Portable HEPA filter air cleaner use during pregnancy and children's behavior problem scores: a secondary analysis of the UGAAR randomized controlled trial.

BACKGROUND: Developmental exposure to particulate matter (PM) air pollution may impair children's behaviors. Our objectives were to quantify the impact of reducing indoor PM using portable HEPA filter air cleaners during pregnancy on behavioral problems in children and to assess associations between indoor fine PM (PM2.5) concentrations during pregnancy and children's behavior. METHODS: This is a secondary analysis of a single-blind parallel-group randomized controlled trial in which we randomly assigned 540 non-smoking pregnant women to receive 1 or 2 HEPA filter air cleaners or no air cleaners. We administered the Behavior Assessment System for Children (BASC-3) to caregivers when children were a mean age of 23 months, and again at a mean age of 48 months. Primary outcomes were the four BASC-3 composite scales: externalizing problems, internalizing problems, adaptive skills, and the behavioral symptoms index. We imputed missing data using multiple imputation with chained equations. The primary analysis was by intention-to-treat. In a secondary analysis, we evaluated associations between BASC-3 composite indices and modeled trimester-specific PM2.5 concentrations inside residences. RESULTS: We enrolled participants at a median of 11 weeks gestation. After excluding miscarriages, still births and neonatal deaths, our analysis included 478 children (233 control and 245 intervention). We observed no differences in the mean BASC-3 scores between treatment groups. An interquartile increase (20.1 µg/m3) in first trimester PM2.5 concentration was associated with higher externalizing problem scores (2.4 units, 95% CI: 0.7, 4.1), higher internalizing problem scores (2.4 units, 95% CI: 0.7, 4.0), lower adaptive skills scores (-1.5 units, 95% CI: -3.0, 0.0), and higher behavior symptoms index scores (2.3 units, 95% CI: 0.7, 3.9). Third trimester PM2.5 concentrations were also associated with some behavioral indices at age 4, but effect estimates were smaller. No significant associations were observed with PM2.5 concentrations during the second trimester or for any of the BASC indices when children were 2 years old. CONCLUSION: We found no benefit of reducing indoor particulate air pollution during pregnancy on parent-reported behaviors in children. Associations between indoor PM2.5 concentrations in the first trimester and behavioral scores among 4-year old children suggest that it may be necessary to intervene early in pregnancy to protect children, but these exploratory findings should be interpreted cautiously. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01741051.

Congenital anomalies in the offspring of occupationally exposed mothers: a systematic review and meta-analysis of studies using expert assessment for occupational exposures.

