Lower cord blood concentrations of SM.C.39.2 and NEFA16:1/16:0 were associated with higher autistic traits among 6-year-old children, adjusted for sex and age at outcome. After more stringent adjustment for confounders, no significant associations of cord blood metabolites and autistic traits at ages 6 and 13 were detected. Differences in lipid metabolism (SM and NEFA) might be involved in ASD-related pathways and are worth further investigation.Autism Spectrum Disorder (ASD) is a diverse neurodevelopmental condition. Gene–environmental interactions in early stages of life might alter metabolic pathways, possibly contributing to ASD pathophysiology. Metabolomics may serve as a tool to identify underlying metabolic mechanisms contributing to ASD phenotype and could help to unravel its complex etiology. In a population-based, prospective cohort study among 783 mother–child pairs, cord blood serum concentrations of amino acids, non-esterified fatty acids, phospholipids, and carnitines were obtained using liquid chromatography coupled with tandem mass spectrometry. Autistic traits were measured at the children’s ages of 6 ( Autism Spectrum Disorder (ASD) is a diverse neurodevelopmental condition characterized by difficulties in social communication and interaction as well as restrictive and repetitive behavior, interests or activities . IncreasWe hypothesize that changes in the blood metabolite composition due to early-life metabolic adaptations may be associated with autistic traits in the general population. We tested this hypothesis on 783 children participating in a population-based prospective cohort study from early fetal life onwards. We used a targeted metabolomics approach for amino acids (AA), non-esterified fatty acids (NEFA), phospholipids (PL), sphingomyelins (SM), and carnitines (Carn) from cord blood. These metabolites play an important role in lipid metabolism, signal transduction, oxidative stress, inflammatory responses, and mitochondrial as well as neurotransmitter metabolism and might therefore be involved in ASD pathophysiology ,21,22,23This study was embedded in the Generation R Study, a prospective population-based cohort from fetal life onwards, designed to identify early environmental and genetic determinants of growth and development. Pregnant women who resided in the Rotterdam area and delivered between April 2002 and January 2006 were eligible for participation. Study approval was obtained by the Medical Ethical Committee of the Erasmus University Medical Center, Rotterdam (MEC 198.782/2001/31). Written informed consent was obtained from all mothers. Umbilical cord blood metabolites were assessed in a subgroup of 921 mother–infant pairs. Of those, 716 and 648 had information on autistic traits at 6 and 13 years, respectively, and 581 had information at both 6 and 13 years ) after birth . Blood sFor the data analysis, individual metabolites were clustered in metabolite groups , as well as in metabolite subgroups based on chemical structure and biological relevance (AA: branched-chain amino acids (BCAA), aromatic amino acids (AAA), essential amino acids (EAA), non-essential amino acids (NEAA); NEFA; PC.aa; PC.ae; Lyso.PC.a; Lyso.PC.e; SM: saturated, mono-unsaturated, poly-unsaturated; Carn.a: short-chain, medium-chain, long-chain) . The sumAt the ages of 6 and 13 years, the primary caregiver of the participating children filled out a short version of the Social Responsiveness Scale (SRS). The SRS is a validated instrument for assessing autistic traits on a continuous scale . It reprDuring pregnancy, data on maternal age at enrollment, educational level (higher education yes/no), smoking , alcohol intake , and folic acid supplement (yes/no) during pregnancy was gathered using questionnaires. A start of folic acid supplementation during the first 10 weeks of pregnancy or preconceptionally was considered positive. Maternal weight and height at enrollment were measured without shoes, and BMI was calculated. Maternal psychopathology during pregnancy was assessed using the Brief Symptom Inventory (BSI). Maternal vitamin D levels were obtained from serum in pregnancy. Vitamin D levels below 50 nmol/L were considered deficient. Information on sex, gestational age at birth, and birth weight according to European growth charts was obtained from medical records. We calculated gestational age and sex-adjusted birth weight standard deviation scores according to growth charts of Niklasson . Data ont-test or Mann–Whitney-U test for normally distributed or skewed continuous variables. We explored the correlation between the SRS scores at 6 and 13 years using Spearman’s correlation. Then, we examined the associations of neonatal metabolite ratios, groups, and individual metabolites with the continuous SRS scores at the ages of 6 and 13 using linear regression models. We chose this approach over data reduction or variable selection analysis methods like Principal Component Analysis because our primary goal was to assess the associations of the individual metabolites using regression models on the outcome autistic traits rather than identifying clusters of metabolites that were jointly associated with the outcome. Analyses were only adjusted for child sex and age at outcome in the basic model and additionally adjusted for our preselected confounders in the main model. Confounders were selected based on previous studies and included maternal age, pre-pregnancy BMI, maternal education level, maternal psychopathology, smoking during pregnancy, alcohol consumption during pregnancy, gestational age at birth, and birth weight [First, we conducted a non-response analysis. We compared mother–child pairs of our subsample with all mother–child pairs with metabolomics data available to identify and take into account possible biases caused by loss to follow-up or exclusion criteria . We usedh weight ,19,43,44As an exploratory analysis, we ran a linear mixed-effects model to investigate whether changes in autistic traits over time are associated with certain metabolites. Models were fit using the lme4 package . Linear p-value of <0.05. To account for missing values of covariates, we performed multiple imputations using the fully conditional specification method, and pooled results from 25 imputed datasets were reported [To account for multiple testing, we applied Benjamini–Hochberg correction separately for each model, using an overall false discovery rate (FDR) adjusted reported . The pro2)  years, and the median body mass index was 22.4 (kg/m2) . Most wo2) . Spearmap-value 0.01) in the basic model     and main model ) per SDS increase in Carn.a.C18.2, FDR-adjusted p-value 0.08), although it did not survive multiple testing  per SDS increase in SM.a.39.2, FDR-adjusted ic model , but notue 0.08) . The NEFe: 0.02)  but did e: 0.08) . We obse testing . No sign testing ). Linear testing .The additional adjustment for vitamin D deficiency and folic acid supplementation did not influence the associations between cord blood metabolites and SRS scores at age 6 or 13 years . AdjustiIn this prospective cohort study, we observed some suggestive evidence for associations between SM, NEFA ratio, and autistic traits at age 6 years, but these associations did not remain significant after multiple testing correction and more rigorous covariate adjustment. No significant associations between cord blood metabolites and autistic traits at the ages of 6 and 13 were observed in our main model. Moreover, no effect modification by vitamin D deficiency or folic acid deficiency was observed. Controlling for gestational age at birth showed the biggest effect modification. Finally, no associations between changes in autistic traits over time and metabolites were detected.The etiology of ASD is complex and poorly understood, but various metabolic pathway disturbances as a result of gene–environment interactions already occurring during the fetal period are believed to contribute to this heterogeneous condition. Cord blood metabolomics is able to capture the metabolic phenotype as a result of the interplay between genetics and environment. Moreover, it presents combined information on both maternal metabolism transferred via the placenta and fetal metabolism . Thus, iWe are the first study to examine the prospective associations of cord blood metabolites and autistic traits in childhood dimensionally. No associations between metabolites at birth and autistic traits at ages 6 and 13 were observed in our main model. Autism is a heterogeneous condition with a complex etiology that is only partly elucidated, and not all pathophysiological mechanisms may be detectable through changes in the metabolic composition of the blood. Furthermore, the neurodevelopment of the brain extends after birth, and processes that contributed to an autistic condition in childhood might not have been present at birth. Moreover, the blood metabolome is influenced by contemporary environmental factors such as diet and stress level and may therefore derive stronger associations in cross-sectional settings. A prior study conducted within the Generation R Study revealed that correlations between metabolite measurements at various time points  were low, ranging between r = −0.10 and r = 0.35 . ObserveHowever, our results provide suggestive evidence for an inverse association between the concentration of SM.a.C39.2 at birth and autistic traits at age 6 years. This association was observed after multiple testing correction in our basic model but did not survive correction after adjusting for a wider set of confounders, even though effect sizes were comparable. While this finding should be interpreted with caution, it is noteworthy that SM has previously been implicated in neurodevelopmental outcomes and ASD ,48,49. SNumerous studies have reported differences in fatty acid concentration, Carn.a, and PL, which are linked to mitochondrial dysfunction, in ASD ,55,56,57This is the first autism-related study to report a decreased NEFA16:1/16:0 ratio associated with higher severity of autistic traits, albeit not significant after multiple testing correction in the main model. The ratio represents a proxy of the stearoyl-CoA desaturase-1 (SCD-1) activity. This enzyme breaks down saturated fatty acids, and decreased levels of SCD-1 have been previously linked to inflammation in, e.g., macrophages and endothelial cells ,59. InflIn our population-based study, we did not identify certain metabolites at birth associated with autistic traits in childhood. Although we found some suggestive evidence that decreased SM, NEFA16:1/16:0 concentrations and increased Carn.a concentrations at birth might be predictive of more severe autistic traits in childhood, associations attenuated after adjusting for a wider set of confounders and disappeared at the age of 13. Thus, we conclude that the measured metabolites within our study are not suitable for the prediction of autistic traits in childhood. For future studies, it might be beneficial to explore associations with a wider set of metabolites or even consider an untargeted approach. Moreover, repeated measurements on both metabolomics and autistic traits would enable us to study their association over time.Among the strengths of this study is the dimensional measure of autistic traits with the SRS score. Although our dimensional approach does not provide a clinical diagnosis, it allows us to account for children with fewer symptoms and model the full range of symptoms in the general population. It also reduces the risk of outcome misclassification and increases power. Moreover, obtaining measurements of SRS scores at two time points is another strength. It allowed us to study the association of longitudinal trajectories of autistic traits with metabolites. Finally, the availability of sociodemographic and lifestyle information of our participants allowed us to control for a broad range of confounders.Some limitations in the current study need to be considered. Unlike previous studies that used a case–control design, our study was embedded in a population-based cohort. Although the percentage of participants above the recommended SRS cutoff value (0.9%) corresponds to the ASD prevalence (0.6–2.2%), it is noteworthy that our participant’s autistic traits primarily fall within a subclinical range . ConsequWe did not find significant associations between cord blood metabolite profiles and autistic traits at the ages of 6 and 13 in our main model. Our results did provide suggestive evidence for associations between SM and NEFA16:1/16:0 abundance at birth and subclinical autistic traits at age 6. These findings should be regarded as hypothesis-generating and require further investigations.


