increase in PFOS was associated with lower Tfh [0.17% (95%CI: -0.30, -0.40)] and greater Th2 [0.27% (95%CI: 0.18, 0.35)] cell percentages at 12 months. Similar trends were observed for PFOA, PFNA, and PFHXS.

Discussion

Maternal PFAS exposures correlate with cell-specific changes in the infant T-cell compartment, including key CD4+ T-cell subpopulations that play central roles in coordinating well-regulated, protective immunity. Future studies into the role of PFAS-associated T-cell distribution and risk of adverse immune-related health outcomes in children are warranted.

Timing sensitivity of prenatal cortisol exposure and neurocognitive development

Prenatal glucocorticoid exposure has been negatively associated with infant neurocognitive outcomes. However, questions about developmental timing effects across gestation remain. Participants were 253 mother-child dyads who participated in a prospective cohort study recruited in the first trimester of pregnancy. Diurnal cortisol was measured in maternal saliva samples collected across a single day within each trimester of pregnancy. Children (49.8% female) completed the Bayley Mental Development Scales, Third Edition at 6, 12, and 24 months and completed three observational executive function tasks at 24 months. Structural equation models adjusting for sociodemographic covariates were used to test study hypotheses. There was significant evidence for timing sensitivity. First-trimester diurnal cortisol (area under the curve) was negatively associated with cognitive and language development at 12 months and poorer inhibition at 24 months. Second-trimester cortisol exposure was negatively associated with language scores at 24 months. Third-trimester cortisol positively predicted performance in shifting between task rules (set shifting) at 24 months. Associations were not reliably moderated by child sex. Findings suggest that neurocognitive development is sensitive to prenatal glucocorticoid exposure as early as the first trimester and underscore the importance of assessing developmental timing in research on prenatal exposures for child health outcomes.

Maternal Dietary Patterns During Pregnancy and Child Autism-Related Traits in the Environmental Influences on Child Health Outcomes Consortium

We examined relationships between prenatal dietary patterns and child autism-related outcomes, including parent-reported clinician diagnoses of autism spectrum disorder (ASD) and Social Responsiveness Scale (SRS-2) scores, in up to 6084 participants (with analytic samples ranging from 1671 to 4128 participants) from 14 cohorts in the Environmental Influences on Child Health Outcomes (ECHO) consortium. Associations between quartiles of the Healthy Eating Index (HEI-2015), the Alternative Healthy Eating Index modified for Pregnancy (AHEI-P), and the Empirical Dietary Inflammatory Pattern (EDIP), calculated based on reported prenatal diet, and outcomes were examined using crude and multivariable regression (quantile for SRS scores and logistic for diagnosis). In adjusted models, the higher quartile of prenatal HEI score was associated with lower SRS scores (Q4 vs. Q1 β for median quantile = -3.41 95% CI = -5.15, -1.26). A similar association was observed for the AHEI-P score when adjusting for total calories (Q4 vs. Q1 β = -2.52 95% -4.59, -0.45). There were no significant associations of prenatal diet with ASD diagnosis. Findings from this large U.S.-based study do not suggest strong associations between prenatal dietary patterns and ASD-related outcomes, although subtle associations with broader traits suggest the need to further consider how prenatal diet may relate to ASD-related phenotypes.

Prenatal Diet and Infant Growth From Birth to Age 24 Months

Importance

Being born either small for gestational age (SGA) or large for gestational age (LGA) and experiencing rapid or slow growth after birth are associated with later-life obesity. Understanding the associations of dietary quality during pregnancy with infant growth may inform obesity prevention strategies.

Objective

To evaluate the associations of prenatal dietary quality according to the Healthy Eating Index (HEI) and the Empirical Dietary Inflammatory Pattern (EDIP) with infant size at birth and infant growth from birth to age 24 months.

Design, Setting, and Participants

This cohort study used data from birthing parent-child dyads in 8 cohorts participating in the Environmental influences on Child Health Outcomes program between 2007 and 2021. Data were analyzed from March 2021 to August 2024.

