An Evidence-Based Discussion of Fetal Pain and Stress.

BACKGROUND: The concept of fetal pain results from procedures conducted without anesthesia in preterm newborns and fetuses, which indicate that it is possible to examine fetal pain based on stress hormone, metabolic, and behavioral changes. Anatomical and physiological data suggest that fetuses become capable of processing nociceptive stimuli around midgestation, although the associated changes in fetal brain development remain unclear. What constitutes fetal pain remains controversial in the light of the definition of pain adopted by the International Association for the Study of Pain (IASP), which posits pain as an "unpleasant sensory and emotional experience." SUMMARY: Here, we examine the notion that human fetuses cannot "experience" pain and potential implications of this claim. We highlight the key scientific evidence related to fetal pain, including clinical studies on pain in fetuses and preterm newborns. We argue that consistent patterns of stress hormones, metabolic changes, body movements, hemodynamic changes, and pain-related facial expressions in fetuses exposed to invasive procedures overcome the need for subjective proof of pain as articulated in the IASP definition. No study to date has conclusively proven the absence of fetal pain beyond the age of viability. KEY MESSAGES: Based on the current evidence, we propose that all fetuses receive anesthesia regardless of the invasive procedures being performed to guarantee the least possible pain and physiological, behavioral, or hormonal responses without exposing the mother or her baby to unnecessary complications.

Chemosensory continuity from prenatal to postnatal life in humans: A systematic review and meta-analysis.

Throughout pregnancy, fetuses are exposed to a range of chemosensory inputs influencing their postnatal behaviors. Such prenatal exposure provides the fetus with continuous sensory information to adapt to the environment they face once born. This study aimed to assess the chemosensory continuity through a systematic review and meta-analysis of existing evidence on chemosensory continuity from prenatal to first postnatal year. Web of Science Core. Collections, MEDLINE, PsycINFO, EBSCOhost ebook collection was searched from 1900 to 2021. Studies identified from the search were grouped according to type of stimuli the fetuses were exposed to prenatally that the neonatal infants' responses to were being evaluated, namely flavors transferred from the maternal diet, and the odor of their own amniotic fluid. Of the 12 studies that met the eligibility criteria for inclusion (k = 6, k = 6, respectively in the first and the second group of studies), and eight studies (k = 4, k = 4, respectively) provided sufficient data suitable for meta-analysis. Infants, during their first year of life, oriented their heads for significantly longer durations in the direction of the prenatally experienced stimuli with large pooled effect sizes (flavor stimuli, d = 1.24, 95% CI [0.56, 1.91]; amniotic fluid odor, d = 0.853; 95% CI [.632, 1.073]). The pooled effect size for the duration of mouthing behavior was significant in response to prenatal flavor exposure through maternal diet (d = 0.72; 95% CI [0.306, 1.136]), but not for the frequency of negative facial expressions (d = -0.87, 95% CI [-2.39, 0.66]). Postnatal evidence suggests that there is a chemosensory continuity from fetal to the first year of postnatal life.

Association between Hyperemesis Gravidarum in pregnancy on postnatal ability of infants to attend to a play task with their mother.

Research indicates a higher prevalence of attention deficits in children exposed to HG in utero compared to controls with some claiming that the deficit is due to prenatal effects of malnutrition in HG mothers and others that it is due to maternal mental health after birth. The current study examines the effect of hyperemesis gravidarum (HG) diagnosis during pregnancy on infant attention controlling for maternal stress, depression anxiety and attachment. Thirty-eight infants mean age 4 months were videotaped with their mothers (19 mothers with a hyperemesis diagnosis and 19 controls) during play with a soft toy and looking at a picture book. Infant attention was operationalized as gaze direction towards the play activity, mother, and 'distracted' (indicated by looking away from play or mother). Mothers completed stress, depression, anxiety, and attachment questionnaires. HG exposed infants attended for significantly less time during play with a book or soft toy compared to controls. Maternal stress, depression, anxiety, and attachment did not differ in HG mothers and controls. Infant ability to attend to the toy, book, mother or being distracted did not relate to maternal postnatal attachment, or mental health. These results suggest that the prenatal environment, especially exposure to HG might be associated with reduced infant attention abilities independent of maternal postnatal health.

Flavor Sensing in Utero and Emerging Discriminative Behaviors in the Human Fetus.

