Friday, October 30, 2009

Flu Shot During Pregnancy Protects Baby

Pregnant women head the list of people who should get H1N1 swine flu and seasonal flu shots, and four new studies highlight the benefits of vaccination for moms-to-be and their babies.

Bigger, healthier newborns, fewer preterm births and reduced rates of hospitalization top the findings, which are to be presented this week at the annual meeting of the Infectious Disease Society of America in Philadelphia.

In one study, U.S. researchers analyzed data on 6,410 births in Georgia and found that the risks of premature delivery and having a low birth-weight infant were significantly reduced among the 15 percent of women who received a flu shot during pregnancy.

During the height of the flu season premature births among vaccinated women fell 70 percent, compared with unvaccinated women, Dr. Saad B. Omer, an assistant professor of global health and epidemiology at Emory University's Rollins School of Public Health, said during a news conference Thursday at which all four studies were discussed.

And the likelihood of having a small baby was reduced 70 percent, Omer added.

Similar positive results would likely be seen among women getting the H1N1 vaccine for swine flu, Omer said. Studies have found in previous flu pandemics that pregnant women were at risk for giving birth prematurely to underweight babies, he said.

In another report, Yale University School of Medicine researchers, led by Dr. Marietta Vazquez, an assistant professor of pediatrics, looked at the relationship between pregnant women who got flu shots and hospitalization rates for those infants.

The researchers found that the mother's flu shot during pregnancy was 78.9 percent effective in preventing her non-vaccinated infant from being hospitalized during the first year of life and 85.3 percent effective in preventing hospitalization from infancy to 6 months.

In another report, a team led by Dr. Mark C. Steinhoff, director of the Global Health Center at Cincinnati Children's Hospital Medical Center, looked at the relationship between flu shots and birth weight in Bangladesh.

Women who were vaccinated were 30 percent less likely to develop respiratory illness with fever, and those women had substantially heavier infants than unvaccinated women, the researchers found. The study confirmed that pregnant women who get the flu are at risk for giving birth to significantly underweight babies.

In addition, flu among infants whose mothers were vaccinated was reduced 63 percent, Steinhoff said.

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Thursday, October 29, 2009

Vegetables During Pregnancy May Prevent Diabetes in Children

A new study finds that women who ate vegetables daily during pregnancy reduced the risk of type 1 diabetes in their children. This is the first study to demonstrate a link between vegetable consumption during pregnancy and the risk of the development of type 1 diabetes.

The Juvenile Diabetes Research Foundation reports that each year in the United States more than 15,000 children are diagnosed with type 1 diabetes, which translates into 40 children per day.

The new study, which appears in Pediatric Diabetes, defined “vegetables” as all but root vegetables (e.g., turnips, potatoes, carrots). The researchers collected blood samples from 5,724 five-year-old children to determine the levels of the antibodies that indicate the autoimmune response; namely, glutamic acid decarboxylase, tyrosine phosphatase, and insulin autoantibodies.

Of all the children tested, 191 (3.3%) had elevated levels of these antibodies or had fully developed type 1 diabetes. The levels of these risk markers for diabetes were up to twice as common in children whose mothers rarely ate vegetables during pregnancy, while the risk was lowest among children whose mothers claimed to have eaten vegetables daily. Overall, there was a 70 percent increased risk of developing diabetes among the children whose mothers had eaten vegetables only three to five times weekly compared with those who ate them daily.

The investigators note that they cannot say for certain that the vegetables provided the protective benefit, but “nor can this protection be explained by other measured dietary factors or other known risk factors,” stated head author Hilda Brekke of the Sahlgrenska Academy at the University of Gothenburg. Several previous studies have indicated that antioxidants (vegetables are rich sources of these nutrients) such as vitamins C and E and polyphenols provide some protection against type 1 diabetes. The results of the current study appear to support the previous findings, although further research is needed to determine their validity.

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Wednesday, October 28, 2009

The Million Baby Crawl – Fighting to Remove Toxins from our Homes

The legendary Erin Brokovich has teamed up with Seventh Generation to promote The Million Baby Crawl – a nationwide effort to raise awareness of outdated chemical laws. They are encouraging parents to ask congress to toughen up on the wide-spread use of harmful chemicals in common household items.