STUDY QUESTION: Is there an association between maternal occupational exposure to solvents, pesticides and metals as assessed by expert-based assessment and congenital anomalies in the offspring? SUMMARY ANSWER: There is an association between maternal occupational exposure to solvents and congenital anomalies in the offspring, including neural tube defects, congenital heart defects and orofacial clefts. WHAT IS KNOWN ALREADY: One important environmental risk factor for development of congenital anomalies is maternal occupational exposure to chemicals in the workplace prior to and during pregnancy. A number of studies have assessed the association with often conflicting results, possibly due to different occupational exposure assessing methods. STUDY DESIGN, SIZE, DURATION: For this systematic review with meta-analysis, the search terms included maternal occupation, exposure, congenital anomalies and offspring. Electronic databases MEDLINE and EMBASE were searched for English studies up to October 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two reviewers independently screened all citations identified by the search. Case-control studies and cohort studies were included if (I) they reported on the association between maternal occupational exposure to solvents, pesticides or metals and congenital anomalies, and (II) assessment of occupational exposure was performed by experts. Data on study characteristics, confounders and odds ratios (ORs) were extracted from the included studies for four subgroups of congenital anomalies. Methodological quality was assessed using the Newcastle-Ottawa Scale. In the meta-analysis, random effects models were used to pool estimates. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 2806 titles and abstracts and 176 full text papers were screened. Finally, 28 studies met the selection criteria, and 27 studies could be included in the meta-analysis. Our meta-analysis showed that maternal occupational exposure to solvents was associated with neural tube defects (OR: 1.51, 95%CI: 1.09-2.09) and congenital heart defects (OR: 1.31, 95%CI:1.06-1.63) in the offspring. Also maternal occupational exposure to glycol ethers, a subgroup of solvents, was associated with neural tube defects (OR: 1.93, 95%CI: 1.17-3.18) and orofacial clefts (OR: 1.95, 95%CI: 1.38-2.75) in the offspring. Only one study investigated the association between maternal occupational exposure to solvents and hypospadias and found an association (OR: 3.63, 95%CI: 1.94-7.17). Results of the included studies were consistent. In our meta-analysis, we found no associations between occupational exposure to pesticides or metals and congenital anomalies in the offspring. LIMITATIONS, REASONS FOR CAUTION: A limited number of studies was included, which made it impossible to calculate pooled estimates for all congenital anomalies, analyse individual chemicals or calculate exposure-response relations. Bias could have been introduced because not all included studies corrected for potentially confounding factors. WIDER IMPLICATIONS OF THE FINDINGS: Employers and female employees should be aware of the possible teratogenic effects of solvent exposure at the workplace. Therefore, is it important that clinicians and occupational health specialist provide women with preconception advice on occupational solvent exposure, to reduce the congenital anomaly risk. STUDY FUNDING/COMPETING INTEREST(S): NSp was paid by the Graduate School of Medical Sciences (MD/PhD program), UMCG, Groningen, the Netherlands. EUROCAT Northern Netherlands is funded by the Dutch Ministry of Health, Welfare and Sports. There are no competing interests. REGISTRATION NUMBER: CRD42017053943.

Why do some women with epilepsy use valproic acid despite current guidelines? A single-center cohort study.

OBJECTIVE: Current guidelines and regulations strongly discourage the use of valproic acid (VPA) in women of childbearing age because of the risk of congenital malformations and neurodevelopmental disability in children exposed to VPA in utero. Our goal was to establish the reasons for continued use of VPA in a cohort of women with epilepsy (WWE) and to characterize the subgroup of WWE who do not consent to withdraw VPA despite potential risks. MATERIAL AND METHODS: The study included consecutive adult premenopausal WWE who visited an outpatient epilepsy clinic between April 2017 and March 2018. Data on demographics (age, age at onset of epilepsy), characteristics of epilepsy (types and frequency of seizures), and its treatment were collected from medical records and seizure diaries. All WWE taking VPA were regularly informed about VPA-related risks and had the opportunity to discuss the withdrawal of VPA. RESULTS: The study involved 353 WWE (mean age: 31.7 years). Focal epilepsy was diagnosed in 244 (69.1%) patients; 180 (51.0%) women had no seizures during last 12 months before the study visit, and 228 patients (64.6%) were on monotherapy. A total of 146 (41.3%) patients used VPA in the past, and 98 (27.8%) never used VPA. Of women who were currently on VPA (n = 109, 30.9%), 30 had concurrent severe disabilities that would make future pregnancy extremely unlikely, in further 15 patients, VPA was recommenced because of failure of alternative treatment and 64 women did not accept the plan of VPA withdrawal. Women currently on VPA were more likely to have genetic generalized epilepsy and to be on monotherapy (both p ≪ 0.001). Among 64 WWE who decided to continue therapy with VPA, 35 (55.5%) had generalized epilepsy and 35 (55.5%) were in remission, 27 (42.2%) had at least one child, 9 (14.1%) planned to have a child in the near future but only 15 (23.4%) used effective contraception. CONCLUSION: Treatment with VPA is unavoidable in many WWE of childbearing age despite recent regulations. About 60% of WWE currently treated with VPA do not consent to withdraw VPA treatment after thorough consideration of potential risks and other 40% use VPA because pregnancy is highly unlikely and/or other treatments failed.

Preterm birth and economic benefits of reduced maternal exposure to fine particulate matter.