The diet of pregnant women exposes fetuses to a variety of flavors consisting of compound sensations involving smell, taste, and chemesthesis. The effects of such prenatal flavor exposure on chemosensory development have so far been measured only postnatally in human infants. Here, we report the first direct evidence of human fetal responsiveness to flavors transferred via maternal consumption of a single-dose capsule by measuring frame-by-frame fetal facial movements. Pregnant women and their fetuses based in the northeast of England were involved in this study from 32 to 36 weeks' gestation. Fetuses exposed to carrot flavor (n = 35) showed "lip-corner puller" and "laughter-face gestalt" more frequently, whereas fetuses exposed to kale flavor (n = 34) showed more "upper-lip raiser," "lower-lip depressor," "lip stretch," "lip presser," and "cry-face gestalt" in comparison with the carrot group and a control group not exposed to any flavors (n = 30). The complexity of facial gestalts increased from 32 to 36 weeks in the kale condition, but not in the carrot condition. Findings of this study have important implications for understanding the earliest evidence for fetal abilities to sense and discriminate different flavors.

Foetal mouth movements: Effects of nicotine.

AIM: To assess whether foetal mouth movement frequency changes across gestation and whether there are differences between cigarette and e-cigarette exposure conditions in comparison to a non-exposed group of foetuses. METHOD: Pregnant women underwent 4-dimensional (4D) foetal ultrasound scans at 32 weeks (106 scans) and 36 weeks of gestational age (87 scans) at James Cook University Hospital, UK. The 4D scans were coded using the Fetal Observable Movement System (FOMS). Measures of maternal smoking status, stress, depression, anxiety, attachment and time of scan were also collected. There were four exposure groups: non-smokers, light smokers (<10 per day), heavy smokers (11-20 per day) and e-cigarette users. RESULTS: No significant differences in relative frequency of mouth movements between the exposure groups at 32- and 36 weeks of gestational age were found. Foetal mouth movements declined from 32 to 36 weeks of gestation for non-exposed and e-cigarette-exposed foetuses. CONCLUSION: Due to variability in foetal behaviour, examining mouth movements alone may not be the most appropriate method for assessing group differences. However, in line with other research, mouth movement frequency declined between 32- and 36 weeks of gestational age. A combination of foetal behavioural assessments is needed to assess the effects of cigarette and e-cigarette exposure on foetal neurobehavioural development.

Effects of maternal mental health on prenatal movement profiles in twins and singletons.

AIM: Prenatal experiences, including maternal stress, depression and anxiety, form crucial building blocks affecting the maturation of the foetal central nervous system. Previous research has examined foetal movements without considering effects of maternal mental health factors critical for healthy foetal development. The aim of this research is to assess the effects of maternal mental health factors on foetal twin compared with singleton movement profiles. METHOD: We coded foetal touch and head movements in 56 ultrasound scans, from a prospective opportunity sample of 30 mothers with a healthy pregnancy (mean gestational age 27.8 weeks for singleton and 27.2 for twins). At the ultrasound scan appointment, participants completed questionnaires assessing their stress, depression and anxiety. RESULTS: Maternal depression increased foetal self-touch significantly. In foetal twins, maternal stress significantly decreased and maternal depression significantly increased other twin touch. Maternal mental health factors affected the head movements of twins significantly more than singletons, with maternal depression decreasing head movement frequency for twins significantly. CONCLUSION: These results indicate that maternal mental health might have an impact on types of body schemata formed in utero, in twin compared with singleton pregnancies. Future research needs to examine whether these prenatal effects affect postnatal differences in body awareness.

Risk perception of cigarette and e-cigarette use during pregnancy: A qualitative postpartum perspective.

AIM: The aim of this exploratory qualitative analysis is to assess the perceptions of risks of cigarette and e-cigarette use during pregnancy. BACKGROUND: An important public health aim is a reduction of smoking at time of delivery (SATOD) from 10.6% to less than 6% by 2022 in the United Kingdom (UK). In order to successfully meet this target, we need to have a better understanding of the perceived risks associated with cigarette smoking. Additionally, the use of e-cigarettes is increasing in the general population, with pregnant women being supported to use such products if it helps them remain smoke free. However, in contrast to cigarette smoking, there is little definitive research assessing the safety of e-cigarette use during pregnancy, with most information disregarding the health of the growing fetus. E-cigarettes are of special interest, given they are an unlicensed product for use during pregnancy, yet women are being supported to use them as a method of harm reduction. A better understanding of perceived risks is essential. METHOD: Fourteen interviews were conducted one month postpartum with women who smoked during pregnancy and continued to smoke after the birth. Thematic analysis was conducted. FINDINGS: Two themes emerged for cigarette smoking; health and justifications. Six themes were identified for e-cigarette use; the unknown, experience, comparison to cigarettes, the product, advice and healthier option. A range of subthemes are discussed. CONCLUSION: Women provided a range of justifications for continuing to smoke during pregnancy. Women felt e-cigarettes were a riskier option than continuing to smoke.