Exposures

The HEI and the EDIP dietary patterns.

Main Outcomes and Measures

Outcomes of interest were infant birth weight, categorized as SGA, reference range, or LGA, and infant growth from birth to ages 6, 12, and 24 months, categorized as slow growth (weight-for-length z score [WLZ] score difference <-0.67), within reference range (WLZ score difference -0.67 to 0.67), or rapid (WLZ score difference, >0.67).

Results

The study included 2854 birthing parent-child dyads (median [IQR] maternal age, 30 [25-34] years; 1464 [51.3%] male infants). The cohort was racially and ethnically diverse, including 225 Asian or Pacific Islander infants (7.9%), 640 Black infants (22.4%), 1022 Hispanic infants (35.8%), 664 White infants (23.3%), and 224 infants (7.8%) with other race or multiple races. A high HEI score (>80), indicative of a healthier diet, was associated with lower odds of LGA (adjusted odds ratio [aOR], 0.88 [95% CI, 0.79-0.98]), rapid growth from birth to age 6 months (aOR, 0.80 [95% CI, 0.37-0.94]) and age 24 months (aOR 0.82 [95% CI, 0.70- 0.96]), and slow growth from birth to age 6 months (aOR, 0.65 [95% CI, 0.50-0.84]), 12 months (aOR, 0.74 [95% CI, 0.65-0.83]), and 24 months (OR, 0.65 [95% CI, 0.56-0.76]) compared with an HEI score 80 or lower. There was no association between high HEI and SGA (aOR, 1.14 [95% CI, 0.95-1.35]). A low EDIP score (ie, ≤63.6), indicative of a less inflammatory diet, was associated with higher odds of LGA (aOR, 1.24 [95% CI, 1.13-1.36]) and rapid infant growth from birth to age 12 months (aOR, 1.50 [95% CI, 1.18-1.91]) and lower odds of rapid growth to age 6 months (aOR, 0.77 [95% CI, 0.71-0.83]), but there was no association with SGA (aOR, 0.80 [95% CI, 0.51-1.25]) compared with an EDIP score of 63.6 or greater.

Conclusions and Relevance

In this cohort study, a prenatal diet that aligned with the US Dietary Guidelines was associated with reduced patterns of rapid and slow infant growth, known risk factors associated with obesity. Future research should examine whether interventions to improve prenatal diet are also beneficial in improving growth trajectory in children.

Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity

Importance

Limited access to healthy foods, resulting from residence in neighborhoods with low food access, is a public health concern. The contribution of this exposure in early life to child obesity remains uncertain.

Objective

To examine associations of neighborhood food access during pregnancy or early childhood with child body mass index (BMI) and obesity risk.

Design, Setting, and Participants

Data from cohorts participating in the US nationwide Environmental Influences on Child Health Outcomes consortium between January 1, 1994, and March 31, 2023, were used. Participant inclusion required a geocoded residential address in pregnancy (mean 32.4 gestational weeks) or early childhood (mean 4.3 years) and information on child BMI.

Exposures

Residence in low-income, low-food access neighborhoods, defined as low-income neighborhoods where the nearest supermarket is more than 0.5 miles for urban areas or more than 10 miles for rural areas.

Main Outcomes and Measures

BMI z score, obesity (age- and sex-specific BMI ≥95th percentile), and severe obesity (age- and sex-specific BMI ≥120% of the 95th percentile) from age 0 to 15 years.

