Maternal obesity and risk of cerebral palsy in children: a systematic review and meta-analysis

A sibling study of the prenatal and perinatal risks for cerebral palsy

BACKGROUND

To evaluate the associations between prenatal and perinatal factors and CP risk using a statewide sibling-comparison design.

METHODS

We established a cohort of over 4 million singleton births in California during 2007-2015, and we identified families with outcome-discordant siblings of 1213 CP and 1544 non-CP. We estimated odds ratio (OR) and 95% confidence interval (CI) for CP according to perinatal factors including preterm birth (PTB), small for gestational age, low Apgar score, and prenatal factors including maternal pregnancy complications (perinatal infection, gestational diabetes, preeclampsia) and lifestyle-related factors (cigarette smoking, pre-pregnancy overweight).

RESULTS

The perinatal factors remained strongly associated with CP using sibling design, although the point estimates were smaller for PTB (cohort OR = 4.72, 95%CI 4.42-5.04, sibling OR = 3.49, 95%CI 2.74-4.46) and low Apgar score (cohort OR = 19.62, 95%CI 17.99-21.41, sibling OR = 8.79, 95%CI 5.49-14.08). In sibling design, the associations between maternal pregnancy complications or pre-pregnancy overweight and CP risk were attenuated to null. We observed stronger effects between maternal cigarette smoking and CP in the sibling design, however sensitivity tests indicated possible bias from carryover effects.

CONCLUSION

Adverse perinatal factors remained strongly associated with childhood CP, while uncontrolled confounding bias required considerations for pregnancy complications and CP development.

IMPACT

We conducted a population-based sibling comparison study to evaluate the associations between several prenatal and perinatal factors and cerebral palsy (CP). Preterm birth, small for gestational age, and low Apgar score at birth remained strongly associated with CP using the sibling comparison design. The associations between several maternal pregnancy complications and CP were close to null in the sibling comparison design, raising the possibility of uncontrolled confounding bias in the cohort analyses. We demonstrated that a sibling comparison design can provide valuable information to triangulate research evidence for CP etiology, but a careful implementation and interpretation of findings is warranted.

Preterm birth increases cerebral palsy hazards in children of mothers with chronic hypertension in pregnancy

BACKGROUND

Children of mothers with chronic-hypertension in pregnancy have high rates of preterm-birth (<37 weeks of gestation) and small-for-gestational-age (SGA), both of which are risk factors of cerebral palsy (CP). This study investigated the cumulative risks of CP in children exposed to maternal chronic-hypertension vs. other types of hypertensive-disorders-of-pregnancy (HDP), and whether preterm-birth and SGA potentiate the antenatal impact of chronic-hypertension to increase CP hazards.

METHODS

This population-based cohort study enrolled 1,417,373 mother-child pairs with singleton live births between 2004 and 2011 from the Taiwan Maternal and Child Health Database. A total of 19,457 pairs with HDP were identified and propensity-score-matched with 97,285 normotensive controls. Children were followed up for CP outcome until age 6-13 years. HDP were classified into chronic-hypertension, gestational-hypertension, preeclampsia, and preeclampsia-with-chronic-hypertension. Using the normotensive group as the reference, the associations between chronic-hypertension and CP hazard were assessed with adjusted hazard ratios (HR) and 95% confidence intervals (CI) in Cox proportional hazards regression models, and the effects of preterm-birth and SGA on the associations were examined.

RESULTS

The HDP group had higher rates of CP (0.8%) than the normotensive group (0.5%), particularly the subgroup of preeclampsia-with-chronic-hypertension (1.0%), followed by preeclampsia (0.9%), chronic-hypertension (0.7%) and gestational-hypertension (0.6%). Preterm-birth, but not SGA, exerted moderating effects to increase CP risks in children exposed to maternal chronic-hypertension. Before adjustments, chronic-hypertension alone had no substantial contribution to CP hazard (HR 1.35, 95% CI 1.00-1.83), while preeclampsia alone (1.64, 1.28-2.11) or with superimposed-chronic-hypertension (1.83, 1.16-2.89) had significant effects. After including preterm-birth in the multivariable model, the CP hazard for chronic-hypertension alone rather than other types of HDP was raised and became significant (1.56, 1.15-2.12), and the significance remained after stepwise adjustments in the final model (1.74, 1.16-2.60).

