Maternal age at pregnancy is increasing worldwide as well as preterm birth. However, the association between prematurity and advanced maternal age remains controversial.To evaluate the impact of maternal age on the occurrence of preterm birth after controlling for multiple known confounders in a large birth cohort.Retrospective cohort study using data from the QUARISMA study, a large Canadian randomized controlled trial, which collected data from 184,000 births in 32 hospitals. Inclusion criteria were maternal age over 20 years. Exclusion criteria were multiple pregnancy, fetal malformation and intra-uterine fetal death. Five maternal age categories were defined and compared for maternal characteristics, gestational and obstetric complications, and risk factors for prematurity. Risk factors for preterm birth <37 weeks, either spontaneous or iatrogenic, were evaluated for different age groups using multivariate logistic regression.165,282 births were included in the study. Chronic hypertension, assisted reproduction techniques, pre-gestational diabetes, invasive procedure in pregnancy, gestational diabetes and placenta praevia were linearly associated with increasing maternal age whereas hypertensive disorders of pregnancy followed a “U” shaped distribution according to maternal age. Crude rates of preterm birth before 37 weeks followed a “U” shaped curve with a nadir at 5.7% for the group of 30–34 years. In multivariate analysis, the adjusted odds ratio (aOR) of prematurity stratified by age group followed a “U” shaped distribution with an aOR of 1.08  for 20–24 years, and 1.20  for 40 years and older. Confounders found to have the greatest impact were placenta praevia, hypertensive complications, and maternal medical history.Even after adjustment for confounders, advanced maternal age (40 years and over) was associated with preterm birth. A maternal age of 30–34 years was associated with the lowest risk of prematurity. During the last decades, a gradual increase of maternal age has been observed worldwide. In the United States, between 1970 and 2006, the proportion of pregnant women aged over 35 years has increased almost eight times . TherefoPreterm birth is the most important factor determining neonatal morbidity and mortality, and has a major impact on it. However, in literature, the association between prematurity and advanced maternal age remains controversial. A study on more than 80,000 women revealed that 36% of the increase in prematurity, between 1990 and 1996 in Canada, was attributable to the change towards increasing maternal age . VariousThe aim of this study was to evaluate the relationship between advanced maternal age and prematurity (both spontaneous and iatrogenic) after controlling for multiple confounders.This is a retrospective cohort study using data obtained from the QUARISMA randomized controlled trial . QUARISMInclusion criteria were those of the QUARISMA trial: birth at or after 24 gestational weeks of a fetus weighing >500 grams; and maternal age >20 years. Non-inclusion criteria were multiple pregnancies, fetal malformations and intra-uterine fetal demise.Five maternal age categories were defined: 20–24, 25–29, 30–34, 35–39 and 40 years and older. Groups of age were compared based on maternal history: past drug use, nulliparity, and medical history including chronic hypertension, diabetes mellitus, renal and cardiac disease, thrombophilia, systemic erythematous lupus and inflammatory bowel disease. Characteristics of the current pregnancy were also studied: drug use, smoking, use of assisted reproductive technologies, and occurrence of an invasive procedure (chorionic villus sampling or amniocentesis). Additionally, groups of age were also compared according to maternal and obstetrical complications: hypertensive complications , gestational diabetes and placenta praevia. All comparisons used chi-square test.The odds ratios for preterm birth (<37 weeks) and very preterm birth (< 32 weeks) were calculated for different age groups before and after adjustment by multivariate logistic regression for known risk factors, maternal characteristics and gestational complications. For these analyses, the reference group corresponded to the group with the lowest rate of prematurity. As our analyses did not focus on the intervention of the primary trial (caesarean section) and since this intervention did not condition the relationship between the explanatory variables and the outcome studied in our paper; we did not performed mixed model analyses accounting for cluster .Preterm birth <37 weeks was divided into spontaneous and iatrogenic preterm birth. For both conditions, risk factors were studied using multivariate logistic analyses after adjustment on covariates. Iatrogenic