Results

Of 28 359 children (55 cohorts; 14 657 [51.7%] male and 13 702 [48.3%] female; 590 [2.2%] American Indian, Alaska Native, Native Hawaiian, or Other Pacific Islander; 1430 [5.4%] Asian; 4034 [15.3%] Black; 17 730 [67.2%] White; and 2592 [9.8%] other [unspecified] or more than 1 race; 5754 [20.9%] Hispanic and 21 838 [79.1%] non-Hispanic) with neighborhood food access data, 23.2% resided in low-income, low-food access neighborhoods in pregnancy and 24.4% in early childhood. After adjusting for individual sociodemographic characteristics, residence in low-income, low-food access (vs non-low-income, low-food access) neighborhoods in pregnancy was associated with higher BMI z scores at ages 5 years (β, 0.07; 95% CI, 0.03-0.11), 10 years (β, 0.11; 95% CI, 0.06-0.17), and 15 years (β, 0.16; 95% CI, 0.07-0.24); higher obesity risk at 5 years (risk ratio [RR], 1.37; 95% CI, 1.21-1.55), 10 years (RR, 1.71; 95% CI, 1.37-2.12), and 15 years (RR, 2.08; 95% CI, 1.53-2.83); and higher severe obesity risk at 5 years (RR, 1.21; 95% CI, 0.95-1.53), 10 years (RR, 1.54; 95% CI, 1.20-1.99), and 15 years (RR, 1.92; 95% CI, 1.32-2.80). Findings were similar for residence in low-income, low-food access neighborhoods in early childhood. These associations were robust to alternative definitions of low income and low food access and additional adjustment for prenatal characteristics associated with child obesity.

Conclusions

Residence in low-income, low-food access neighborhoods in early life was associated with higher subsequent child BMI and higher risk of obesity and severe obesity. We encourage future studies to examine whether investments in neighborhood resources to improve food access in early life would prevent child obesity.

Gene-environment interactions in human health

Gene-environment interactions (G × E), the interplay of genetic variation with environmental factors, have a pivotal impact on human complex traits and diseases. Statistically, G × E can be assessed by determining the deviation from expectation of predictive models based solely on the phenotypic effects of genetics or environmental exposures. Despite the unprecedented, widespread and diverse use of G × E analytical frameworks, heterogeneity in their application and reporting hinders their applicability in public health. In this Review, we discuss study design considerations as well as G × E analytical frameworks to assess polygenic liability dependent on the environment, to identify specific genetic variants exhibiting G × E, and to characterize environmental context for these dynamics. We conclude with recommendations to address the most common challenges and pitfalls in the conceptualization, methodology and reporting of G × E studies, as well as future directions.

Using ECHO program data to develop a brief measure of caregiver support and cognitive stimulation using the home observation for measurement of the environment-infant/toddler (HOME-IT)

Data from three NIH Environmental influences on Child Health Outcomes (ECHO) Program cohorts that collected the HOME-Infant-Toddler (HOME-IT age 0-3 years) version were used to examine the reliability of a brief scale of caregiver support and cognitive stimulation. Participants with HOME-IT data (N = 2518) were included in this analysis. Mean child age at HOME-IT assessment was 1.51 years, 48% of children were female, and 43% of children identified as Black. A four-stage analysis plan was used to evaluate item response theory assumptions, item response theory model fit, monotonicity, scalability, item fit, and differential item functioning. Results indicate the feasibility of developing a reliable 10-item scale (reliability >0.7) with particularly high precision for children with lower levels of cognitive stimulation.

An Examination of Family Transmission of Traits Measured by the Social Responsiveness Scale-Short Form

PURPOSE

The Social Responsiveness Scale (SRS) is frequently used in research settings to measure characteristics associated with autism spectrum disorders (ASD). A short version has been developed but not yet tested for certain properties of the full SRS, such as familiality. The purpose of this study was to determine if prior familiality findings for the full SRS can be replicated using the short form by measuring the associations of the parental Social Responsiveness Scale-Short Form (SRS-SF) scores with child ASD diagnoses and child SRS-SF scores.

METHODS

We used a nested case-control study within a longitudinal cohort study design. Participants were selected from the Nurses' Health Study II (NHS II). Cases were children of study participants who had been diagnosed with ASD, while controls had not been diagnosed with ASD and were frequency matched by year of birth to cases. 2144 out of 3161 eligible participants returned SRS forms for a child and at least one parent. Participants in NHS II completed SRS forms for their spouses and spouses completed SRS forms for NHS II participants. Parental SRS-SF scores were based on a subset of 16 questions from the SRS. ASD diagnosis among children was reported by the mothers and validated in a subset using the Autism Diagnostic Interview-Revised, as well as child SRS-SF scores.

