Early Prenatal Anemia May Increase Risk of Autism, ADHD

A new Swedish study suggests anemia early in pregnancy may increase the risk of autism, ADHD and intellectual disability in children. Anemia is a common condition in late pregnancy and researchers discovered anemia toward the end of pregnancy did not have the same correlation.

The findings, published in JAMA Psychiatry, underscore the importance of early screening for iron status and nutrition counseling.

An estimated 15-20% of pregnant women worldwide suffer from iron deficiency anemia — lower blood oxygen levels due to a lack of iron. By the third trimester, pregnant women have nearly 50% more blood than they did pre-pregnancy in order to provide enough oxygen for both the woman and the fetus, and their iron requirements are nearly double that of nonpregnant women. Thus, the vast majority of anemia diagnoses are made toward the end of pregnancy, when blood levels are at their highest.

In the current study, the researchers examined what impact the timing of an anemia diagnosis had on the fetus’ neurodevelopment. Investigators specifically assessed if there was an association between an earlier diagnosis in the mother and the risk of intellectual disability (ID), autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) in the child.

Overall, very few women are diagnosed with anemia early in pregnancy. In this study of nearly 300,000 mothers and more than half a million children born in Sweden between 1987-2010, less than 1% of all mothers were diagnosed with anemia before the 31st week of pregnancy. Among the 5.8% of mothers who were diagnosed with anemia, only 5% received their diagnosis early on.

The researchers found that children born to mothers with anemia diagnosed before the 31st week of pregnancy had a somewhat higher risk of developing autism and ADHD and a significantly higher risk of intellectual disability compared to healthy mothers and mothers diagnosed with anemia later in pregnancy.

Among the early anemic mothers, 4.9% of the children were diagnosed with autism compared to 3.5% of children born to non-anemic mothers, 9.3% were diagnosed with ADHD compared to 7.1%, and 3.1% were diagnosed with intellectual disability compared to 1.3%.

After considering other factors such as income level and maternal age, the researchers concluded that the risk of autism in children born to mothers with early anemia was 44% higher compared to children with non-anemic mothers. The risk of ADHD was 37% higher and the risk of intellectual disability was 120% higher.

Even when compared to their siblings, children exposed to early maternal anemia were at higher risk of autism and intellectual disability. Importantly, anemia diagnosed after the 30th week of pregnancy was not associated with a higher risk for any of these conditions.

“A diagnosis of anemia earlier in pregnancy might represent a more severe and long-lasting nutrition deficiency for the fetus,” says Renee Gardner, project coordinator at the Department of Public Health Sciences at Karolinska Institutet and the study’s lead researcher.

“Different parts of the brain and nervous system develop at different times during pregnancy, so an earlier exposure to anemia might affect the brain differently compared to a later exposure.”

The researchers also noted that early anemia diagnoses were associated with infants being born small for gestational age while later anemia diagnoses were associated with infants being born large for gestational age.

Babies born to mothers with late-stage anemia are typically born with a good iron supply, unlike babies born to mothers with early anemia.

Although researchers could not specify whether iron deficiency anemia is more detrimental than anemia caused by other factors, iron deficiency is by far the most common cause of anemia. Investigators say the findings may thus support regular iron supplementation in maternity care.

Scientists emphasize the importance of early screening for iron status and nutrition counseling but note that more research is needed to find out if early maternal iron supplementation could help reduce the risk of neurodevelopmental disorders in children.

Adult women 19 to 50 years old typically need 18 mg of iron per day, though needs increase during pregnancy. Since excessive iron intake can be toxic, pregnant women should discuss their iron intake with their midwife or doctor.

Source: JAMA

Home Environment May Improve Psychiatric Outcomes for Earliest Preemies

A new study suggests that a preterm infant’s home and family environment has more of an impact on the child’s psychiatric health than medical challenges at birth.

The findings are published in The Journal of Child Psychology and Psychiatry.

In general, babies who are born at least 10 weeks before their due dates are at greater risk for developing psychiatric issues such as attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder and anxiety disorders.

They are also at greater risk for other neurodevelopmental problems, including cognitive and language difficulties, and motor delays.