delivery was defined as performance of a cesarean delivery before onset of labor or induction of labor using cervical ripening or oxytocin.Results were considered significant when p<0.05. All statistical analyses were performed with the use of SAS software, version 9.3 (SAS Institute)QUARISMA trial reported the outcome of 184,952 deliveries. After exclusions, a total of 165,195 births were finally included in the study and distributed as follows: 24 650 aged 20–24 years; 59 124 aged 25–29 years; 55 867 aged 30–34 years; 21 416 aged 35–39 years; 4138 aged 40 years or more .Comparison of excluded  and included  births did not show any discrepancy regarding maternal distribution of age or maternal characteristics. Risk factors for prematurity by age category are presented in Rates of preterm birth <37 weeks and very preterm birth <32 weeks were lowest in the 30–34 years old group (5.7% and 0.6% respectively) and highest in women over 40 years (7.8% and 1.0% respectively) . Crude aAfter adjustment for potential confounders, advanced maternal age (40 years and over), compared to the reference group (30–34 years), was associated with preterm birth <37 weeks and iatrogenic preterm birth (aOR 1.20 (95% CI 1.06–1.36) and aOR 1.31 (95% CI 1.05–1.64) respectively). Age 35–39 years was also associated with iatrogenic prematurity (aOR 1.15 (1.01–1.31)). Younger women (20–24 years) had an increased risk of preterm birth (aOR 1.08 (95% CI 1.01–1.15) and spontaneous preterm birth (aOR 1.09 (95% CI 1.02–1.18). Detailed results of the multivariate analysis are presented in We found that advanced maternal age (40 years and over) was associated with an increased risk of preterm birth even after adjustment for confounders. The lowest risk of prematurity was found in mothers aged 30–34 years. Preterm birth was mainly spontaneous in younger women (20–24 years) whereas it was more frequently of iatrogenic origin in women over 40.Our results are in accordance with those of two recently published cohort studies. Lawlor et al, in a population of Danish women, found a U shaped relationship between maternal age and risk of preterm birth, with the lowest risk age at 24–30 years . A more Confounders identified in our study are known risk factors for prematurity. Placenta praevia, gestational diabetes, medical history, use of assisted reproduction technologies and occurrence of an invasive procedure were all more common in aged mothers. On the other hand, nulliparity, past drug use and smoking were more prevalent in younger mothers. Furthermore, the prevalence of hypertensive disorders was lowest in middle-aged groups. This distribution of risks factors probably accounts for the “U” shaped distribution of preterm birth risk among age groups. Past research has already shown that younger mothers tend to have higher prematurity rates, but the persistence of this effect until 30 years old has rarely been identified . In contA common hypothesis is that the increased risk of preterm birth among aged mothers is largely explained by early labor induction for medical conditions. However, our analysis of iatrogenic versus spontaneous prematurity rates among aged mothers does not confirm this hypothesis. Khalil et al. found opposite results in a recent cohort study . This diThe principal strength of this study is the size of the cohort with more than 165 000 patients studied. Furthermore, the sampling represents a broad spectrum of patients, including patients from rural and urban communities across a Canadian province. This prospective cohort nested in a large and well-designed randomized controlled trial allowed controlling for a large number of variables, with a standardized data collection and a strict quality control. Hence, the confounding effect of data such as the use of assisted reproductive technologies and occurrence of an invasive procedure has rarely been studied. Yet these factors are important, with aORs for extreme prematurity of 1.58 (95% IC 1.06–2.33) and 1.67 (95% IC 1.29–2.16).This study has some limitations. Some potential confounders could not be studied. BMI information was missing in 28% of patients, therefore, it was not used in multivariate analysis. In the population studied, obesity was more common in advanced maternal age mothers. Previous research has shown that excess weight is associated with overall prematurity before 32 weeks and induced prematurity before 37 weeks . Thus, cIn conclusion, this study based on a large birth cohort was able to demonstrate that even after adjustment for many potential confounders known to be associated with preterm birth, advanced maternal age was independently associated with preterm delivery. Women of 30–34 years had the lowest risk of preterm delivery.