Preterm birth (PTB) is a predictor of infant mortality and later-life morbidity. Despite recent declines, PTB rates remain high in the United States. Growing research suggests a possible relationship between a mother's exposure to common air pollutants, including fine particulate matter (PM2.5), and PTB of her baby. Many policy actions to reduce exposure to common air pollutants require benefit-cost analysis (BCA), and it's possible that PTB will need to be included in BCA in the future. However, an estimate of the willingness to pay (WTP) to avoid PTB risk is not available, and a comprehensive alternative valuation of the health benefits of reducing pollutant-related PTB currently does not exist. This paper demonstrates an approach to assess potential economic benefits of reducing PTB resulting from environmental exposures when an estimate of WTP to avoid PTB risk is unavailable. We utilized a recent meta-analysis, county-level air quality data and county-level PTB prevalence data to estimate the potential health and economic benefits of a reduction in air pollution-related PTB, with PM2.5 as our case study pollutant. Using this method, a simulated nationwide 10% decrease from 2008 PM2.5 levels resulted in an estimated reduction of 5016 PTBs and benefits of at least $339 million, potentially reaching over one billion dollars when considering later-life effects of PTB.

Designing an educational intervention on second-hand smoke in smoker men on the exposure of pregnant wives: a protocol for a randomized controlled trial.

BACKGROUND: Complications of exposure to second-hand smoke (SHS) are known to affect the health of pregnant women; it requires designing an educational program to reduce the exposure of pregnant women to smoke. Therefore, the purpose of this study was to design an educational program to reduce the exposure of pregnant women with the second-hand smoke of their husband. METHODS: This research-based program is designed in three phases, in the first phase of the study, the level of knowledge, attitude, and practice of men regarding SHS will be measured using a questionnaire. The questionnaire will be based on a literature review and experts opinions. In the next phase the educational program will be designed based on the results of the first phase of the study on the level of knowledge, attitude, self-efficacy, and practice of men, as well as a literature review and experts opinions, and the research team will finalize it according to priorities. To follow up the training will be sent reminders messages. Pregnant women will also be trained to protect themselves and support their husbands to quit smoking. The third phase includes the implementation of educational intervention with pretest-posttest with two intervention and control groups. DISCUSSION: The present study provides strong information and data regarding the needs and strategies for reducing the exposure to second-hand smoke in pregnant women. Therefore, designing a program, and a review article and updated evidences can lead to avoid pregnant women the exposure to second hand smoke and reducing smoking in smoker husbands. It can also reduce their medical and treatment costs. TRIAL REGISTRATION: Registration of this randomized control trial has been completed with the Iranian Registry of Clinical Trials, IRCT20180722040555N1 .

Simultaneous analysis of bisphenol A fractions in maternal and fetal compartments in early second trimester of pregnancy.

Background Bisphenol A (BPA) is an estrogenic, endocrine-disrupting compound widely used in the industry. It is also a ubiquitous environmental pollutant. Its presence was confirmed in human fetuses, which results from maternal exposure during pregnancy. The mechanisms behind maternal-fetal transfer, and relationships between pregnant women and fetal exposures remain unclear. The aim of this study was to assess the impact of maternal exposure to BPA on the exposure of the fetus. Methods Maternal plasma and amniotic fluid samples were collected from 52 pregnant women undergoing amniocentesis for prenatal diagnosis of chromosomal abnormalities. BPA was measured by gas chromatography-mass spectrometry (GC-MS). The permeability factor - a ratio of fetal-to-maternal BPA concentration - was used as a measure delineating the transplacental transfer of BPA. Results The median concentration of maternal plasma BPA was 8 times higher than the total BPA concentration in the amniotic fluid (8.69 ng/mL, range: 4.3 ng/mL-55.3 ng/mL vs. median 1.03 ng/mL, range: 0.3 ng/mL-10.1 ng/mL). There was no direct relationship between the levels of BPA in maternal plasma and amniotic fluid levels. The permeability factor, in turn, negatively correlated with fetal development (birth weight) (R = -0.54, P < 0.001). Conclusion Our results suggest that the risk of fetal BPA exposure depends on placental BPA permeability rather than the levels of maternal BPA plasma concentration and support general recommendations to become aware and avoid BPA-containing products.