Considering the role of fear of childbirth (FOC) in the enhancement of unnecessary cesarean sections (CS), the present study aimed at evaluating the effect of Cognitive-Behavioral Therapy (CBT) and haptonomy on the FOC (as primary outcome) and intended birth method and final birth method (as secondary outcomes) among primigravida women.This randomized clinical trial was conducted on 99 primigravida women in Tabriz, Iran 2022. Participants were assigned to three groups with a ratio of 1:1:1 using stratified block randomization based on the fear intensity. One of the intervention groups (n = 33) received eight group sessions of CBT from 24 to 28 weeks of gestation and the other intervention group (n = 33) received haptonomy during seven sessions once a week. The control group (n = 33) received routine prenatal care. The Wijma questionnaire was completed by the participants before the intervention, after the intervention at 35–37 weeks of gestation, and after birth. The intended birth method was investigated before and after the intervention at 35–37 weeks of gestation. The final birth method and the reasons for CS were recorded based on the mother’s medical profile. The one-way ANOVA was used before the intervention and RMANOVA after the intervention to compare the mean scores of FOC among the three groups. Further, chi-square test was applied to compare the intended and final birth method.P < 0.001). The means (SDs) of FOC in the haptonomy group were 76.81 (13.09), 46.59 (15.81), and 45.09 (20.11), respectively (P < 0.001). The mean (SD) of FOC in the control group decreased from 70.31 (6.71) to 66.56 (18.92) and then, increased to 71.00 (21.14) after birth (P = 0.878). After the intervention, there was no statistically significant difference among the three groups in terms of the intended birth method (P = 0.278), and final birth method (P = 0.107).The mean (standard deviation: SD) of FOC in the CBT group changed from 74.09 (11.35) at 24–28 weeks of gestation to 46.50 (18.28) at 35–37 weeks and 48.78 (20.64) after birth (The findings of the present study revealed that both CBT and haptonomy interventions reduce FOC. Although the desire for vaginal birth and final vaginal birth in the haptonomy group was more than that in the other two groups, there was no statistically significant difference among the three groups.http://en.irct.ir.Iranian Registry of Clinical Trials: IRCT20170506033834N9. Date of registration: 02.01.2022. URL:  Pregnancy is considered as a very important and short-term experience with long-term effects on women’s life . This peThe global prevalence of severe FOC was reported 16% among low risk pregnant women . The preFOC is acknowledged as one of the important reasons to request elective CS among primigravida women, leading to the repeated CS following the initial CS . Over reSome of the complications of CS compared to vaginal birth include anesthesia complications, post-operative infection, more bleeding, and risk of embolism . The sevIn literature review, different interventions, such as group psychotherapy , relaxatAnother relatively new method for reducing FOC is haptonomy intervention, including communication techniques between the mother’s mind and body and raising mother’s self-awareness about her ability for the physiological process of pregnancy and childbirth, strengthening feelings and a positive attitude towards pregnancy, and the fetal-mother communication techniques, such as touch and interaction with the fetus –32. AccoIn literature review, both CBT and haptonomy interventions are identified to be effective in reducing FOC , 30, 33.The mean score of FOC differs between CBT, haptonomy, and control groups.Intended birth method and final birth method differs between these three groups.This study is the result of a research project approved by Vice Chancellor for Research of Tabriz University of Medical Sciences, Faculty of Nursing and Midwifery with ethics code IR.TBZMED.REC.1400.678 and registration code of (IRCT20170506033834N9) on Iranian Registry of Clinical Trials site. This randomized controlled clinical trial was carried out on 99 pregnant women referred to health centers in Tabriz, Iran from January 5 to August 11, 2022.The inclusion criteria were primigravida women aged 18–45 years with gestational age of 24–28 weeks and a Wijma Delivery Expectancy/ Experience Questionnaire (WDE-Q) score above 65 . The exc1 = 93, m2 = 79.05, with the assumption of 15% reduction, SD1 = SD2 = 16.93, and two-sided hypothesis, and Power = 90%, sample size was obtained 30 in each group and regarding 10% attrition, the final sample size was 33 in each group.The sample size was calculated based on the FOC variable in the study of Dorosti et al.  using G Sampling was done in eleven crowded health centers with different socio-economic levels in the city. The researcher attended the selected health centers and after preparing a list of primigravida women aged 18–45 years with gestational age of 24–28 weeks, called and evaluated them in terms of the inclusion and exclusion criteria and invited the eligible women. Participants completed WDE-Q in the face-to-face session and the objectives and method of the study were explained for women who gained WDE-Q score above 65. The eligible women completed the written informed consent form to participate in the study and the demographic and obstetric form. Then, their intended birth method was recorded.Participants were assigned to three groups with a ratio of 1:1:1 using stratified block randomization based on the high (66–85) and severe (> 85) FOC  using RaEight group sessions of CBT were held for one of the intervention groups from 24 to 28 weeks of gestation for 45–60 min once a week. Counseling sessions were held by a clinical psychologist. Table Another intervention group, received haptonomy in groups of 3 people during seven sessions from 24 to 28 weeks of gestation for 45–60 min once a week. A significant and positive correlation was found between the WDE-Q mean scores of the pregnant women and gestaional age . Given tThe researcher sent the intervention groups reminder messages one day before each session to increase the participants adherence to the interventions. All interventions were presented in the counseling room of the nearest health center to the participants’ home. The control group received routine prenatal care. During the gestational age of 35–37 weeks, the researcher called the participants and asked them to fill out the WDE-Q when they attended the health centers for antenatal care. In the following, their intended birth method was asked and indications for CS were evaluated. Participants completed WDE-Q again after childbirth, and birth method was recorded according to the mother’s medical profile.This form included the variables of age, education, occupation, family income, history of abortion/ ectopic pregnancy, and gender of the fetus which were completed by the participants before the intervention.The WDE-Q was employed to evaluate FOC. Mothers specified their feelings based on a 6-point Likert scale ranging from 0 to 5. The total score range is between 0 and 165, as higher score indicates more FOC, a score of 66–85 represents high FOC, and a score above 85 denotes severe FOC. The Cronbach’s alpha coefficient and Intra Class Correlation Coefficient (ICC) of the instrument were reported 0.70 and > 0.9, respectively . The valThe question of “If there is no medical prohibition for vaginal birth, which birth method do you prefer?“ was asked before the intervention at 24–28 weeks of gestation and after intervention at 35–37 weeks to know women’s preferred birth method. Birth method was recorded according to the mother’s medical profile. In the case of CS, the reasons were recorded.24 software and Shapiro-Wilk test was used to assess the data normality. Descriptive statistics as mean (SD), and frequency (%) were used in the analysis of data collected in this study. Chi-Square test and One-way ANOVA were used to compare the socio-demographic characteristics of three groups. The One-way ANOVA was employed before the intervention and RMANOVA after the intervention to compare the mean scores of FOC among the three groups. Furthermore, chi-square test was applied to compare the intended and final birth method. The intention to treat (ITT) method was employed for data analysis, which means “once randomized and always analyzed, regardless of noncompliance and protocol deviations’’ [The collected data were analyzed by SPSSations’’ . The p-vA total of 241 pregnant women were examined, of whom 110 women were excluded, due to not fulfilling eligibility criteria. Eventually, 99 individuals participated in the study and were randomly assigned to the CBT, haptonomy, and control groups. In the CBT group, one person was reluctant to continue the study   Table . So that1) Table . FollowiP = 0.278). In the comparison of the final birth method among the three groups, although vaginal birth in the haptonomy group was more than that in the CBT and control groups, the difference was not statistically significant (P = 0.107) (Table P = 0.143).Although after the intervention, the desire for vaginal birth in the haptonomy group was more than that in the other two groups at 35–37 weeks, there was no statistically significant difference among the three groups in terms of intended birth method (7) Table . Based oThe present study for the first time compared the effect of CBT and haptonomy interventions on FOC. Based on the results of the present study, CBT and haptonomy interventions significantly reduced FOC at 35–37 weeks of gestation and after birth compared to the control group. However, there was no significant difference between the intervention groups. In line with the findings of the present study, Ucar and Golbasi  investigIn another study, Ghazaei et al.  revealedIn the present study, FOC in the haptonomy group was less than that in the other two groups after intervention. Consistent with the findings of the present study, in the study of Ozbek and pinar , followiIn the present study, although the desire for vaginal birth and final vaginal birth in the haptonomy group was more than that in the other two groups and the request for elective CS was less in the haptonomy and CBT groups, there was no statistically significant difference in terms of final birth method, and the rate of CS among the three groups. In this study, the rate of caesarean section with medical indication in the CBT group was higher than that in the other two groups. It is worth mentioning that choosing the birth method is not just a personal matter and several factors, such as medical indications, spouse preference, and socio-cultural factors are involved in this regard , 47.In line with the results of the present study, Tata et al.  indicateThe present study was the first one evaluated the effect of haptonomy intervention on the birth method and no study was found in the literature review in this area. One of the limitations of the present study was the impossibility of blinding of participants due to the nature of study. In addition, this study was conducted on primigravida women, and the results cannot be generalized to multiparous women with secondary FOC caused by traumatic childbirth experience. Duration of laber and social support were not measured in this study which could affect the FOC score after birth.Based on the findings of the present study, CBT and haptonomy reduce the FOC. Given that the desire for vaginal birth and final vaginal birth in the haptonomy group was more than that in the other two groups, midwives are suggested to use haptonomy intervention as a midwifery skill and preferred approach in reducing FOC, due to the lack of need for psychological techniques of CBT. It is suggested to integrate haptonomy intervention in the care package of primigravida women with FOC. It is recommoned to perform more studies regarding the impact of haptonomy on the birth method. Also, it is suggested to conduct a similar study on multiparous women with secondary FOC to compare the results.