There is little knowledge about how factors early in life affect the development of migraine and tension-type headache. We aimed to examine whether growth restriction in utero is associated with development of migraine and frequent tension-type headache in adults.th-90th percentile), small for gestational age  or very small for gestational age . Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI) for migraine and tension-type headache, with exposure being growth restriction at birth.The population-based Nord-Trøndelag Health Study (HUNT 3) contained a validated headache questionnaire, which differentiated between migraine and tension-type headache. These data were linked to information on weight and gestational age at birth from the Norwegian Medical Birth Registry. In total 4557 females and 2789 males, aged 19–41 years, were included in this registry-based study. Participants were categorized as appropriate for gestational age , but not in females (p = 0.20). In particular, males born VSGA were at increased risk of developing migraine , with an intermediate risk among those born SGA  compared to those born AGA. There was no significant association between growth restriction and frequent TTH (p = 0.051).Growth restriction was associated with increased risk of migraine in adulthood among males, but not among females. This suggests that migraine might, in part, be influenced by early life events, and that males seem to be particularly vulnerable. Migraine and tension-type headache (TTH) are the most common primary headache disorders, affecting about 15% and 21% of the world’s population respectively . For botth percentile. FGR affects up to 9% of pregnancies in developed countries, and six times that number in developing countries [Foetal growth restriction (FGR) is traditionally defined as birth weight by gestational age and gender below the 10ountries . Causes ountries . FGR is ountries , as wellountries , 15.Few previous studies have examined the effect of pre- and perinatal factors on the risk of developing headache later in life, and no study has examined the effect of FGR on the development of headache in adulthood. In one study examining FGR and headache among 11-year old children, no effect was found on FGR and migraine, but the sample included an age group where migraine has low prevalence . Only a We utilized the population-based Nord-Trøndelag Health Survey (HUNT), in which participants were assessed for headache disorders. In order to examine the effect of FGR on the development of migraine and TTH in adulthood, survey data were linked to the Norwegian Medical Birth Registry for near complete objective body measurements at birth.All inhabitants 20 years or older in Nord-Trøndelag county of Norway were invited to participate in the Nord-Trøndelag Health Study, HUNT 3 (2006–2008). The study population, including both participants and non-participants has been described in detail previously . In brieth or > 44th weeks of gestational age (n = 69), had weight for gestational age > 5 standard deviations (SD) away from the Scandinavian reference mean [Information on weight by gestational age was obtain through The Norwegian Medical Birth Registry, which contains information on all registered births in Norway since 1967 . Of thosnce mean  (n = 14)nce mean , and theParticipation was based on informed, written consent, and the study was approved by the Regional Committee for Medical and Health Research (2015/463/REK midt).The 14 headache questions in the second questionnaire (Q2) were designed mainly to determine whether the individual had headache, the frequency of headache, and, when headache were reported, to diagnose migraine and TTH according to a modified version of the second version of the International Classification of Headache Disorders (ICHD-II) . Subjectth percentile, the definition being equal to small for gestational age (SGA) [rd percentile) to better identify foetuses at risk [rd and 10th percentile, termed SGA, and those below the 3rd percentile, termed very small for gestational age (VSGA). Participants born with a weight appropriate for gestational age  were used as a reference group. Those born large for gestational age  were included in prevalence calculations, but were not included in analyses of FGR. In order to calculate the percentile for each individual, birth weight was standardized according to gestational age and sex based on national reference data [We used the traditional definition of FGR, that is a birth weight by gestational age and gender below the 10ge (SGA) . Since ige (SGA) , some ha at risk , 29. Fornce data , and expAdditional information from the Norwegian Medical Birth Registry, such as specific diagnoses in the newborn, complications during pregnancy or labour, maternal smoking, alcohol use, medical conditions and medication use, could unfortunately not be included, due to lack of data or high level of missingness in the birth notification forms used before 1999.Considering an explanatory strategy, our major hypothesis was that FGR is associated with headache status in adulthood. We estimated the effect of having FGR at birth (exposure) on the presence of headache in HUNT 3 (outcome) using binary logistic regression. Those suffering from migraine and frequent TTH were examined separately, and compared to participants free of headache. For the exposure variable, the effect of SGA and VSGA was examined by using those born AGA as a reference. The results are reported as odds ratios (OR) with 