CONCLUSIONS

Preterm-birth might potentiate CP hazards in children of mothers with chronic-hypertension in pregnancy.

Maternal body mass index and cerebral palsy in children: A systematic review and dose-response meta-analysis

BACKGROUND

Accumulating studies indicate that maternal obesity is associated with the risk of cerebral palsy (CP); however, their conclusions have been inconsistent.

OBJECTIVES

To quantitatively estimate the association between maternal body mass index (BMI) and CP in offspring.

DATA SOURCES

PubMed, Embase and Web of Science.

STUDY SELECTION AND DATA EXTRACTION

Articles published up to 18 September 2022 were searched that reported the correlation between maternal BMI and CP in children. Two reviewers independently extracted data and critically assessed articles.

SYNTHESIS

Pooled relative risks (RR) and 95% confidence intervals (CI) were estimated by the random-effects model. Subgroup analysis and meta-regression were performed to explore sources of heterogeneity.

RESULTS

In total, 11 articles (8,407,668 participants) were identified for inclusion in our meta-analysis. For maternal underweight, no significant association was found with CP risk (RR 1.11, 95% CI 0.90, 1.38). The risk of CP was increased by 25% (RR 1.25, 95% CI 1.06, 1.47), 38% (RR 1.38, 95% CI 1.18, 1.61) and 127% (RR 2.27, 95% CI 1.82, 2.83) for maternal overweight, obesity and obesity grade 3, respectively. In addition, we observed a positive linear dose-response relationship, with the pooled risk of cerebral palsy in offspring increasing by 3% with each unit increase in maternal BMI.

CONCLUSION

This meta-analysis indicates that the risk of CP in offspring grew with maternal overweight or obesity grades increasing, and was positively correlated with maternal BMI.

The association of maternal overweight on long-term neurodevelopmental outcomes in premature infants (< 29 weeks) at 18-24 months corrected age

OBJECTIVE

To determine the association of maternal pre-pregnancy body mass index (BMI) and neurodevelopmental impairment (NDI) at 18-24 months corrected age (CA) in infants born < 29 weeks gestation.

STUDY DESIGN

Infants born between 2005 and 2015 at < 29 weeks gestation were included. BMI was categorized into BMI1 [18.5-24.9 kg/m2], BMI2 [25-29.9 kg/m2], BMI3 [ ≥ 30 kg/m2]. Primary outcome was death or NDI (Bayley-III scores < 85, cerebral palsy, hearing or visual impairment). Univariate and multivariate analysis were used.

RESULTS

There were 315 infants in BMI1, 235 in BMI2, and 147 in BMI3 groups. Adjusted odds ratio (aOR) of death or NDI in BMI2 vs. BMI1 and BMI3 vs BMI1 groups were 1.33 (95% CI 0.86-2.06) and 0.76 (95% CI 0.47-1.22). Adjusted odds ratio of Bayley-III language composite < 85 was 2.06 (95% CI 1.28-3.32).

CONCLUSION

Pre-pregnancy BMI was not associated with death or NDI in extremely preterm infants. Infants born to overweight mothers had higher odds of low language scores.

Maternal obesity and the impact of associated early-life inflammation on long-term health of offspring

The prevalence of obesity is increasingly common in the United States, with ~25% of women of reproductive age being overweight or obese. Metaflammation, a chronic low grade inflammatory state caused by altered metabolism, is often present in pregnancies complicated by obesity. As a result, the fetuses of mothers who are obese are exposed to an in-utero environment that has altered nutrients and cytokines. Notably, both human and preclinical studies have shown that children born to mothers with obesity have higher risks of developing chronic illnesses affecting various organ systems. In this review, the authors sought to present the role of cytokines and inflammation during healthy pregnancy and determine how maternal obesity changes the inflammatory landscape of the mother, leading to fetal reprogramming. Next, the negative long-term impact on offspring’s health in numerous disease contexts, including offspring’s risk of developing neuropsychiatric disorders (autism, attention deficit and hyperactive disorder), metabolic diseases (obesity, type 2 diabetes), atopy, and malignancies will be discussed along with the potential of altered immune/inflammatory status in offspring as a contributor of these diseases. Finally, the authors will list critical knowledge gaps in the field of developmental programming of health and diseases in the context of offspring of mothers with obesity, particularly the understudied role of hematopoietic stem and progenitor cells.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Trends in maternal body mass index in Northern Ireland: a cross-sectional and longitudinal study

Objectives

Explore (1) associations between maternal body mass index (BMI), demographic and clinical characteristics, (2) longitudinal trends in BMI, (3) geographical distributions in prevalence of maternal overweight and obesity.