The epidemiology of preterm birth among Pacific Islanders is minimally understood. The purpose of this study was to estimate pooled prevalence of preterm birth among Pacific Islanders and to estimate their risk of preterm birth compared to White/European women. We searched MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Library, CINAHL, Global Health, and two regional journals in March 2023. Observational studies were included if they reported preterm birth-related outcomes among Pacific Islanders. Random-effects models were used to estimate the pooled prevalence of preterm birth with 95% confidence interval (CI). Bayes meta-analysis was conducted to estimate pooled odds ratios (OR) with 95% highest posterior density intervals (HPDI). The Joanna Briggs Institute checklists were used for risk of bias assessment. We estimated preterm birth prevalence among Pacific Islanders in the United States , the US-Affiliated Pacific Islands , New Zealand , Australia , and Papua New Guinea . Pacific Islanders resident in the US were more likely to experience preterm birth compared to White women , but in New Zealand their risk was similar  to European women. Existing literature indicates that Pacific Islanders in the US had a higher prevalence of preterm birth and experienced health inequities. Learning from New Zealand’s culturally-sensitive approach to health care provision may provide a starting point for addressing disparities. The limited number of studies identified may contribute to higher risk of bias and the heterogeneity in our estimates; more data is needed to understand the true burden of preterm birth in the Pacific region. In light of persistent disparities in perinatal health between minority and majority populations globally, greater attention is being paid to understanding unique risks that explain minority populations increased risk of preterm birth (live birth before 37 weeks gestation ). DespitPacific Islanders are particularly underrepresented in perinatal health research, and little is known about the prevalence of preterm birth among this group. Data from the Pacific Islands themselves is sparse, both as a result of geographic isolation  and nasHealth challenges common among Pacific Islanders, such as, disproportionately high prevalence of obesity and obesity-related complications , may putTo better understand the epidemiology of preterm birth among Pacific Islanders and the need for perinatal health intervention, this systematic review and meta-analysis aims to: (a) estimate the pooled prevalence of preterm birth among Pacific Islanders globally; and (b) identify whether Pacific Islanders were more likely to experience preterm birth compared to non-Hispanic White/European women.This review , EMBASE (Ovid), Web of Science Core Collection , CochraS1 Table) and archived  to the within-study variances, with tau2[IV] larger than within-study variance indicating the weights of any two studies are approximately equal ) than the tau2[IV] there was strong evidence of heterogeneity in meta-analyses comparing risk between Pacific Islander and White/European women in the US (95.2%) and New Zealand (100.0%).Checking the proportion of the studies with a smaller variance than the tauFor preterm birth prevalence meta-analyses, we did not identify any publication bias . This assessment was not available for Australia since Egger’s test cannot be used with <3 studies. For the risk comparison meta-analyses, the robust Bayesian model expressed weak evidence of publication bias in the US  and New Zealand .To our knowledge, this is the first systematic review and meta-analysis to summarize data from both Pacific Islander immigrants in high income settings and those resident in the Pacific Islands. Results indicate that US-resident Pacific Islanders had a relatively higher prevalence of preterm birth than in New Zealand and Australia and experienced poorer birth outcomes than White women, which was an inequity not observed in New Zealand. Estimates in other settings were limited by sparse data.Te Tiriti o Waitangi (the Treaty of Waitangi) [iwi -based primary care consistent with Māori values, attitudes, and aspirations [Our Pacific Islander-specific findings mirror the most recent country level estimates reported by the WHO. In 2014, among the three developed nations, the US had the highest overall preterm birth prevalence , while the estimates in New Zealand  and Australia  were similar . Notablyaitangi) , which pirations , 87. In irations , 17, disirations , and misirations –18. Replirations  may be i12, which likely explains the limited number of Pacific Islander-related studies reporting preterm birth. Australia has continuously supported seven surrounding Pacific Island countries to promote universal health coverage since 1995, including Fiji, Kiribati, Nauru, Samoa, Solomon Islands, Tonga and Vanuatu [While Australia has among the largest absolute number of Pacific Islander migrants, they make up a small proportion (0.9%) of the population Vanuatu , but did Vanuatu . Studies Vanuatu , but furData from the Pacific Islands themselves were sparse and limited conclusions about the prevalence of preterm birth. While Pacific Islander women in the USAPI had a lower preterm birth estimate than the US, the wider prediction interval should be noted. All of the USAPIs are medically underserved  and, altAlthough Papua New Guinea is the largest of the Pacific Islands, with 8.9 million residents , studiesLimitations of our study should be noted. Beyond the USAPIs, Papua New Guinea and New Zealand there was little data on perinatal health from the remaining Pacific Islands. We identified only one study from Vanuatu  Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.


Major Depressive Disorder (MDD) and Bipolar Disorder Depression (BDD) are common psychiatric illnesses characterized by structural and functional brain alterations and signs of neuroinflammation. In line with the neuroinflammatory pathogenesis of depressive syndromes :e946), recent studies have demonstrated how white matter (WM) microstructural impairments detected by Diffusion Tensor Imaging (DTI) are correlated to peripheral immunomarkers in depressed patients.In this context, the aim of our review is to report an updated overview of the evidence on the correlation between the blood immuno-markers changes and the brain WM disruptions in MDD and BDD patients.Based on PRISMA 2020 guidelines , we performed a systematic search on original DTI studies exploring the association between WM integrity, neuroimmune alterations and inflammation in patients affected by MDD or BDD.Concerning MDD, most of the reviewed studies provided evidence of a link between systemic immune dysregulation, detected through the elevation of peripheral markers  or an altered ratio between proinflammatory and counterregulatory cytokines (IL-8/IL-10), and DTI alterations in specific WM tracts, such as the genu of corpus callosum and the IFOF. As for the BDD, we detected an increase of pro-inflammatory molecules  that correlated with DTI changes in different cerebral areas such as cingulum, forceps, corona radiata, corpus callosum, longitudinal fasciculus and internal capsule. Furthermore, other molecules seem to play a specific role in BDD pathogenesis, including counter-regulatory cytokines, kynurenine and specific lymphocyte classes, such as Th1 and Th17.Taken together, these pathogenetic insights could outline an integrated clinical perspective to affective disorders, helping psychiatrists to develop novel biotype-to-phenotype models of depression and opening the way to tailored approaches in treatments.None Declared


Lactobacillus acidophilus LA-5, Bifidobacterium animalis subsp. lactis BB-12, Lacticaseibacillus rhamnosus LGG, and Bifidobacterium longum subsp. infantis Bifin02 from gestational week thirty-three until four weeks after birth (n = 24) or dosed directly (IS) with the same strains except for LA-5 starting within 24 h after birth until day 28 (n = 23). Infant stool samples were collected on day 0, 14, 28, and 42 after birth. Gastrointestinal symptoms were assessed by parents using an electronic diary. Microbiota composition was determined using 16S rRNA sequencing, and strain recovery was analyzed by qPCR. Notably, 100% of the IS infants were colonized with Bifin02 after 14 days as opposed to only 25% of the MS infants. Mean stool frequency was significantly lower in IS infants compared to MS infants and IS infants had softer stools on day 14, 28, and 42. A significantly steeper slope of progression of inconsolable crying and fussing was observed in MS infants compared to IS infants. In conclusion, direct infant seeding induced a faster increase in fecal bifidobacteria abundancy and Bifin02 recovery compared to dosed through the maternal intake.We investigated the effects of two dosing regimens of two multi-strain probiotic products on the gut microbiota of breastfed infants, including the transfer of the dosed strains and clinical outcomes. In forty-seven dyads, infants were either exposed through maternal intake (MS) of  Bifidobacterium-dominated microbiome in early infancy and the associated potential health benefits in later life, such as a reduced risk of developing allergies [Emerging knowledge has consolidated the importance of a llergies ,2 and otllergies . Bifidobacterium longum subsp. infantis (B. infantis), Bifidobacterium bifidum, Bifidobacterium breve, and Bifidobacterium longum subsp. longum [B. infantis has been acknowledged to hold one of the largest HMO clusters in its genome, which provides it with a competitive potential that increases colonization success in the infant gut [B. infantis, specifically in the context of managing underweight infants and immune development [Bifidobacterial dominance in the infant gut, including the ability of the bifidobacteria to colonize during the neonatal period, is affected by the mode of delivery, e.g., vaginal birth or caesarean section , antibio. longum ,10,11. S. longum ,13. B. ifant gut . During fant gut , folate fant gut , and arofant gut . This emelopment ,18,19. Ielopment ,21,22. Ielopment ,24. The elopment . Moreoveelopment ,27. Theselopment . Inconsoelopment ,30. The first major bacterial encounter of an infant is of maternal origin and occurs during and directly after vaginal birth . DependiC. trachomatis, N. gonorrhea, human papilloma virus, group A streptococci, and herpes simplex virus [Bifidobacterium animalis subsp. lactis BB-12 (DSM15954) (BB-12®), Lacticaseibacillus rhamnosus LGG (DSM33156) (LGG®), Lactobacillus acidophilus LA-5 (DSM13241) (LA-5®), and infant-type Bifidobacterium longum subsp. infantis Bifin02 (DSM33361) (ISTILOS™) at a relatively low dose in two proof-of-concept single arm clinical studies including equivalent cohorts, performed simultaneously at the same site, either through the child-giving person or directly to the infant. LGG, BB-12, and LA-5 have previously been used in clinical studies investigating perinatal maternal dosing and were found safe and were suggested to have an impact on reduction in the incidence of atopic dermatitis in the offspring [Intrapartum antibiotics, elective cesarean sections, and low breastfeeding rates have been shown to disturb natural maternal-to-infant microbiome transmission . In the ex virus . Anotherffspring ,38. LGG ffspring ,39,40,41B. infantis has been identified as one of the key ‘infant-type’ species which has been related to intestinal and immune maturation and is an abundant member of the gut microbiota during infancy [ infancy ,32,42, wClinicalTrials.gov (identifier NCT04987593 and NCT04994834) before recruitment.The two proof-of-concept studies, maternal seeding (MS) and infant seeding (IS) were conducted at Aarhus University Hospital, Denmark in accordance with the current version of Good Clinical Practice and the Declaration of Helsinki. The study protocols were approved by the local independent ethical committee of Region Midt Denmark (case numbers 1-10-72-15-21 and 1-10-72-14-21). Before any study procedures or collection of data, the General Data Protection Regulation (GDPR) was complied with by written informed consent from the pregnant person and the legal guardians of the