95% confidence intervals (95% CI). The exposure variables  were also incorporated as a single ordinal variable in a two-sided test for trend. Sex and age were considered as potential confounders or effect modifiers on this association. The confounding effect was quantified by comparing the adjusted OR to the crude OR. Variables with a confounding effect > 5% were included in the final analysis. Effect modification was examined by including an interaction term in the model, where we defined effect modification as significant interaction at p < 0.05. Modification was handled by performing stratified analyses. All tests were two-sided and p-values < 0.05 were considered statistically significant.Estimated marginal probabilities of migraine were based on a model including the interaction of gender and growth restriction, holding age at its mean, and visualized graphically. For this analysis we included the whole study sample, including those with non-classified headache, in order to obtain representative probability estimates.All analyses were performed using Stata/SE 14.1 for Mac .To study the association between FGR and migraine we included 1335 subjects with migraine and 3723 subjects without headache. The overall prevalence of migraine in our study sample was 22.8% for females and 10.5% for males, which is comparable to the expected migraine prevalence for this age group, in this region , 30. TheThere was a significant effect modification of sex on the relationship between being born VSGA and migraine (p = 0.009), and subsequent analyses were therefore performed separately for males and females. Including age in the model did not alter the estimates, and age was therefore not included as a covariate in the final model. The results are summarized in Age-adjusted estimates for prevalence (probabilities) of migraine by sex and weight by gestational age are given in The same procedure was used to investigate the association between FGR and frequent TTH (n = 1160). Characteristics of the participants are summarized in No effect modifiers were identified. Sex had a confounding effect and was therefore included in the model, but age did not.FGR was not significantly associated with the development of frequent TTH (p for trend = 0.051). There were no significant differences in odds for migraine for those born SGA  or VSGA , compared to those born AGA.In this population-based study of 7354 adults with information on measurements at birth, we found that FGR was associated with increased odds of developing migraine in males. This relationship was most pronounced in those born VSGA, among whom the odds of migraine in adulthood were almost three times higher than in the non-growth restricted group. The study revealed no association between FGR and migraine in females, or between FGR and frequent TTH.Few previous studies have investigated the effect of perinatal factors on the risk of headache. In contrast to our findings, one longitudinal study of 871 11-year old children did not report an effect of FGR on migraine or TTH . The stuFGR is defined, by its true meaning, as a foetus who does not reach its predetermined growth potential . This caSpecific structural and functional changes in the brain associated with FGR include delayed myelination, a reduced number of synapses and altered dendritic morphology, changes in grey and white matter volume, and reduced brain connectivity particularly in the prefrontal and limbic networks, the latter correlating with neurobehavioral impairments, such as hyperactivity and cognitive executive deficits . Of partSeveral studies have also indicated that altered hemodynamics in utero may result in dysfunctional development of the cardiovascular system, “programming” the foetus for lifelong cardiovascular morbidity . A higheIt could also be speculated that the effect of FGR on the later development of migraine might be mediated through admission to the neonatal intensive care unit (NICU), which involves exposure to painful procedures and stressful events. This experience may play a role in the later development of headaches .Somewhat surprisingly, we found a significant effect modification of sex. The risk of developing migraine was clearly increased in growth restricted males, but not in females. This greater effect of FGR on males is in line with previous studies on other conditions, suggesting that it may have a biological basis , 45. ComWe did not find any associations between being growth restricted at birth and frequent TTH. A reason for this might, in part, be that migraine and TTH are caused by separate underlying mechanisms, as has been suggested previously .Strengths of our study include the large and unselected population, the use of validated headache diagnoses, and near complete objective measurements of height and weight at delivery, making it possible to define FGR.th percentile. Both types of misclassification will result in an underestimation of the effect of FGR on the development of headache in the current study. To minimize the risk of misclassification, we studied the group born VSGA, where the proportion of true FGR will be higher, separately. Lastly, while we examined age and sex as potential confounders, we cannot exclude residual confounding from variables not available in our material, such as maternal psychiatric comorbidity, health, lifestyle and medication use during pregnancy, complications in pregnancy, complications/conditions in the newborn, socioeconomic status and other hardships that may affect