Individual Differences in Executive Function: The Role of Parental Monitoring as a Moderator.

Objective: Parental monitoring is a factor which affects verbal and nonverbal inhibition components of children's executive functions.,. Method: 112 sixth-grade Kurdish children (mean age: 11 years 5 months) participated in the study. Children were matched on level of hyperactivity. Parents completed the Parental Monitoring Assessment (PMA) and the Strengths and Difficulties Questionnaire (SDQ). Children completed theStop-Signal task, Modified Opposite Worlds and a challenging star puzzle in order to assess executive function components. PROCESS analysis was also used to perform the moderation analysis. Results: Children characterized by poor parental monitoring had deficits in inhibitory control and had significantly slower processing speeds and made significantly more errors than their matched controls. Furthermore, children with high levels of hyperactivity had difficulties in inhibitory control, accuracy, processing speed, and task persistence compared with the control group.Contrary to our prediction, there were no significant differences in reaction times compared with the control group. PROCESS analysis showed a significant moderating role of parental monitoring in the association between each of accuracy, verbal inhibition, and task persistence with hyperactivity. Conclusion: the current study suggests that, similar to hyperactivity, children with poor parental monitoring appear to have difficulties in executive function.

Feasibility of a psychoeducational group intervention to improve parental reflective functioning and bonding in pregnancy: a randomised trial.

OBJECTIVE: To develop and evaluate Baby CHAT, a single-session psychoeducational intervention for expectant parents. Baby CHAT aims to improve parental reflective functioning (RF) and bonding. BACKGROUND: The early years of a child's life, including pregnancy, are vital for healthy physical and emotional development. Caregivers who provide responsive parenting, enhanced through strong bonds and good RF, can aid healthy development.. However, limited interventions exist to enhance RF and bonding in expectant parents. METHODS: Feasibility of Baby CHAT was assessed using a mixed methods randomised controlled trial design. It evaluated uptake and retention of participants, effect size calculations, and acceptability and satisfaction with Baby CHAT. RESULTS: Participants (N = 20) were aged 30-39 years (n = 17) in their third trimester of pregnancy (n = 12). Nine males and 11 females were recruited. Content analysis of qualitative feedback after the intervention resulted in four themes; positive group aspects, group improvements, 4D scan footage and relating content to my baby. CONCLUSIONS: Baby CHAT can help expectant parents think about their baby as a separate person and has potential to improve prenatal RF and bonding. However, further research is required to assess the effectiveness of Baby CHAT to improve bonding and RF.

The effects of prenatal cigarette and e-cigarette exposure on infant neurobehaviour: A comparison to a control group.

BACKGROUND: Infant neurobehaviour provides an insight into the development of the central nervous system during infancy, with behavioural abnormalities highlighting a cause for concern. Research has demonstrated that prenatal exposure to cigarettes leads to deficits within neurobehavioural development, along with negative birth outcomes detrimental to subsequent development. With the growing use of e-cigarettes amongst pregnant women, this study explores how prenatal e-cigarette exposure compares to prenatal cigarette exposure. METHODS: Eighty-three infants were involved in the study, either exposed prenatally to cigarettes or e-cigarettes or not exposed to either. Differences were assessed between these three groups for birth outcomes and scores on the Neonatal Behavioural Assessment Scale (NBAS) at one month of age. FINDINGS: Both cigarette and e-cigarette exposed infants had a significantly greater number of abnormal reflexes (p = ·001; p  =  ·002). For both self-regulation and motor maturity, cigarette exposed infants performed significantly worse (p = ·010; p = ·002), with e-cigarette exposed infants having decreased motor maturity (p = ·036) abilities and marginally decreased for self-regulation (p = ·057). Birth outcomes, namely birthweight, gestation and head circumference, did not differ for e-cigarette exposed infants compared with infants who were not prenatally exposed to nicotine. Cigarette exposed infants had a significantly lower birthweight (p = ·021) and reduced head circumference (p = ·008) in comparison to non-exposed infants. INTERPRETATION: To our knowledge, this is the first research study assessing a neurological outcome as a result of e-cigarette exposure. Findings of this have potentially important implications for public health policies regarding the safety and use of e-cigarettes throughout pregnancy. FUNDING: This research was funded by a doctoral training partnership scholarship via the ESRC, ES/P000762/1.

Infant neurobehavioural consequences of prenatal cigarette exposure: A systematic review and meta-analysis.

