Bifidobacterium and the quantity of this genus and its species Bifidobacterium longum subsp. infantis in the infant gut microbiota. We implemented such a study. Methods: Among 1654 Canadian full-term infants, the gut microbiota of faecal samples collected at 3 months were profiled by 16S rRNA sequencing; the genus Bifidobacterium and Bifidobacterium longum subsp. infantis were quantified by qPCR. Associations between Bifidobacterium and other gut microbiota were examined by Spearman’s rank correlation. Results: Following vaginal birth, maternal IAP exposure was associated with reduced absolute quantities of bifidobacteria among vaginally delivered infants (6.80 vs. 7.14 log10 (gene-copies/g faeces), p < 0.05), as well as their lowered abundance relative to other gut microbiota. IAP differences in infant gut bifidobacterial quantity were independent of maternal pre-pregnancy body-mass-index (BMI), and remarkably, they were limited to breastfed infants. Pre-pregnancy BMI adjustment revealed negative associations between absolute quantities of bifidobacteria and CS with or without labour in non-breastfed infants, and CS with labour in exclusively breastfed infants. Significant correlations between Bifidobacterium abundance and other microbial taxa were observed. Conclusions: This study documented the impact of the birth mode and feeding status on the abundance of gut Bifidobacterium, and pointed to the important ecological role of the genus Bifidobacterium in gut microbiota due to its strong interaction with other gut microbiota in early infancy.Background and Aims: Few studies consider the joint effect of multiple factors related to birth, delivery mode, intrapartum antibiotic prophylaxis and the onset of labour, on the abundance of  How we are born shapes the development of our gut microbiota. Caesarean section (CS) birth alters the gut microbiota of the young infant with its signature influence being the substantial reduction in the abundance of Bacteroidetes species ,2. BifidBifidobacterium [Streptococcus (GBS) in North America [Bifidobacterium at 3–4 months was not found in a subpopulation of the CHILD birth cohort [Whereas the imprint of caesarean section is substantive, other birth events also influence the infant gut microbial composition during the first year of life. Although not often reported, prolonged labour during birth is associated with reduced abundance of acterium . As vagiacterium ,11, comp America . Within  America . Howeverh cohort . In thish cohort ,16.Bifidobacterium are pioneer gut colonizers and are considered foundational microbiota members that influence the early-life gut microbial community and exert positive effects on host health [Bifidobacterium [Bifidobacterium [Bifidobacterium, is associated with detrimental health outcomes, such as overweight, allergies and asthma [Members of the genus t health . In addiacterium ,19. Breaacterium ,20. Inded asthma ,22.Bifidobacterium in gut microbiota is well-known, factors related to birth, such as maternal IAP exposure and CS with labour, have been less studied. The objective of our paper was to fill this gap in the literature and build on findings from our previous research [Bifidobacterium and other gut microbial taxa in early infancy. Faeces were collected from infants at 3 months of age, and profiled by 16S rRNA sequencing, as well as quantitative PCR (qPCR), to provide an accurate measure of the absolute quantities of bifidobacteria. Breastfeeding status was taken into account.Although the influence of breastfeeding in promoting research  to deterwww.childstudy.ca, accessed on 1 May 2021), in which 3-month infant faecal samples were additionally profiled for Bifidobacterium by qPCR. Mothers of studied infants were recruited in their second or third trimester of pregnancy and their newborns enrolled if they were a singleton live birth at 35 weeks of gestation with a birth weight of 2500 g. In vitro fertilized births were excluded to avoid multiple gestation or preterm births. Hospital birth records provided information on sex, mode of delivery , duration of the first and second stage of labour, and maternal IAP. Women colonized with vaginal GBS or delivered by caesarean section received intrapartum administration of penicillin and cefazolin, respectively. These data were utilized to classify infants into mutually exclusive groups as follows: vaginal delivery with no IAP, vaginal delivery with IAP, CS delivery with no labour and CS delivery with labour. CS delivery was also defined clinically as elective CS  and emergency CS, as per our previous study [Bifidobacterium longum subsp. infantis. A directed acyclic graph (DAG) was generated to illustrate putative relations between the birth mode and infant gut microbiota at 3 months using the daggity.net program (Accessed date: 01 May 2021) [This study includes a subset of 1654 infants enrolled in the Canadian Healthy Infant Longitudinal Development (CHILD) Study between 2009 and 2012  ,27 , total bifidobacteria (Bif) and total bacteria  [A quantitative PCR assay of DNA isolated from infant faecal samples was conducted following a published protocol . To mini  ,34 (TablB. longum subsp. infantis (DSM-20088) genomic DNA starting at 1 ng/μL. We calculated the lower limit of detection for the multiplex assay to be 2.8 × 10−6 ng of DNA or 1 gene-copy of B. longum based on the amplification data from the serial dilution and the non-template control. Because each template sample represented a different starting mass of stool, the limit of quantification for the analysis was variable from sample-to-sample, and ranged from 200 to 2 × 109 gene-copies/g stool (B. longum subsp. infantis) and 40 to 4.5 × 109 gene-copies/g stool . The relative abundance of B. longum subsp. infantis and total bifidobacteria was calculated as the percentage of respective taxa (gene-copies per gram stool) relative to the total bacteria (gene-copies per gram stool) quantified by qPCR. This relative abundance measure of Bifidobacterium was plotted against that of 16S relative abundance to determine the extent of agreement. In calculating qPCR-based abundance, almost every DNA product amplified from target 16S rDNA regions resulted in a much larger denominator and lower abundance values than 16S relative abundance. Overall   within Rp value < 0.05, using vaginal delivery with no IAP as the reference group. The associations between Bifidobacterium and other gut microbial genera were examined using Spearman’s rank correlation. False discovery rates (FDR) were controlled using Benjamini–Hochberg adjustment [p-values < 0.1 were considered significantly different and displayed. Statistically significant differences in 16S alpha diversity indices, relative and absolute quantity of total bifidobacteria measured by qPCR and 16S rRNA sequencing were determined using the Kruskal-Wallis test; and pairwise comparisons were conducted by Dunn’s post hoc test for multiple comparison with Benjamini-Hochberg p value adjustments. Independence of association between birth mode and absolute quantity of Bifidobacterium was determined by univariable and multivariable linear regressions. To improve normality of data, the absolute quantity of genus Bifidobacterium was Box–Cox transformed prior to linear regression [B. longum subsp. Infantis.To determine the modifying effect of breastfeeding, statistical analyses were conducted following stratification by breastfeeding status . The discriminative 16S taxonomic biomarkers of infant gut microbiota were identified using linear discriminant analysis (LDA) effect size (LEfSe) , and sigjustment , with ‘Fjustment . FDR-corgression . Logistin = 172) and 13.97% (n = 231) of infants were delivered by CS with and without labour, respectively. Compared with infants delivered vaginally without IAP exposure, a greater proportion of CS delivered infants, particularly those who did not experience labour, was born to mothers who were Asian, with age over 30, and overweight and obese pre-pregnancy; more infants delivered by CS with no labour were male, and partial or non-breastfed than infants delivered vaginally without IAP exposure. Meanwhile, the lowest level of postnatal infant antibiotic use was observed among vaginally delivered infants without IAP, while infants delivered by CS with labour had the highest level of postnatal antibiotic use , 53.75% were male. The mean gestational age was 39 weeks . Over half of their mothers were of Caucasian ethnicity (74.30%), obtained a university degree (56.83%) and did not smoke (95.11%), and were between the ages of 30 and 39 years (65.48%). In addition, 55.08% and 27.27% of infants were exclusively and partially breastfed, and 17.65% of infants were formula-fed. Further, 876 infants were born vaginally without maternal IAP exposure (52.96%) and 375 were born vaginally following maternal IAP (22.67%); 10.40% , p < 0.05) and partially breastfed (6.75 vs. 7.25 log10 (gene-copies/g faeces), p < 0.05, 10 (gene-copies/g faeces) vs. 6.94 log10 (gene-copies/g faeces) for vaginal delivery without IAP).Against a backdrop of other changes to gut microbiota, 3-month old infants with maternal IAP exposure during vaginal birth had reduced relative abundance of the phylum Actinobacteria and its the actinobacterial genus acterium . Specifiacterium A,D. As nh no IAP . When coBifidobacterium, while infants born by emergency CS had 1.63% of this genus in their faecal gut microbiota  (p ≤ 0.05)  displayed the impact of maternal IAP on the structure of infant gut microbial communities (< 0.001) . Vaginal ≤ 0.05) .Bacteroides than vaginal delivery with no IAP  between t labour . Bacteroexposure . Membersh labour .10 (gene-copies/g faeces), p < 0.05), as well as their lowered abundance relative to other gut microbiota. These results are consistent with a systematic review of eight studies showing depletion of bifidobacteria in the gut microbiota of infants exposed to intrapartum antibiotics, although this difference did not persist to one month after birth in three studies [Bifidobacterium are sensitive to penicillin antibiotics but less so to the cephalosporins [10 (gene-copies/g faeces), p < 0.05) or partially breastfed (6.75 vs. 7.25 log10 (gene-copies/g faeces), p < 0.05), even when adjusted for pre-pregnancy BMI. In the next paragraphs, we turn to findings on correlations between Bifidobacterium and other microbiota, as proxy measures for cooperation and competition among gut microbiota, to speculate on the meaning of the study’s findings.In a general population birth cohort of 1654 infants, maternal IAP exposure was associated with reduced absolute quantities of bifidobacteria among vaginally delivered infants  using the species-specific qPCR.There are several strengths of this study. Firstly, the CHILD cohort is a well-characterized birth cohort, such that we were able to investigate in-depth the impact of IAP and birth mode on infant gut microbiota. Secondly, an adequate sample size allowed us to adjust for important confounding factors, particularly breastfeeding. Last but not least, the qPCR-based abundance data were complementary to the 16S-based relative abundance data typically analysed in many microbiome studies. Although our Illumina MiSeq method was cost-effective for the sequencing of the 16S rRNA gene in a large number of faecal samples, several studies noted the under-representation of the genus Bifidobacterium, even among breastfed infants. Moreover, absolute quantities of bifidobacteria were negatively affected by CS birth, with or without labour. Our epidemiological study points to the important ecological role of the genus Bifidobacterium in terms of its interaction with other gut microbiota during early infancy.In conclusion, this study revealed the impact of the birth mode on the bifidobacterial abundance in infant gut microbiota after 3 months. Specifically, we found that maternal IAP exposure during vaginal birth significantly decreased the absolute and relative abundance of