later caregiving, psychosocial environment and family lifestyle. It would have been of particular value to further examine the growth restricted males with migraine, regarding the above-mentioned factors, to evaluate if they differed from the normal-weighted newborns in other ways than being small. Future studies where such factors are assessed, should consider the extent to which they affect the relationship between FGR and later migraine.One limitation of our study may be the low number of growth restricted headache sufferers, in particular growth restricted males with headache. However, despite large confidence intervals, the findings were still significant. Another limitation is that headache diagnoses were based on responses to a questionnaire, and not on clinical diagnosis. For this reason people who suffer from aura without headache will also not be included. Also, while we used a traditional definition of FGR, true FGR should optimally be determined using Doppler ultrasound of the foetal blood vessels during pregnancy. In particular, an abnormal ratio between cerebral and placental vascular function is a stronger predictor of pregnancy complications than birth weight by gestational age . It mighrd percentile), who had almost three times higher odds of migraine in adulthood. No significant relationship between FGR and the development of migraine was found in females. That the association was limited to males corresponds with previous findings of a more prominent effect of FGR in males than in females on various neurological outcomes. No relationship was found between FGR and TTH, substantiating the notion that migraine and TTH may be influenced by different pathophysiological and psychological mechanisms. The biological mechanisms involved in a relationship between FGR and migraine remain unclear, but may include altered neurotransmitter activity or alterations in brain structure and connectivity. Further research is needed to reveal these underlying mechanisms.In conclusion, in this first population-based study examining the effect of FGR at birth on the later development of headache, we found that FGR was a predictor for migraine in adulthood among males. This association was strongest for those born VSGA (<3


Dear SirA 38-year-old lady, gravida 4, attended antenatal check-up at 34 weeks of gestation, ultrasonography was done and the fetus noted to have an intra-abdominal cystic mass. She had no significant past medical history, and previous antenatal follow up was uneventful. The mass was hyperechoic with well-defined margin. It measures 8.2cm x 7.7cm, and occupied nearly the entire fetal abdomen. Reassessment of the mass at 35-week gestation noted increment in its size. On suspicion of intra-cystic haemorrhage and the mother’s obstetric history of multiple caesarean sections, delivery via emergency lower segment caesarean section was chosen. The baby was delivered with a good Apgar score and her birth weight was 2.65kg. She was clinically pink and not in respiratory distress despite having a grossly distended abdomen. Further investigations found her to be anemic requiring blood transfusion. Beta-hCG level was 153.8 IU/L, and alpha-feto protein level was 995328 ug/mL. The abdominal ultrasound and CT scan showed a huge, complex cystic pelvic mass measuring 10 x 7 x 10cm . Laparotomy was done on day 2 of life. Intraoperatively, she had a huge left ovarian cyst with intra-cystic haemorrhage . The cyst was twisted and adherent to the left fallopian tube. Left salphingoopherectomy was done. The right ovary and fallopian tube was normal. Histopathological examination confirmed a haemorrhagic follicular ovarian cyst with no malignant component. She had an uneventful recovery.Neonatal ovarian cyst (OC) was first reported in 1889 by Mudholkar et al [2]. Since the routine use of prenatal ultrasound, the diagnosis of fetal ovarian cyst becomes more common [1]. Most cases of fetal OC are diagnosed in third trimester. Nussbaum et al [3] classified ultrasonic criteria of neonatal OC into simple and complex cyst. Complex cysts are associated with intracystic hemorrhage and ovarian torsion in 89% of cases, although there has been report of intracystic hemorrhage without torsion [4]. In our patient, we have found a huge complex left ovarian cyst with torsion and intra-cystic hemorrhage. Some authors have practiced intrauterine puncture and aspiration of both simple and complex cysts [5]. In our case as the baby was near term so we went for delivering the fetus for any intervention. Operative procedure should be as conservative as possible, with laparoscopic exploration preferred over open method, and viable ovary should be attempted to be preserved whenever possible. In our case, unfortunately the ovarian cyst was adhered to the fallopian tube and no viable ovary was seen hence salphingo-oophorectomy was done.Source of Support: NilConflict of Interest: None