Seventh Generation is the leading non-toxic, environmentally-friendly maker of cleaning products in the nation. One of the demands they are bringing to congress is to require cleaning products to list ingredients with warning labels that detail possible health effects. Seventh Generation has always listed their ingredients on each product label.

The Toxic Substances Control Act (TSCA) is the decades-old legislation that currently regulates synthetic chemicals in the U.S. Of the 80,000 chemicals commonly used, only 200 are routinely tested. Under TSCA, the Environmental Protection Agency (EPA) can only demand a manufacturer turn over information necessary to evaluate a chemical’s safety after finding that it is dangerous. When the TSCA was passed in 1976, it allowed over 60,000 chemicals to be deemed as “safe” without a single scientific study.

Thankfully, two senators are introducing new legislation to address these concerns in the form of the Kids Safe Chemical Act (also known as Kid-Safe). The legislation would require manufacturers to prove that their chemicals are safe before being put on the market. Right now, products containing chemicals are only pulled off the market after they’ve been found to be dangerous.

Interestingly, the U.S. has the highest cancer rate of any country in the world and it’s a sad statistic that 1.25 million children are unintentionally poisoned in America each year.

In support of such legislation moving forward, Erin Brokovich, Seventh Generation, healthystuff.org and Safer Chemicals, Healthy Families are promoting this virtual baby crawl to raise awareness to parents. Watch more funny promotional videos here and sign up to become a crawler!

This Week's Celebrity Baby Bumps

Sarah Chalke debuts her bump, Karolina Kurkova nears the finish line, Gisele is finally showing as she multi-tasks down the street, Rebecca Gayheart looks happy in a cute art-deco frock, Jenna Elfman does the black and red pattern look again, and Camila Alves goes out for a date night in shoes that look like a cross between ballet slippers and warrior princess boots. As you can see, red is in!

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Depressed Pregnant Women at Greater Risk from Flu Infection

Pregnant women with significant symptoms of depression tend to have a stronger biological reaction to the seasonal flu vaccine than do women with lower depression levels, according to a new study.

An internal inflammatory response to vaccination is not uncommon -- it's an essential part of the process the immune system initiates to prepare for a successful fight against an actual infection. But it's also expected to be a weak and brief response.

"Inflammatory responses to vaccination do no harm, are mild, and typically go away within a few days. But an extended inflammatory response to vaccination, such as the one seen in women with the most depressive symptoms, isn't expected, and it serves as a way to estimate how somebody might respond to an actual infection or illness," said Lisa Christian, an assistant professor of psychiatry at Ohio State University and lead author of the research.

She and colleagues also recently published a study in the same journal indicating that pregnant women experiencing depressive symptoms and certain stressors had higher levels of inflammatory markers in their blood than did pregnant women with lower depression and stress levels.

Though this mind-body connection is well established in people with chronic stress, Christian said few studies have examined the effects of depression and stress during pregnancy. Research has shown that pregnancy suppresses certain functions of the immune system to prevent rejection of the fetus and to protect the fetus from inflammation that accompanies fevers and other illnesses.

In the flu vaccine study, 22 pregnant women completed questionnaires about their depressive symptoms and gave blood samples before they received a seasonal influenza shot. Between six and nine days later, a second round of blood samples was collected.

Researchers assessed the women's depressive symptoms using the Center for Epidemiologic Studies Depression Scale, a series of 20 questions about physical, emotional and cognitive symptoms. The women were classified in three groups: having either no or minimal depression; mild or moderate depressive symptoms; and significant depressive symptoms. A diagnosis of depression can be made only after an interview with a doctor.

The scientists analyzed the post-vaccination blood samples for the presence of macrophage migration inhibitory factor, or MIF, a protein that promotes inflammation by suppressing other substances in the blood that fight inflammation.

A week after receiving the flu shots, the women with the highest scores on the depression scale had about twice as much MIF in their blood as did women reporting minimal symptoms.

Christian's previous study on inflammatory markers in the blood during pregnancy involved 60 women, including the 22 who participated in the flu study.

In this study, researchers assessed the women using a variety of measures: the depressive symptom scale, a perceived stress scale measuring experiences of stress and coping with stress in the past month; a questionnaire gauging how much social support the women had; tests for frequency of stressful social interactions; and a short survey of how happy the women and their partners were about the pregnancy.