participating infant. At Visit 1, the pregnant persons were asked if their perceived gender matches their biological gender or if their perceived gender differs from their biological gender (non-specific). All 47 pregnant persons in the two studies identified themselves as the female gender they were assigned at birth and are henceforth referred to as women or mothers. The infant–mother dyads were recruited from a public midwifery practice between July 2021 and September 2021. The studies were registered at For both studies, the mother–infant dyads were included according to the following criteria: The pregnant women were eligible if the pregnancy was uncomplicated, they aimed to give birth vaginally, aimed to breastfeed the infant, and could abstain from the intake of probiotics other than the experimental intervention. Eligible infants were healthy, born at full-term , with a birth weight between 2500–4500 g, and an APGAR score of at least 7 within the first 10 min of life. Infants were excluded if they had any congenital disorders that could affect their safety or the study outcome or if they were admitted to a neonatal intensive care unit for more than 48 h. The two separate open-labelled proof-of-concept studies were conducted at the same site, during the same time, with overall similarity in design and assessments, except for which subject (mother or infant) received the intervention . Due to The screening took place at a public midwifery practice, where the pregnant woman could receive oral and written information about both studies. If eligible and willing to participate, the pregnant woman could choose which study to participate in, whereafter written consent was given on behalf of themselves. During the entire study period, five home visits by the study research midwife were scheduled. Visit 1 consisted of information about the study, obtaining informed consent from the legal parent(s) on behalf of the unborn child, and obtaining maternal information via an electronic case report form (eCRF) . For participants in the MS study, the intervention product was handed out.Visit 2 was on the day of birth or within 72 h, where the inclusion and exclusion criteria for the infant were checked and infant weight, length, and head circumference were measured. From Visit 2 to Visit 4, the parents completed an electronic diary (electronic patient-reported outcomes) . The diary contained selected questions from ROME IV Section A: Infant Gastrointestinal Problems, GERD, and the Amsterdam Stool Form Chart. Some questions were answered daily while others were answered weekly. In Visits 3, 4, and 5, the parents were asked about occurrences of infections, fever, or rash.Infant growth and thriving were monitored by clinical examinations during Visit 3, 4, and 5. Length and head circumference was measured to the nearest 1 cm by the same non-stretchable measuring tape as the baseline data obtained from the public labor ward. Body weight was measured to the nearest 5.0 g by using an insert on a hanging balance (Kern HDB 10K-2XL). The mean value of two measurements was used. All information collected during the visits was entered into an eCRF by the study research midwife.In both studies, maternal fecal samples were collected using OMNIgene GUT OM-200 , urine samples were collected using sterile urine sample collection kits , and vaginal samples were collected using OMNIgene Vaginal OMR-130 . Participants in the MS study collected all three biological samples before the intervention (baseline status GA week 33+0) and at day 42. In both studies, the three sample types were all collected at gestational week 37 and at day 42. In both studies the legal parent(s) had agreed to collect infant stool samples at four timepoints: the first bowel movements after birth (meconium) and on day 14, 28, and 42 after birth using a fecal sample kit. Additionally, breast milk samples were collected as soon as possible after birth and on day 14, 28, and 42 in both studies. Stool samples and breast milk samples were stored in the household freezer of the participant at a minimum of −18 °C and subsequently transferred to a −80 °C freezer, where they were stored until analysis.Bifidobacterium longum subsp. infantis Bifin02 (DSM33361) and a capsule containing a least 2 billion CFU of Bifidobacterium animalis subsp. lactis BB-12 (DSM15954), 2 billion CFU of Lacticaseibacillus rhamnosus LGG (DSM33156), and 2 billion CFU of Lactobacillus acidophilus LA-5 (DSM13241). In the MS study, the mother consumed the study product from GA week 33+0, to ensure at least four weeks of intervention before term birth (GA week 37–42), and continued consumption for 28 days postnatally followed by a two-week follow-up period without any intake of the study product. The study product used in the MS study consisted of a sachet and a capsule intended to be consumed at the same time. The daily dose was 1 g sachets containing at least 0.1 billion CFU  of Bifidobacterium longum subsp. infantis Bifin02 (DSM33361) or at least 1 billon CFU of Bifidobacterium animalis subsp. lactis BB-12 (DSM15954) and Lacticaseibacillus rhamnosus LGG (DSM33156) in total, resulting in a daily dose of at least 1.1 billion CFU. The contents of the two sachets were mixed with 3–5 mL of human breast milk or boiled tap water cooled down to 37 °C before they were given to the infant. In the IS study, infants were given the study product for 28 days, followed by a two-week follow-up period without any intake of the study product. The first dose was given within 24 (+48) hours after birth. The supplementation continued for 28 days. The study products for the infants were provided as two 1 g sachets containing either freeze-dried culture of at least 0.1 billion CFU of Bifidobacterium longum subsp. infantis Bifin02 has previously been studied as BB-02 and will be commercialized under the name ISTILOS™. The other strains are commercially available as BB-12®, LGG®, and LA-5®, trademarks of Chr. Hansen A/S. A subject was considered adherent with study product intake when they consumed at least 80% of the anticipated quantity. The study products were manufactured by Chr. Hansen A/S  and provided in blank containers without any commercial artwork. The strain TM 5 Real-Time PCR system . The primary endpoint was recovery of the dosed strains, Bifin02, BB-12, LGG, and LA-5, in infant fecal samples after 28 days of intervention, measured via strain-specific quantitative polymerase chain reaction (qPCR) and performed by Baseclear B.V., The Netherlands. The primers used were designed and validated against a relevant panel of genomes that were available at the time of search on the National Center for Biotechnology Information (NCBI) and its internal database (January 2020)  PCRs were performed alongside each separate amplification without the addition of a template. Amplification data were exported from QuantStudioTM Design & Analysis software v1.4.2, followed by the determination of the target quantity per µL of DNA preparation using the standard curves and calculation of the number of targets per g of raw material using the formula below. This method was applied to all qPCR outcomes. Thus, the quantities of specific primer target DNA are expressed as target copies/g material across all sample types.© AMPure®XP (Becker Coulter) and DNA concentration was measured by fluorometric analysis . PCR amplicons were equimolarly pooled, followed by sequencing on an Illumina MiSeq with the paired-end 300 cycles protocol and indexing. FASTQ read sequence files were generated using bcl2fastq version 2.20 . Initial quality assessment was based on data passing Illumina chastity filtering. The secondary endpoint was the total relative abundance of bifidobacteria in infant fecal samples after 4 weeks of supplementation and was calculated using 16S rRNA gene amplicon data. Taxonomic profiling using the 16S rRNA gene of the microbiome was performed by BaseClear, The Netherlands, as described below. DNA was extracted from feces using the ZymoBIOMICS 96 MagBead DNA Kit (Zymo Research) and quantified with Quant-iT™ dsDNA Broad-Range Assay Kit  and agarose gel electrophoresis for DNA integrity. The DNA served as a template for PCR amplification of a portion of 16S rRNA genes and subsequent analysis by next generation sequencing using Illumina MiSeq. Amplicons of the V3–V4 regions of 16S rRNA genes, generated by PCR with primers 341F and 785R, which produced a ~630 bp amplicon , complemSubsequently, reads containing PhiX control signal were removed using an in-house filtering protocol. In addition, reads containing  adapters were clipped (up to a minimum read length of 50 bp). The second quality assessment was based on the remaining reads using the FASTQC quality control tool version 0.11.8. To generate OTUs , paired-end reads were collapsed into so-called pseudoreads using sequence overlap with USEARCH version 9.2 . ClassifGastrointestinal symptoms of infants were assessed daily during the intervention period using questions from ROME IV Diagnostic Questionnaires for Pediatric Functional Gastrointestinal Disorders for Neonates and Toddlers: Parent-Report Form for Neonates Section A Infant Gastrointestinal Problems . PeriodsDemographics, including information on maternal health and medical history and socioeconomic and household characteristics, were collected at the baseline. Infant baseline characteristics including anthropometry were collected from birth journals. Adverse events, concomitant medication, and healthcare utilization were assessed at each visit and documented in the eCRF. During the COVID-19 pandemic (May–November 2021), the assessments and contacts with subjects were carried out according to relevant national health guidelines.The calprotectin (MRP8/MRP14) assay was based on a sandwich enzyme-linked immunosorbent assay (ELISA) (LEGEND MAX™ Human MRP8/14i). The detection range was 3.13–200 ng/mL. The results were normalized to the weight of the original fecal sample.Endotoxin concentration was analyzed with a specific chromogenic and colorimetric assay (Pierce™ Chromogenic Endotoxin Quant Kit). The detection range was 0.1–1.0 endotoxin units/mL. The results were normalized to the weight of the original fecal sample.Lactic acid, acetic acid, total SCFA, propionic acid, and butyric acid were derived from the respective phenyl esters using a phenyl chloroformate reagent. Resulting esters were analyzed by Agilent GC-FID. For the quantification, matrix-matched internal standard calibration with butyric-d7 and acetic-d3 acids was used. pH was measured in fecal water samples with a regular pH meter.p-value of less than 0.05 was considered statistically significant. Due to the proof-of-concept and open label design of the two studies, no formal power considerations or sample size calculations were performed. Intending to use one of the studies as a control, we applied the method of stepped rules of thumb for the estimation of the pilot study sample size, which is why a sample size of 25 mother–infant dyads in each study was considered suitable [All statistical analyses on demographics and clinical outcomes were carried out using SAS v9.4. Windows . The safety dataset (SS) consisted of all subjects, whereas the intention-to-treat dataset (ITT) included all mother–infant dyads that completed Visit 2 and met the final eligibility criteria. The per-protocol dataset (PPS) included all mother–infant dyads from the ITT without any major deviations. A suitable .Baseline demographics, maternal health, medical history, and infant characteristics were analyzed using Mann–Whitney tests for continuous variables and Pearson Chi-square tests for categorical variables. To determine differences in stool consistency between groups, we calculated the area under the curve for each treatment and then a linear mixed model was applied. Inconsolable crying and fussing were analyzed using generalized linear regression analysis.t-test for pairwise comparisons was used. Specifically, to test for differences in the relative abundance of species between two groups, due to the compositionality [For gut microbiota data and biomarkers of microbial activity, all analyses were performed in R version 4.2.0  and the