Maternal fatty acids (FAs) intake has an effect on birth weight, birth length, and gestational age, as fetal development is entirely dependent on the maternal essential FA supply. This study aimed to identify the association between the maternal intake of FAs and birth outcomes among pregnant women who participated in the Mothers and Children’s Environmental Health (MOCEH) prospective cohort study in South Korea.A total of 1407 pregnant women, aged 30.2 ± 3.7 years, at 12 to 28 weeks’ gestation were recruited between August 2006 and December 2010. Their dietary intake during pregnancy was investigated by the 1-day 24-h dietary recall method. The pregnancy outcome data—namely infant’s gestational age, birth weight, and birth length—were analyzed for their associations with their mothers’ intake of FAs.P = 0.031) and birth length (P = 0.025) with high maternal intake of omega-6 FAs. In the multiple logistic regression analysis, the odds ratio (OR) for the risk of being below the 10th percentile for birth weight was higher in the highest quintile (Q5) compared to the lowest quintile (Q1) of omega-6 FA intake levels . Also, the OR for being above the 90th percentile of birth length was lower in the highest quintile (Q5) compared to that in the lowest quintile (Q1) of omega-6 FA intake . However, the maternal intake of omega-3 FAs was not related to gestational age, birth weight, or birth length.When adjusted for confounding factors, multiple regression analysis revealed adverse effects on birth weight (A high maternal omega-6 FA intake was negatively associated with birth weight and birth length. Despite these findings, the mechanisms underlying the correlation between maternal FAs intake and fetal size have not been fully elucidated. Nevertheless, deficiencies in the levels of the mothers’ FAs intake could have negative outcomes on the birth weight, birth length, and gestational age of the infant, as fetal development is entirely dependent on the maternal supply of essential FAs . Long-chcid ARA; 0:4 n-6, Omega-3 FAs have received considerable attention in exploring the correlations of maternal FAs intake with birth weight. Several studies have indicated that gestational age, birth weight, and birth length increase when the consumption of omega-3 FAs during pregnancy increases –11. Howen-6), suggesting an inverted U–shaped relationship [Nonetheless, few investigations have focused on the relationship between maternal omega-6 FAs intake and birth outcomes, with only one literature report, to date, which pertained to pregnant women in India. It found that the birth weight was low at both low and high intakes of maternal linoleic acid  study .Study subjects were 1751 midstage (12–28 weeks of gestation) pregnant women enrolled in the MOCEH study  between 2) by employing self-reported height and weight values before conception. Education levels were categorized as less than high school graduation, university level graduation, or higher than university level graduation. Family monthly income was categorized as less than US$2000, US$2000 to US$4000, and greater than US$4000. Cigarette smoking was classified as current smoker or nonsmoker, and alcohol drinking was categorized into current drinker or nondrinker. Exposure to secondhand smoke was defined as living with someone who smoked or working in an environment where smoking was permitted. Smoking and drinking were assessed by self-report.General information on demographic factors, socioeconomic factors, and health-related behaviors was collected at a regular midtrimester checkup through an individual interview. Detailed data included subject’s age, height, weight, parity, education level, family monthly income, dietary supplement use, smoking behavior, and alcohol. Pre-pregnancy body mass index (BMI) was calculated as weight (kg) divided by height  . For theInformation on neonates such as gestational age, birth weight, birth length, and gender was obtained from birth records. Gestational age at delivery was counted from the last menstrual period and examined by ultrasound.P < 0.05.General characteristics of the pregnant women and their neonates were expressed as means with standard deviations or as numbers with percentages. Multiple linear regression analysis was performed to evaluate the association between maternal FA intake and pregnancy outcome, such as birth weight and birth length. Multiple logistic regression analysis was also performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of less than 10th percentile or more than 90th percentile for birth weight and length across dietary FA intake level (quintiles). The covariates included maternal age , pre-pre2 (Table The mean (SD) maternal age at study enrollment was 30.2 ± 3.7 years, and prepregnancy BMI was 21.3 ± 3.1 kg/mThe average total FA intake of subjects was 43.5 ± 25.5 g per day. Saturated, monounsaturated, and polyunsaturated FA intakes were respectively 14.8 ± 10.0 g, 16.6 ± 11.2 g, and 11.9 ± 6.7 g per day. Total omega-3 FA intake was 1.47 ± 1.45 g per day, and the intake of DHA was 0.30 ± 0.83 g per day. Total omega-6 FA intake was 10.73 ± 6.34 g per day. The ratio of omega-6 to omega-3 FAs was 9.82 ± 7.00  and length .In a multiple regression analysis Table —after adP for trend = 0.010). In addition, the odds ratio for a greater birth length (above the than 90th percentile) was significantly low in the 5th quintile compared with that in the 1st quintile of total omega-6 FA intake . When we further analyzed the relationship between the %E of n-6 FA intakes and birth weight and length, no significant association was found in multiple regressions. However, when we based our analysis on the recommended level of n-6 FA intakes for Korean (4–10%E), the odds ratio (OR) for the risk of being below the 10th percentile for birth weight was higher in the > 10%E (Q5) than in the < 4%E for omega-6 FA intake levels  (data not shown).As shown in Table P for trend = 0.010). Maternal omega-3 FAs intake and omega-6/omega-3 ratio, however, were not associated with birth weight or length.In our study, fetal growth was inversely