AIM: Prenatal exposure to cigarettes leads to alterations in brain development during pregnancy. This has an impact on postnatal psychological and behavioural processes, affecting an infant's neurobehavioural profile with little known about which aspects are affected. The evidence was synthesised to assess the effects of prenatal cigarette smoke exposure on neurobehavioural outcomes within the first year of life. METHODS: Six databases were searched (Web of Science Core Collections, MEDLINE, PsycINFO, CINAHL, EBSCOhost eBook Collection and OpenGrey) in November 2018. Eligible studies (n = 17) had to include a measure of prenatal cigarette exposure and a neurobehavioural assessment ≤1 year of age. RESULTS: In the first year of life, specific areas of neurobehavioural functioning are related to prenatal cigarette exposure with eight out of 10 areas of neurobehaviour having significant medium (negative affect, attention, excitability, irritability and orientation) or small (muscle tone, regulation and difficult temperament) pooled effect sizes. Only lethargy and stress did not show any significant pooled effects. CONCLUSION: Prenatal cigarette exposure affects a significant range of behaviours during the first year of life.

Effects of parental intervention on behavioural and psychological outcomes for Kurdish parents and their children.

BACKGROUND: Parenting interventions are rarely offered in developing countries and there is an urgent need to include low-income countries. AIMS: To examine the effectiveness of Systematic Training for Effective Parenting (STEP) among Kurdish parents and their children. METHODS: This was a randomized control pilot trial using pre- and post-test scores of 17 mothers (mean age 35.25 years, standard deviation 4.3 years; range: 29.58-45.3 years) who agreed to participate in the intervention. We utilized the Alabama Parenting Questionnaire (APQ) to assess parenting style; Parental Stress Scale (PSS) to investigate parental stress; and Step Parenting Assessment Technique (SPAT) to identify whether participants in the treatment group had learned the material of the intervention. RESULTS: There were significant differences between the groups on 3 subscales of the APQ: mother involvement subscale, F(1.13) = 25.81, P < 0.001, η2 p = 0.67; inconsistent discipline subscale, F(1.13) = 25.46, P < 0.001, η2 p = 0.66; and corporal punishment subscale F(1.13) = 17.3, P < 0.005, η2 p = 0.57. A significant difference between groups was also found on the PSS, F(1.13) = 19.63, P < 0.001, η2 p = 0.60. The changes were sustained over a 3-month period. No significant differences were found in academic self-concept and behavioural problems between children whose mothers attended STEP and others whose mothers did not attend. CONCLUSIONS: The STEP programme appears to promote parenting style and reduce the level of parental stress in Kurdish mothers. TRIAL REGISTRATION: IRCT2016032527125N1.

The impact of parenting styles on children developmental outcome: The role of academic self-concept as a mediator.

Although the importance of parenting styles directly influencing child development is well established, fewer studied have examined whether parenting styles also affect children's behavioural problems indirectly, mediated through children's academic self-concept (ASC). We examined direct and shared effects of parenting styles on behavioural problems of 199 Kurdish primary school children with a mean age of 11 years 7 months (range 11 years 5 months to 12 years 3 months). Questionnaires measured parenting styles (child version of Alabama Parenting Questionnaire), assessed children's ASC (Myself-As-Learner Scale) and identified children's behavioural problems with the Strengths and Difficulties Questionnaire (SDQ). PROCESS analysis was used to perform the mediation analysis. The results revealed that positive and negative parenting composites are indirectly related to children's internalising behaviour problems. In addition, ASC partially mediated the relationship between the negative parenting composite and prosocial behaviour. However, the mediation analysis did not show the expected indirect effect of parenting styles on externalising problems as being mediated via ASC. Hence, we argue that the ASC serves as a significant mediator in the relationship between parenting styles with prosocial behaviour and internalising problems.

Mimicking emotions: how 3-12-month-old infants use the facial expressions and eyes of a model.

While there is an extensive literature on the tendency to mimic emotional expressions in adults, it is unclear how this skill emerges and develops over time. Specifically, it is unclear whether infants mimic discrete emotion-related facial actions, whether their facial displays are moderated by contextual cues and whether infants' emotional mimicry is constrained by developmental changes in the ability to discriminate emotions. We therefore investigate these questions using Baby-FACS to code infants' facial displays and eye-movement tracking to examine infants' looking times at facial expressions. Three-, 7-, and 12-month-old participants were exposed to dynamic facial expressions (joy, anger, fear, disgust, sadness) of a virtual model which either looked at the infant or had an averted gaze. Infants did not match emotion-specific facial actions shown by the model, but they produced valence-congruent facial responses to the distinct expressions. Furthermore, only the 7- and 12-month-olds displayed negative responses to the model's negative expressions and they looked more at areas of the face recruiting facial actions involved in specific expressions. Our results suggest that valence-congruent expressions emerge in infancy during a period where the decoding of facial expressions becomes increasingly sensitive to the social signal value of emotions.