ionality  of the 1ionality  and corrEighty-three pregnant women were screened for eligibility for the two studies at Aarhus University Hospital and provided with both oral and written information about the two studies. They all signed the GDPR consent, which allowed the research midwife to send the informed consent form via an e-mail link. In total, 47 pregnant subjects volunteered to join one of the studies: 24 for the MS study and 23 for the IS study .Streptococcus (GBS) within 24 h before birth due to the risk of infection. Three women (two women from the IS group and one woman from the MS group) tested positive and antibiotic treatment was initiated. There was no difference in mean hours from the pre-labor rupture of membranes (PROM) to birth between the groups or between the number of vaginal explorations before PROM/labor and the volume of postpartum hemorrhages. Maternal baseline and clinical characteristics are presented in Maternal age at enrollment, ethnicity, body mass index (BMI), activity level before pregnancy, smoking, and dietary habits did not differ between the two study groups . An equaAll infants were term born (GA week 37–42) except for one in the MS group, born in GA week 34+1. One infant in each group was born by an emergency cesarean section. Gender distribution, birth weight, length, and head circumference were not different between the infants in the two studies. Two infants from the IS group and one from the MS group were exposed to antibiotics postnatally due to a suspected infection. Skin-to-skin contact was established for all infants within 24 h, and no infants had a bath within 24 h after birth. An intramuscular K-vitamin injection (1 mg phytomenadione) was given to all infants within the first two hours after birth in compliance with the recommendation of the Danish National Board of Health. All infants were put to the breast immediately after birth and received colostrum within the first hours after birth. They were predominantly breastfed from birth throughout the study. Five (21.7%) infants in the IS group and four (16.7%) infants in the MS group were supplemented with infant formula during the first 24 h after birth due to various reasons. The given volume of infant formula ranged from below 20 mL to 80 mL, did not contain pre- or probiotics, and was equally distributed in the two groups. Twenty-one (91.3%) of the infants in the IS group were exclusively breastfed throughout the study, compared to twenty-three (95.8%) infants in the MS study. The number of infants who received partially mixed feeding during the first two weeks after birth was equal in both groups (three in the IS group vs. four in the MS group). In compliance with Danish dietary recommendations, all infants received a D-vitamin supplement as a drop suspension (without probiotics) from two weeks of age. Infant baseline characteristics are presented in Both maternal and infant supplementation with the probiotic strains Bifin02, BB-12, and LGG resulted in the recovery of these strains from infant fecal samples . In the IS group, the recovery (% of infants with a detected strain) of Bifin02 was identified in 100% of the infants from 14 days onwards, compared to 25%, 22%, and 29%, for day 14, day 28, and day 42 in the MS group, respectively. Similar patterns were observed for LGG: 100% recovery in the IS group compared to 21%, 24%, and 17%, respectively, in the MS group. In the IS group, recovery of BB-12 was 100% on day 14 and day 28 but declined to 35% on day 42, compared to 8%, 17%, and 8% on day 14, 28, and 42, respectively, in the MS group. Three infants in the IS group received the first dose of the study product before it was possible to collect the first fecal sample; therefore, those infants had all three dosed strains present in the first fecal sample. Although in the IS group, the prevalence of Bifin02 was already 100% from 14 days onwards, the mean abundance slightly increased throughout A. The inIn the IS group, the trajectory LGG showed that the quantity of this strain decreased after dosing was stopped. Nevertheless, its prevalence was still 100% 14 days after the cessation of dosing, indicating that, at least during the study period, this strain colonized all infants D. LA-5 wAbundances of the dosed strains were also measured in different biological specimen samples from the mother, including fecal, urine, vaginal, and breastmilk samples. The strains dosed in the IS study were detected at all four timepoints in up to 60% of the breastmilk samples, in contrast to the MS study, where only one to two subjects had the presence of the dosed strains .The dosed strains were detected in the majority of the maternal fecal samples in the MS group  at GA weRemarkably, BB-12 and LA-5 were also recovered from fecal samples from five mothers in the IS group who had inadvertently used a common probiotic fermented milk product that includes these strains. Nevertheless, their intake was limited to a few occasions. Bifidobacterium was higher compared to that at birth at all timepoints  (Bifidobacterium abundance between the two groups diminished over time. The lower abundance of B. longum (infantis) in the MS group was compensated for by a higher abundance of B. breve and B. adolescentis OTUs  compared to the IS group . Microbiota profiling was successful for 183 samples and yielded a mean of 12812 ± SD 2778 reads per sample. In the IS group, the relative abundance of ctively) B. The diIS group A,B. AltoBifidobacterium increased more from birth to day 14 in the IS group compared to the MS group, the total Bifidobacterium abundance on day 14 was not significantly different between the two interventions due to large inter-individual differences and correction for multiple testing  (Although  = 0.18) A,B.Lactobacillaceae, Staphylococcaceae, and Enterobacteriaceae. These were all aerobic and aerotolerant/microaerophilic species, and the compositions were similar between studies.In the first fecal sample, collected soon after birth, the microbiota contained bacteria typically associated with the birth canal, vagina, and skin, including In the IS group, compositional changes were mainly due to large increases in bifidobacteria, lactobacilli, and streptococci and concomitant decreases in typical skin bacteria such as corynebacteria, cutibacteria, and staphylococci, as well as several proteobacteria. Although the most dramatic effects occurred from birth to day 14, these dynamics further evolved even after the cessation of dosing. In contrast, these dynamics were delayed by 14 days or more in the MS group, largely because some infants still had bifidobacteria below the detection threshold (while the IS infants were mostly above 40%). The aforementioned large increases in bifidobacteria, lactobacilli, and streptococci and concomitant decreases in typical skin bacteria such as corynebacteria, cutibacteria, and staphylococci, as well as several proteobacteria, were not observed in the MS group until day 28.p = 0.3151). From day 14 onward, mean stool frequency was significantly lower in the IS group (p = 0.0058) compared to the MS group. Additionally, the IS group passed fewer stools per day (at day 14 p = 0.0027 and at day 28 p = 0.0231) and in total over the 28 days of intervention calculated by AUC (area under curve), p = 0.0052 (Infant stool frequency (number of bowel movements per day) during the first week after birth was similar in the IS and MS groups  . The mean number of watery, formed, and hard stools was similar in both groups throughout the intervention   C.No differences were observed between the two groups regarding gastrointestinal signs and symptoms .p = 0.0046)  A. p < 0.0001) were higher in the IS group compared to the MS group (p < 0.05) (p < 0.05) and day 28 (p < 0.05) (p = 0.012)   C. The sa < 0.05) D. No sta < 0.05) E. Butyra= 0.012) F. p < 0.0001) and day 42  compared to fecal levels from MS infants   . The numteroides .There were no significant differences in mean infant weight, length, or head circumference between the two intervention groups during the study, and all infants were thriving. No differences were observed in the safety and tolerability assessments either . No adverse events were reported for the duration of both interventions. One infant in the IS group reported wheezing and problems with eating during the first two weeks after birth. This was assessed by the research midwife as not being related to intake of study products.Streptococcus was diagnosed during labor in two mothers from the IS group and one mother from the MS group. One mother from the MS group reported a bladder infection during the follow-up period. All four cases were treated and not related to the study product intake. The presence of Group B These two studies are the first of their kind to compare the recovery, route of transfer, and potential colonization of probiotic strains after two different infant dosing regimens. Infants were either dosed directly after birth or indirectly via the mothers during the last months of pregnancy and the first 28 days after birth, thus relying on vertical bacterial transmission during or soon after birth for colonization. It is noteworthy to mention that dosing the infants directly from birth does not raise any safety concerns.Bifidobacterium spp. [Transfer of bacteria from mother to infant during vaginal birth is proposed to be conveyed through vertical transmission of microbes from the delivery environment through maternal body sites such as the skin, vagina, and feces ,54,55. Cium spp. . Our datium spp. , as we dium spp. . Interesium spp. . In contB. infantis EVC001 was dosed to infants in significantly higher doses of 18 billion CFU or more, which led to dominance of Bifidobacteriaceae  [Importantly, infants directly seeded with Bifin02 maintained it over time. The persistence of Bifin02 after termination of the intervention and the stable trajectories of the strain in individual infants, as observed in both treatment groups, strongly suggests engraftment of the strain even after being dosed at a relatively modest daily dose of 0.1 billion CFU. In several previous studies, strain l group) ,59. In contrast, our findings suggest that Bifin02 engrafts without complete dominance and enhanced colonization of other bifidobacteria. These changes are supported by the observed alterations in the metabolic output of the microbiome on day 14, resulting in a lower fecal pH and endotoxin level and increased acetate, butyrate, and total SCFA production in the IS infants. Butyrate, a SCFA, has been shown to exert immunomodulatory functions by the inhibition of histone deacetylases (HDAC) and the activation of G protein-coupled receptors (GPCR) on epithelial and immune cells. Overall, SCFA supports the development of a healthy gastrointestinal tract, modulates immune responses, and promotes the growth of colonocytes during infancy .The other dosed strains, mainly BB-12 and LGG, were detectable in the infant fecal samples, though at a lower level and frequency in the fecal samples from MS-dosed infants compared to directly dosed infants. Lactobacilli are frequently found in the infant microbiome ,61, and Infancy is characterized by large variations in stool frequency and consistency, both between and within infants . In a coBifidobacterium species on intestinal maturation, including skewing T-cell proliferation, leading to a more anti-inflammatory state and modulation of barrier integrity [Previous studies have shown an effect of BB-12 on reducing crying and fussing in infants with colic ,21. Infantegrity .The impact of the neonatal microbiome on clinical signs and symptoms from the gastrointestinal tract, such as crying and fussing, and on the normal healthy immune maturation underlines the importance of this period. It is believed that early infancy is a window of opportunity in which the gut microbiota is easier to modulate  and in wBifidobacterium longum subspecies infantis known for its prodigious capacity to digest and consume human milk oligosaccharide structures due to the result of a unique cluster of bacterial genes encoding an array of glycosidases and oligosaccharide transporters not found in other bacterial species [All infants