In the study, researchers from Washington University School of Medicine in St. Louis discovered that the children who were most likely to overcome the complications of being born so early, and who showed normal psychiatric and neurodevelopmental outcomes, were those with healthier, more nurturing mothers and more stable home lives.

“Home environment is what really differentiated these kids,” said first author Rachel E. Lean, Ph.D., a postdoctoral research associate in child psychiatry.

“Preterm children who did the best had mothers who reported lower levels of depression and parenting stress. These children received more cognitive stimulation in the home, with parents who read to them and did other learning-type activities with their children.”

“There also tended to be more stability in their families. That suggests to us that modifiable factors in the home life of a child could lead to positive outcomes for these very preterm infants.”

The researchers evaluated 125 children at age 5. Of these, 85 had been born at least 10 weeks before their due dates. The other 40 children in the study were born full term, at 40 weeks’ gestation.

The 5-year-olds completed standardized tests to assess their cognitive, language and motor skills. Parents and teachers were asked to complete checklists to help determine whether a child might have issues indicative of ADHD or autism spectrum disorder, as well as social or emotional problems or behavioral issues.

Among all the children who had been born at 30 weeks of gestation or sooner (very preterm), 27% were found to be particularly resilient.

“They had cognitive, language and motor skills in the normal range, the range we would expect for children their age, and they tended not to have psychiatric issues,” Lean said.

Another 45% of the very preterm children, although within the normal range, tended to be at the low end of normal. “They were healthy, but they weren’t doing quite as well as the more resilient kids in the first group,” said Lean.

The rest of the children had clear psychiatric issues such as ADHD, autism spectrum disorder or anxiety with about 13% having moderate-to-severe psychiatric problems. About 15% displayed a combination of problems with inattention and hyperactive and impulsive behavior, according to surveys from teachers.

The children with psychiatric problems weren’t markedly different from other kids in the study in terms of cognitive, language and motor skills, but they had higher rates of ADHD, autism spectrum disorder and other problems.

“The children with psychiatric problems also came from homes with mothers who experienced more ADHD symptoms, higher levels of psychosocial stress, high parenting stress, just more family dysfunction in general,” said senior investigator Cynthia E. Rogers, M.D., an associate professor of child psychiatry.

“The mothers’ issues and the characteristics of the family environment were likely to be factors for children in these groups with significant impairment. In our clinical programs, we screen mothers for depression and other mental health issues while their babies still are patients in the NICU.”

The researchers believe the findings may indicate good news because maternal psychiatric health and family environment may be flexible factors that can be targeted with interventions that have the potential to improve long-term outcomes for children who are born prematurely.

“Our results show that it wasn’t necessarily the clinical characteristics infants faced in the NICU that put them at risk for problems later on,” Rogers said.

“It was what happened after a baby went home from the NICU. Many people have thought that babies who are born extremely preterm will be the most impaired, but we really didn’t see that in our data.”

“What that means is in addition to focusing on babies’ health in the NICU, we need also to focus on maternal and family functioning if we want to promote optimal development.”

The researchers are continuing to follow the children from the study.

Source: Washington University School of Medicine

IBD in Childhood May Up Risk of Mental Health Issues

A new Swedish study suggests children with inflammatory bowel disease (IBD) have a greater risk for psychiatric disorders. Researchers believe that more psychological support and longer follow-up is needed for the children affected and their parents.

Investigators explain that it is already known that adults with IBD (ulcerative colitis or Crohn’s disease) run an increased risk of psychiatric disorders. Now their new study shows that children with IBD also run a higher risk of mental health problems.

The research by investigators at the Karolinska Institutet in Sweden appears in JAMA Pediatrics.

For the study, Karolinska scientists assessed more than 6,400 children with IBD, born between 1973 and 2013. Using population registers, the researchers compared the risk of psychiatric disorders later on in life with both healthy children from the general population and with the patients’ own siblings.

Investigators believe the study methodology which compared patients with their siblings, allowed precise analysis of a large number of so-called confounders. Confounders such as socioeconomics, lifestyle and heredity are factors that are known to affect the risk of psychiatric disorders in children.

During an average follow-up period of 9 years, approximately 17 percent of the children with IBD were given a psychiatric diagnosis compared with just under 12 percent of the healthy children and about 10 percent of the siblings.

