Use of Swedish smokeless tobacco during pregnancy: A systematic review of pregnancy and early life health risk.

BACKGROUND AND AIMS: Smokeless tobacco is a heterogeneous product group with diverse composition and prevalence globally. Tobacco use during pregnancy is concerning due to the risk of adverse pregnancy outcomes and effects on child health. Nicotine may mediate several of these effects. This systematic review measured health outcomes from Swedish smokeless tobacco (snus) use during pregnancy. METHOD: Literature search was conducted by an information specialist in May 2022. We included human studies of snus use during pregnancy compared with no tobacco use, assessed risk of bias, conducted a meta-analysis and assessed confidence in effect-estimates using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: We included 18 cohort studies (42 to 1 006 398 participants). Snus use during pregnancy probably (moderate confidence in risk estimates) increase the risk of neonatal apnea, adjusted odds ratio 95% confidence interval [aOR (95% CI)] 1.96 (1.30 to 2.96). Snus use during pregnancy possibly (low confidence in risk estimates) increase the risk of stillbirths aOR 1.43 (1.02 to 1.99), extremely premature births aOR 1.69 (1.17 to 2.45), moderately premature birth aOR 1.26 (1.15 to 1.38), SGA aOR 1.26 (1.09 to 1.46), reduced birth weight mean difference of 72.47 g (110.58 g to 34.35 g reduction) and oral cleft malformations aOR 1.48 (1.00 to 2.21). It is uncertain (low confidence in risk estimates, CI crossing 1) whether snus use during pregnancy affects risk of preeclampsia aOR 1.11 (0.97 to 1.28), antenatal bleeding aOR 1.15 (0.92 to 1.44) and very premature birth aOR 1.26 (0.95 to 1.66). Risk of early neonatal mortality and altered heart rate variability is uncertain, very low confidence. Snus using mothers had increased prevalence of caesarean sections, low confidence. CONCLUSIONS: This systematic review reveals that use of smokeless tobacco (snus) during pregnancy may adversely impact the developing child.

Fetal thoracic circumference in mid-pregnancy and infant lung function.

BACKGROUND AND AIM: Impaired lung function in early infancy is associated with later wheeze and asthma, while fetal thoracic circumference (TC) predicts severity of neonatal lung hypoplasia. Exploring fetal origins of lung function in infancy, we aimed to determine if fetal TC in mid-pregnancy was associated with infant lung function. METHODS: From the prospective Scandinavian general population-based PreventADALL mother-child birth cohort, all 851 3-month-old infants with tidal flow-volume measurements in the awake state and ultrasound fetal size measures at 18 (min-max 16-22) weeks gestational age were included. Associations between fetal TC and time to peak tidal expiratory flow to expiratory time (tPTEF /tE ) were analyzed in linear regression models. To account for gestational age variation, we adjusted TC for simultaneously measured general fetal size, by head circumference (TC/HC), abdominal circumference (TC/AC), and femur length (TC/FL). Multivariable models were adjusted for maternal age, maternal asthma, pre-pregnancy body mass index, parity, nicotine exposure in utero, and infant sex. RESULTS: The infants (47.8% girls) were born at mean (SD) gestational age of 40.2 (1.30) weeks. The mean (SD) tPTEF /tE  was 0.39 (0.08). The mean (SD) TC/HC was 0.75 (0.04), TC/AC 0.87 (0.04), and TC/FL 4.17 (0.26), respectively. Neither TC/HC nor TC/AC were associated with infant tPTEF /tE while a week inverse association was observed between TC/FL and tPTEF /tE  ( ß ^ $\hat{\beta }$ = -0.03, 95% confidence interval [-0.05, -0.007], p = 0.01). CONCLUSION: Mid-pregnancy fetal TC adjusted for fetal head or abdominal size was not associated with tPTEF /tE in healthy, awake 3-month-old infants, while a weak association was observed adjusting for fetal femur length.

Maternal food-avoidance diets and dietary supplements during breastfeeding.