included in our two studies were predominantly breastfed, the only difference was the intervention. It has been shown that breastfed infants have a higher abundance of lactate and acetate metabolites compared to bottle-fed children . These f species The strength of our studies is the high compliance and adherence to the study procedures, which resulted in robust and detailed data from both mothers and infants. We also acknowledge several limitations. Randomized trials are considered the gold standard when assessing efficacy, and the current studies were conducted as open-label studies with no control groups. It was an active choice not to include control groups due to the proof-of-concept design and the ambition to use each study group as a control for the other. The use of a placebo group in this uniquely vulnerable period of life should always be considered carefully and should always be justified by a positive risk–benefit analysis. Another limitation is the use of 16S rRNA, which does not provide the most accurate and reliable profiling of bacterial subspecies. However, complementary analysis and the use of strain-specific qPCR confirmed our conclusions regarding the presence of the dosed strains. To confirm the potential positive influence of early seeding on health later in life, follow-up studies are warranted.Bifidobacterium longum subsp. infantis Bifin02 (DSM33361), Bifidobacterium animalis subsp. lactis BB-12 (DSM15954), and Lacticaseibacillus rhamnosus LGG (DSM33156) was safe and well tolerated. Dosing infants directly after birth resulted in 100% of the infants being colonized with Bifin02 after 14 days, as opposed to 25% after 28 days of dosing the mothers during the last months of pregnancy and the first 28 days after birth. Thus, maternal oral supplementation with these strains supports a direct strain transfer from mother-to-child through fecal transmission. Bifin02 colonization was achieved with a moderate dose of only 108 CFU (0.1 billion). Additionally, dosing infants directly modulated the microbiota, leading to a faster transition towards Bifidobacterium domination, which was correlated with a lower defecation frequency and a slower increase in the incidence of crying and fussing.Dosing infants directly or indirectly via maternal consumption with Our observations support safe and targeted food supplementation both pre- and postnatally to the mother and directly to the newborns to ensure a healthy gut microbiome for the infant child.


Leukomalacia is a serious form of neonatal brain injury that often leads to neurodevelopmental impairment, and studies on neonatal leukomalacia and its long-term outcomes are lacking. The aim of this study was to analyze the clinical manifestations, imaging features, and long-term neurodevelopmental outcomes in preterm infants and term infants with leukomalacia.Newborns diagnosed with leukomalacia by head magnetic resonance imaging (MRI) and who were admitted to intensive care units from January 2015 to June 2020 were enrolled. All infants were followed up to June 2022 (2–7 years old), and their neurodevelopmental outcomes were evaluated. The clinical data and long- term outcomes of preterm infants and term infants was analyzed by Chi-square tests.2 = 55.166; p < 0.001). When followed up to 2–7 years old, the incidence of neurodevelopmental impairment in the preterm group and term group was not significantly different . However, the incidence of cerebral palsy (CP) in the preterm group was significantly higher , while the incidence of intellectual disability (ID) , epilepsy (EP) , and CP combined with ID andEP  was significantly lower than that in the term group.A total of 218 surviving infants with leukomalacia including 114 preterm infants and 104 term infants completed the follow-up. The major typesof leukomalacia on MRI were periventricular leukomalacia in the preterm group and subcortical cystic leukomalacia in the term group, respectively (χPeriventricular leukomalacia mainly occurred in preterm infants while subcortical cystic leukomalacia was commonly seen in term infants. Although the long-term neurodevelopmental outcomes of leukomalacia were both poor, preterm infants were more prone to CP, while term infants were more prone to ID, EP, and the combination of CP with ID and EP. In recent years, the popularization of neonatal intensive care units (NICUs) and rapid progress in intensive care technology have reduced the mortality of premature infants, low-birth-weight infants, and severely asphyxiated infants, but the incidence of neonatal brain injury remains high . LeukomaThe main pathological types of leukomalacia are periventricular leukomalacia (PVL) and subcortical cystic leukomalacia (SCL) . PVL is Up to now, studies on leukomalacia have mainly focused on the clinical features, pathogenesis, prevention, and treatments in premature infants, and only a few studies have looked at leukomalacia in term infants and the differences between preterm infants and term infants. In addition, studies on neurological outcomes in children with leukomalacia are often limited to small sample sizes and short-term follow-up times and do not always involve all types of leukomalacia , 12. TheThis was a double-center prospective cohort study. Newborns diagnosed with leukomalacia by head magnetic resonance imaging (MRI) who were admitted to the Neonatal Department of the Third Affiliated Hospital of Zhengzhou University and Henan Children’s Hospital from January 2015 to June 2020 were enrolled. Infants with inherited metabolic disorders and congenital brain malformations were excluded. All eligible infants were divided into the preterm group  and term group  and followed up to June 2022 (2–7 years old). Clinical characteristics and long-term neurological outcomes of infants with leukomalacia who survived and completed the follow-up were analyzed. This study was approved by the Ethics Committee of the Third Affiliated Hospital of Zhengzhou University, and informed consent was signed by all parents.Clinical information including gender, birth weight, gestational age, small for gestational age, 5-min Apgar score, delivery mode, and mechanical ventilation as well as neonatal complications such as apnea (requiring drug intervention or upgrading of oxygen therapy), neonatal seizures, symptomatic hypoglycemia, sepsis, hemodynamically significant patent ductus arteriosus (hs-PDA), intraventricular hemorrhage (IVH), cerebral parenchymal hemorrhage, and purulent meningitis were collected. Symptomatic hypoglycemia was defined as blood sugar below 2.6 mmol/L (47 mg/dl) accompanied by drowsiness, feeding difficulty, and/or seizures , and IVH1WI , T2WI , T2 Flair . Sag: T1WI . The type, severity, and cyst sites of leukomalacia were evaluated and divided into PVL and SCL by head MRI. In this study, we took into account the classifications of Vries et al. and Choi et al. [All infants were routinely screened with cranial ultrasound within 3 days after birth, then on day 7 and weekly thereafter until discharge. Head MRI (GE SIGNA Creator 1.5 T) was performed immediately when cystic lesions were detected on ultrasound, and at 40 weeks of corrected gestational age, and then at 3–6 months intervals. All participants were sedated with phenobarbital sodium and then scanned under pulse oxygen saturation monitoring (breathing support if necessary). A conventional MRI sequence protocol was applied in all of the participants: AX: Ti et al. , 16 and All eligible infants were followed up for growth and neurological development at the age of 3 months, 6 months, 12 months, 18 months, and 24 months and at least once a year thereafter until June 2022 when they were 2–7 years old. NDI was defined in this study as survival with one or more adverse neurodevelopmental outcomes including CP, ID, EP, vision problems, and deafness. According to the criteria of Bax et al. , CP was Follow-up was carried out by specialists including neonatologists, neurologists, rehabilitation physicians, ophthalmologists, and otolaryngologists. Follow-up data were obtained through outpatient follow-up records, in-patient electronic medical records , and remote video and telephone interviews.The SPSS 26.0 software was used to analyze the data. Quantitative data with a normal distribution are presented as the mean ± standard deviation, while quantitative data with a non-normal distribution are presented as the median (inter-quartile range). Quantitative data with normal distribution or non-normal distribution were analyzed using the Student’s t-test or the Mann–Whitney U-test, respectively. All count data were analyzed using the Chi-square test or Fisher’s exact test. A two-sided p-value < 0.05 was considered statistically significant.During the study period, a total of 270 newborns diagnosed with leukomalacia were enrolled, and 6 infants were excluded, including 3 with inherited metabolic disorders  and 3 with congenital brain malformations . The remaining 264 eligible infants with leukomalacia were divided into the preterm group (139 infants) and the term group (125 infants). During the follow-up, 17 preterm infants were lost to follow-up and 8 died within the first year , while 17 term infants were lost to follow-up and 4 died within the first year (3 died from sepsis and 1 died from severe pneumonia). At the end of the follow-up, 218 surviving infants, including 114 preterm infants and 104 term infants, were included in the analysis  and mechanical ventilation  in the preterm group was significantly increased compared to the term group. Preterm infants with leukomalacia were more prone to apnea , sepsis , and hs-PDA , while term infants with leukomalacia were more prone to neonatal seizures  and symptomatic hypoglycemia .The clinical manifestations in the two groups are shown in Table 2 = 11.547; p = 0.001). The major types of leukomalacia were PVL in the preterm group and SCL in the term group, respectively . Grade II PVL accounted for the largest proportion of PVL in both groups . However, the incidence of CP in the preterm group was significantly higher than that in term group , and the incidence of ID  and EP  in the preterm group was significantly lower than that in term group. The most common EP seizure type was West syndrome in both groups , while the rate of spastic hemiplegia in the term group was significantly higher than that in preterm group  . The incidence of CP combined with ID and EP  in the term group was significantly higher than that in preterm group 3). The hWe conducted a prospective cohort study in neonates with leukomalacia with long-term follow-up to 2–7 years of age and found that there were obvious characteristic differences in clinical manifestations, MRI imaging features, and long-term neurodevelopmental outcomes between preterm infants and term infants with leukomalacia. Our study thus provides a more comprehensive understanding of leukomalacia in newborns compared to previous studies.In terms of clinical manifestations, preterm infants had higher incidence of 5-min Apgar score ≤ 7, mechanical ventilation, apnea, hs-PDA, and sepsis. These complications were mainly related to hypoxia–ischemia and inflammation. Several previous studies have reported that the white matter in preterm infants is more sensitive to the damage caused by hypoxia–ischemia and inflammation than the white matter in term infants , 23. WhiThis study showed that symptomatic hypoglycemia was more likely to occur in the term group, which was similar to a study conducted in Turkey . They foWe found that the MRI features of leukomalacia in preterm infants were different from those in term infants. Although the cysts in the two groups were mainly bilaterally distributed, the proportion of unilateral cysts in the term group was significantly higher than that in the preterm group. PVL is the main type of leukomalacia in preterm infants, while SCL is the main type of leukomalacia in term infants, which indicates that the brain injury patterns of preterm infants and term infants are different. In preterm infants, the distal region of the perforator artery that supplies the ventricular white matter is very sensitive to hypoxia and ischemia due to immature cerebral vascular development. Once hypoxic-ischemic events occur, the injury will easily involve this region and lead to PVL , and theCurrently there are only a few studies on the long-term neurodevelopmental outcomes of leukomalacia. Resch  and ChoiThere were several limitations to this study. First, there was no significant difference in the regions of the cysts of grade III PVL and SCL between the preterm and term groups, which was probably due to the small sample size. Second, in children who developed West syndrome, whole exome sequencing should be used for further understanding of the disease. Finally, the follow-up to 2–7 years of age was not long enough because both intelligence and language development require longer follow-up to school years. However, at the very least, we have provided clinical evidence for the long-term neurological outcomes of preterm and term infants with leukomalacia.We found differences in the clinical manifestations of leukomalacia in term infants and preterm infants, and PVL mainly occurred in preterm infants, while SCL was commonly seen in term infants. Although the long-term neurodevelopmental outcomes of both types of leukomalacia were both poor, preterm infants were more prone to CP, while term infants were more prone to ID, EP, and the combination of CP with ID and EP. Further well-designed prospective multicenter studies with larger sample sizes and with follow-up to school age or longer are still needed to confirm the long-term neurological outcomes of leukomalacia.