This means that the risk of psychiatric disorders was 1.6 times higher in children with IBD compared to Swedish children from general population. Likewise, the risk for the children with IBD was greater than for their siblings.

The higher risk applied to a number of psychiatric diagnoses such as depression, anxiety, eating disorders, personality disorders, ADHD and autism spectrum disorder. There was also a higher risk of suicide attempt after reaching adulthood.

“The study shows that children with IBD and their parents are in need of psychological support and longer follow-up,” said Dr. Agnieszka Butwicka, a researcher at the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet.

“Special help could be offered to children who become ill at a young age and to children of parents with mental health problems.”

Investigators discovered the risk of mental health problems was greatest during the first year with IBD. The risk was particularly high for children who were diagnosed with IBD before the age of 6 years and for children of parents with psychiatric disorders.

However, although the study is an observation study an absolute link cannot be identified with certainty. Nevertheless, the results do indicate that IBD contributes to mental health problems.

“Because the risk for these children is higher compared with their own siblings, it is likely that it is IBD affecting their mental health rather than other factors such as socioeconomics, lifestyle or heredity in the family,” said Dr. Jonas F. Ludvigsson, a professor in the Department of Medical Epidemiology and Biostatistics.

Source: Karolinska Institute

Uninsured Kids With Mental Health Emergencies Often Transferred to Another Hospital

Children without health insurance who present to the emergency department (ED) for mental health issues are more likely to be transferred to another hospital compared to kids with private insurance, according to a new study by researchers at the University of California (UC) Davis Children’s Hospital and the UC Davis Department of Psychiatry.

Previous research has shown a significant increase in the number of children and teens presenting to the ED for mental health issues. Between 2012 and 2016, hospital EDs saw a 55 percent jump in kids with mental health problems, according to findings presented at a meeting of the American Academy of Pediatrics in 2018. The increase is highest among minorities.

Transferring a child from one hospital to another creates additional burdens for the patient, family and health care system as a whole. It can add to overcrowding in busy emergency departments, higher costs of care and higher out-of-pocket costs for the family.

For the study, the researchers analyzed a national sample of 9,081 acute mental health events among children in EDs. They looked at the patient’s insurance coverage and a hospital’s decision to admit or transfer patients with a mental health disorder.

“We found that children without insurance are 3.3 times more likely to be transferred than those with private insurance,” said Jamie Kissee Mouzoon, research manager for the Pediatric Telemedicine Program at UC Davis Children’s Hospital and first author on the study.

“The rate was even higher for patients presenting with bipolar disorder, attention-deficit and conduct disorders and schizophrenia.”

The findings, published in the journal Pediatric Emergency Care, reveal gaps in providing equitable and quality care to pediatric patients with mental health emergencies based on their insurance coverage.

According to James Marcin, senior author on the study, there are regulations in place to prevent EDs from making treatment decisions based on the patients’ insurance. Transferring a patient for any other reason than clinical necessity should be avoided.

“Unfortunately, the financial incentives are sometimes hard to ignore and can be even unconscious,” said Marcin, who also is director for the UC Davis Center for Health and Technology and leads the telemedicine program at UC Davis Health.

“What we have found in this study is consistent with other research that demonstrates that patients without health insurance are more likely to get transferred from clinic to clinic or hospital to hospital.”

Marcin is currently looking into how telemedicine — video visits delivered to the children who seek care in remote EDs — might be a solution to the tendency to transfer the patient to another hospital.

Source: University of California – Davis Health

Study: Too Many Kids With ADHD Given Antipsychotic Drugs

A new study finds that many antipsychotic drug prescriptions given to children and teens with attention-deficit/ hyperactivity disorder (ADHD) do not appear to be clinically warranted.

The findings, published in the journal JAMA Network Open, show that fewer than half of the youth in the study who were prescribed antipsychotic drugs had first been treated with stimulants such as Adderall and Ritalin, the recommended medication treatments for ADHD.

“We didn’t know how widespread this practice was among young people starting ADHD treatment,” said senior author Mark Olfson, M.D., M.P.H., Elizabeth K Dollard Professor of Psychiatry, Medicine, and Law at Columbia University Vagelos College of Physicians and Surgeons. “There are substantial risks associated with the use of antipsychotic drugs in young people, including weight gain, hyperlipidemia, diabetes, and even unexpected death.”