AIMS: To identify maternal food-avoidance diets and dietary supplement use during breastfeeding, and to explore factors associated with food avoidance diets. DESIGN: A prospective mother-child birth cohort study. METHODS: Electronic questionnaires were answered by 1,462 breastfeeding mothers 6 months postpartum in the Preventing Atopic Dermatitis and Allergies in Children (PreventADALL) study from 2014-2016. Demographic and antenatal factors were analysed for associations with food avoidance diets in 1,368 women by multiple logistic regression. RESULTS: Overall, 289 breastfeeding women (19.8%) avoided at least one food item in their diet, most commonly cow's milk in 99 women (6.8%). Foods were most often avoided due to conditions in the child, maternal factors or lifestyle choice. The odds for food avoidance diets were 2.1 (95% CI: 1.3, 3.4) for food allergy (presumed or diagnosed) and 19.4 (5.4, 70.1) for celiac disease in the mother. Dietary supplements were reported by nearly 80%, most commonly cod liver oil.

Infant tidal flow-volume parameters and arousal state.

Background: Infant lung function can be assessed with tidal flow-volume (TFV) loops. While TFV loops can be measured in both awake and sleeping infants, the influence of arousal state in early infancy is not established. The aim of the present study was to determine whether TFV loop parameters in healthy infants differed while awake compared to the sleeping state at 3 months of age. Methods: From the population-based Scandinavian Preventing Atopic Dermatitis and ALLergies in children (PreventADALL) birth cohort, 91 infants had reproducible TFV loops measured with Exhalyzer® D in both the awake and sleeping state at 3 months of age. The TFV loops were manually selected according to a standardised procedure. The ratio of time to peak tidal expiratory flow (t PTEF) to expiratory time (t E) and the corresponding volume ratio (V PTEF/V E), as well as tidal volume (V T) and respiratory rate were compared using nonparametric tests. Results: The mean (95% CI) t PTEF/t E was significantly higher while awake compared to the sleeping state: 0.39 (0.37-0.41) versus 0.28 (0.27-0.29); with the corresponding V PTEF/V E of 0.38 (0.36-0.40) versus 0.29 (0.28-0.30). The V T was similar, while the respiratory rate was higher while awake compared to the sleeping state: 53 (51-56) breaths·min-1 versus 38 (36-40) breaths·min-1. Conclusion: Higher t PTEF/t E, V PTEF/V E and respiratory rate, but similar V T while awake compared to the sleeping state suggests that separate normative TFV loop values according to arousal state may be required in early infancy.

Extract and molecular-based early infant sensitization and associated factors-A PreventADALL study.

BACKGROUND: More knowledge about sensitization patterns in early infancy, including impact of molecular allergology, is needed to help predict future allergy development more accurately. OBJECTIVE: We aimed to determine the prevalence and patterns of allergic sensitization at 3 months of age, and explore possible associated factors. METHODS: From the Scandinavian antenatally recruited PreventADALL mother-child cohort, we included 1110 3-month infants with available serum. Sensitization was defined as s-IgE of ≥0.1 kUA /L by Phadiatop Infant® (ThermoFisher Scientific) including birch, cat, grass, dog, milk, egg, peanut and wheat. Further ImmunoCAP analyses to ovomucoid, casein, Ara h 1-3, omega-5-gliadin were performed in food extract s-IgE-positive children. Maternal sensitization was defined as s-IgE ≥ 0.35 kUA /L to Phadiatop® (inhalant allergen mix) and/or Fx5 (food allergen mix) at 18-week pregnancy. RESULTS: Overall 79 (7.3%) infants had specific sensitization, many with low s-IgE-levels (IQR 0.16-0.81 kUA /L), with 78 being sensitized to food extract allergens; 41 to egg, 27 to milk, 10 to peanut, and 25 to wheat. A total of 62/78 were further analysed, 18 (29%) had s-IgE to ovomucoid, casein, Ara h 1-3 and/or omega-5-gliadin. Eight infants (0.7%) were sensitized to inhalant allergens. Maternal sensitization to food allergens was associated with infant sensitization, odds ratio 3.64 (95% CI 1.53-8.68). CONCLUSION: Already at 3 months of age, 7% were sensitized to food, mostly without detectable s-IgE to food allergen molecules, and <1% to inhalant allergens. Maternal food sensitization was associated with infants' sensitization.

