Maternal persistent marijuana use and cigarette smoking are independently associated with shorter gestational age.

BACKGROUND: Research assessing the effects of marijuana use on preterm birth has found mixed results, in part, due to lack of attention to the role of maternal tobacco smoking during pregnancy. OBJECTIVES: The study objective was to investigate whether maternal marijuana use was independently associated with gestational age, preterm birth, and two preterm birth subtypes (spontaneous vs clinician-initiated). METHODS: Participants included 8261 mother-newborn pairs from the Boston Birth Cohort. Information on gestational age was collected from electronic medical records. Marijuana use and tobacco smoking during pregnancy were assessed through a standard questionnaire after birth. Linear and log-linear regression models were used to assess associations between marijuana use with and without tobacco smoking during pregnancy and the outcomes of interest. RESULTS: Of the 8261 mothers, 27.5% had preterm births. About 3.5% of mothers with term deliveries and 5.2% of mothers with preterm births used marijuana during pregnancy. Marijuana use and cigarette smoking were independently associated with a decrease in gestational age by 0.50 weeks (95% confidence interval [CI] -0.87, -0.13) and 0.52 weeks (95% CI -0.76, -0.28), respectively. Marijuana use during early or late pregnancy was associated with a similar decrease in gestational age by 0.50 weeks. When we examined the effects on the preterm birth subtypes, simultaneous marijuana use and tobacco smoking were associated with higher risk of spontaneous preterm birth (RR 1.64, 95% CI 1.23, 2.18). The elevated risk was not observed with clinician-initiated preterm birth. CONCLUSIONS: In this high-risk US population, maternal marijuana use and cigarette smoking during pregnancy were independently associated with shorter gestational age. When we examined the effects on preterm birth subtypes, the elevated risk was only observed with spontaneous preterm birth.

Polydrug Use During Pregnancy and Preterm Birth in a Low-Income, Multiethnic Birth Cohort, Boston, 1998-2018.

OBJECTIVE: The opioid epidemic in the United States increasingly affects women of reproductive age and has resulted in a rise in concurrent polydrug use. The objective of this study was to investigate the effect of this polydrug use on preterm birth in a multiethnic birth cohort. METHODS: We analyzed data from 8261 mothers enrolled in the Boston Birth Cohort from 1998 to 2018 in Boston, Massachusetts. We grouped substances used during pregnancy based on their primary effects (stimulant or depressant) and assessed independent and combined associations with smoking on preterm birth. RESULTS: Of 8261 mothers, 131 used stimulant drugs and 193 used depressant drugs during pregnancy. The preterm birth rate was 27.5% (2271 of 8261) in the sample. Mothers who smoked had 35% increased odds of preterm birth across adjusted models. Mothers who used stimulant drugs without smoking were not at increased risk of preterm delivery compared with mothers who used neither (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.19-1.98), whereas mothers who used depressant drugs without smoking had more than twice the odds of having preterm delivery (OR = 2.31; 95% CI, 1.19-4.44), and infants were at risk of a 1-week reduction in gestational age (OR = -1.05; 95% CI, -2.07 to -0.03). Concurrently smoking and using depressant drugs was associated with increased odds of preterm birth (OR = 1.83; 95% CI, 1.28-2.61), as was concurrently smoking and using stimulant drugs (OR = 1.73; 95% CI, 1.14-2.59). CONCLUSIONS: Using stimulant drugs and depressant drugs during pregnancy is a risk factor for preterm birth. The individual and combined effects of using these drugs with smoking must be considered together to reduce the risk of preterm birth in the United States.

Association Between Maternal Exposure to Lead, Maternal Folate Status, and Intergenerational Risk of Childhood Overweight and Obesity.