Design

Retrospective population-based study.

Setting

Linked, anonymised, routinely collected healthcare data and official statistics from Northern Ireland.

Participants

All pregnancies in Northern Ireland (2011–2017) with BMI measured at ≤16 weeks gestation.

Methods

Analysis of variance and χ² tests were used to explore associations. Multiple linear regression was used to explore longitudinal trends and spatial visualisation illustrated geographical distribution. Main outcomes are prevalence of overweight (BMI ≥25 kg/m²) and obesity (BMI ≥30 kg/m²).

Results

152 961 singleton and 2362 multiple pregnancies were included. A high prevalence of maternal overweight and obesity in Northern Ireland is apparent (singleton: 52.4%; multiple: 48.3%) and is increasing. Obesity was positively associated with older age, larger numbers of previous pregnancies and unplanned pregnancy (p<0.001). BMI category was also positively associated with unemployment (35% in obese class III vs 22% in normal BMI category) (p<0.001). Higher BMI categories were associated with increased rate of comorbidities, including hypertension (normal BMI: 1.8% vs obese III: 12.4%), diabetes mellitus (normal BMI: 0.04% vs obese III: 1.29%) and mental ill-health (normal BMI: 5.0% vs obese III: 11.8%) (p<0.001). Prevalence of maternal obesity varied with deprivation (most deprived: 22.8% vs least deprived: 15.7%) (p<0.001). Low BMI was associated with age <20 years, nulliparity, unemployment and mental ill-health (p<0.001).

Conclusions

The prevalence of maternal BMI >25 kg/m² is increasing over time in Northern Ireland. Women are entering pregnancy with additional comorbidities likely to impact their life course beyond pregnancy. This highlights the need for prioritisation of preconception and inter-pregnancy support for management of weight and chronic conditions.

Maternal Chronic Conditions and Risk of Cerebral Palsy in Offspring: A National Cohort Study

BACKGROUND AND OBJECTIVES

Previous studies suggest that children of mothers with certain chronic conditions may be at increased risk of cerebral palsy (CP). We explored possible associations between 17 maternal chronic conditions and CP in offspring.

METHODS

We conducted a prospective cohort study of Norwegian children born in 1990-2012 and surviving to 2 years of age. Information on maternal chronic conditions during pregnancy were extracted from the Medical Birth Registry of Norway (1990-2012). Information on chronic conditions in mothers and fathers recorded in the Norwegian Patient Registry (2008-2014) was available for a subset of children. CP diagnoses were extracted from the National Insurance Scheme (1990-2014) and the Norwegian Patient Registry (2008-2014). We estimated relative risks (RRs) and 95% confidence intervals (CIs) of CP in offspring of parents with chronic conditions compared with the general population using log binominal regression models.

RESULTS

A total of 1 360 149 Norwegian children, including 3575 children with CP (2.6 per 1000 live births), fulfilled the inclusion criteria. The highest risk of CP was among offspring of mothers with type 2 diabetes (RR 3.2; 95% CI 1.8-5.4), lupus erythematosus (RR 2.7; 95% CI 0.9-8.3), type 1 diabetes (RR 2.2; 95% CI 1.4-3.4), and Crohn disease (RR 2.1; 95% CI 1.0-4.1) during pregnancy. No increased risks were seen for offspring of fathers with chronic conditions.

CONCLUSIONS

Several maternal chronic conditions were associated with increased risk of CP in offspring. Maternal autoimmune disorders carried a particular risk.

Adult obesity and its complications: a pediatric disease?

PURPOSE OF REVIEW

Approximately 2.6 million people die each year secondary to obesity related diseases. The risk of developing serious comorbidities depends on the age of onset as well as duration of obesity. In this review, we discuss trends in BMI trajectories from early childhood to adulthood with latest evidence on comorbidities in adulthood stemming from pediatric obesity and benefits of early intervention and treatment in childhood obesity.