In this article, I seek to understand how the COVID-19 pandemic has impacted childbirth in Puerto Rico, an island that was already in recovery following the occurrence of two devastating hurricanes in the fall of 2017 and a major earthquake in the winter of 2020. Thus, I argue that it is important to discuss not only how individual disasters impact birth, but also how their compounding effects do so. In order to address these research questions, I conducted remote interviews with Puerto Rican birth workers and researchers. During times of crisis, this pandemic included, home and midwife-attended births have become increasingly more popular. However, Puerto Rican midwives and doulas currently have less institutional support than ever. In a time of quarantine when home births are rising, we need to consider whether society is designed to facilitate these models of care. In Puerto Rico, pre-pandemic, there was a less than 1% home birth rate and there still is a lack of legal recognition and protections for homebirth midwives. As this article demonstrates, an acknowledgment of the near-invisible labors of these birth workers is needed, in addition to supplies, support, and protections for them—and not just in times of “crisis.” From Ebola to Zika, a primary concern in recent epidemics has been how infectious disease impacts pregnant women and infants. The COVID-19 crisis is no different, with headlines across the nation reporting on women who have decided to labor in their homes  or on doWhen Hurricanes Irma and Maria hit Puerto Rico in 2017, many laboring women were unable to get in touch with their primary providers or to get to the hospital . During In order to understand how COVID impacted birth in Puerto Rico, and how this differed from or was similar to previous disasters, I conducted remote interviews with 11 Puerto Rican women working in the fields of reproductive health and justice, including: 5 midwives, a doula, a clinical psychologist working in a Neonatal Intensive Care Unit (NICU), a social worker focused on combating gender violence, a child birth photo journalist, a midwifery student, and a fellow researcher. As midwives, doulas, and their allies are often found on the frontlines of disasters, working directly with laboring people, they are most knowledgeable about how these adverse events impact birth. I conducted these interviews via Zoom and on the phone, primarily in English (a second language for the birth workers) with some Spanish spoken intermittently. Individual interviews were conducted multiple times to track how the pandemic and responses to it changed over the April to August 2020 timespan. During this time, I closely monitored the media on birth experiences in quarantine and continued to review the literature on maternal services in times of disaster.This project was granted exemption status from the Temple University Institutional Review Board because it consists entirely of interviews that are more in the tradition of journalism or oral history (and thus do are not subject to IRB oversight), and because there are adequate provisions in place to protect the privacy of any respondents who wish to remain anonymous. Verbal consent was obtained.Interview results were mixed, with some stories of difficulty and despair and some messages of hope and resilience. I will describe and analyze these findings in terms of four emergent themes: birth location; vulnerability and isolation; advantages and disadvantages of telehealth; and midwives’ reaction to obstetrician’s increased domain protection. The information presented below comes directly from the accounts of my interlocutors (unless otherwise cited).less, and hospital and clinic births are the default. Even for those who have homes, blue tarp “roofs” are not uncommon following Maria, and the additional economic constraints put in place by COVID have made it difficult to access necessary supplies and safe, secure, sanitary spaces.Regarding birth location, my midwife interlocutors informed me that home births have become more popular and by extension, their services have been in high demand. However, they note that these services are still not accessible to everyone. This is especially true for those of a lower socioeconomic status—whether they want to or not, often they have no choice but to deliver at no cost in the public hospitals, where COVID cases are worst. The exceptions are those who are able to access free or reduced-cost midwifery and doula services, which some of my interlocutors offer. This issue of access is due to both the lack of insurance coverage of midwives and home birth and to the lack of stable housing and necessary resources such as clean water, clean surfaces, and supplies. Many people lost their homes during the hurricanes and the earthquakes; home birth is impossible for those who are home-are able to give birth within the home, home births and midwifery services have been significantly altered by the virus, as my interlocutors have explained. Midwives must wear gowns, face masks and face shields, and of course gloves. If they are visiting homes for prenatal or postnatal check-ups in person, they must practice social distancing, wash their hands persistently, and keep hand sanitizer with them at all times. Some are simply using telehealth for these appointments (leading up to and following delivery). During labor and birth, all midwife care must obviously be administered in person, cautiously. Similar to the in-person appointments, social distancing guidelines are followed, and protective gear is worn. Midwives keep their distance as much as they can, relying heavily on the family to offer physical support to the laboring woman. They have to be close when the baby comes, so that they can catch and attend to it, but some say that they have heard stories of women being taught to catch their own babies while under the supervision of trained midwives. The company of healthy family members and doulas is encouraged, but smaller group sizes are preferred. This differs drastically from pre-COVID home births in which family, friends, and neighbors alike were all encouraged to attend, and midwives provided hands-on care throughout.For those who Additionally, for the protection of midwives, their clients, and the community, the screening process is much more intense—including inquiring about COVID symptoms and contact with infected individuals. Many midwives had to wait for their own test results before they could serve their clients. I was not told whether or not these midwives required that their clients get tested, but one midwife informed me that the midwives have great difficulties in accessing rapid COVID tests. Other articles in this Special Issue echo the accounts of my interlocutors.While home birth may be challenging amid COVID, for those who give birth within the hospital, labor can be even more challenging. My interlocutors have reported that, unfortunately, during this time, cases of obstetric violence have increased. The isolation of birthing women has most likely contributed to this problem. Doulas are being banned in most hospitals on the island  along with other support persons. The lack of company, advocacy, and thus provider accountability has left many women vulnerable to the abusive practices of hospital personnel. Yet part of the poor treatment and care that women are receiving in hospitals is due to negligence rather than direct abuse. Hospitals are overburdened by COVID and were already dealing with a shortage of personnel as a result of the mass exodus that followed Hurricane Maria. One midwife told me about a client of hers who was transferred to the hospital, only to have her baby die there:One of my clients called me in May and said she hadn’t felt the baby move. I went to check up on her and could hear movement but could also tell that something was wrong. So I took my client to the hospital and called and told them about what was going on and how this woman needed a nurse to check her vitals and physically examine her...the thing is they  aren’t hiring nurses and other personnel like they should be. So, I spoke with a nurse and said, “I’m sending my client and you need to do these things” and she (my client) showed up at the hospital and they didn’t do anything.Guess what? There was one nurse on that floor. In the end the baby died in the hospital, she had a stillbirth. They  need more people, things would have been different if there was a nurse who could have attended to my client. It probably would have been a C-section, but that baby would be alive today. There are less and less people in the hospitals. This has been such an issue and continues to be one. And the people who are there are giving worse care too. They are overextended because so many left—the mass exodus after Maria. You can feel that.in the absence of a positive test result or evidence that demonstrates mother-infant viral transfer. Immediate skin-to-skin contact is thus often disallowed, making breastfeeding initiation difficult, both of which can seriously impact maternal-infant health and relationships, as well as postpartum recovery, and can force use of expensive formula often unavailable to the poor, or can result in cheap powdered formula being mixed with contaminated water—a potentially deadly situation for infants.While this midwife wished to remain anonymous in regard to this specific account , she was determined that I share it, noting how crucial it is for people to hear about these preventable tragedies. I was told that, shockingly, some maternal deaths may have been attributed to COVID with insufficient evidence. Midwives fear that the virus is being used to cover up malpractice and justify any maternal deaths for which the hospital does not want to be held liable. COVID has also given practitioners justifications for many unnecessary and excessive practices; when negligence is not the issue, increased intervention is. Most notably, the performance of more inductions and cesareans is being reported, with the justification that these move women more quickly through the system, thereby limiting potential viral exposure . MothersWhen I discussed this issue with a clinical psychologist, she was adamant that the harm of initial separation is not irreparable—you can still bond and breastfeed once you are finally reunited with your infant. She reminded me that this resilience perspective is crucial for survival, something she learned working in the NICU:always have to separate the mothers and infants and yet we still try to encourage these practices  in the long run. Even if a baby has been in the NICU for 7 months they can develop a close relationship with their parents and can still be successful in breastfeeding after they finally get to go home...this is difficult for people to comprehend if they haven’t seen it. But we’ve seen it, and we know.I do believe in immediate breastfeeding initiation and skin-to-skin contact and bonding, but I think that we need to be very careful to communicate to mothers that they can still connect and still breastfeed even after separation. They do not “miss” that one opportunity, they can make the best of the situation from there...I guess I have this perspective from working in the NICU, because (compared to these most recent COVID separations) we While birth location can certainly impact experiences and outcomes, it is important to remember that these beneficial practices can be utilized and encouraged at various stages and in many places.Puerto Rican midwives have worked tirelessly to gain respect and recognition. In addition to navigating a pandemic, they must also dispel myths that midwives are “dirty,” unsanitary, uneducated, and ill-equipped.” They face stereotypes that date back centuries in Latin America and the Caribbean and are often associated with the race and ethnicity of the midwife, especially African ancestry and Indigeneity. Even as their work becomes more visible, local birth workers such as midwives and doulas are not recognized as healthcare professionals; therefore, they have not been given the same support , supplies, and PPE as other healthcare workers. This has left them in a very vulnerable place, given that their services are in demand now more than ever. And it is also a dangerous time for them to be working and coming into contact with so many different people . Midwives worry about contracting COVID, both for themselves and for the safety of their own families. They talk about having to take everything off before entering the home, having to shower thoroughly and wash laundry multiple times, being cautious around their own children. Many worry that midwives will contract COVID at higher rates than any other essential workers. One midwife I spoke with, Tamara, wondered how many COVID cases we would see among midwives in the coming months:are. Midwives are acknowledged in other parts of the world, but they’re not seen here. Because we aren’t classified as healthcare providers, disaster funding goes to doctors but not to us. We are working for free and risking ourselves...We are having a lot of difficulty accessing COVID rapid tests. . .Because we don't have access, we are exposing ourselves going into the houses of these women who need our help. Other healthcare providers are given the tests and essential supplies but we have only gotten them through donations (we have had to buy supplies as well)...I think in September or October we could look back, gather our statistics, and say “our midwives got sick even when they used protection” because no one supported us. Right now, we’re dealing with something that affects us all and it’s pretty darn scary.Even if the Puerto Rican government doesn’t want to acknowledge that we’re health providers, we This constant stress and anxiety can take a serious toll on the mental health of community birth workers, as can the physical distance from their patients and the separation/disconnection that they feel due to protective measures such as masks and face guards. A number of midwives told me that one of the most difficult things about COVID has been not being able to embrace the baby after it is born. It saddens them that they cannot hold it, hug it, smell it, place a kiss on its forehead. There is sadness for both the mothers and the midwives in these home births.COVID can be an incredibly lonely and isolating time, not only for midwives, but also for those who are about to or who have just given birth. One interlocutor told me that in Puerto Rico, pregnant women and new mothers are more than anyone else are self-isolating; they are worried for themselves, their babies, and their families. This isolation and constant worry can be detrimental to the mental health of both pregnant women and new mothers. What used to be a celebration is now a time of grave concern. They are lacking support in so many ways. They cannot have their older relatives  present for the birth; they must be careful of how many people they allow to attend the delivery or visit afterward, and they even have to be cautious around their own birth workers. One midwife, Gina, told me that one of her clients rejected postpartum care because she was so fearful of having anyone (other than herself and her immediate family) come into contact with her newborn baby:Pregnant families are taking care of themselves the most. They are the ones quarantining in the house. I had a client who canceled her appointment with me 6 weeks away because she was worried about COVID. I had worked with her leading up to her birth, which ended up being a c-section, but even after a c-In this general environment of fear and uncertainty, mothers are anxious about bringing children into this world and about allowing them to interact with others. This stress surely impacts the birth experience itself. Many mothers in Puerto Rico and elsewhere are dealing with postpartum depression, which is not uncommon following a trauma or disaster, but has been compounded by the crushing loneliness and despair of COVID. And quality of care can be seriously compromised—especially in the hospitals; some women are coming out of their pandemic hospital births more traumatized than ever due to the obstetric violence—and/or the neglect--they experience there.Over time, as the virus has been better understood and managed in some regions, families have begun to feel slightly less anxious. As government restrictions on the island have begun to relax, so too have citizens. Accordingly, some women may begin to feel less fearful, which could significantly reduce the stress that has been present in their deliveries. Most hospitals have started letting support persons into the delivery room (at the least a family member/partner), with the exception of one hospital  that continues to ban any support persons.The telehealth journey has been particularly interesting, with arguments for both its advantages and disadvantages. For medical professionals, the implementation and use of telehealth could be seen as shifting power differentials. Patients are now in the position where they are the ones taking their own vitals, monitoring their own pregnancies, and guiding their own  appointments, leading up to and in preparationWith telehealth and remote appointments there is a lot of emphasis on self-care and being aware of your health-it is empowering for women. Parents use to be taught how to take their blood pressure and things like that, but now they are learning about fetal heart monitoring and measuring their own belly. Telehealth, telemedicine teaches them (parents) those things. Being very hands on with health can change a lot in you and make you very conscious.This account was echoed by the researcher I spoke with, and these initial interactions had me under the impression that telehealth could be a positive experience within the clinical context; however, some midwives worry that telehealth may actually be abused by medical professionals. They are concerned that doctors are exploiting this new system in order to “not do their job and still get paid,” and that now that doctors realize this is an option and something they could have been doing all along, they will continue to find reasons to do it more and more. This was the sentiment of one midwife I spoke with, Zulgeil:I don’t like to use telehealth; I think it is pretty dangerous actually. I worry that it’s being abused by a lot of the doctors who are using it. Because they think, “oh, I don’t even have to touch someone, and I can still make money from my home?” It’s negligent really. I will do my initial interview through telehealth, but I will not recruit clients online, and then after that I will go in person and wear a mask and screen the clients and discuss ethics and protocols. But these doctors, they were doing 5-min appointments anyway, even before COVID! Now it’s like nothing. I mean I know some midwives are doing it, especially birth centers, and it’s a choice, but I’m just not comfortable with that. I’m following protocols in person, and anything I can do additionally online, I will. I just worry that now that telehealth is an option, it is just going to continue to be abused.This is a legitimate concern that Zulgiel spoke to, and while telehealth is primarily used for prenatal and postnatal check-ups , limited attention in birth and lack of continuity of care can be real issues in the hospital, just as brief, condensed appointments are.For midwives, telehealth has had little impact on the power differentials between practitioners and patients, as midwives already prided themselves on embracing a model of care that treated mothers as equals. Even before COVID, midwives were conscientious in supporting mothers to be active agents in their own pregnancies and births, constantly educating and involving them in decision-making. This client involvement is still there; however, some midwives argue that COVID, social distancing, and telehealth have impacted crucial patient-practitioner interactions in more negative ways. The midwifery model of care is based on humanistic and holistic care that relies heavily on physical, social, emotional, mental, and spiritual support . The midwifery student whom I spoke with explained to me that:The pandemic has impacted the medical culture in Puerto Rico, emboldening doctors to “protect” their “domain,” which appears to be threatened by the growing preference for midwives. While some few humanistic obstetricians (one midwife approximated that their number was somewhere close to 4 out of 84) are being supportive of community birth workers during this time, especially doulas Parents are being guilted if they choose home birth. Doctors tell them that this is dangerous, negligent, abusive. They say it is the start of bad parenting and a bad childhood...many of these arguments are not evidence-based, they are fear-based. This is not, and should not be, a moral issue. This pressure was already there, but COVID is just a way in which they (the doctors) are reinforcing their message, which they already felt justified in promoting. Some people are emboldened during the time of the virus thoughSome midwives worry that the precautions taken during COVID are leading the way to midwifery becoming “too clinical.”Most midwives want to be able to work alongside the local institutions, rather than against them, and they do want institutional recognition, but they also realize that such recognition may risk the values and standards they have set for themselves as community birth workers. Gaining the approval of the government will mean that they will essentially have to unionize, offer standardized care, all be on exactly the same page, and be governed by a set of laws/principles and protocols imposed by technocratic medicineAdditionally, it would be difficult for midwives to work with an institution that does not want to work with them. The divide between medicine and midwifery existed pre-COVID but is more exaggerated now and characterized by vitriol and intolerance. The midwives call their increased persecution by the Puerto Rican obstetric community “a witch hunt,” “a fear campaign,” and “a crusade against midwives.” The birth workers I spoke with agreed overall that more than anything, COVID has been making matters of reproductive health and justice more polarized. The virus is also making more evident the extreme structural inequalities between the wealthy and the poor that already existed but are more visible now, and more severe due to the fragile state of the economy during the pandemic.As COVID has been making matters of inequality and injustice more visible—including the divide between midwives and the medical community and the economic disparities among clients--this visibility is integral to structural reform and change. For example, doula’s rights were temporarily restricted at the beginning of the pandemic, making many feel that the island’s maternity care system had “regressed,” “lost progress,” and “gone backwards” in a number of ways. They also worried that these changes would be difficult to reverse (and that the journey back would be just as long as the journey there had been). However, doulas, mothers, and allies alike rallied to have support persons recognized and protected, and they eventually were allowed to return back to the labor and delivery wards (as noted above)In Puerto Rico, the impacts that COVID has had on birth have been very similar to the impacts of previous disasters—the hurricanes and