Importance: The first pediatric lead screening typically occurs at 1-year well-child care visits. However, data on the extent of maternal lead exposure and its long-term consequences for child health are lacking. Objective: To investigate the associations between maternal red blood cell (RBC) lead levels and intergenerational risk of overweight or obesity (OWO) and whether adequate maternal folate status is associated with a reduction in OWO risk. Design, Setting, and Participants: Prospective birth cohort study. The analysis was conducted from July 14, 2018, to August 2, 2019, at Johns Hopkins Bloomberg School of Public Health. This study included 1442 mother-child pairs recruited at birth from October 27, 2002, to October 10, 2013, and followed up prospectively at Boston Medical Center. Main Outcomes and Measures: Child body mass index (BMI) z score, calculated according to US national reference data, and OWO, defined as BMI at or exceeding the 85th percentile for age and sex. Maternal RBC lead levels and plasma folate levels were measured in samples obtained 24 to 72 hours after delivery; child whole-blood lead level was obtained from the first pediatric lead screening. Results: The mean (SD) age of mothers and children was 28.6 (6.5) years and 8.1 (3.1) years, respectively; 50.1% of children were boys. The median maternal RBC lead level and plasma folate level were 2.5 (interquartile range [IQR], 1.7-3.8) µg/dL and 32.2 (IQR, 22.1-44.4) nmol/L, respectively. The median child whole-blood lead level and child BMI z score were 1.4 (IQR, 1.4-2.0) µg/dL and 0.78 (IQR, -0.08 to 1.71), respectively. Maternal RBC lead level was associated with child OWO risk in a dose-response fashion, with an odds ratio (OR) of 1.65 (95% CI, 1.18-2.32) for high maternal RBC lead level (≥5.0 µg/dL) compared with low maternal RBC lead level (<2.0 µg/dL). Child OWO was highest among children of OWO mothers with high RBC lead levels (adjusted OR, 4.24; 95% CI, 2.64-6.82) compared with children of non-OWO mothers with low RBC lead levels. Children of OWO mothers with high RBC lead levels had 41% lower OWO risk (OR, 0.59; 95% CI, 0.36-0.95; P = .03) if their mothers had adequate plasma folate levels (≥20.4 nmol/L) compared with their counterparts. Conclusions and Relevance: In this sample of a US urban population, findings suggest that maternal elevated lead exposure was associated with increased risk of intergenerational OWO independent of postnatal blood lead levels. Adequate maternal folate status appeared to be associated with lower OWO risk. If confirmed by additional studies, these findings have implications for prenatal lead screening and management to minimize adverse health consequences on children.

Free Tax Services in Pediatric Clinics.

OBJECTIVES: The earned income tax credit (EITC), refundable monies for America's working poor, is associated with improved child health. Yet, 20% of eligible families do not receive it. We provided free tax preparation services in clinics serving low-income families and assessed use, financial impact, and accuracy. METHODS: Free tax preparation services ("StreetCred") were available at 4 clinics in Boston in 2016 and 2017. We surveyed a convenience sample of clients (n = 244) about experiences with StreetCred and previous tax services and of nonparticipants (n = 100; 69% response rate) and clinic staff (n = 41; 48% response rate) about acceptability and feasibility. RESULTS: A total of 753 clients received $1 619 650 in federal tax refunds. StreetCred was associated with significant improvement in tax filing rates. Of surveyed clients, 21% were new filers, 47% were new users of free tax preparation, 14% reported new receipt of the EITC, and 21% reported new knowledge of the EITC. StreetCred had high client acceptability; 96% would use StreetCred again. Families with children were significantly more likely to report StreetCred made them feel more connected to their doctor (P = .02). Clinic staff viewed the program favorably (97% approval). CONCLUSIONS: Free tax services in urban clinics are a promising, feasible financial intervention to increase tax filing and refunds, save fees, and link clients to the EITC. With future studies, we will assess scalability and measure impact on health. StreetCred offers an innovative approach to improving child health in primary care settings through a financial intervention.

Differential effects of stress and African ancestry on preterm birth and related traits among US born and immigrant Black mothers.