Physical activity in pregnancy: a Norwegian-Swedish mother-child birth cohort study.

BACKGROUND: Physical activity during pregnancy is important for maternal and offspring health. Optimal conditions during pregnancy may help reduce the burden of noncommunicable diseases. National and international guidelines recommend at least 150 minutes of physical activity of at least moderate intensity per week. To optimize physical activity in pregnant women, it is important to identify factors associated with higher levels of physical activity. OBJECTIVE: This study aimed to explore types and levels of physical activity in midpregnancy in Norway and Sweden and to identify factors associated with higher levels of physical activity. MATERIALS AND METHODS: From the population-based mother-child cohort Preventing Atopic Dermatitis and Allergies in Children study recruiting 2697 women in Norway and Sweden from 2014 to 2016, we included 2349 women who answered an electronic questionnaire at enrollment in midpregnancy. Women were asked about regular physical activity in the last 2 weeks of pregnancy and afterward for types and levels of physical activity in pregnancy and before pregnancy and socioeconomic status, lifestyle, and maternal health. Logistic regression analyses were used to identify factors associated with higher levels of physical activity in pregnancy, defined as >30 minutes per session of ≥2 times per week of moderate- or high-intensity brisk walking, strength training, jogging, and bicycling. RESULTS: No regular physical activity during the last 2 weeks before answering the questionnaire at midpregnancy was reported by 689 women (29%). In this study, 1787 women (76%) reported weekly strolling during pregnancy. Regular physical activity at least twice weekly in the first half of pregnancy was reported as brisk walking by 839 women (36%), bicycling by 361 women (15%), strength training by 322 women (14%), and other activities by <10% of women. Among the 1430 women with regular moderate- or high-intensity physical activity, the estimated median duration per week was 120 minutes. Higher physical activity levels were achieved in 553 women (23.5%) by brisk walking, 287 women (12.2%) by strength training, 263 women (11.2%) by bicycling, and 114 women (4.9%) by jogging. Higher physical activity levels were positively associated with regular physical activity before pregnancy, dog ownership, and atopic dermatitis and negatively associated with higher body mass index, study location in Østfold, previous pregnancy or pregnancies, non-Nordic origin, suburban living, and sick leave. CONCLUSION: At midpregnancy, 29% of women were inactive, and less than 50% of women had at least 2 hours of moderate-intensity physical activity weekly. Awareness of physical activity in pregnancy should be discussed at pregnancy follow-up visits, particularly among women with higher body mass index, sick leave, previous pregnancy or pregnancies, and non-Nordic origin.

Maternal use of nicotine products and breastfeeding 3 months postpartum.

AIM: We aimed to determine the prevalence of and factors associated with maternal use of nicotine products in relation to breastfeeding. METHODS: Nicotine use 3 months postpartum was determined in the Scandinavian PreventADALL mother-child birth cohort study recruiting 1837 women from 2014 to 2016. Electronic questionnaires at 18 weeks pregnancy and 3 months postpartum provided information on snus use, smoking or other nicotine use, infant feeding and socio-economic factors. The risk of nicotine use in relation to breastfeeding was analysed with logistic regression. RESULTS: Overall, 5.6% of women used snus (2.9%), smoked (2.7%) or both (n = 2) 3 months postpartum, while one used other nicotine products. Among the 1717 breastfeeding women, 95.1% reported no nicotine use, while 2.4% used snus, 2.5% smoked and one dual user. Compared to 3.7% nicotine use in exclusively breastfeeding women (n = 1242), the risk of nicotine use increased by partly (OR 2.26, 95% CI 1.45-3.52) and no breastfeeding (OR 4.58, 95% CI 2.57-8.21). Nicotine use before (14.5% snus, 16.4% smoking) or in pregnancy (0.2% snus, 0.4% smoking) significantly increased the risk of using nicotine during breastfeeding. CONCLUSION: Few breastfeeding women used snus or smoked 3 months postpartum, with increased risk by nicotine use before or during pregnancy.