A screening questionnaire for occupational and hobby exposures during pregnancy.

BACKGROUND: Occupational and environmental exposures during the prenatal period may be associated with adverse pregnancy outcomes and lifelong health effects. Yet, identification and evaluation of these potential hazards is lacking in routine obstetric care. AIMS: To assess the feasibility of incorporating a self-administered occupational and environmental exposure questionnaire into obstetric clinics. METHODS: A cross-sectional survey assessed prenatal clinic patients at a public hospital who were currently employed and <20 weeks gestation. Questionnaires evaluated job characteristics, workplace and hobby exposures, protective equipment use and symptoms during pregnancy. RESULTS: Of 69 participants (96% response rate), 46% were predominantly Spanish-speaking. Primary occupations were caregiver (16%), cleaner (14%) and administrative assistant (14%). Overall, 93% were exposed to a workplace hazard, with most participants reporting physical stressors (82%) or organic solvent exposure (78%). Most women (74%) used some personal protective equipment. Nearly half (54%) reported at least one non-pregnancy symptom, and 52% were referred for follow-up with an occupational medicine practitioner. Household and hobby-related chemical exposures were common in our sample (91%). We observed moderate consistency between job task and chemical use responses: 67-99% of intentionally redundant questions were fully or partially matched. Closed- compared to open-ended activity questions identified a higher proportion of physical stressors (82% versus 12%) and cleaning product (76% versus 30%) exposures. CONCLUSIONS: A self-administered questionnaire is an effective screening tool for identifying women with occupational and hobby-related exposures during pregnancy. Consistent incorporation of exposure assessment into prenatal care can improve clinical communications and early interventions for at-risk pregnant women.

Consequences of prenatal geophagy for maternal prenatal health, risk of childhood geophagy and child psychomotor development.

OBJECTIVE: To investigate the relationship between prenatal geophagy, maternal prenatal haematological indices, malaria, helminth infections and cognitive and motor development among offspring. METHODS: At least a year after delivery, 552 of 863 HIV-negative mothers with singleton births who completed a clinical trial comparing the efficacy of sulfadoxine-pyrimethamine and mefloquine during pregnancy in Allada, Benin, responded to a nutrition questionnaire including their geophagous habits during pregnancy. During the clinical trial, helminth infection, malaria, haemoglobin and ferritin concentrations were assessed at 1st and 2nd antenatal care visits (ANV) and at delivery. After the first ANV, women were administered daily iron and folic acid supplements until three what? post-delivery. Singleton children were assessed for cognitive function at age 1 year using the Mullen Scales of Early Learning. RESULTS: The prevalence of geophagy during pregnancy was 31.9%. Pregnant women reporting geophagy were more likely to be anaemic (AOR = 1.9, 95% CI [1.1, 3.4]) at their first ANV if they reported geophagy at the first trimester. Overall, prenatal geophagy was not associated with maternal haematological indices, malaria or helminth infections, but geophagy during the third trimester and throughout pregnancy was associated with poor motor function (AOR = -3.8, 95% CI [-6.9, -0.6]) and increased odds of geophagous behaviour in early childhood, respectively. CONCLUSIONS: Prenatal geophagy is not associated with haematological indices in the presence of micronutrient supplementation. However, it may be associated with poor child motor function and infant geophagy. Geophagy should be screened early in pregnancy.

Pregnancy in Patients With Chronic Myeloid Leukemia.

Estimates suggest that nearly 30% of patients diagnosed with chronic myeloid leukemia (CML) are aged <49 years, with approximately half being women. For many of these women, childbearing concerns are a major factor as they initiate treatment with tyrosine kinase inhibitors, which are known to be teratogenic. During her presentation at the NCCN 23rd Annual Conference, Dr. Berman identified the challenges in helping women undergoing treatment for CML who want to have children, and emphasized the importance of an individualized and multidisciplinary approach to management. In addition, she encouraged NCCN to create a pregnancy registry of this patient population to enable clinicians to collect firm data to guide clinical decision-making.