Preterm birth (PTB, <37 weeks of gestation) is influenced by a wide range of environmental, genetic and psychosocial factors, and their interactions. However, the individual and joint effects of genetic factors and psychosocial stress on PTB have remained largely unexplored among U.S. born versus immigrant mothers.We studied 1121 African American women from the Boston Birth Cohort enrolled from 1998 to 2008. Regression-based analyses were performed to examine the individual and joint effects of genetic ancestry and stress (including lifetime stress [LS] and stress during pregnancy [PS]) on PTB and related traits among U.S. born and immigrant mothers.Significant associations between LS and PTB and related traits were found in the total study population and in immigrant mothers, including gestational age, birthweight, PTB, and spontaneous PTB; but no association was found in U.S. born mothers. Furthermore, significant joint associations of LS (or PS) and African ancestral proportion (AAP) on PTB were found in immigrant mothers, but not in U.S. born mothers.Although, overall, immigrant women had lower rates of PTB compared to U.S. born women, our study is one of the first to identify a subset of immigrant women could be at significantly increased risk of PTB and related outcomes if they have high AAP and are under high LS or PS. In light of the growing number of immigrant mothers in the U.S., our findings may have important clinical and public health implications.

Specialized care of overweight children in community health centers.

We have developed a new approach to child obesity that supports the delivery of so-called secondary care-referral-based specialized visits-by primary care teams within community health centers. The Healthy Weight Clinic reorganizes care to provide access to a trained team consisting of a pediatric provider, nutritionist, and case manager during dedicated weight management visits. Our model improves obesity care by promoting local specialization and increasing capacity for specialized care; building multidisciplinary teams within primary care; focusing on health behavior change as a critical determinant of chronic disease outcomes; and using health information technology to promote high-quality care.

Primary care pediatricians' roles and perceived responsibilities in the identification and management of maternal depression.

OBJECTIVE: To describe the attitudes and approaches of primary care pediatricians in the identification and management of postpartum and other maternal depression. METHODS: A national survey of randomly selected primary care pediatricians reported their management of the last recalled case of postpartum or other maternal depression, barriers to care, their attitudes about recognition and management, confidence in skills, and their willingness to implement new strategies to improve care. RESULTS: Of 888 eligible primary care pediatricians, 508 (57%) completed surveys. Of these pediatricians, 57% felt responsible for recognizing maternal depression. In their last recalled case, respondents used an unstructured approach for identification based primarily on maternal appearance or complaints. When maternal depression was suspected, additional assessment of any kind was done by 48% of pediatricians. Although 7% perceived themselves to be responsible for treating maternal depression, pediatricians indicated they had an active role in 66% of cases in which they provided 1 or more brief interventions. The major barriers that were believed to limit their diagnosis or management were insufficient time for adequate history (70%) or education/counseling (73%) and insufficient training/knowledge to diagnose/counsel (64%) or treat (48%). Responses with cases involving maternal depression and the specific situation of postpartum depression were very similar. Forty-five percent were confident in their ability to diagnose maternal depression, whereas 32% were confident in their ability to diagnose postpartum depression. Nearly one fourth of pediatricians were willing to change their approach to identification. Pediatricians who felt responsible for recognizing maternal depression were more likely to assess more completely and intervene in cases as well as consider implementing change in their practice. CONCLUSION: Pediatricians' current attitudes and skills that are relevant to maternal depression limit their ability to play an effective role in recognition and management. Future interventions need to address each of these issues. Educational efforts and new clinical approaches may be more effective with those who feel responsible and willing to change their approach to maternal depression.

Neonatal Neurobehavioral and Neuroanatomic Correlates of Prenatal Cocaine Exposure: Problems of Dose and Confounding.

Complex methodologic challenges face researchers studying the effects of prenatal cocaine exposure on infant outcome. These include unavoidable imprecision in ascertaining the gestational timing and dose of cocaine to which the fetus was exposed and difficulties in identifying and quantifying the confounding, mediating, and moderating variables. Review of research on neonatal behavioral and cranial ultrasound findings following in utero cocaine exposure is used to illustrate these issues. We conclude that there are measurable but not dramatic dose-related effects of prenatal cocaine exposure on infant central nervous system structure and function. The effects of dose of prenatal cocaine exposure on later child development remain to be determined. Such research would be facilitated by a scientific consensus delineating relative doses of prenatal cocaine exposure.