Blood samples were taken to measure levels of two proteins, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-a). Both are proinflammatory cytokines, chemical messengers that are mobilized when the body is injured or has an infection, and they cause inflammation in their effort to make repairs in the body.

When these proteins circulate without an infection to fight, the body experiences excess inflammation, which is associated with a variety of diseases depending on which cells are producing the proteins. Previous studies have shown that such inflammation during pregnancy can increase the risk of preterm birth and preeclampsia, a high blood pressure condition that can occur during the last half of pregnancy.

Overall, the women reporting more depressive symptoms had significantly higher levels of IL-6 in their blood than did women with fewer symptoms. The association between depressive symptoms and TNF-a was not as strong, but was still considered significant.

In both studies, the researchers assessed a variety of health behaviors and measures, such as body mass index, cigarette smoking, prenatal vitamin use and physical activity, to gauge whether these factors might affect the presence of inflammation markers. None of the measures had a significant effect, Christian said.

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Use of Forceps Before C-Section May Not Raise Risks

Attempting to aid a difficult childbirth with forceps instead of immediately performing a C-section may not raise the risks to the baby in most cases, a new study suggests.

When a woman has difficulties in the second, or "pushing," stage of labor, the doctor can use forceps or a vacuum pump to pull the baby through the birth canal. That practice, however, has fallen out of favor in recent years, as cesarean section has become the preferred option -- partly because of concerns about the risks of using forceps and vacuums.

Those potential risks include skull fracture or bleeding on the brain in newborns, and tissue damage in mothers.

However, performing a C-section during the second stage of labor also presents risks, like increased odds of hemorrhage and bladder damage in mothers.

Therefore, some have questioned the wisdom of the decline in instrument-assisted delivery, according to the researchers on the new study, led by Dr. James M. Alexander of the University of Texas Southwestern Medical Center at Dallas.

Their study, published in the journal Obstetrics & Gynecology, looked at nearly 3,200 women who underwent an unplanned C-section at one of 13 U.S. hospitals. In 640 of these cases, doctors had first attempted to deliver using forceps, vacuum or both.

Overall, rates of certain fetal and maternal complications were higher when there was a try at instrument-assisted delivery.

Mothers were more likely to develop an infection, bruising or fluid buildup at their incision site -- nearly 3 percent versus 1 percent of women who had an immediate C-section. They also had a higher rate of failed local anesthesia, which meant they had to be put under general anesthesia -- 8 percent, compared with 4 percent of the C- section-only group.

Some newborn complications were also more common with instrument-assisted attempts. One percent of infants developed brain damage due to oxygen deprivation, compared with 0.1 percent of those delivered by immediate C-section.

They were also more likely to have a low Apgar score -- a measure of heart rate, breathing and muscle tone -- five minutes after birth; just under 2 percent had a low Apgar score, versus 0.6 percent among the other newborns.

However, the researchers found, all 10 of the cases of brain damage were seen in cases where there was a concerning fetal heart rate during delivery. There was no evidence, Alexander's team notes, that the complication stemmed from damage to skull from the forceps or vacuum.

And when the researchers excluded cases with concerning fetal heart rate readings, there were no differences in the risks of any complications between the two groups of infants.

Fetal heart rate concerns were more common when doctors first attempted an instrument-assisted delivery: in 18 percent of cases, heart rate concerns prompted the C-section, compared with 14 percent of cases where the C-section was done immediately.

The findings suggest that in the absence of heart rate problems, there is no increase in the risk of newborn complications, the researchers conclude.

Together with past research, the findings suggest that attempting an instrument-assisted delivery in "the properly selected patient" minimizes the risks to mothers without increasing the risks to newborns, they wrote.

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Tuesday, October 27, 2009

Anxiety During Pregnancy can Lead to Smaller Babies

A new study published in the journal Paediatric and Perinatal Epidemiology reveals that anxiety in pregnant women impacts their babies' size and gestational age. Specifically, women with more severe and chronic anxiety during pregnancy are more likely to have affected babies.

Shahla M. Hosseini, Minhnoi W. Biglan, Cynthia Larkby, Maria M. Brooks, Michael B. Gorin, and Nancy L. Day studied a sample of low-income women, half of whom were African American and the other half Caucasian. The group already had well-known risk factors such as alcohol and cigarette use. The authors demonstrated that the mother's anxiety during pregnancy impacts birth outcomes over and beyond factors such as drug use, education, and race.