Detection of Drug-Exposed Newborns.

Maternal substance abuse during pregnancy is a growing problem with major public health and legal concerns. In utero substance exposure may adversely affect neonatal development; pregnancy outcome; and the long-term behavioral, cognitive, and developmental abilities of the child. Also, serious legal implications are associated with substance abuse during pregnancy, including charges of child abuse and neglect that may result in the removal of the neonate from parental care and loss of custodial rights. Timely detection of in utero drug exposure is necessary for early identification and effective management of exposed newborns. Accurate identification of drug-exposed newborns relies on maternal history; clinical presentation of the newborn; and laboratory testing of biological maternal matrices (ie, urine, blood, oral fluid, sweat, hair, and breast milk), neonatal matrices (ie, urine, meconium, hair, and umbilical cord blood and tissue), and/or matrices from both the mother and neonate (ie, placenta and amniotic fluid). Evaluation of biological matrices can account for in utero exposure at various stages of gestation and approximate the period (recent versus chronic use) of substance exposure. Each matrix has its own unique advantages and limitations in terms of ease of collection, the window of gestational exposure represented, and sensitivity for different parent drug analytes and metabolites, which must be carefully considered for accurate interpretation of results. Analytical approaches to sample preparation and analysis vary based on the complexity of these biological matrices. Immunoassays are routinely used for screening, and chromatographic separation coupled to mass spectrometry detection method is commonly used for definitive (confirmatory) testing. Some laboratories use a single technology for all testing. This review provides a discussion on approaches used to detect drug-exposed newborns, biological specimens that have been studied to identify and characterize drug exposures, example analytical methods for meconium and umbilical cord tissue as well as considerations surrounding the interpretation of results. A possible algorithm for testing is also proposed.

Association between secondhand smoke exposure and quality of life in pregnant women and postpartum women and the consequences on the newborns.

PURPOSE: Secondhand smoke (SHS) exposure is prevalent and could damage the health of non-smokers, especially that of pregnant women (PW) and postpartum women (PPW). Nevertheless, there is no study on the impact of SHS during pregnancy on the quality of life (QOL) of PW and PPW. The study's purpose is to study the effects of exposure to SHS on the QOL of pregnant and postpartum women and health of the newborns. METHODS: Self-reports and urine tests for cotinine were used to obtain data on SSH exposure in 296 women in the second trimester of pregnancy and 106 women in the postpartum period at the Obstetrics & Gynecology Clinic located in a university hospital. The WHOQOL-BREF-THAI and the Edinburgh Postnatal Depression Scale were used to assess QOL and postpartum depression, respectively. RESULTS: Of the participants, 88.2% of PW and 62.3% of PPW reported exposure to SHS during pregnancy. Of the PPW, 5.7% had postpartum depression. PW with good QOL were less likely to have family member who smoked (p = 0.007) or to be exposed to SHS in public parks (p = 0.037) or in the household or workplace (p = 0.011). Likewise, PPW with good QOL in the psychological domain were less likely to be exposed to SHS during pregnancy, as shown in both verbal report (p = 0.010) and objective measure of urine cotinine test (p = 0.034). In addition, maternal exposure to SHS during pregnancy is associated with low birth weight and other health problems in the newborns (p < 0.05). CONCLUSIONS: Exposure to SHS during pregnancy is associated with a lower QOL and a poorer health condition in the newborns.

Implementation, mechanisms and effects of maternity protection legislation: a realist narrative review of the literature.