Systemic corticosteroids are often used to treat inflammatory bowel disease (IBD) flares during pregnancy as maintenance of disease remission is crucial to optimize pregnancy outcomes. However, there is little data regarding the effect of in utero exposure to corticosteroids on the risk of adverse birth outcomes and early-life infections in the offspring.We used the Danish national registries to establish a nationwide cohort of all singleton live births in women with IBD from 1995 to 2015. Outcomes in children exposed in utero to corticosteroids were compared to those who were not exposed. In logistic and Cox proportional hazard regression models, we adjusted the outcomes  for confounders such as body mass index, smoking, comorbidity, and additional medical IBD treatment.n = 707), the adjusted hazard ratio of major congenital malformation was 1.28 (95% CI: 0.82–2.00) compared to children born to women with IBD, but not exposed to corticosteroids in utero (n = 9371). After in utero exposure to corticosteroids at any time during pregnancy (n = 1336), the adjusted odds ratios for preterm birth, small for gestational age, and low 5-min Apgar score were 2.45 (95% CI: 1.91–3.13), 1.21 (95% CI: 0.76–1.90), and 0.91 (95% CI: 0.33–2.52), respectively. Finally, the adjusted hazard ratio of overall infections in the first year of life was 1.14 (95% CI: 0.94–1.39).After in utero exposure to corticosteroids at any time between 30 days prior to conception through the first trimester (This nationwide cohort study suggests that children of women with IBD exposed to corticosteroids in utero had an almost 2.5-fold increased risk of preterm birth. Use of corticosteroids is closely related to disease activity and we cannot adjust for the independent role of disease activity. It is however reassuring that the other examined birth and early-life outcomes were not statistically significantly increased.The online version contains supplementary material available at 10.1186/s12916-023-02817-7. Inflammatory bowel disease (IBD) is prevalent in the fertile years and reproductive issues frequently arise . Due to Based on nationwide population-based Danish register data, we aimed to examine if in utero exposure to corticosteroids in women with IBD is associated with an increased risk of major congenital malformation, preterm birth, small for gestational age, low 5-min Apgar score, and infections diagnosed in the first year of life, including an overall infection risk, and the risk of site-specific infection groups, compared to women with IBD not treated with corticosteroids during pregnancy.th revision (ICD-8) to ICD-10 , normal weight [18.5–24.9 kg/m2], overweight [25.0–29.9 kg/m2], and obese [25.0–29.9 kg/m2]). Information on BMI is available in the register from 2005. From the National Prescription Register [The covariates were selected a priori from the different registries and applied to the statistical models when relevant. From the Medical Birth Register, we extracted data on maternal age at the time of birth (continuous), parity , maternal smoking when entering the pregnancy (yes/no), sex of the child , calendaRegister , and theRegister . This inThe analytic unit of this study was births, and contingency tables were constructed for the main study variables according to the two exposed cohorts, and the unexposed cohort. The statistical model took the clustering of children born by the same mother into account. When examining the different dichotomous outcomes, i.e., risk of preterm birth, small for gestational age, and low 5-min Apgar score, we used univariate and multivariate logistic regression analyses by in utero corticosteroid exposure as crude and adjusted odds ratios (OR) with 95% confidence intervals (95% CI). In the logistic regression models, we adjusted for maternal age at child birth, calendar year of birth, maternal smoking, BMI, comorbidity, parity, the sex of the child, and medical treatment for IBD with biologic therapy, azathioprine/mercaptopurine, and 5-ASA. When we examined the time-to-event outcomes, i.e., major congenital malformation and the risk of infections within the first year of life, the follow-up of the children started on the date of birth and ended on the date of the first specified outcome of interest, emigration, death or the child’s first birthday, whichever came first. In order to analyze whether major congenital malformations or infections were different between the exposed and unexposed cohort, we used a Cox proportional hazard regression model estimating the hazard ratio (HR). First infection and each site-specific infection were visualized using Kaplan–Meier plots stratified for the IBD subtype, ulcerative colitis or Crohn’s disease. The distribution of the types of different major congenital malformations is presented in the Additional file All analyses were made using STATA Release 16 (StataCorp).In a first sensitivity analysis, we analyzed the confounding impact of maternal BMI as these data were only available for a restricted time period, and in a second sensitivity analysis, we excluded women with obstetrical diagnoses related to threatening preterm birth. Furthermore, in a sub-analysis, we stratified on a maternal underlying diagnosis of either ulcerative colitis or Crohn’s disease.In total, 6986 unique pregnant women with IBD were included in the study. Table Across the three cohorts, women had equivalent use of biologic therapy within 30 days prior to conception and during pregnancy. Slightly fewer women used azathioprine in the unexposed cohort; 5.9% vs. 12.9% and 10.8% in the two exposed cohorts. The same pattern was present regarding 5-ASA treatment during pregnancy with 28.2% in the unexposed cohort and 65.8% and 69.8% in the two exposed cohorts.For major congenital malformations, the adjusted HR of the first diagnosed malformation was 1.28 (95% CI: 0.82–2.00) for children exposed to corticosteroids in early pregnancy, compared to children not exposed to corticosteroids . In the second sensitivity analysis excluding patients with obstetrical diagnoses, the risk estimates obtained from the main model did not alter (data not shown). Finally, in the sub-analysis stratifying the women according to their underlying IBD diagnosis of either ulcerative colitis or Crohn’s disease, we did not detect an impact of underlying maternal disease on the risk estimates. Data not shown.Our results are based on all live-born children in women with IBD in Denmark from 1995 to 2015 , and represent important and useful information for pregnant women with IBD, their partners, and clinicians. We found that neonates born to women with IBD who were treated with corticosteroids during pregnancy had a significantly increased risk of being born preterm. We found no statistically increased risk for the other examined outcomes, i.e., small for gestational age, low 5-min Apgar score, major congenital malformations, and hospital-diagnosed infections.Although most women with IBD may conceive while their IBD is in remission, disease activity and flares can complicate up to 20% of all pregnancies in women with Crohn’s disease and 35% in women with ulcerative colitis . CorticoRegarding in utero exposure to corticosteroids and congenital malformations, first-trimester exposures to corticosteroids have been thought to confer an increased risk of orofacial clefts –7. In a n = 469) examining the risk of preterm birth by the time of exposure. Exposure in the first half of gestation provided an adjusted relative risk of 1.06 (95% CI: 0.59–1.89) and exposure with corticosteroids in the second half of gestation was not associated with an increased risk of preterm birth and adjusted hazard ratio 2.13 (95% CI: 0.99–4.59) [Additionally, in women with Crohn’s disease, the exposure to topical or systemic corticosteroids has been examined according to various birth outcomes including preterm birth, congenital abnormalities, and low birth weight at term in 73 women with corticosteroids prescribed during pregnancy. None of the risk estimates provided were significant , 36. Our99–4.59) . We did 99–4.59) . Althoug99–4.59) .An association between maternal IBD and low 5-min Apgar score has been examined in prior studies. Boyd et al. found an increased risk of a low 5-min Apgar score in neonates born at term to women with IBD, with a relative risk of 2.19 (95% CI: 1.03–4.66). This risk was increased further in neonates born to women with Crohn’s disease, relative risk 3.55 (95% CI: 1.45–8.67) . HoweverCorticosteroids may influence the development of the immune system but it is reassuring that we did not detect any statistically significant increased risk of infections in corticosteroid-exposed infants in the first 12 months after birth. Furthermore, we adjusted for preterm birth which per se is associated with an increased risk of early-life infections , 40.This study has several strengths. Our nationwide cohort study examines the largest number of exposed infants to date with a unique opportunity for robust statistical risk estimates. We were also able to control for some of the most important confounders based on information from the national health registries which are highly valid, accurate, and complete . We retrOur study also has limitations. In a study like this, it is not possible to separate the distinct effect of corticosteroids from an effect of disease activity but this applies to other studies in this area as well, as an indication for the use of corticosteroids is closely related to disease severity. These are well-known aspects and challenges in observational studies , 29, 35.In conclusion, corticosteroid use at any time during pregnancy in women with IBD was associated with a 2.5-fold increased risk of preterm birth. Corticosteroid use was not statistically significantly associated with any overall risk of major congenital malformations, being small for gestational age, having a low 5-min Apgar score, or hospital-diagnosed infections in the first year of life. Our study demonstrates and supports previous literature on the finding of an increased risk of preterm birth. Future studies in this area are warranted, especially studies that examine the underlying mechanisms for preterm birth but also other important outcomes such as neonatal hypoglycemia, neonatal intensive care unit admission, and extended postpartum hospitalization.Additional file 1: Table S1. All diagnoses of infections with related ICD-10 codes with the subdivision into site-specific groups. Table S2. List of ICD-10 codes used to define congenital malformations in accordance with the EUROCAT classification of malformations. Table S3. Distribution of congenital malformations in the exposed cohort #1 and the unexposed cohort.