earthquakes. During all of these events, midwives have been and continue to be primary disaster responders; home births have increased ; and pregnant people  continue to become more aware of this alternative option. This growing awareness is due in large part to the Puerto Rican media coverage of midwifery care and home birth during disasters, which has continued to increase over these past three years see . Yet theSo many of these impacts observed in Puerto Rico can also be witnessed in disaster responses worldwide. Globally, and historically, we see that midwives are often the first to respond in the immediate aftermath of disasters, as they are trained in “low-tech/skilled touch”  methods As I demonstrate in this article, COVID, among other disasters, has shifted a great deal of childbirth to the care of Puerto Rican community birth workers such as doulas and midwives. As the other articles in this special issue show, this is a pattern observed worldwide as well, and one that inspires hope for a future that embraces humanistic birth practices that incorporate necessary technologies . HoweverMoving forward, we will need to consider: How high did the home birth rate go during the pandemic? The induction and cesarean rates? What can be done about birth workers’ increased risk of contracting COVID? What are the impacts? Will the transition to home birth and midwifery be sustainable ? Will midwifery be altered by the pandemic, made more official and therefore more clinical? Will problematic hospital practices persist? And of course, the people of Puerto Rico are constantly asking “What about the next catastrophe?” As I write, they have been coping with more earthquakes, weathering severe storms, and are preparing for a hurricane season that they know will be complicated by this ongoing pandemic. It is already being hypothesized that COVID will make hurricane response more difficult, due to a declining economy, compromised infrastructure, and fear of spreading disease .And, unfortunately, the people of Puerto Rico are not alone in asking the question, “What next?” Worldwide in this Anthropocene Era, we are seeing disasters, including epidemics and pandemics, increase as a result of human-driven climate change . Whether


Empagliflozin is a selective sodium–glucose cotransporter 2 (SGLT2) inhibitor used to lower blood sugar in adults with type 2 diabetes. Empagliflozin also exerts cardioprotective effects independent from glucose control, but its benefits on arrhythmogenesis and sudden cardiac death are not known. The purpose of this study was to examine the effect of empagliflozin on myocardial ischemia/reperfusion-provoked cardiac arrhythmia and sudden cardiac death in vivo.Male Sprague Dawley rats were randomly assigned to sham-operated, control or empagliflozin groups. All except for the sham-operated rats were subjected to 5-min left main coronary artery ligation followed by 20-min reperfusion. A standard limb lead II electrocardiogram was continuously measured throughout the experiment. Coronary artery reperfusion-induced ventricular arrhythmogenesis and empagliflozin therapy were evaluated. The hearts were used for protein phosphorylation analysis and immunohistological assessment.Empagliflozin did not alter baseline cardiac normal conduction activity. However, empagliflozin eliminated myocardial vulnerability to sudden cardiac death  and reduced the susceptibility to reperfusion-induced arrhythmias post I/R injury. Empagliflozin increased phosphorylation of cardiac ERK1/2 after reperfusion injury. Furthermore, inhibition of ERK1/2 using U0126 abolished the anti-arrhythmic action of empagliflozin and ERK1/2 phosphorylation.Pretreatment with empagliflozin protects the heart from subsequent severe lethal ventricular arrhythmia induced by myocardial ischemia and reperfusion injury. These protective benefits may occur as a consequence of activation of the ERK1/2-dependent cell-survival signaling pathway in a glucose-independent manner. Sudden cardiac death (SCD) is one of the most common causes of mortality worldwide, and ischemic heart disease remains the dominant cause of SCD. To essentially resuscitate the ischemic myocardium, beneficial coronary artery revascularization strategies, such as pharmacological thrombolysis, angioplasty, coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) can effectively restore myocardial blood reperfusion. However, the sudden restoration of oxygenated blood flow may also lead to subsequent severe ischemia/reperfusion (I/R) injury and provoke lethal arrhythmias . Lethal Sodium–glucose co-transporter 2 (SGLT2) inhibitors are licensed for the treatment of type 2 diabetes mellitus (T2DM); however, emerging evidence has also confirmed their powerful therapeutic effect against heart failure. The EMPA-REG OUTCOME trial, including over 7000 diabetic patients with cardiovascular diseases, showed that empagliflozin, a SGLT-2 inhibitor, reduced risk of death from cardiovascular causes, and decreased risk of hospitalization for heart failure . ThereafVarious signaling pathways have been implicated in cardioprotection, including the pro-survival reperfusion injury salvage kinase (RISK) pathway, and the JAK-STAT pathway. The protective effects of these pathways during reperfusion have been identified . CardiopThe aims of the present study were first to determine whether empagliflozin treatment can protect the heart and reduce predisposition to sudden cardiac death induced by myocardial ischemia-reperfusion injury during acute myocardial infarction. Second, we aimed to identify the potential role of reperfusion-related signaling pathways in anti-arrhythmic activity afforded by empagliflozin, to potentially provide a basis for the identification of novel strategies for targeted prevention of ischemia-provoked arrhythmias.Animal experiments were performed according to the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health . The experimental procedures and protocols were approved by the Institutional Animal Care and Use Committee of Sichuan University . Male Sprague Dawley rats  were obtained from Chengdu Dashuo Experimental Animal Research Center , and were housed in 12-h light–dark cycles at 20–25 °C, with free access to food and water. The experimental protocol is illustrated in Fig. As previous described , rats we1/2.A standard limb lead II configuration electrocardiographic system was used for monitoring cardiac conduction activity throughout the experiments . After anesthesia, the needle electrodes were placed under the skin. Heart rate, RR, PR, QRS, and QT intervals were measured, and corrected QT interval (QTc) was calculated based on Mitchell’s formular : QTc = QECG was continuously recorded throughout the entire cardiac reperfusion injury period. Arrhythmia parameters were analyzed offline using LabChart7.2.1 software . Arrhythmia events included: (1) cardiac arrhythmia; (2) ventricular tachycardia (VT), (3) polymorphic VT (PVT); (4) sustained ventricular tachycardia over 1 min (SVT); (5) AV block (AVB); (6) sudden cardiac death (SCD); (7) ventricular fibrillation (VF); (8) VT duration; (9) the longest VT episode; (10) the latency to first recorded VT episode.The main left coronary artery was then re-occluded, 1% Evans blue  was injected into the left ventricle to label the perfused (not stained) and non-perfused (stained blue) myocardium. Tissues constituting the perfused region (Area at Risk) were then either fixed in 10% buffered formalin for immunohistological assessment or stored in − 80 °C freezer for western blotting analysis.Freshly frozen myocardial tissue samples were homogenized in RIPA lysis buffer containing: 50 mM Tris-HCl (pH7.4), 150 mM NaCl, 1% NP-40, 1 mM EDTA, 0.25% sodium deoxycholate, 1X protease inhibitor cocktail  and 1X protease inhibitor cocktail . The homogenate was centrifuged to extract the total protein. The supernatant was collected. The BCA method was used to determine protein concentration . Protein lysates were separated using 12% sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). The proteins were then transferred onto nitrocellulose blotting Membrane  and blocked with 5% non-fat milk for 45 min at room temperature. The blocked membrane was incubated at 4 °C overnight with specific primary antibodies including phosphorylated P38 MAPK (Thr180/Tyr182) (p-P38 MAPK), total P38 MAPK, phosphorylated STAT-3 (Tyr705)(p-STAT3), total STAT-3, phosphorylated STAT-1(Tyr701)(p-STAT1), total STAT-1, phosphorylated STAT-5 (Tyr694)(p-STAT5), total STAT-5, phosphorylated Akt (ser473)(p-AKT), total Akt, phosphorylated glycogen synthase kinase-3β(Ser9) (p-GSK-3β), total GSK-3β, extracellular signal-regulated kinase1/2 (ERK1/2)(Thr202/Tyr204)(p-ERK), and total ERK1/2 . Blots were then incubated with horseradish peroxidase (HRP)-conjugated goat anti-rabbit IgG secondary antibody  for 2 h at room temperature. After 3 washes with PBS containing 0.1% Tween-20 (PBST), the membranes were incubated in ECL substrate solution  and imaged on an AmershamImager 600 system . Band densities were determined by ImageJ Data Acquisition Software . Relative abundance was obtained by normalizing the density of target phosphorylated protein against total protein.2O2 for 20 min at room temperature. The heart sections were blocked at 37 °C and then were incubated with primary antibody raised against phosphorylated extracellular signal-regulated kinase1/2 (p-ERK1/2) (Thr202/Tyr204)  overnight at 4 °C. After that, the sections were washed in PBS for 4 times, followed by incubation with secondary antibody. The sections were then incubated in DAB for chromogen staining and counterstained with hematoxylin. The primary antibody was replaced by a phosphate buffer solution as negative control. Images were obtained by an inverted microscope . Ten sub-images were randomly selected for each slide. Brown staining in the cytoplasm of myocyte was recognized as positive expression. Images were analyzed with Image-pro plus software .AAR regions within the left ventricle were identified with the use of Evans blue. The heart tissues were fixed in 10% neutral buffered formalin for 24 h, and then were embedded in paraffin, sectioned at 5 μm thickness. Serial sections of transverse myocardial were deparaffinized. Antigen retrieval was performed at 100 °C temperature for 15 min, and the slices were treated with HAll values were expressed as the mean ± standard deviation (SD). and analyzed with GraphPad Prism version 8.0 . Fisher’s exact test was used to compare the arrhythmogenesis between non-empagliflozin-treated control and empagliflozin-treated rats. Statistical analyses of two independent values including baseline ECG parameters, VT/LVT durations and VT starting time between control and empagliflozin groups were performed by unpaired two-tailed student’s t-test. One-way analysis of variance (ANOVA) was applied for multiple comparisons over three groups. The Levene’s test was used to test homogeneity of variance. If the variance was equal, the Student Newman Keuls test was performed, while the Dunnett’s T3 test was used when variance was not equal. All P values were two-sided. A P value < 0.05 was considered statistically significant.We observed similar electrocardiographic parameters such as heart rate, PR, RR, QRS, QT intervals at baseline in rats with or without empagliflozin treatment, indicating that empagliflozin administration does not affect baseline cardiac normal conduction activity Fig. A, B. We VF occurred frequently in control rats, with 53.8% of the control group exhibiting VF (7 out of 13), while none of the empagliflozin-treated rats that ultimately developed VF . Death was frequently caused by VF or severe AV block in the control group. Importantly, we found in our study that empagliflozin exerted a powerful protective effect against SCD . Furthermore, during the cardiac reperfusion period, empagliflozin successfully reduced the duration of ventricular arrhythmogenesis; for example, mean VT and the mean longest VT duration were 3.9-fold and 4.3-folder longer, respectively, in control rats compared to empagliflozin-treated ones  pathway, specifically p38 MAPK, ERK1/2, AKT, and GSK-3β; and in the JAK-STAT pathway, specifically STAT-1, STAT-3, and STAT-5. Representative western blots and quantitative results are presented in Fig. Although reperfusion injury caused  >  fivefold greater STAT3 phosphorylation in control and empagliflozin-treated ventricles when compared to sham-operated ones, there was no difference in the expression of phosphorylated STAT3 Fig. A, STAT1 Notably, although no differences were detected between sham-operated and control rats, pretreatment with empagliflozin markedly changed phosphorylation of ventricular ERK1/2 (Thr202/Tyr204) . Meanwhile, there was no difference between U0126-treated control and U0126-treated empagliflozin rats with respect to the phosphorylation level of ERK1/2 after reperfusion  to 0.56 ± 0.22 (empagliflozin + U0126) arbitrary units  is a leading cause of morbidity and mortality worldwide. CVD takes an estimated 17.9 million lives annually, accounting for 31% of all global deaths according to World Health Organization (WHO) estimates. Ischemic heart disease is the most common type of CVD. Over 750 thousand individuals suffer myocardial infarction in the United States alone annually . WithoutNumerous experimental studies have therefore been focused upon finding protective strategies or elucidating underlying arrhythmogenic mechanisms, with the rat being a popular model system. Sakamoto et al. found that the relationship between ischemia duration and incidence of reperfusion-induced lethal arrhythmia was “bell shaped” in rats, i.e., a maximum of 5 min of myocardial ischemia resulted in the highest incidence of VF upon reperfusion . MoreoveT2DM is a chronic metabolic disease that affects 415 million people worldwide . Over 32Accumulating experimental evidence has confirmed the benefits of SGLT2 inhibitors in various animal models, showing their favorable role in reducing the development and progression of cardiovascular diseases. For example, the cardioprotective effects of empagliflozin were attributed to the alleviation of atrial remodeling in high-fat diet/streptozotocin-induced diabetic rats , improveFocusing on acute cardiac I/R injury, recent reports also demonstrated that empagliflozin  or dapagAlthough the above-mentioned beneficial effect of empagliflozin in the presence or absence of T2DM has been confirmed by both clinical and experimental studies, its underlying molecular mechanism is still in the exploratory stage. Moreover, the possible mechanisms of empagliflozin-induced anti-arrhythmic effects after acute myocardial ischemia are unclear. Intensive analysis of the underlying mechanisms for cardioprotection against reperfusion, especially the signaling pathways, has identified major pro-survival pathways, the JAK-STAT pathway and the reperfusion injury salvage kinase (RISK) pathway, both of which transmit cardioprotective signals from the sarcolemmal caveolae to the mitochondria.in vivo rat heart, indicating that there may be an alternative prosurvival signal transduction pathway responsible for the protection of the myocardium against lethal reperfusion-induced arrhythmia.The JAK/STAT pathway, originally discovered as a cytokine-stimulated signal transduction pathway , is now The concept of a cardioprotective RISK pathway was first proposed by the Yellon group . p38 mitWe acknowledge potential limitations of this study. First, the dosing of empagliflozin in clinical trials (10 mg or 25 mg/day , 8, 11. In summary, our data confirm benefits of empagliflozin in terms of reducing predisposition to lethal arrhythmia and sudden cardiac death induced by reperfusion injury after acute myocardial infarction. Furthermore, this empagliflozin-induced cardioprotection is independent from glucose control and is associated with the ERK1/2-dependent cell-survival signaling pathway.


Throughout the year, temperature sensitivities were consistently stronger for interpolated time series than observations. Such a better representation of regional phenology by interpolation was equally supported by satellite-derived phenological indices. Nevertheless, simulation of observer numbers indicated that a decline to less than 40% leads to a strong decrease in interpolation accuracy. To better understand the risk of declining phenological observations and to motivate volunteer observers, a Shiny app is proposed to visualize spatial and temporal phenological patterns across Bavaria and their links to climate change–induced temperature changes.Phenology serves as a major indicator of ongoing climate change. Long-term phenological observations are critically important for tracking and communicating these changes. The phenological observation network across Germany is operated by the National Meteorological Service with a major contribution from volunteering activities. However, the number of observers has strongly decreased for the last decades, possibly resulting in increasing uncertainties when extracting reliable phenological information from map interpolation. We studied uncertainties in interpolated maps from decreasing phenological records, by comparing long-term trends based on grid-based interpolated and station-wise observed time series, as well as their correlations with temperature. Interpolated maps in spring were characterized by the largest spatial variabilities across Bavaria, Germany, with respective lowest interpolated uncertainties. Long-term phenological trends for both interpolations and observations exhibited mean advances of −0.2 to −0.3 days yearThe online version contains supplementary material available at 10.1007/s00484-021-02110-3. In Europe, the spring and summer phenological events were earlier by 0.25 days year−1 on average from 1971 to 2000  during 1951–2018. At the same time, prolongation of the phenological growing season has been identified not only for trees and shrubs  perspective  calculated for each interpolated phenophase. The phenological trends as well as correlation analyses were calculated and compared between observations and interpolated maps. At the end, a selected observation station was compared for local agreements together with the satellite-derived normalized difference vegetation index (NDVI) and a Shiny app proposed to support volunteer observers in getting access to these types of analyses.The two main research questions of this study are (1) how is the performance of the phenological map interpolation impacted by varying number of observations/observers and (2) how do the long-term phenological time series spatially and temporally change when comparing observations versus interpolated products. The interpolated product was produced following a similar interpolation technique developed by the German Meteorological Service  for climatological and phenological maps  interpolation (with power of 1) for all available grid points based on their surrounding circles involved . Due to the lack of phenological observations for elevated regions (area size less than 1% of Bavaria), this study only focuses on the areas with elevations lower than 1000 m above sea level (a.s.l.) with 70,609 1-km grid points.where the corresponding regression coefficients RMSE. To assess the multiple regression fits of circles as well as the predictive interpolation performances, the leave-one-out cross validation LOOCV was used for all 30 circles by calculating the circle-specific RMSE. The multiple regression models for each circle were trained on all available phenological observations in the corresponding circle except for the ith one. The test errors were averaged after all observations had been excluded once as RMSELOOCV and assigned to the centered points.Interpolated phenological maps were validated by the root-mean-square errors Pii) of the phenological observations in each interpolation circle were done in order to mimic the real observing situation.We also studied the potential influence of reduced observation numbers on the uncertainty of interpolated phenology in a bootstrap method. This was done by randomly selecting certain percentages of the available phenological observations  and then calculating the respective The interpolated phenological onset dates were visualized as anomalies which were determined as onset dates subtracted from the gridded 2019 values averaged over all available grid points  in Bavaria, for each of ten phenological seasons. The long-term phenological trends for each phenological season across Bavaria, Germany, from 1951 to 2019 were calculated and compared between in situ observations (Obs) and interpolated maps (Interpol) by using the Theil-Sen slope estimator Sen . For intThe Spearman’s rank correlations were calculated for onset dates of all ten phenophases in relation to respective air temperature. Grids of monthly averaged daily air temperature (2 m) over Germany from DWD Climate Data Center (CDC) were used, being aggregated into an averaged air temperature raster layer of grids (same as interpolation) from the temperature of the current, first, and second preseason months of the onset dates for each phenophase.R2 of simple linear regression. For this site, ground-level phenological onset dates were compared with satellite indices start of the season (SOS) and end of the season (EOS) using phenological seasons first spring and winter, since high correlations were found between green-up and flowering dates  , was chosen to show the local differences between the phenological observations and interpolated values regarding R programming language , while it decreased afterwards, more considerably in the late 1990s. The decreasing trends were weakened since 2000 but still traceable until the end of the record. From 2001 to 2019, simple linear regressions on the annual numbers of observations resulted in similar decreasing trends for all phenophases, ranging from −28.4 observations year−1 (fruiting of black elder) to −19.6 observations year−1 (fruiting of early ripening apple varieties).Across 69 years, there were in total 6576 phenological annual observers (both active and inactive) all over Germany, with 1171 being located in Bavaria. In 2019, for whole Germany, only 1034 observers have actively reported phenological events of the studied phenophases shown in Fig. The spatially interpolated maps for the Bavarian region of 2019 revealed gridded mean onset dates for the ten phenological seasons ranging from DOY 53.9 to 313.7  showing a clear seasonal difference.In Table −1) for all phenophases. The long-term trends exhibited more negative  for earlier phenophases than for later phases, as well as indicating positive changes  for late autumn and winter only.Figure −1 for both seasons). Interestingly, the trend slopes derived from interpolated grids did not only follow the above-described patterns but also presented a much more enhanced picture. Most of the significant proportions amounted to nearly 100% in the overall trend slopes (prespring to late autumn), and even in winter a clear difference (6%/46%) could be seen. With such clearly significant signs of trending, the interpolated maps seem to be very suitable for showing climate change in the regional  scale with respect to change in phenology.Considering the significance of trends, the proportions of significantly negative trend slopes were between 80 and 90% of the total negative trends, where the positive respective proportions varied from 16 to 65% for phenophases from prespring to full autumn see Fig. . No cleaFrom prespring to full autumn, the mean air temperature