PURPOSE: Most industrialized countries have introduced maternity protection legislation (MPL) to protect the health of pregnant workers and their unborn children from workplace exposure. This review aimed to assess this legislation's level of implementation, barriers and facilitators to it, and its expected or unexpected effects. METHODS: A realist narrative review was conducted. Keyword searches of the PubMed, CINAHL, PsycINFO, MIDIRS, Sociological abstracts and Google Scholar electronic databases were performed in March 2018. RESULTS: The 42 publications included show that the implementation of MPL is deficient in most countries. Allowing pregnant women to withdraw from work on preventive leave or sick leave is favored over workplace adaptations or worker reassignments. The publications highlight mechanisms which encourage or obstruct the enforcement of legislation at the levels of the individual, the physical and social environment, and the macrosocial context. The delay between the conception and implementation of maternity protection measures appears to be a major barrier to the efficacy of MPL. The literature also suggests that unexpected adverse effects, such as degradation in working relationships or discrimination can obstruct the implementation of protective measures. CONCLUSIONS: This study showed the need for a better implementation of MPL during pregnancy. Further research and recommendations for improvements in MPL should consider the diverse mechanisms and effects of its implementation. Barriers and adverse effects of this implementation do not only ensure a lack of information or awareness about MPL, but are also linked to contradictions between requirements to protect employment and protect pregnancy.

Effect of valproic acid administration during pregnancy on postnatal development of cerebellar cortex and the possible protective role of folic acid.

BACKGROUND: Valproic acid (VPA), one of the most important antiepileptic drugs, proved to be inevitable for epileptic pregnant women to limit the hazards of convulsions on the foetuses and mothers. Periconceptional folic acid supple-mentation was investigated to protect against several birth defects. However, its role against VPA cerebellar toxicity was not properly investigated. The present study was conducted to evaluate the protective effect of folic acid against VPA cerebellar neurotoxicity. MATERIALS AND METHODS: Twenty-four pregnant female albino rats were divided into three groups; group I (control group, did not receive any drugs), group II (given VPA at a dose of 50 mg/kg body weight once daily) and group III (given the same dose of VPA and 400 µg/kg of body weight folic acid once daily). Ten male offspring from each group were sacrificed at two ages: at 2 and 12 weeks after birth. Samples of cerebellar cortex were taken and prepared for light, electron microscopic examination, glial fibrillary acidic protein (GFAP) immunohistochemical study and histomorphometric analysis. RESULTS: The present study confirmed the neurotoxic effect of prenatal VPA on the cerebellar cortex, especially on Purkinje cells. The cells appeared shrunken, reduced in density, disorganised and surrounded by empty haloes. Nuclear damage and axon degeneration in the form of vacuolation, loss of organelles and absence of neurofilaments with myelin sheath depletion were detected. Concomitant supply of folic acid was shown to retain the normal architecture of Purkinje cells with their axons and nuclei. In many animals receiving folic acid, the thickness of all layers of the cortex increased up to that of the control groups, after being markedly reduced in VPA-treated groups. GFAP immunoreaction was also improved against the strong positive gliosis detected in VPA-treated groups. CONCLUSIONS: The present study confirmed the protective role of folic acid against the cerebellar neurotoxic effects of VPA prenatal exposure. It is recommended that folic acid supplements should be given to every epileptic pregnant mother treated with VPA. (Folia Morphol 2018; 77, 2: 201-209).

Behaviour change interventions to reduce second-hand smoke exposure at home in pregnant women - a systematic review and intervention appraisal.