associated with maternal omega-6 FA intake, because, after confounding variables were corrected, birth weight decreased with increasing maternal omega-6 FAs intake during pregnancy. In addition, when the maternal omega-6 FA intake was divided into quintiles, the odds ratio for a birth weight below the 10th percentile was significantly higher in the 5th quintile (Q5), which represents a higher intake of omega-6 FAs than in the 1st quintile , similar to the study in India.The results of our study, showing that maternal omega-6 FAs intake is inversely related to birth weight, are quite unlike those of other studies; therefore it was difficult to find similar results. However, a recent report from India states that maternal intake of LA, which accounts for a large proportion of omega-6 FAs, is inversely related to birth weight. In that study , the birth weight was low when the maternal LA intake was high. In addition, birth weight was lower in the low maternal LA intake group, indicating an inverted U–shaped relationship between maternal LA intake and birth weight . In our Western diets are typically high in omega-6 FAs and low in omega-3 FAs, while the average intake of omega-3 FAs among our subjects was significantly higher. Therefore, omega-6 FAs may have different effects on pregnancy outcomes. Previous studies have also reported that birth weight is affected by race , 35. TheThe mechanisms of the relationship between maternal intake of omega-6 FAs and infant birth weight is not well established. However, some investigators have indeed found that pregnant women who had higher levels of total omega-6 FAs and ARA in their blood at late pregnancy delivered low-birth-weight babies , 39. In Our study did not show any association between maternal intake of omega-3 FAs and birth weight. Some studies relating maternal intake of omega-3 FAs during pregnancy with birth outcome report a positive association between maternal omega-3 FAs intake and birth size , 49–51, The average fat intake of our subjects was 43.5 g , which is lower than the 71.8 g (31.9% of EI) in the United States , 99.1 g This study has several limitations. First, it was difficult to accurately reflect the daily intake because the dietary intake of pregnant women was measured by a 1-day 24-h recall survey. However, in order to improve the accuracy of this method, we conducted a dietary survey employing trained dietitians using standard protocols, which helped the subjects reflect on their daily diets in detail, and we asked subjects whether their meal on the day of the dietary survey was the same as usual to reduce within-person variations. In addition, a study that was part of the Korean Health and Nutrition Survey showed that the values of fat intake obtained in each interview did not differ much from those of an additional one-day, 24-h recall and the original one-day diet interview, which was 2.5% . Second,This study was the first to investigate the relationship between the intake of FAs and pregnancy outcome among pregnant women in Korea. Despite adequate levels of omega-3 FAs, women who had high levels of omega-6 FAs tended to have lower birth weight infants. Therefore, reducing excessive omega-6 FAs intake of pregnant women in Korea will improve maternal nutritional status and also have more positive outcomes of pregnancy.


These observations were confirmed by voxelwise and regional analysis of DTI maps, demonstrating reduced fractional anisotropy (FA) in distinct regions such as the optic tract. Similar regions were identified by quantitative histology and exhibited axonal damage as well as robust gliosis. Additional analysis using a machine-learning algorithm was performed to identify regions and metrics important for injury classification in a manner free from potential user bias. This analysis found that diffusion metrics were able to identify injured brains almost with the same degree of accuracy as the histology metrics. Good agreement between regions detected as abnormal by histology and MRI was also found. The findings of this work elucidate the complexity of cellular changes that give rise to imaging abnormalities and provide a comprehensive and quantitative evaluation of the relative importance of DTI and histological measures to detect brain injury.Diffuse axonal injury (DAI) is a hallmark of traumatic brain injury (TBI) pathology. Recently, the Closed Head Injury Model of Engineered Rotational Acceleration (CHIMERA) was developed to generate an experimental model of DAI in a mouse. The characterization of DAI using diffusion tensor magnetic resonance imaging  may provide a useful set of outcome measures for preclinical and clinical studies. The objective of this study was to identify the complex neurobiological underpinnings of DTI features following DAI using a comprehensive and quantitative evaluation of DTI and histopathology in the CHIMERA mouse model. A consistent neuroanatomical pattern of pathology in specific white matter tracts was identified across  This work analyzes a recently developed brain injury model  with a clinically available imaging modality, diffusion tensor imaging (DTI), to identify pathophysiological features of traumatic brain injury (TBI) that effect diffusion imaging metrics. A comprehensive analysis of DTI metrics and histopathology was performed. Anisotropic metrics corresponded with several neurobiological features of injury including neuroinflammatory cell infiltration. A machine-learning algorithm was able to identify important regions