exhibited on average negative correlations with the phenological onset dates  fit well with the lowest number observations available. Afterwards, the effect of observation numbers on the uncertainty seemed to be limited, since the RMSELOOCV continually exhibited a slightly decreasing trend with fluctuations. On the other hand, a continuing warming trend was observed in spring temperature, and it can also be observed that the temperature extremes could influence the RMSELOOCV to some extent, but whether it is positive/negative/lagged still remains unclear.Furthermore, we looked more into the temporal changes in the historical time series of first spring regarding RMSELOOCV (see Table R2 ≈ 0.8) than in later ones (R2 ≤ 0.4). And the interpolated phenology always exhibited less variation than the phenological observations as supported by the highly consistent phenological trends shown in Fig. Taking a closer look on how mapping phenology differs from in situ observation on the point scale, a selected observation station Burgbernheim (Ph) with best possible data coverages for most of the phenological seasons was chosen and presented in Fig. n = 652/135) and full autumn (n = 613/103), there are throughout 800–1000 phenological observations in Germany and 160–200 in Bavaria for spatial interpolation, respectively. Besides, a lack of phenological data for regions above 1000 m is also critical for the uncertainty assessment since interpolation in mountainous regions was evaluated to be associated with high uncertainty according to Gerstmann et al. . The trends on observational data exhibited much higher fluctuations across stations than the gridded interpolation across Bavaria. This result clearly underlines that the differences among temporal trends of single phenological observers/stations could be considerable due to two likely reasons: shorter (30+) time series instead of the full 1951–2019 series and observer sites with considerable microclimatic variation, perhaps also switch in observed individuals. In contrast, the spatial interpolation approach with multiple linear regression models was advantageous by transferring single observations into central integrations and then assigning the theoretically phenological onset date back to each grid point. Even more in situ observations were basis of this interpolation, as records from regions outside Bavaria which still fell into the modeled circles were taken into consideration. Therefore, from this perspective, the interpolated phenological maps are more representative for a broader scale (from point to region). Furthermore, a number of observations seem not to be decisive for interpolation performance yet until 10–20% observations remained, but spring temperature might play a role in the interpolation uncertainty especially from the observed inter-annual variations shown in Fig. Regarding the performance of interpolated phenology, similar uncertainty estimations were derived by other studies. Ziegler et al.  used metWe observed a contrasting phenological response to temperature between early and later phenophases. This mirrors previous findings in the literature that spring onset is advanced by the prominent increase in preseason temperatures and autumn coloring is delayed by warm summers , which matches the respective goodness of fit of 83% and 32% for the beginning and the end of growing season in Rötzer and Chmielewski . The sysi et al.  reportedi et al. . HoweverVisualizing the phenological changes is important and needs further contributions, especially with unforeseen climatic changing conditions as well as losing contributions from regular phenological observers. An insightful implementation of citizen scientists and decision-making communities is of great potential to gain insights attributing to climate


Background: Young maternal age is associated with negative outcomes at birth and with offspring's growth. In low- and middle-income countries, adolescents' offspring growth little has been studied.Objective: To determine the association of maternal sociodemographic characteristics with weight, length, and BMI change in adolescents' offspring in their first year of life.Methods: This is a one-year follow-up study that included adolescent mothers and their offspring from 2010 to 2017. The infant anthropometric variables were performed at birth, 3, 6, and 12 months. Maternal health, pregnancy, and social variables were evaluated as well as birth outcomes. Crude, percentage, Z score, and percentile changes of weight, length, and BMI were evaluated from birth to 1-year-old. Statistical analyses were adjusted by maternal chronological age, socioeconomic status, breastfeeding duration, the timing of introduction of complementary feeding, among other variables.Results: We examined 186 dyads (mother-infant). The median maternal age was 15.5 years, and the mean pre-pregnancy BMI was 20. The mean gestational age was 39.1 weeks for infants, birth weight was 3,039 g, and length at birth was 49.5-cm. Maternal chronological age, the timing of introduction of complementary feeding, socioeconomic status, and maternal occupation were associated with offspring's weight gain at 12 months. Length gain was associated with exclusive breastfeeding. Socioeconomic status and occupation were associated with offspring's BMI change. When performing adjusted multivariable analyses, weight and length at birth were associated weight and BMI at 12 months.Conclusions: Weight at birth may negatively predict infant's weight and BMI changes at 12 months, while length at birth may positively predict the changes. Maternal chronological age, socioeconomic level, occupation, and the timing of the introduction of complementary feeding were associated with the weight change. Only exclusive breastfeeding was associated with length Z-score change in adolescents' offspring in their first 12-months of life. Adolescent pregnancy is associated with an increased risk of eclampsia, puerperal endometritis, systemic infections, maternal mortality, and preterm delivery compared to pregnant adults (≥20 years old) . Most ofThe reasons for the adverse maternal and neonatal outcomes in adolescents are not clear yet, but it seems that inadequate/absent prenatal care is one of the main risk factors . EvidencSocial and cultural factors are also associated with perinatal outcomes in pregnant adolescents. Many pregnant adolescents drop out of school, leading to a cycle of unemployment and poverty for life. These structural challenges resonate to promote the care of adolescent mothers. For example, the adolescents who go back to school often stop breastfeeding their children, contributing to the low rates of exclusive breastfeeding (8% at 6 months) . TherefoFor the adolescents' offspring, the risk of perinatal morbidity and mortality, low birth weight, small for gestational age, and severe neonatal conditions is increased . Also, bCurrently, very few longitudinal studies have investigated the after-birth growth of adolescents' offspring. Therefore, the purpose of the study was to determine the association of maternal sociodemographic characteristics with weight, length, and BMI change in adolescents' offspring in their first year of life.We conducted a prospective cohort study at Mexico's Instituto Nacional de Perinatología (INPer) from 2010 to 2017. INPer is a public tertiary care institution that treats high-risk pregnancies of women who do not have formal employment or health insurance. The participants were 186 dyads of pregnant adolescents and their offspring. The children were born in the toco-surgical unit of INPer, and we followed them from birth to their first year of life. Sampling was non-probabilistic, and women who met the selection criteria were included consecutively. The participants were pregnant adolescents from 10 to 19 years old, primiparous, with a singleton pregnancy, with <20 weeks of gestation, and without chronic, metabolic, or genetic diseases. All participants signed informed assent, and their respective parents or guardians signed informed consent. We eliminated the participants that had gestational diabetes or hypertensive disorders during pregnancy. Also, dyads were eliminated if the offspring had a disease that affected growth, such as hypothyroidism, diabetes, heart diseases, neoplasms, or 21-trisomy. A structured questionnaire was used to gather sociodemographic data, like age, marital status, level of education, occupation, socioeconomic level, pre-pregnancy weight, history of diseases, and smoking and alcohol drinking habits.Trained health workers obtained the mothers' and their offspring's data using the questionnaire, clinical records, and performing interviews during the postnatal nutritional visits. We calculated the mother's chronological age at the moment of the delivery from the baseline data. We obtained the date of birth, sex, gestational age, birth weight, and length at birth directly from clinical records. We calculated gestational age at baseline evaluation or from the clinical record according to the last menstrual period. Neonatal outcomes were defined as follows: low birth weight <2,500 g, and small for gestational age as birth weight below the 10th percentile for specific gestational age and sex, according to the World Health Organization (WHO) criteria using AnthroPlus-WHO® .Trained health professionals performed anthropometric measurements of the offspring at 3, 6, and 12 months. Birth weight was determined in grams on a pediatric digital scale Tanita 1583  with an accuracy of 0.01 kg. Length at birth was measured in centimeters with an infanto-meter Harpenden with an accuracy of 0.1 cm . Length-for-age and weight-for-length were converted into sex-specific and gestational-age-adjusted Z-scores, respectively. Growth retardation was defined as a Z-score of length-for-age and weight-for-length and BMI below −2 SD, respectively .Breastfeeding practice was prospectively assessed every 3 months during follow-up visits and was associate with growth variables: weight, length, and BMI. According to the definitions provided by the WHO , we evalThe socioeconomic level was considered a potential confounder; it was assessed with six dimensions of well-being within the household: Human Capital, Practical infrastructure, Connectivity and entertainment, Health infrastructure, Planning and future, and Basic infrastructure and space .The Institutional Review Board and Ethics Committees from INPer approved the study with registration number 212250-49451. All data gathering was confidential. All participants received nutritional counseling to help them to improve their eating habits.t-Student or a U Mann–Whitney test. Several univariate linear models were carried out to identify the variables that explained the weight, length, and BMI changes. These models were adjusted for possible confounding variables such as breastfeeding, maternal age, gestational age, educational lag, educational level, type of delivery, among others. All data were analyzed using the 21st version SPSS for Windows . Statistical significance was declared at p < 0.05.Frequencies and percentages were obtained for categorical variables. We calculated measures of central tendency and dispersion for numerical variables. We used the Kolmogorov-Smirnoff test to assess the distribution of numerical variables. Crude, percentage, Z score, and percentile changes of weight, length, and BMI were evaluated from birth to 1-year-old. Sociodemographic and clinical variables and breastfeeding duration were classified into two categories; then, weight, length, and BMI changes were compared between categories using a A total of 186 dyads (adolescent mothers and their children) participated in the study. All pregnancies were at term. Mean maternal age was 15.5 years and the median pre-pregnancy