In recent years, pediatricians and parents have expressed concern that some physicians are prescribing antipsychotic drugs to children with ADHD who have significant aggressive or impulsive behavior.

Children and teens with ADHD who are treated with antipsychotics are often also diagnosed with depression, oppositional defiant disorder (ODD), or conduct disorders (CD), even though there is limited evidence that the drugs are effective for ODD or CD and no evidence they are effective in treating depression.

To determine the prevalence of antipsychotic use in youths with ADHD, the researchers analyzed medical and prescription drug data on 187,563 commercially insured children and young people (ages 3 to 24) who were diagnosed with ADHD between 2010 and 2015.

The team discovered that 2.6% of youths diagnosed with ADHD were prescribed an antipsychotic drug within a year of diagnosis — four times the rate among young people in general. Antipsychotic drug use was highest (4.3%) in the youngest children diagnosed with ADHD, those ages 3-5 years.

“It’s reassuring that only a relatively small percentage of these children were prescribed antipsychotics,” Olfson says. “But we should be working to reduce that number even further.

“For at least half of the young people in our sample who were prescribed antipsychotics, we couldn’t find a rationale in their claims records to explain why they were taking these medications.”

Around half of the young people taking antipsychotic drugs had a diagnosis such as bipolar disorder, psychosis, ODD, or CD.

“While antipsychotics are not FDA-approved for these diagnoses, there is scientific evidence to support their use in treating severe symptoms of ADHD,” said Ryan S. Sultan, M.D., lead author of the paper and assistant professor of clinical psychiatry at Columbia University Vagelos College of Physicians and Surgeons.

The findings show that fewer than half of the young people taking antipsychotic drugs had been treated first with stimulants such as Adderall and Ritalin, the recommended medication treatment for ADHD.

The researchers suggest that many of the behavioral symptoms that prompted physicians to prescribe antipsychotic medications as an initial treatment might have been resolved by prescribing recommended ADHD medications first.

“Many physicians bypassed stimulants and went right to antipsychotics — contrary to expert opinion about treatment for ADHD, and unnecessarily exposing patients to the risk of severe side effects such as substantial weight gain,” said Sultan.

“Antipsychotic medications play a small role in the treatment of severe ADHD symptoms, but in the absence of severe symptoms, there are safer, more effective medications for youths with ADHD.”

Source: Columbia University Irving Medical Center

Study IDs Gene Sets Tied to 5 Mental Disorders

An international study has revealed specific sets of genes associated with the development of ADHD, autism spectrum disorder, bipolar disorder, major depression and schizophrenia.

Researchers analyzed more than 400,000 individuals to determine the genes behind these five mental health disorders.

Researchers from The University of Queensland and Vrije Universiteit in Amsterdam discovered several sets of genes marked all five disorders.

“Before this analysis, we knew a lot of psychiatric disorders were related to each other due to their hereditary nature,” said UQ psychiatrist Professor Christel Middeldorp.

“We often see multiple family members with mental illness in one family, but not necessarily with the same disorder.

“We investigated if specific sets of genes were involved in the development of multiple disorders, which genes are not only related to say, ADHD, but also to the other four psychiatric disorders.

“These are genes that play a role in the same biological pathway or are active in the same tissue type.

“Genes that are highly expressed in the brain were shown to affect the different disorders, and some genes were related to all the illnesses we studied.

“It shows that there is a common set of genes that increase your risk for all five disorders.”

Study leader Dr. Anke Hammerschlag believes this occurs because of biological pathways shared by the genes in the brain. Research findings appear in the journal Psychological Medicine.

“We found that there are shared biological mechanisms acting across disorders that all point to functions in brain cells,”  Hammerschlag said.

“We also found that genes especially active in the brain are important, while genes active in other tissues do not play a role.”

The finding is important as new pharmaceutical drugs could potentially target the shared pathways.

“Our findings are an important first step towards the development of new drugs which may be effective for a wide range of patients, regardless of their exact diagnosis,” she said.

“This knowledge will bring us closer to the development of more effective personalized medicine.”

Source: University of Queensland