BACKGROUND: Second-hand smoke (SHS) exposure during pregnancy is associated with poor pregnancy and foetal outcomes. Theory-based behaviour change interventions (BCI) have been used successfully to change smoking related behaviours and offer the potential to reduce exposure of SHS in pregnant women. Systematic reviews conducted so far do not evaluate the generalisability and scalability of interventions. The objectives of this review were to (1) report the BCIs for reduction in home exposure to SHS for pregnant women; and (2) critically appraise intervention-reporting, generalisability, feasibility and scalability of the BCIs employed. METHODS: Standard methods following PRISMA guidelines were employed. Eight databases were searched from 2000 to 2015 in English. The studies included used BCIs on pregnant women to reduce their home SHS exposure by targeting husbands/partners. The Workgroup for Intervention Development and Evaluation Research (WIDER) guidelines were used to assess intervention reporting. Generalisability, feasibility and scalability were assessed against criteria described by Bonell and Milat. RESULTS: Of 3479 papers identified, six studies met the inclusion criteria. These studies found that BCIs led to increased knowledge about SHS harms, reduction or husbands quitting smoking, and increased susceptibility and change in level of actions to reduce SHS at home. Two studies reported objective exposure measures, and one reported objective health outcomes. The studies partially followed WIDER guidelines for reporting, and none met all generalisability, feasibility and scalability criteria. CONCLUSIONS: There is a dearth of literature in this area and the quality of studies reviewed was moderate to low. The BCIs appear effective in reducing SHS, however, weak study methodology (self-reported exposure, lack of objective outcome assessment, short follow-up, absence of control group) preclude firm conclusion. Some components of the WIDER checklist were followed for BCI reporting, scalability and feasibility of the studies were not described. More rigorous studies using biochemical and clinical measures for exposures and health outcomes in varied study settings are required. Studies should report interventions in detail using WIDER checklist and assess them for generalisability, feasibility and scalability. TRIAL REGISTRATION: CRD40125026666.

Primary Prevention of Congenital Anomalies: Special Focus on Environmental Chemicals and other Toxicants, Maternal Health and Health Services and Infectious Diseases.

Congenital anomalies (CA) represent an important fraction of rare diseases, due to the critical role of non-genetic factors in their pathogenesis. CA are the main group of rare diseases in which primary prevention measures will have a beneficial impact. Indeed, since 2013 the European Union has endorsed a body of evidence-based recommendations for CA primary prevention; the recommendations aim at facilitating the inclusion of primary prevention actions the National Rare Disease Plans of EU Member States and encompass different public health fields, from environment through to maternal diseases and lifestyles.The chapter overviews and discusses the assessment of main risk factors for CA, such as environmental toxicants, maternal health and lifestyles and infections, with a special attention to issues that are emerging or need more knowledge.Overall, the availability of CA registries is important for estimating the health burden of CA, identifying possible hotspots, assessing the impact of interventions and addressing further, fit-to-purpose research.The integration of relevant public health actions that are already in place (e.g., control of noxious chemicals, vaccination programmes, public health services addressing chronic maternal conditions) can increase the affordability and sustainability of CA primary prevention. In developing countries with less primary prevention in place and limited overall resources, a first recognition phase may be pivotal in order to identify priority targets. In the meanwhile, policy makers should be made aware that primary prevention of RD supports publicly endorsed societal values like the knowledge-based promotion of health, empowerment, equity and social inclusiveness.

Hypospadias and maternal exposure to atrazine via drinking water in the National Birth Defects Prevention study.

BACKGROUND: Hypospadias is a relatively common birth defect affecting the male urinary tract. It has been suggested that exposure to endocrine disrupting chemicals might increase the risk of hypospadias by interrupting normal urethral development. METHODS: Using data from the National Birth Defects Prevention Study, a population-based case-control study, we considered the role of maternal exposure to atrazine, a widely used herbicide and potential endocrine disruptor, via drinking water in the etiology of 2nd and 3rd degree hypospadias. We used data on 343 hypospadias cases and 1,422 male controls in North Carolina, Arkansas, Iowa, and Texas from 1998-2005. Using catchment level stream and groundwater contaminant models from the US Geological Survey, we estimated atrazine concentrations in public water supplies and in private wells. We assigned case and control mothers to public water supplies based on geocoded maternal address during the critical window of exposure for hypospadias (i.e., gestational weeks 6-16). Using maternal questionnaire data about water consumption and drinking water, we estimated a surrogate for total maternal consumption of atrazine via drinking water. We then included additional maternal covariates, including age, race/ethnicity, parity, and plurality, in logistic regression analyses to consider an association between atrazine and hypospadias. RESULTS: When controlling for maternal characteristics, any association between hypospadias and daily maternal atrazine exposure during the critical window of genitourinary development was found to be weak or null (odds ratio for atrazine in drinking water = 1. 00, 95 % CI = 0.97 to 1.03 per 0.04 µg/day increase; odds ratio for maternal consumption = 1.02, 95 % CI = 0.99 to 1.05; per 0.05 µg/day increase). CONCLUSIONS: While the association that we observed was weak, our results suggest that additional research into a possible association between atrazine and hypospadias occurrence, using a more sensitive exposure metric, would be useful.