RESULTS

Children whose parents both had elevated SRS-SF scores (those in the top 20% of the study distribution) had a higher odds of ASD diagnosis than those who did not have elevated parental scores (OR 2.25; 95% CI 1.41, 3.58). Additionally, children whose fathers had elevated SRS-SF scores had a higher odds of ASD diagnosis (OR 2.18; 95% CI 1.60, 2.97) than those whose fathers scores were not elevated. In sex-stratified analyses, male children with elevated parental SRS-SF scores had a higher odds of ASD diagnosis than those who did not have elevated parental scores. These associations were not as evident among female children. Parental SRS-SF scores also predicted child SRS-SF scores among controls.

CONCLUSION

These findings are similar to prior findings for the full SRS and support the ability of the SRS-SF to capture familiality of ASD-related traits.

Prenatal maternal immune activation predicts observed fearfulness in infancy

Fear reactivity is an early emerging temperament trait that predicts longer term behavioral and health outcomes. The current analysis tests the hypothesis, an extension of prior research on maternal immune activation (MIA), that the prenatal maternal immune system is a reliable predictor of observed fear reactivity in infancy. The analysis is based on a prospective longitudinal cohort study that collected data from the first trimester and conducted observational assessments of temperament at approximately 12 months of age (n = 281 infants). MIA was assessed from immune biomarkers measured in maternal blood at each trimester; infant temperament was assessed using the Laboratory Temperament Assessment Battery assessment at 12 months; covariates included family and sociodemographic factors. Patterns of inflammatory markers across gestation reliably predicted observed temperament: elevated prenatal MIA was associated with high fear reactivity to novel stimuli. The findings provide novel evidence of prenatal origins of fear reactivity and suggest developmental mechanisms that may underlie early emerging individual differences in child temperament. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Wasserstein regression with empirical measures and density estimation for sparse data

The problem of modeling the relationship between univariate distributions and one or more explanatory variables lately has found increasing interest. Existing approaches proceed by substituting proxy estimated distributions for the typically unknown response distributions. These estimates are obtained from available data but are problematic when for some of the distributions only few data are available. Such situations are common in practice and cannot be addressed with currently available approaches, especially when one aims at density estimates. We show how this and other problems associated with density estimation such as tuning parameter selection and bias issues can be side-stepped when covariates are available. We also introduce a novel version of distribution-response regression that is based on empirical measures. By avoiding the preprocessing step of recovering complete individual response distributions, the proposed approach is applicable when the sample size available for each distribution varies and especially when it is small for some of the distributions but large for others. In this case, one can still obtain consistent distribution estimates even for distributions with only few data by gaining strength across the entire sample of distributions, while traditional approaches where distributions or densities are estimated individually fail, since sparsely sampled densities cannot be consistently estimated. The proposed model is demonstrated to outperform existing approaches through simulations and Environmental Influences on Child Health Outcomes data.

The HEALthy Brain and Child Development Study (HBCD): NIH collaboration to understand the impacts of prenatal and early life experiences on brain development

The human brain undergoes rapid development during the first years of life. Beginning in utero, a wide array of biological, social, and environmental factors can have lasting impacts on brain structure and function. To understand how prenatal and early life experiences alter neurodevelopmental trajectories and shape health outcomes, several NIH Institutes, Centers, and Offices collaborated to support and launch the HEALthy Brain and Child Development (HBCD) Study. The HBCD Study is a multi-site prospective longitudinal cohort study, that will examine human brain, cognitive, behavioral, social, and emotional development beginning prenatally and planned through early childhood. Influenced by the success of the ongoing Adolescent Brain Cognitive DevelopmentSM Study (ABCD Study®) and in partnership with the NIH Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, the HBCD Study aims to establish a diverse cohort of over 7000 pregnant participants to understand how early life experiences, including prenatal exposure to addictive substances and adverse social environments as well as their interactions with an individual's genes, can affect neurodevelopmental trajectories and outcomes. Knowledge gained from the HBCD Study will help identify targets for early interventions and inform policies that promote resilience and mitigate the neurodevelopmental effects of adverse childhood experiences and environments.