Anxiety during the third trimester predicted women delivering significantly smaller babies. In the first and second trimesters, the effects of anxiety were significant only among those women who had severe anxiety.

Low to moderate levels of anxiety in women during either the first or second trimester did not significantly affect the birth outcomes, but women who are severely anxious during much of their pregnancy should be considered for anxiety-reducing interventions.

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Monday, October 26, 2009

Obese Women Have Increased Pregnancy and Postpartum Risks

Women who are obese during pregnancy are at increased risk for preterm birth, preeclampsia, gestational diabetes, cesarean delivery and postpartum weight retention, according to data presented today.

Kimberly K. Vesco, MD, MPH, obstetrician-gynecologist at Mount Talbert Medical Office and Kaiser Sunnyside Medical Center, presented data on pregnancy outcomes and postpartum weight retention for 5,551 normal-weight women and 3,110 obese women included in an HMO database.

Weight gain at one year defined the difference between baseline weight during pregnancy and weight at 300 to 420 days postpartum.

Mean baseline weight was 131 lb for normal-weight women vs. 214 lb for obese women. Mean gestational weight gain was lower among obese women compared with normal-weight women (22 lb vs. 32 lb; P<.001). However, 33% of obese women gained more than 10 lb at one year postpartum compared with 22% of normal-weight women (P=.0001).

Obese women had an increased risk for preterm birth (10% vs. 8%), preeclampsia (15% vs. 6%), gestational diabetes (8% vs. 3%) and cesarean delivery (36% vs. 20%; P<.001).

Further, infants born to obese women had a higher mean birth weight when compared with infants born to normal-weight women (P<.001).

Study results also revealed that obese women were more likely to smoke (7% vs. 10%), have a diagnosis of depression (7% vs. 11%) and hypertension during pregnancy (9% vs. 22%), and have diabetes (1% vs. 5%; P=.0001) compared with leaner women.

“There should be inquiries to prevent weight loss among obese reproductive-age women, particularly those planning a pregnancy,” Vesco said during the oral presentation. “In addition, programs should be developed to limit gestational weight gain during pregnancy and to assist with weight loss after delivery.”

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Hospitals Cut Back on Scheduled Inductions

Hoping to schedule your baby's birth while your mother's in town, or before the doctor goes on vacation? Labor is becoming less of a late-night surprise, but some hospitals are starting to tighten the rules for elective deliveries — because some babies are being delivered too early.

More hospitals are expected to crack down as regulators begin new quality measurements next spring that aim to reduce too-early elective inductions and first-time cesareans.

Induced labor is on the rise for lots of reasons, some medical and some not. But recent research shows a troubling link between elective inductions and these so-called "late preemies." These aren't the dire too-small babies that the word premature conjures, but near-term babies who nonetheless are at higher risk of breathing disorders and other problems than babies who finish their very last weeks in the womb.

National guidelines from the American College of Obstetricians and Gynecologists have long discouraged elective deliveries before the 39th week of pregnancy. But some hospitals that took a close look were surprised. At Utah's Intermountain Healthcare, for example, 28 percent of elective deliveries were breaking ACOG's rule in 2001, Oshiro told a March of Dimes meeting on preventable prematurity this month.

Most were being induced in week 37, such a small difference that local obstetricians argued it wasn't a problem. So Oshiro pulled the medical charts and found those near-term babies had more than double the risk of ending up in neonatal ICU, suffering respiratory distress, even needing a ventilator.

It took several years of policing: Inductions now are allowed only after meeting a checklist of requirements. But today, only about 3 percent of Intermountain's elective deliveries occur before 39 weeks — and infant hospitalizations have dropped, saving money, too, says Oshiro, now a maternal-fetal medicine specialist at Loma Linda University in California. He's about to pilot a similar program at hospitals in that area.

"If there's no need to intervene, please don't intervene," is Oshiro's message.

Labor is induced in more than one in five births, double the rate in 1990, according to the Centers for Disease Control and Prevention. Many cases are for clear health reasons, such as a problem with the fetus or a sick mom or a pregnancy that has dragged well beyond the woman's due date.