Pregnant Women's perceptions of exposure to brominated flame retardants.

BACKGROUND: Recent media reports on human studies associating brominated flame retardants (BFRs) in household products in pregnancy with urogenital anomalies in boys and endocrine disruption in both sexes. We sought to explore the perceptions of pregnant women of brominated flame retardant (BFR) exposure, in light of recent media reports on the adverse health effects of BFR exposure prenatally. METHODS: Pregnant women were recruited for interviews through posters and pamphlets in prenatal clinics, prenatal fairs and community centres. Interviews were audiotaped and transcribed verbatim for Charmaz-based qualitative analysis supported by NVIVO 10™. RESULTS: Theoretical sufficiency was reached after analyzing the interviews of 23 pregnant women. Themes co-constructed were: I-Lack of Awareness of BFRs; II-Factors Influencing BFR Exposure; III-Responsibility; IV-Informed Choice. Almost all participants felt it was difficult to make informed choices to avoid BFRs, and wanted communication from clinicians and regulation from governments regarding decreasing BFR exposure. CONCLUSION: Pregnant women in Canada may be unaware of the potential risks of exposure to BFRs. Professional organizations and governments should further study risk associated with BFR exposure in pregnancy and provide educational materials for pregnant women and clinicians regarding BFR exposure.

Intrauterine Tobacco Smoke Exposure and Congenital Heart Defects.

Tobacco use and second-hand smoke exposure during pregnancy are linked to a host of deleterious effects on the pregnancy, fetus, and infant. Health outcomes improve when women quit smoking at any time during the pregnancy. However, the developing heart is vulnerable to noxious stimuli in the early weeks of fetal development, a time when many women are not aware of being pregnant. Congenital heart defects are the most common birth defects. Research shows an association between maternal tobacco exposure, both active and passive, and congenital heart defects. This article presents recent evidence supporting the association between intrauterine cigarette smoke exposure in the periconceptional period and congenital heart defects and discusses clinical implications for practice for perinatal and neonatal nurses.

Maternal diet and its influence on the development of allergic disease.

The early presentation of childhood allergies and the rise in their prevalence suggest that changes in early-life exposures may increase the predisposition. Very early-life exposures may act upon the developing foetal immune system and include infection, environmental tobacco smoke, other pollutants and nutrients provided via the mother. Three nutrients have come under close scrutiny: vitamin D, omega 3 polyunsaturated fatty acids (PUFAs) and folate (or the synthetic form, folic acid). Much of the data on these nutrients are observational although some randomised, placebo-controlled trials have been conducted with omega 3 PUFAs and one with vitamin D. Some studies with omega 3 PUFA supplements in pregnancy have demonstrated immunomodulatory effects on the neonate and a reduction in risk of early sensitisation to allergens. A few studies with omega 3 polyunsaturated fatty acid supplements in pregnancy have shown a reduction in proportion of children affected by allergic symptoms (food allergy) or in symptom severity (atopic dermatitis). Observational studies investigating the association of maternal vitamin D intake or maternal or neonatal vitamin D status have been inconsistent. One randomised, controlled trial of vitamin D supplementation during pregnancy did not show any significant effect on allergic outcome in the offspring. Studies investigating the association between maternal folic acid or folate intake or maternal or neonatal folate status and offspring risk of allergic disease have been equivocal. Further evidence is required to clarify whether increased intake of these nutrients during pregnancy influences allergic disease in the offspring. In the light of current evidence, mothers should not either increase or avoid consuming these nutrients to prevent or ameliorate allergic disease in their offspring. However, these essential nutrients each have important roles in foetal development. This is reflected in current government recommendations for intake of these nutrients by pregnant women.