Do small effects matter more in vulnerable populations? an investigation using Environmental influences on Child Health Outcomes (ECHO) cohorts

BACKGROUND

A major challenge in epidemiology is knowing when an exposure effect is large enough to be clinically important, in particular how to interpret a difference in mean outcome in unexposed/exposed groups. Where it can be calculated, the proportion/percentage beyond a suitable cut-point is useful in defining individuals at high risk to give a more meaningful outcome. In this simulation study we compute differences in outcome means and proportions that arise from hypothetical small effects in vulnerable sub-populations.

METHODS

Data from over 28,000 mother/child pairs belonging to the Environmental influences on Child Health Outcomes Program were used to examine the impact of hypothetical environmental exposures on mean birthweight, and low birthweight (LBW) (birthweight < 2500g). We computed mean birthweight in unexposed/exposed groups by sociodemographic categories (maternal education, health insurance, race, ethnicity) using a range of hypothetical exposure effect sizes. We compared the difference in mean birthweight and the percentage LBW, calculated using a distributional approach.

RESULTS

When the hypothetical mean exposure effect was fixed (at 50, 125, 167 or 250g), the absolute difference in % LBW (risk difference) was not constant but varied by socioeconomic categories. The risk differences were greater in sub-populations with the highest baseline percentages LBW: ranging from 3.1-5.3 percentage points for exposure effect of 125g. Similar patterns were seen for other mean exposure sizes simulated.

CONCLUSIONS

Vulnerable sub-populations with greater baseline percentages at high risk fare worse when exposed to a small insult compared to the general population. This illustrates another facet of health disparity in vulnerable individuals.

Exposure to Low-Level Air Pollution and Hyperglycemia Markers during Pregnancy: A Repeated Measure Analysis

Epidemiologic evidence has emerged showing an association between exposure to air pollution and increased risks of gestational diabetes mellitus (GDM). This study examines the effect of low-level air pollution exposure on a subclinical biomarker of hyperglycemia (i.e., HbA1c) in pregnant people without diabetes before conception. We measured HbA1c in 577 samples repeatedly collected from 224 pregnant people in Rochester, NY, and estimated residential concentrations of PM2.5 and NO2 using high-resolution spatiotemporal models. We observed a U-shaped trajectory of HbA1c during pregnancy with average HbA1c levels of 5.13 (±0.52), 4.97 (±0.54), and 5.43 (±0.40)% in early-, mid-, and late pregnancy, respectively. After adjustment for the U-shaped trajectory and classic GDM risk factors, each interquartile range increase in 10 week NO2 concentration (8.0 ppb) was associated with 0.09% (95% CI: 0.02 to 0.16%) and 0.18% (95% CI: 0.08 to 0.28%) increases in HbA1c over the entire pregnancy and in late pregnancy, respectively. These associations remained robust among participants without GDM. Using separate distributed lag models, we identified a period between 8th and 14th gestational weeks as critical windows responsible for increased levels of HbA1c measured at 14th, 22nd, and 30th gestational weeks. Our results suggest that low-level air pollution contributes to hyperglycemia in medically low-risk pregnant people.

How the Environmental Influences on Child Health Outcome (ECHO) cohort can spur discoveries in environmental epidemiology

The Environmental Influences on Child Health Outcome (ECHO) program at the National Institutes of Health is an innovative, large, collaborative research initiative whose mission is to enhance the health of children for generations to come. The goal of the ECHO program is to examine effects of a broad array of early environmental exposures on child health and development. The information includes longitudinal data and biospecimens from more than 100 000 children and family members from diverse settings across the United States ECHO investigators have published collaborative analyses showing associations of environmental exposures-primarily in the developmentally sensitive pre-, peri-, and postnatal periods-with preterm birth and childhood asthma, obesity, neurodevelopment, and positive health. Investigators have addressed health disparities, joint effects of environmental and social determinants, and effects of mixtures of chemicals. The ECHO cohort is now entering its second 7-year cycle (2023-2030), which will add the preconception period to its current focus on prenatal through adolescence. Through a controlled access public-use database, ECHO makes its deidentified data available to the general scientific community. ECHO cohort data provide opportunities to fill major knowledge gaps in environmental epidemiology and to inform policies, practices, and programs to enhance child health. This article is part of a Special Collection on Environmental Epidemiology.