There's little data on how many are elective. But a Hospital Corporation of America study of nearly 18,000 births at 27 of its hospitals around the country suggests 10 percent of all births are performed electively before the 39-week mark. (That date is considered the point at which doctors can be sure a pregnancy has reached full-term, typically defined as 40 weeks give or take about a week.)

There are many reasons to perform an elective induction, such as if mom lives two hours from a hospital, notes Dr. John Fisch of the University of Pittsburgh Medical Center's Magee-Women's Hospital.

Patient and doctor preference helped drive the rise in inductions, such as women timing grandma's arrival to take care of the siblings, or minimizing 3 a.m. deliveries. Then there's defensive medicine, where doctors worried about litigation induce for minor reasons like a slight uptick of the mother's blood pressure.

So Pittsburgh also had "a little bit of a hard sell" after discovering nearly 12 percent of elective deliveries broke the 39-week rule in 2004, Fisch says. "It was perceived to be a safe and effective way in delivering a baby — and it is, as long as it meets certain criteria."

After Magee began strict enforcement — requiring that a mother's cervix be nearly ready for natural labor, and limiting the beds available for elective inductions — too-early inductions dropped to 4 percent by 2007 and are "effectively zero" today, Fisch says. Overall, elective inductions dropped 30 percent.

More hospitals are expected to start enforcing those criteria this spring, when the Joint Commission that regulates health quality will require hospitals to report all elective deliveries and the gestational age to its public database, providing peer pressure for improvement. Hospitals also will have to report cesareans for first-time mothers, too often a result of a failed induction.

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Baby Einstein Refunds Offered

The Bush White House blundered when it singled out Julie Aigner-Clark, founder of the Baby Einstein Co., to sit by First Lady Laura Bush as President George W. Bush rhapsodized, in his State of the Union address, "Julie represents the great enterprising spirit of America." Seated alongside Aigner-Clark in the House visitor's gallery were Wesley Autrey, who had leapt in front of a New York City subway train to rescue a complete stranger, and Army Sgt. Tommy Reiman, who had repelled an enemy attack in Iraq with two legs full of shrapnel and bullet wounds in his arms and chest.

Aigner-Clarke's act of heroism had been to get rich marketing "educational" DVDs for an age group (zero to 2) that, pediatricians agreed, shouldn't be watching TV at all. Baby Einstein videos were at best devoid of their promised education benefits ("your child will learn to identify her different body parts, and also discover her five senses … in Spanish, English, and French!") and at worst actively harmful to brain development. Bush's own Federal Trade Commission was at that very moment weighing a complaint against Baby Einstein for making false and deceptive claims.

Aigner-Clark had sold Baby Einstein to Disney in 2001, she claimed, and therefore bore no current resonsibility for the company's product pitch.

The FTC dismissed the complaint late in 2007, largely because publicity generated by it had embarrassed Disney into abandoning its gaudiest educational claims. But escalating bad publicity and the threat of further legal action last month persuaded the company to offer a refund to anyone who purchased a Baby Einstein DVD between June 5, 2004, and Sept. 4, 2009. The company already offered a 60-day money-back guarantee for its videos, but the new refund offer gives consumers until March 2010 to return videos purchased during the designated time period and requires no receipt. That gives the transaction some flavor of a product recall.

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Donovan McNabb is Expecting Baby #4!

Philadelphia Eagles quarterback Donovan McNabb and wife Roxie are in for another exciting December – Philly.com reports that the couple is expecting their fourth child!

Just last December, Donovan and Roxie welcomed twins Sariah and Donovan Jr., now 10 ½ months old. They are also proud parents to 5-year-old Alexis.

The couple also announced that they have partnered up with the Neonatal Intensive Care Unit at Virtua Voorhees – the southern New Jersey Hospital where each of their children were born. They have made a six-figure donation to help with the construction of the new NICU, called the McNabb Family Neonatal Intensive Care Unit, scheduled to open in 2011. They’ve also committed to helping raise $2.5 million to help fund the project.

Donovan and Roxie, who were college sweethearts at Syracuse University, were married in June 2003.

Congratulations to the McNabbs!

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The Effects of an Unusual Baby Name

Unusual baby names are becoming more and more, well, common these days. A mere one percent of babies are named Emma or Jacob, the most popular names, and only about ten percent are given one of the Top Ten names. Compare that to a hundred years ago, when five percent of babies were given the most popular names John or Mary, and 30 percent of boys and 20 percent of girls received one of the Top Ten Names. For the first time, less than half of all babies get one of the Top 50 names.