To evaluate the use of UmbiFlow™ in field settings to assess the impact of heat stress on umbilical artery resistance index (RI).This feasibility study was conducted in West Kiang, The Gambia, West Africa; a rural area with increasing exposure to extreme heat. We recruited women with singleton fetuses who performed manual tasks (such as farming) during pregnancy to an observational cohort study. The umbilical artery RI was measured at rest, and during and at the end of a typical working shift in women at 28 weeks or more of pregnancy. Adverse pregnancy outcomes (APO) were classified as stillbirth, preterm birth, low birth weight, or small for gestational age, and all other outcomes as normal.A total of 40 participants were included; 23 normal births and 17 APO. Umbilical artery RI demonstrated a nonlinear relationship to heat stress, with indication of a potential threshold value for placental insufficiency at 32°C by universal thermal climate index and 30°C by wet bulb globe temperature.The Umbiflow device proved to be an effective field method for assessing placental function. Dynamic changes in RI may begin to explain the association between extreme heat and APO with an identified threshold of effect. Extreme heat exposure is increasing and a low‐cost umbilical artery Doppler device, UmbiFlow™, can aid understanding of fetoplacental function under heat stress conditions. First‐trimester exposure leads to increased embryonic death, and cardiac and neurologic anomalies.to determine if the UmbiFlow™ identifies a change in umbilical artery resistance index under heat stress; andto determine the practical considerations needed to use UmbiFlow™ in the field.Direct measurement of blood flow to the placenta through the uterine arteries can be challenging because it requires highly specialized non‐portable equipment in conjunction with fluid dynamic modeling.2This feasibility study follows the guidelines on reporting non‐randomized pilot and feasibility studies /systolic velocity. The hand‐held probe attaches to a laptop/tablet, signal processing occurs within the specialized software to give both a waveform and an audible umbilical artery blood flow. Validated reference values by gestational age indicate if the RI is within a normal, intermediate, or high‐risk risk range . On a single occasion for each participant the RI was measured at baseline in an air‐conditioned environment with the participant supine at rest, and with abdominal lateral tilt, and then at two time points during her working day—determined based on the length of the work shift to correspond with a mid‐point and end‐point of the manual tasks. At each time point, two measurements were taken, assessed for quality , mean values were taken when good/moderate quality and discarded if poor quality. The risk category was recorded at each reading as well as the exact value of the RI. Fetal heart rate was measured concurrently, and average values over 5 min were taken. When fetal heart rate or umbilical artery RI was identified as high risk during the study and did not resolve within 30 min, participants were referred for urgent care. This involved being assessed by the rural antenatal clinic (staffed by a midwife and four doctors), with the option to be referred to a tertiary center should they identify a clinical need. All participants were followed until after delivery and data on birth outcome were collected. APOs were defined as follows: stillbirth—pregnancy longer than 20 weeks where the baby was born dead; PTB—live birth before the completion of 37 weeks of pregnancy; low birth weight—birth weight less than or equal to 2.5 kg; small for gestational age—birth weight 10% below expected weight for gestational age based on Intergrowth‐21 standardized curves.To determine practical considerations, the study team recorded any issues with the software, the use of UmbiFlow in the field, and the results generated.Z score (which is age adjusted) or change in RI by UTCI was best explained by a non‐linear model with a cubic spline with one knot at the median.All analyses were performed in R version 4.1.0. Descriptive characteristics are presented as mean ± standard deviation or median (interquartile range) by outcome, depending on distribution. The relationship between UTCI, fetal heart rate, and umbilical artery RI were explored using linear and non‐linear models. Non‐linear models were tested across different spline definitions and different knots placed at the median and 90th centile. The lowest Akaike information criterion was used to determine best model fit. Change in fetal heart rate by UTCI was best explained by a linear model. RI Z score and heat stress was explored both with and without cubic splines, with the best fit determined by Akaike information criterion. The final model is shown as:Z score is umbilical artery RI Z score for individual i at time j and heat stress is UTCI for individual i at time j.A multilevel linear regression model, with individual as random effect, of the association between umbilical artery RI Z score under heat stress.Multilevel model assumptions were assessed by examining the normality of residuals and performing Levene tests for homogeneity of variance. The simr package was used to run a simulation‐based power analysis on the multilevel model to give estimations of sample size requirements to detect a difference in umbilical artery RI 3Full umbilical artery Doppler was completed on 40 participants the field. Of these 40 participants, 17 had APO and 23 did not. Of those with APO, three experienced stillbirths, seven delivered preterm (spontaneously), six were low birth weight, and eight had SGA. Descriptive characteristics of all participants are presented in Table Environmental conditions and physiologic parameters at baseline, during the work shift, and at the end of the work shift are presented in Table Fetal heart rate demonstrated a linear relationship with heat stress, giving an increase of 10.7  beats/min for each 10°C UTCI increase and 13.4 (95% CI 9.5–17.2) beats/min for each 10°C WBGT increase Figure . Based oZ scores. Several challenges were identified: software compatibility, delay in loading of the program when in the field, and interference with the signal when using windows 7. The programming for the software can only run on windows and is incompatible with Apple devices. It also required a laptop versus a tablet so requiring multiple electronic devices to be carried into the field because all study records were taken directly onto tablets. There was a delay in loading the software at each start up, which required planning for especially considering the need to capture dynamic changes. We also struggled with interference in the signal when using windows 7, which resolved on upgrading to windows 10, but made measurements difficult. All these issues were worked through and we were able to successfully record umbilical artery RI in the field at all the required time points. Furthermore, the manufacturers of UmbiFlow™ are working to resolve many of the points raised.Practical considerations for use in the field included ensuring a comfortable and private area to scan—which was provided by local vegetation or screens; protection from extreme weather—provided by portable shade/rain protector; and need for accurate gestational age to calculate RI 4We show that the UmbiFlow™ device is highly suited to field work, being light and compact, and that the measurement of umbilical artery Doppler in field conditions is possible and shows promising evidence of potentially enhancing the understanding of the fetoplacental circulation response to heat stress. Under heat stress conditions below 32°C UTCI/30°C WBGT there was a reduction in the umbilical artery RI from baseline, which would indicate increased blood velocity within the fetoplacental circulation as we would expect. However, above these temperature thresholds there appears to be a trend towards increasing RI, which would indicate insufficiency in the fetoplacental circulation. The response to heat stress may be different in those individuals that went on to have an APO as shown in the difference in z‐scores presented in Table There are few studies exploring the impact of heat on uterine or placental blood flow. A study from Sweden on sauna use (20 min at 70°C) in late pregnancy found a reactive increase in fetal heart rate, but no change in umbilical artery blood flow.The study has several limitations. The sample size was reduced because the COVID‐19 pandemic halted all field work activity from March 2020, limiting the scope of analysis available. Maternal core temperature could not be measured in the field  and therefore the less accurate and less precise tympanic temperature was measured. Additionally, pregnancy and neonatal outcomes in the general population of The Gambia are worse than the global average, which may impact on the generalizability of the findings globally, although they could be reasonably representative of a rural sub‐Saharan Africa population. We found the number of participants with pre‐eclampsia was higher in those without an APO, but this is most likely due to chance. This study comes at a time when extreme heat exposure is becoming a reality for much of the global population. Despite this, those most commonly experiencing these extreme conditions are often missing from the medical literature. This study is set in a rural African setting, with a population of women that can be difficult to access but are often exposed to extreme environmental conditions. By exploring ways to improve the understanding of pathophysiologic mechanisms in a real‐life setting we highlight the need for future work. The simulation‐based sample size calculations . The funders had no role in study design, data collection, analysis, manuscript writing, or decision to submit.The authors have declared that there are no conflicts of interest.Data S1Click here for additional data file.