Maternal affective symptoms and sleep quality have sex-specific associations with placental topography

BACKGROUND

The impacts of prenatal maternal affective symptoms on the placental structure are not well-established. Employing Geographic Information System (GIS) spatial autocorrelation, Moran's I, can help characterize placental thickness uniformity/variability and evaluate the impacts of maternal distress on placental topography.

METHODS

This study (N = 126) utilized cohort data on prenatal maternal affective symptoms and placental 2D and 3D morphology. Prenatal maternal depression, stress, anxiety and sleep quality were scored for each trimester using the Edinburgh Postnatal Depression Scale (EPDS), Stressful Life Event Scale (SLE), Penn State Worry Questionnaire (PSWQ), and Pittsburgh Sleep Quality Index (PSQI), respectively. Placental shape was divided into Voronoi cells and thickness variability among these cells was computed using Moran's I for 4-nearest neighbors and neighbors within a 10 cm radius. Sex-stratified Spearman correlations and linear regression were used to study associations between mean placental thickness, placental GIS variables, placental weight and the average score of each maternal variable.

RESULTS

For mothers carrying boys, poor sleep was associated with higher mean thickness (r = 0.308,p = 0.035) and lower placental thickness uniformity (r = -0.36,p = 0.012). Lower placental weight (r = 0.395,p = 0.003), higher maternal depression (r = -0.318,p = 0.019) and worry/anxiety (r = -0.362,p = 0.007) were associated with lower placental thickness uniformity for mothers carrying girls.

LIMITATIONS

The study is exploratory and not all GIS models were developed. Excluding high-risk pregnancies prevented investigating pregnancy complications related hypotheses. A larger sample size is needed for greater confidence for clinical application.

CONCLUSIONS

Placental topography can be studied using GIS theory and has shown that prenatal maternal affective symptoms and sleep have sex-specific associations with placental thickness.

Association of maternal fish consumption and ω-3 supplement use during pregnancy with child autism-related outcomes: results from a cohort consortium analysis

BACKGROUND

Prenatal fish intake is a key source of omega-3 (ω-3) polyunsaturated fatty acids needed for brain development, yet intake is generally low, and studies addressing associations with autism spectrum disorder (ASD) and related traits are lacking.

OBJECTIVE

This study aimed to examine associations of prenatal fish intake and ω-3 supplement use with both autism diagnosis and broader autism-related traits.

METHODS

Participants were drawn from 32 cohorts in the Environmental influences on Child Health Outcomes Cohort Consortium. Children were born between 1999 and 2019 and part of ongoing follow-up with data available for analysis by August 2022. Exposures included self-reported maternal fish intake and ω-3/fish oil supplement use during pregnancy. Outcome measures included parent report of clinician-diagnosed ASD and parent-reported autism-related traits measured by the Social Responsiveness Scale (SRS)-second edition (n = 3939 and v3609 for fish intake analyses, respectively; n = 4537 and n = 3925 for supplement intake analyses, respectively).

RESULTS

In adjusted regression models, relative to no fish intake, fish intake during pregnancy was associated with reduced odds of autism diagnosis (odds ratio: 0.84; 95% confidence interval [CI]: 0.77, 0.92), and a modest reduction in raw total SRS scores (β: -1.69; 95% CI: -3.3, -0.08). Estimates were similar across categories of fish consumption from "any" or "less than once per week" to "more than twice per week." For ω-3 supplement use, relative to no use, no significant associations with autism diagnosis were identified, whereas a modest relation with SRS score was suggested (β: 1.98; 95% CI: 0.33, 3.64).