RECENT FINDINGS

Childhood obesity poses high risk of metabolic and cardiovascular disorders like type 2 diabetes, hypertension, atherosclerosis, coronary artery disease, and some types of cancer in adulthood. Early life obesity also increases risks of developing menstrual irregularities, infertility, and pregnancy complications. Several grave concerns including malignancies, autoimmune disorders, higher asthma morbidity, and psychiatric implications are found to be associated with childhood obesity. Disease outcomes can be transgenerational, causing suboptimal health in children of mothers with obesity. Encouragingly, many risks associated with childhood obesity can be reduced, delayed, or even reversed by early resolution of obesity necessitating close BMI monitoring and treatment early.

SUMMARY

Early identification and aggressive management of childhood obesity is critical in prevention of debilitating comorbidities in adult life.

VIDEO ABSTRACT

http://links.lww.com/COE/A19.

Association of Chorioamnionitis with Cerebral Palsy at Two Years after Spontaneous Very Preterm Birth: The EPIPAGE-2 Cohort Study

OBJECTIVE

To assess whether chorioamnionitis is associated with cerebral palsy (CP) or death at 2 years' corrected age in infants born before 32 weeks of gestation after spontaneous birth.

STUDY DESIGN

EPIPAGE-2 is a national, prospective, population-based cohort study of children born preterm in France in 2011; recruitment periods varied by gestational age. This analysis includes infants born alive after preterm labor or preterm premature rupture of membranes from 24^0/7 to 31^6/7 weeks of gestation. We compared the outcomes of CP, death at 2 years' corrected age, and "CP or death at age 2" according to the presence of either clinical chorioamnionitis or histologic chorioamnionitis. All percentages were weighted by the duration of the recruitment period.

RESULTS

Among 2252 infants born alive spontaneously before 32 weeks of gestation, 116 (5.2%) were exposed to clinical chorioamnionitis. Among 1470 with placental examination data available, 639 (43.5%) had histologic chorioamnionitis. In total, 346 infants died before 2 years and 1586 (83.2% of the survivors) were evaluated for CP at age 2 years. CP rates were 11.1% with and 5.0% without clinical chorioamnionitis (P = .03) and 6.1% with and 5.3% without histologic chorioamnionitis (P = .49). After adjustment for confounding factors, CP risk rose with clinical chorioamnionitis (aOR 2.13, 95% CI 1.12-4.05) but not histologic chorioamnionitis (aOR 1.21, 95% 0.75-1.93). Neither form was associated with the composite outcome "CP or death at age 2."

CONCLUSIONS

Among infants very preterm born spontaneously, the risk of CP at a corrected age of 2 years was associated with exposure to clinical chorioamnionitis but not histologic chorioamnionitis.

Effects of Overweight and Obesity in Pregnancy on Health of the Offspring

Overweight and obesity in pregnancy confer a wide range of risks on mother, fetus, and offspring throughout their lives. In addition to compounding many common pregnancy complications, including both iatrogenic preterm delivery and cesarean delivery, obesity is associated with multiple fetal anomalies, metabolic sequelae including diabetes and obesity, allergy and asthma, attention-deficit disorder, and likely many other challenges for the offspring. As targeted interventions are being developed, encouraging solid nutrition and exercise in women of childbearing age may stave off risks and mitigate obesity in the next generation.

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

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

Impact of parental over- and underweight on the health of offspring

Parental excess weight and especially pregestational maternal obesity and excessive weight gain during pregnancy have been related to an increased risk of metabolic (obesity, type 2 diabetes, cardiovascular disease, metabolic syndrome) and nonmetabolic (cancer, osteoporosis, asthma, neurologic alterations) diseases in the offspring, probably mediated by epigenetic mechanisms of fetal programming. Maternal underweight is less common in developed societies, but the discrepancy between a poor nutritional environment in utero and a normal or excessive postnatal food supply with rapid growth catch-up appears to be the main candidate mechanism of the development of chronic diseases during the offspring's adulthood. The role of the postnatal environment in both scenarios (parental overweight or underweight) also seems to influence the offspring's health. Lifestyle interventions before and during pregnancy in both parents, but especially in the mother, as well as in children after birth, are advisable to counteract the many undesirable chronic conditions described.