BMI was 20. Eighteen percent of the adolescents had a job or was a student; for educational level 27.4% had elementary school and 72.6% were at junior high, 36.6% of participants were ≤15 years, and 72.1% were from very low, low, and low-median socioeconomic levels.The offspring' characteristics were as follows: 46% of the children were born by vaginal delivery, and 62% were female. The mean gestational age was 39.1 weeks of gestation, mean birth weight 3,039 g, and mean length at birth was 49.5 cm .p = 0.028). There were no statistical differences in birth weight between mothers ≤15 years than mothers of 16 to 19 years ; neither did the length at birth . Low birth weight prevalence was 6.5% (12 out of 186), the timing of the introduction of complementary feeding was ≤5 months in 125 (67.2%) infants, and only 35.5% were exclusively breastfed for at least 6 months.Boys and girls had similar birth weights . In contrast, the length was greater among the boys than the girls were . Infants who initiate complementary feeding before 6 months of age weighted less at 12 months of age than infants who initiated complementary feeding after 6 months of age .After 12 months of follow-up, there was only one case of low weight for age (0.5%). In contrast, 17 children (9.1%) were already in the percentiles of overweight or obesity. The rest of the children had an appropriate weight for their age. The offspring's mean weight at 12 months was lower in mothers ≤15 years compared to ≥16 years , the rest of sociodemographic variables did not have any statistical significance  and length (p < 0.001), although the speed and slope of growth were similar over time when compared with growth standards, and with data from the children of adult mothers. Wu et al. . This finding adds up to the understanding that the care of the infant by its mother translates into better growth  at 12 months old than offspring of adolescents who had a job or were students  and paternal factors, so it is not known if we can rule out residual confounders.Weight at birth negatively predicted offspring weight and BMI changes at 12 months, while length at birth positively predicted the changes. Only exclusive breastfeeding was associated with length Z-score change in adolescents' offspring in their first 12-months of life.The offspring of adolescent mothers had lower weight and height, despite the fact that the speed and slope of the growth patterns were similar over time with the growth standards established by the WHO.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The Institutional Review Board and Ethics Committees from INPer approved the study with registration number 212250-49451. The participant's legal guardian/next of kin provided written informed consent to participate in this study.RS, HM-R, and GC-B: Conceptualization. RS, HM-R, GC-B, and MH-T: Data curation and Supervision. RS, HM-R, GC-B, MH-T, MB, and ML-V: Formal analysis. RS: Funding acquisition and project administration. RS, HM-R, GC-B, MH-T, MB, ML-V, and JD: Investigation. RS, HM-R, GC-B, MH-T, MB, ML-V, GG-L, JD, and CM-G: Methodology, writing – original draft and writing – review editing. RS, HM-R, and GC-B: resources and validation. RS, HM-R, GC-B, MH-T, and ML-V: Visualization. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Multivariate analysis confirmed that HiTG independently influenced the duration of invasive mechanical ventilation, also in the subgroups with gestational age ≤28 + 6/7 weeks or birth weight ≤1000 g; (4) Conclusion: Newborns with HiTG related to ILEs had a longer duration of invasive mechanical ventilation. Temporary suspension or reduction in ILEs in the case of HiTG is associated with an improvement of respiratory outcome.(1) Background: Hypertriglyceridemia (HiTG) is a metabolic complication of intravenous lipid emulsions (ILEs) infusion. We aimed to evaluate the influence of HiTG on the respiratory outcome of preterm babies; (2) Methods: We enrolled, in a case–control study, newborns with gestational age <32 weeks or birth weight <1500 g, over a 3-year period. They were divided into cases and controls; cases were defined by the detection of HiTG defined as serum triglycerides (TG) value >150 mg/dL; (3) Results: We enrolled 40 cases and 105 controls. Cases had an increased incidence of bronchopulmonary dysplasia (30.0% vs. 14.3%,  Malnutrition is one of the major prematurity-related complications. To reduce extra-uterine growth retardation (EUGR) as a consequence of malnutrition, current European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines recommend high energy intake in parenteral nutrition (PN) soon after birth . This apStarting from these considerations, we designed a study to evaluate the relation between HiTG and mechanical ventilation support in preterm newborns.Newborns with gestational age (GA) <32 weeks or birth weight (BW) <1500 g, receiving PN and consecutively admitted to the neonatal intensive care unit (NICU) of Policlinico Umberto I Hospital, from January 2017 to November 2019 were enrolled in our study. Newborns with congenital diseases, inborn errors of metabolism, congenital infections, familiar history of allergy, use of pre- or probiotics during hospital stay and hospital discharge or death within 72 h of life were excluded ,14,15,16Prenatal, perinatal, and postnatal data were retrospectively recorded in a specific data form by researchers not involved in routine clinical practice. In our policy, we collected nutritional data daily on PN, EN and feeding tolerance in a specific database ,5.In addition, data regarding neonatal morbidities and administration of invasive or noninvasive mechanical ventilation were collected. We defined morbidity as the presence of at least one of the major prematurity complications including necrotizing enterocolitis (NEC) Bell-Stage ≥II, periventricular leukomalacia (PVL), late-onset culture proven sepsis, retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD). The diagnoses of neonatal morbidities were performed according with standard criteria, by physicians unaware of the study design and aims, as previously described ,18. We dNutritional  protocol was previously described ,20. In b®; Fresenius Kabi, Lake Zurich, IL, USA) intake was 1 g/kg/day, progressively increased by 0.5–1 g/kg up to 3.5 g/kg/day at 7 days of life (DOL). We defined total PN (TPN) when PN represented more than 70% of total nutrition  during the first 7 DOL. Plasma TG were measured every 72 h for all enrolled neonates in PN with ILEs infusion.The PN, started early after birth, was administered via a central venous access device to maintain adequate fluids, electrolytes and nutrient intakes until full enteral feeding  was achieved . As prev2 test for categorical variable and t-test or Mann–Whitney for paired and unpaired variables.Statistical analysis was performed using Statistical Package for Social Science software , version 25.0. We checked for normality using Shapiro–Wilk test. The mean and 95% confidence interval (CI) summarized continuous variables and number and percentage described categorial variables. We used χp < 0.05). In addition, we performed a binary regression analysis to evaluate the influence of covariates  on secondary outcome.To evaluate the influence of HiTG on respiratory outcome, independently to GA or BW, we identified a subgroup of newborns with GA ≤28 + 6/7 weeks or BW ≤1000 g . We performed a binary regression analysis to evaluate the influences of covariates  at birth) on the duration of prolonged invasive mechanical ventilation (more than 7 days), on BPD and on post-natal steroids administration for the overall population and for the subgroup with GA ≤28 + 6/7 weeks or ELBW. The level of significance for all statistical tests was 2-sided . The percentage of newborns fed by enteral nutrition in the first 72 h of life was lower in cases (50%) compared to controls ; cases achieved FEF later in life  in comparison with controls . The percentage of neonates receiving TPN was similar between the two groups . The rate of morbidity and mortality were similar between cases and controls .Cases  had a longer length of hospital stay compared to controls   compared to newborns that suspended or reduced the infusion of ILEs, (11.8% = 0.038) .p = 0.930) and lipids  intakes given by PN in the first 7 DOL, compared to neonates for whom ILEs were not suspended or reduced. Additionally, the rate of EUGR were similar between these groups of newborns .Newborns with HiTG for whom ILEs were suspended or reduced did not show differences on energy .Binary logistic regression analysis showed that HiTG is independently related with more than 7 days of invasive mechanical ventilation . The mulp = 0.193 and OR 95% CI 2441, 0.785 to 7587, p = 0.123, respectively). Mortality, for all newborns enrolled including those with GA ≤28 + 6/7 weeks or ELBW, appeared to not be influenced by covariates.The baseline clinical characteristics of newborns with GA ≤ 28 + 6/7 weeks or ELBW were showed in We demonstrated that HiTG in the first 7 DOL is associated with a worse respiratory outcome in preterm newborns. In particular, we observed a higher risk of prolonged invasive mechanical ventilation related with HiTG. These findings are particularly evident in newborns with GA less than 28 weeks or body weight less than 1000 g at birth. A temporary suspension or reduction in ILEs rapidly improve the respiratory outcome in preterm newborns with HiTG. Finally, the occurrence of HiTG in babies born preterm did not influence the rate of mortality at discharge but prolonged the length of hospital stay.Previous evidences suggest that higher plasma lipid concentrations could affect lung function in clinical settings different from the neonatal population ,25,26. IFew studies have examined this specific topic with regard to the neonatal population. Periera et al.  in a smaSimilar to previous studies, our findings suggest that GA, BW and to be SGA at birth were significant risk factors for the development of HiTG ,30. SimiThe appropriate threshold for serum TG in preterm infants is still a debated topic . The incIt has been reported that ILEs containing fish oil reduce the serum TG levels  and imprWe hypothesized some mechanisms that may support our results. Preterm newborns in PN with ILEs infusion are at risk of developing lipid micro-emboli, with a decrease in diffusion capacity and oxygenation ,25,27. WDespite being interesting, the results of our study should be interpreted taking into account several limitations. The association between worse respiratory outcome and HiTG may be related to the effects of chance (random error), bias or confounding factors. We verified that the effects on the lungs of HiTG persisted even after we corrected results for confounding variables for overall and newborn born before to 29 weeks of GA or ELBW at birth. However, confounding variables still unknown or not considered in our statistical analysis may have influenced the results. To limit observer bias, the data for the analysis were collected by researchers not involved in the eligibility assessment and who were unaware of the study outcome and design. We discussed and defined a protocol for the collection, measurement and interpretation of data before starting the study. Besides, a blinded statistician performed the data analysis.The HiTG related to ILEs influence the respiratory outcome of babies born preterm, particularly when GA is ≤28 + 6/7 weeks or they are ELBW at birth. Levels of TG should be strictly monitored and the withdrawal or avoidance of ILEs should be considered in newborns with respiratory distress. Our results suggest monitoring the metabolic status of infants in PN, in order to suspend or reduce the ILEs in case of HiTG, thus improving the respiratory outcome of this critically ill population.