The Human Fetus Preferentially Engages with Face-like Visual Stimuli.

In the third trimester of pregnancy, the human fetus has the capacity to process perceptual information [1-3]. With advances in 4D ultrasound technology, detailed assessment of fetal behavior [4] is now possible. Furthermore, modeling of intrauterine conditions has indicated a substantially greater luminance within the uterus than previously thought [5]. Consequently, light conveying perceptual content could be projected through the uterine wall and perceived by the fetus, dependent on how light interfaces with maternal tissue. We do know that human infants at birth show a preference to engage with a top-heavy, face-like stimulus when contrasted with all other forms of stimuli [6, 7]. However, the viability of performing such an experiment based on visual stimuli projected through the uterine wall with fetal participants is not currently known. We examined fetal head turns to visually presented upright and inverted face-like stimuli. Here we show that the fetus in the third trimester of pregnancy is more likely to engage with upright configural stimuli when contrasted to inverted visual stimuli, in a manner similar to results with newborn participants. The current study suggests that postnatal experience is not required for this preference. In addition, we describe a new method whereby it is possible to deliver specific visual stimuli to the fetus. This new technique provides an important new pathway for the assessment of prenatal visual perceptual capacities.

Do fetuses move their lips to the sound that they hear? An observational feasibility study on auditory stimulation in the womb.

BACKGROUND: We investigate in this feasibility study whether specific lip movements increase prenatally when hearing a particular sound. We hypothesised that fetuses would produce more mouth movements resembling those required to make the sound stimulus they heard (i.e. mouth stretch) compared with a no-sound control group who heard no specific auditory stimuli. Secondly, we predicted that fetuses hearing the sound would produce a similar number of mouth movements unrelated to the sound heard (i.e. lip pucker) as the no-sound group of fetuses. METHODS: In an observational feasibility study, 17 fetuses were scanned twice at 32 and 36 weeks of gestation, and two different types of mouth movements were recorded. Three fetuses received an auditory stimulus, and 14 did not. A generalised mixed effects log-linear model was used to determine statistical significance. RESULTS: Fetuses in the sound group performed one specific mouth movement (mouth stretch) significantly more frequently than fetuses in the no-sound group. A significant interaction between group and gestational age indicates that there was differential change in this specific movement as age increases (X2 = 7.58 on 1 df, p = 0.006), with the no-sound group showing a decline of 76 % between 32 weeks and 36 weeks (p < 0.001), whereas the sound group showed no significant change over time (p = 0.41). There was no significant difference between the sound group and no-sound group in the frequency of lip puckering-the second, unrelated mouth movement (p = 0.35). CONCLUSIONS: These results suggest that a sound stimulus is associated with an increase in specific, rather than general, mouth movements. The results are informative for the development of infant speech and potentially could also lead to a diagnostic test for deafness in utero. More research is needed to replicate this research with a randomised design and with a range of different auditory stimuli which would be produced with different mouth movements, such as "o" which would be seen as pursed lips.

Emotional expressiveness of 5-6 month-old infants born very premature versus full-term at initial exposure to weaning foods.

Facial expressions of 5-6 month-old infants born preterm and at term were compared while tasting for the first time solid foods (two fruit and two vegetable purées) given by the mother. Videotapes of facial reactions to these foods were objectively coded during the first six successive spoons of each test food using Baby FACS and subjectively rated by naïve judges. Infant temperament was also assessed by the parents using the Infant Behaviour Questionnaire. Contrary to our expectations, infants born preterm expressed fewer negative emotions than infants born full-term. Naïve judges rated infants born preterm as displaying more liking than their full-term counterparts when tasting the novel foods. The analysis of facial expressions during the six spoonfuls of four successive meals (at 1-week intervals) suggested a familiarization effect with the frequency of negative expressions decreasing after tasting the second spoon, regardless of infant age, type of food and order of presentation. Finally, positive and negative dimensions of temperament reported by the parents were related with objective and subjective coding of affective reactions toward foods in infants born preterm or full-term. Our research indicates that premature infants are more accepting of novel foods than term infants and this could be used for supporting the development of healthy eating patterns in premature infants. Further research is needed to clarify whether reduced negativity by infants born prematurely to the exposure to novel solid foods reflects a reduction of an adaptive avoidant behaviour during the introduction of novel foods.