CONCLUSIONS

These results extend previous work by suggesting that prenatal fish intake, but not ω-3 supplement use, may be associated with lower likelihood of both autism diagnosis and related traits. Given the low-fish intake in the United States general population and the rising autism prevalence, these findings suggest the need for better public health messaging regarding guidelines on fish intake for pregnant individuals.

Advancing Understanding of Chemical Exposures and Maternal-child Health Through the U.S. Environmental Influences on Child Health Outcomes (ECHO) Program: A Scoping Review

PURPOSE OF REVIEW

Environmental chemical exposures may disrupt child development, with long-lasting health impacts. To date, U.S. studies of early environmental exposures have been limited in size and diversity, hindering power and generalizability. With harmonized data from over 60,000 participants representing 69 pregnancy cohorts, the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) Program is the largest study of U.S. children's health. Here, we: (1) review ECHO-wide studies of chemical exposures and maternal-child health; and (2) outline opportunities for future research using ECHO data.

RECENT FINDINGS

As of early 2024, in addition to over 200 single-cohort (or award) papers on chemical exposures supported by ECHO, ten collaborative multi-cohort papers have been made possible by ECHO data harmonization and new data collection. Multi-cohort papers have examined prenatal exposure to per- and polyfluoroalkyl substances (PFAS), phthalates, phenols and parabens, organophosphate esters (OPEs), metals, melamine and aromatic amines, and emerging contaminants. They have primarily focused on describing patterns of maternal exposure or examining associations with maternal and infant outcomes; fewer studies have examined later child outcomes (e.g., autism) although follow up of enrolled ECHO children continues. The NICHD's Data and Specimen Hub (DASH) database houses extensive ECHO data including over 470,000 chemical assay results and complementary data on priority outcome areas (pre, peri-, and postnatal, airway, obesity, neurodevelopment, and positive health), making it a rich resource for future analyses. ECHO's extensive data repository, including biomarkers of chemical exposures, can be used to advance our understanding of environmental influences on children's health. Although few published studies have capitalized on these unique harmonized data to date, many analyses are underway with data now widely available.

Developmental characteristics and accuracy of autism screening among two-year-old toddlers in the ECHO program

BACKGROUND

The Modified Checklist for Autism in Toddlers (M-CHAT) is a common pediatric screening tool with mixed accuracy findings. Prior evidence supports M-CHAT screening for developmental concerns, especially in toddlers born preterm. This study examined M-CHAT accuracy in a large, nationwide sample.

METHODS

3393 participants from the Environmental influences on Child Health Outcomes (ECHO) program were included. Harmonized M-CHAT (M-CHAT-H) results were compared with parent-reported autism diagnosis and autism-related characteristics to assess accuracy for term and preterm children, together and separately. Generalized estimating equations, clustering for ECHO cohort and controlling for demographic covariates, were used to examine associations between developmental and behavioral characteristics with M-CHAT-H accuracy.

RESULTS

Sensitivity of the M-CHAT-H ranged from 36 to 60%; specificity ranged from 88 to 99%. Positive M-CHAT-H was associated with more developmental delays and behavior problems. Children with severe motor delays and more autism-related problems were more likely to have a false-negative M-CHAT-H. Children with fewer behavior problems and fewer autism-related concerns were more likely to have a false-positive screen.

CONCLUSION

The M-CHAT-H accurately detects children at low risk for autism and children at increased risk with moderate accuracy. These findings support use of the M-CHAT-H in assessing autism risk and developmental and behavioral concerns in children.

IMPACT

Previous literature regarding accuracy of the Modified Checklist for Autism in Toddlers (M-CHAT) is mixed but this study provides evidence that the M-CHAT performs well in detecting children at low risk for autism and consistently detects children with developmental delays and behavioral problems. The M-CHAT moderately detects children at increased risk for autism and remains a useful screening tool. This study examines M-CHAT accuracy in a large-scale, nationwide sample, examining associations between screening accuracy and developmental outcomes. These findings impact pediatric screening for autism, supporting continued use of the M-CHAT while further elucidating the factors associated with inaccurate screens.