Iron deficiency anemia (IDA) accounts for most of the anemia in pregnancy, and iron is essential for neurodevelopment. Tics and Tourette’s syndrome (TS) are neurodevelopmental disorders that manifest in childhood. A few studies reported an inconclusive association between iron deficiency and tics in children. No study has investigated the relationship between prenatal maternal anemia and tics in children. We aimed to assess the relationship between prenatal anemia exposure and the incidence of tics or TS in offspring. We linked the Taiwan National Health Insurance Research Database to the Maternal and Child Health Database for the analysis and identified 153,854 children with prenatal anemia exposure and 2,014,619 children without prenatal anemia exposure from 2004 to 2016 and followed them through 2017. Cox regression models were applied to compare the risk of tics or TS between the exposed and nonexposed groups. Among the exposed group, 37,832 were exposed at ≤12 weeks of gestational age (GA) and 116,022 at >12 weeks of GA. We observed an increased risk of tics and TS in those exposed at ≤12 weeks compared with the nonexposed group (adjusted hazard ratio (aHR) = 1.23, 95% confidence interval (CI): 1.12–1.34). The result remained consistent after adjusting for birth year, sex, birth order, maternal age, low-income levels, gestational age, birth weight, and alcohol use and smoking during pregnancy . Fetuses exposed to maternal anemia at ≤12 weeks of GA are at high risk of tics or TS. However, this effect was attenuated to insignificance in the sibling comparison. Our study highlights the importance of detection of anemia during pregnancy and proper timing of iron supplementation. Anemia is common during pregnancy and is a globally recognized health problem. Because of hemodilution and increased iron requirements for fetal and placental growth, iron deficiency often occurs and is the leading cause of anemia in pregnancy ,2. Iron Tics and Tourette’s syndrome (TS) are neurodevelopmental disorders that often manifest in childhood and peak in adolescence . Tics arThe developing brain is particularly sensitive and susceptible to prenatal environmental events, as has been widely proven through experimental animal models . MoreoveTo the best of our knowledge, no study has examined the association between prenatal exposure to anemic conditions and the subsequent occurrence of tics. This study, therefore, employed a retrospective cohort approach based on a national insurance database to investigate the association between prenatal anemia exposure and the incidence of tics in offspring. To minimize the interference of preterm births, which may have neurodevelopmental abnormalities, we included only births at term in our follow-up cohort. We hypothesized that prenatal anemia exposure would increase the risk of tics in offspring and that the earlier the exposure, the more pronounced the effect would be.The Taiwanese government launched a single-payer nationwide insurance program, the National Health Insurance (NHI), on March 1, 1995. The NHI has covered 99.6% of the national population as of December 2010 . The BurWe identified cases of maternal anemia according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 648.2, 280, 285.9, and 285.8 and ICD-10-CM codes O99.0, O99.81, D50, D64.9, and D64.89. The above diagnostic codes include IDA, anemia complicating pregnancy, and anemia without specific causes. Mothers with congenital disorders known to be associated with hereditary hemolytic anemias, including thalassemia and sickle-cell disease , were excluded. At least one inpatient or outpatient diagnosis of maternal anemia from 1 January 2004 to 31 December 2016 was required for inclusion in the study. To compare the critical windows of exposure to prenatal anemia, we further divided the exposure time into two periods: (1) ≤12 weeks of gestational age (GA); and (2) >12 weeks of GA . The datAll children with and without prenatal anemia exposure were followed from birth to 31 December 2017 or until death. The primary outcomes were incident diagnoses of tics or TS. The diagnoses were ascertained on the basis of at least one inpatient record or at least three outpatient diagnoses based on ICD-9-CM code 307.2 and ICD-10-CM code F95.The covariates included sex, GA, birth weight, age of the child (by the end of the study period), birth order, maternal age at index birth, alcohol use and smoking during pregnancy, and low-income level. Low-income level was determined using the Low-Income and Middle–Low-Income Households dataset from the government welfare databases .p-value were calculated. SAS 9.4 was used for all statistical analyses.We first examined the demographic characteristics of the whole sample. Then, we performed an analysis of the characteristics of the two groups by different periods of maternal anemia . To determine the effect of maternal anemia on tic disorders, we made two comparisons: a whole-population comparison and a sibling comparison. The whole-population comparison group comprised children born to mothers with and without anemia. Cox regression and proportional hazard analyses were used to estimate the risks of tic disorders. In model 1, we adjusted only for birth year and sex. In model 2, to control for possible confounders, we adjusted for birth year, sex, low-income level, maternal age at birth, birth order, birth weight, and alcohol use and smoking during pregnancy. We repeated the analysis after categorizing the exposure by time of diagnosis of maternal anemia . We used the sibling comparison to automatically match some unmeasured confounding factors such as gene liability and background environment. For the sibling comparison, within-family analysis was conducted using conditional logistic and Cox regression models. We used the biological mother as the stratum variable to compare risks of tic disorders between exposed and unexposed siblings. We also adjusted for birth year, sex, maternal age at childbirth, birth order, GA, birth weight, and alcohol use and smoking during pregnancy. In these analyses, invariant variables related to the biological mother  remained constant in each stratum and were therefore not included as covariates. These analyses were stratified by different exposure periods to maternal anemia. Adjusted hazard ratios and their 95% confidence intervals (CI) and n = 2,302,001) from the Taiwanese Birth Certificate Registry. We excluded 13 cases because of missing data on the infant’s gender. Since the Taiwanese Birth Certificate Registry database only contains the national identification number of the woman who gave birth, we further linked the Taiwanese Birth Certificate Registry database to the Taiwan Maternal and Child Health Database and used the mother’s national identification number, the child’s gender, and their year of birth as key variables to obtain the national identification number of the child. Through this process, we determined the mother–child pairing . The pairing comprised 153,854 children exposed to prenatal maternal anemia and 2,014,619 unexposed children. Among the exposed group, 37,832 children were exposed in early GA, defined as ≤12 weeks, and 116,022 children in later GA (>12 weeks). We identified all single live births (p < 0.001) in the whole-population comparison model, which was adjusted only for birth year and sex (p = 0.008) (p = 0.685).We observed no statistically significant differences when comparing solely the risk of tics between the exposed and nonexposed groups, either in the crude model or in the adjusted models . After s and sex . In the = 0.008) . In the In this nationwide population-based study, we observed an association between maternal anemia at ≤12 weeks of GA and the risk of tics or TS in offspring. The association remained significant after adjusting for income status, maternal age, sex, GA, birth order, and alcohol use and smoking during pregnancy. In the analysis of discordant sibling pairs with a relatively limited number of participants, the effect of early prenatal anemia exposure on the risk of tics and TS diminished to insignificance. To the best of our knowledge, this is the first study to explore the relationship between prenatal maternal anemia and tics or TS in offspring.Early life iron deficiency is associated with a number of cognitive, motor, and emotional disorders, as well as other neurodevelopmental disorders . Only a As reported in previous studies, mothers with low ferritin levels were more likely to give birth to infants with low ferritin levels ,44. ThisThis study has some limitations, and the negative findings should be interpreted with caution before presuming the effect of maternal anemia or ID on tics or TS. Several methodological factors need to be considered. First, the validity of tics or TS diagnoses was limited, and the insurance claims data did not include symptom severity. Although board-certified psychiatrists or neurologists made the diagnoses, which improved the diagnostic reliability, no studies were conducted to verify the validity of the diagnoses. Second, some covariates, such as labor presentation, the body mass index of mothers, and environmental information, are not documented in the NHIRD; hence, their effect on tics or TS risk could not be evaluated. In addition, the prevalence of smoking during pregnancy in the NHIRD was about 7 per 10,000, which was significantly lower than the prevalence of smoking among pregnant women in the previous study on the Taiwanese birth cohort . In the In this study, maternal anemia at ≤12 weeks of GA was found to increase the risk of tics and TS in offspring. This effect was attenuated when shared genetic and environmental factors were considered. Our findings provide insight into both the effects of ID according to gestational age and the role of the proper timing of iron supplementation in pregnancy. Monitoring for possible tic or TS symptoms in offspring previously exposed to maternal ID might facilitate early intervention. Further cohort studies with comprehensive laboratory and neuroimaging examinations are required to clarify the causal relationship between early life ID and the risk of tics and TS.