And it's not only American parents who are choosing unusual baby names. Chinese parents, seeking individuality in a country with 1.3 billion people sharing only 129 surnames, are turning to unconventional combinations of letters, numbers and symbols for their children's names. One couple wanted to name their baby 1A while others use the @ symbol, pronounced "aita" and meaning "love him" in Chinese.

Many European countries restrict the pool of possible names, though many parents are testing the centuries-old boundaries. But Belgium, with no such laws, over half of children receive such unique names as Testimony, Cherub, and Edelweiss.

If you're considering giving your baby an unusual name, your biggest question may be: How will an unusual name affect my child for better and worse throughout his or her life?

Having an unusual name associated with low socio-economic status -- one that contains such markers as apostrophes, little-used consonants such as z or q, and invented spellings -- can have an actual negative effect on a child's performance in school, according to Florida State psychologist David Figlio. "Teachers tend to treat children differently depending on their names, and these same patterns apparently translate into large differences in test scores," said Figlio, who found that children with conventional names such as David or Drew performed better on tests than their own siblings named Damarcus or Da'Quan.

When you control for poorer or less educated parents, most modern studies find that children with unusual names do as well as others in school and with peers. The probability of an unusual name having a positive effect on a child's development is as large as that of it having a negative effect, says Martin Ford, a developmental psychologist at George Mason University who authored one such study.

The authors of Bad Baby Names claim that the bearers of such monikers as Ima Muskrat and Happy Day were less distressed by their names than they were proud of standing out in the crowd - though that may be truer for Happy than for Ima.

Your associations with your own name can influence what you do with your life, affecting where you live, which career you choose, even whom you fall in love with, according to psychologist Brett Pelham. Pelham found that dentists are named Dennis more often than are, say, bond traders, and that people named Georgia are more likely to become geologists, move to Atlanta, and marry men named George than they are to make choices less connected with their names.

People who like themselves and their names tend to be attracted to other people, places, and things connected with their names, says Pelham, who named his own son Lincoln because people associate that name with compassion and caring. The disadvantage of a very unusual or unique name, according to Pelham: No cultural associations, or ones that it's more difficult to anticipate and control.

If, after weighing the evidence, you're still interested in choosing an unusual name for your child, here are a few possibilities: Arava, Ceres, or Keturah for girls; Eben, Gower, or Piran for boys; Calixto, Padgett, or Sorrell for either.

Read more at: http://www.huffingtonpost.com/pamela-redmond-satran/unusual-names-why----and_b_333282.html

Smoking During Pregnancy can Increase Infant Distress

Studies have consistently found that prenatal cigarette smoke exposure is associated with increased rates of behavior problems, irritability, attention-deficit/hyperactivity disorder, the risk of violent offenses, conduct disorder, adolescent onset of drug dependence, and the risk for criminal arrest in offspring. This study adds another potential negative outcome to the list of reasons for mothers to stop smoking while pregnant.

Most of the effects of tobacco either during pregnancy or on postnatal outcomes are attributed to nicotine. However, smoking is associated with reduced monoamine oxidase A (MAO-A) activity, enzymes that degrade brain neurotransmitters in smokers. Prenatal smoke exposure-induced low MAO-A activity in fetal life may dysregulate brain neurotransmission, creating a potential vulnerability to develop behavioral disorders later in life. This dysregulation can occur with or without interaction with nicotine's effect on the developing brain.

French scientists compared blood biomarkers of MAO-A activity in smoking and non-smoking pregnant women and in the cord blood of their newborns. They also assessed the newborns' comfort level during their first 48 hours of life. They found that MAO-A activity is reduced both in pregnant smokers and in their newborns. The newborns of smoking mothers also showed significantly more discomfort than those of non-smoking mothers, potentially related to MAO-A inhibition.

"We know that maternal smoking can negatively affect a newborn in many ways, such as contributing to low birth weight. Berlin and colleagues provide new evidence that the newborns of mothers who smoke experience more behavioral discomfort, and they suggest a mechanism that helps to explain the cause of this discomfort," commented Dr. John Krystal, Editor of Biological Psychiatry. Although additional studies are needed, this work highlights the importance of targeting pregnant women for help to stop smoking.

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