Snus in pregnancy and infant birth size: a mother-child birth cohort study.

RATIONALE: While recent studies show that maternal use of snus during pregnancy is increasing, the potential effects on infant birth size is less investigated, with conflicting results. OBJECTIVES: We aimed to determine if maternal use of snus during pregnancy influences the infant anthropometric and proportional size measures at birth. METHODS: In 2313 mother-child pairs from the population-based, mother-child birth cohort PreventADALL (Preventing Atopic Dermatitis and ALLergies) in Norway and Sweden, we assessed nicotine exposure by electronic questionnaire(s) at 18 and 34 weeks of pregnancy, and anthropometric measurements at birth. Associations between snus exposure and birth size outcomes were analysed by general linear regression. RESULTS: Birthweight was not significantly different in infants exposed to snus in general, and up to 18 weeks of pregnancy in particular, when adjusting for relevant confounders including maternal age, gestational age at birth, pre-pregnancy body mass index, parity, fetal sex and maternal gestational weight gain up to 18 weeks. We found no significant effect of snus use on the other anthropometric or proportional size measures in multivariable linear regression models. Most women stopped snus use in early pregnancy. CONCLUSION: Exposure to snus use in early pregnancy, with most women stopping when knowing about their pregnancy, was not associated with birth size. We were unable to conclude on effects of continued snus use during pregnancy because of lack of exposure in our cohort.

Stopping when knowing: use of snus and nicotine during pregnancy in Scandinavia.

In young women, the use of snus increases in parallel with decreasing smoking rates but the  use in pregnancy is unclear. Our aims were to determine the prevalence of snus use, smoking and other nicotine-containing product use during pregnancy, and to identify predictors for snus use in pregnancy. Prevalence was determined for 2528 women in Norway and Sweden based on the Preventing Atopic Dermatitis and ALLergies (PreventADALL) study, a population-based, mother-child birth cohort. Electronic questionnaires were completed in pregnancy week 18 and/or week 34, and potential predictors of snus use were analysed using logistic regression models. Ever use of any snus, tobacco or nicotine-containing products was reported by 35.7% of women, with similar rates of snus use (22.5%) and smoking (22.6%). Overall, 11.3% of women reported any use of nicotine-containing products in pregnancy up to 34 weeks, most often snus alone (6.5%). Most women (87.2%) stopped using snus by week 6 of pregnancy. Snus use in pregnancy was inversely associated with age and positively associated with urban living and personal or maternal history of smoking. While 11.3% of women used snus or other nicotine-containing products at some time, most stopped when recognising their pregnancy. Younger, urban living, previously smoking women were more likely to use snus in pregnancy.

A falls case summary: Application of the public health nursing intervention wheel.

BACKGROUND: The Public Health Intervention Wheel (PHIW) is a population-based practice model that encompasses three levels of practice (community, systems, and individual/family) and 17 public health interventions. Each intervention and practice level contributes to improving population health. Public health nurses (PHNs) provide care at the three levels of practice. Prevention of falls is a public health issue and the majority of falls happen at home. Therefore, prevention and management of falls in the community could benefit from a public health systems approach by PHNs underpinned by the PHIW. CASE PRESENTATION: A hypothetical case is presented of a 78-year-old gentleman who had a fall which resulted in a fractured right acetabulum and surgery before being discharged home. METHODS: The aim of this paper was to use a case summary to illustrate PHN practice in the context of the PHIW as applied to falls management and prevention. This paper focuses on fall incidence and PHN response in Ireland and Norway. The PHIW is described and relevant interventions from the PHIW are applied to PHN practice in managing the case. CONCLUSIONS: The PHIW model provides insight into the potential scope of public health nursing in falls, articulating PHN practice in the community.