and metrics for injury classification in an unsupervised way. The current study elucidated potential imaging biomarkers for experimental TBI as well as a statistical method for handling multiparametric data.Over 2 million traumatic brain injuries (TBIs) occur in the United States every year . The acuAccurate diagnosis of TBI is clinically challenging, as there is no validated means of predicting which patients will have long lasting deficits and which will recover without intervention. Advances in noninvasive imaging approaches including magnetic resonance imaging (MRI) may help to close this gap. Computed tomography (CT) and structural MRI are commonly used clinical tools for diagnosis of TBI, but fail to identify more subtle pathology . DiffusiThe recently developed Closed Head Impact Model of Engineered Rotational Acceleration (CHIMERA) uses precise delivery of acceleration of the head to reliably create DAI in several white matter tracts throughout the brain  that mimex vivo using high resolution and high-quality T2-weighted MRI as well as DTI. When scanning was complete, coronal sections of the entire cerebrum and the underlying neuroanatomy were stained to identify cellular alterations after injury. These observations were confirmed quantitatively by group analysis and extended by classifier analysis to identify from the rich set of histologic and DTI values, the metrics most predictive of injury status. The results of this work extend the understanding of the neurobiological substrates underlying DTI abnormalities in white matter following TBI as well as identify potential DTI biomarkers that can distinguish injured versus noninjured tissue.The objective of the current study was to comprehensively evaluate MRI and histologic markers of pathology in the same brain tissue to identify key DTI abnormalities that accompany DAI and also to better understand the relationship between these DTI changes to histologic measures of specific secondary injury pathology. Brain specimens were taken 7 d following CHIMERA injury and scanned ad libitum. All the animals in this study were male to reduce variability in this small sample study. Future studies will take into account sex as a biological variable. Mice were housed four to a cage and cage-mates were evenly distributed into the two groups of the study, CHIMERA-injured and sham. Injury was performed initially and an identical injury occurred twenty-four hours later. Briefly, male C57BL/6 mice were anesthetized with isoflurane  in oxygen (0.9 l/min). Mice were placed supine on the holding bed and their body strapped down with two restraints, allowing the head to move freely. A piston impacted the vertex of the head with a force of 0.5J or 0.65J. Qualitative analysis of silver stain was used to determine presence of injury. All animals included in the CHIMERA injury group showed evidence of white matter damage via silver stain (n = 5). Sham animals were anesthetized and strapped down on the apparatus; however, they did not receive an impact from the piston (n = 5). Animals were then removed from the holding bed and observed until recovery of ambulatory function. Mice were sacrificed one week after the second injury and fixed with 4% formaldehyde in PBS via transcardial perfusion. Brains remained in the skull to preserve the gross anatomy and integrity of the nerves during MRI. After a postfixation period of 2 d in formaldehyde, specimens were rehydrated in several changes of PBS for a minimum of one week before imaging. During imaging the specimens were placed in a 15mm diameter NMR tube filled with fluorinert , which has no hydrogen nuclei and is therefore invisible to proton MRI but reduces susceptibility variations between the brain and the space around it.Repetitive CHIMERA injury was performed as described in 2 and six directions and two high b-value shells with b = 1500–1700 and 3000–3800 s/mm2 and 32 directions. Two repetitions were acquired for each DWI having opposite phase-encode directions for geometric distortion correction using DRBUDDI  with eight segments, echo time (TE) and repetition time (TR) = 38/617 ms and 1 nex was used to acquire 152 volumes with 100-μm isotropic resolution and the diffusion-weighted imaging (DWI) sampling scheme included two low b-value shells with b = 250 and 500 s/mm DRBUDDI . A T2-wehttp://mipav.cit.nih.gov), and this aligned structural image was used as a target for registration and artifact correction of the DWIs. DWIs were processed using the TORTOISE software package , fractional anisotropy (FA) and the trace (T) of the diffusion tensor (1 and RD = (λ2+ λ3)/2. Measures of linear  and planar  anisotropy were computed according to First the T2-weighted structural image was rigidly registered to template space  using la package . To corr package . Correctn tensor . Radial To compare DTI values across the whole brain for the bias-free identification of quantitative group differences, individual DTI maps for each brain were warped into a common space using a recently developed diffeomorphic and tensor based image registration technique . DiffereROIs were selected based on regions exhibiting an abundance of silver stain in CHIMERA-injured tissue . Several other ROIs exhibiting absence of silver stain from both white and gray matter were also investigated to use the availability of an internal negative control for each sample  Bilateral white  and gray  matter regions were analyzed along with the anterior commissure, anterior corpus callosum (bregma 0.14 mm) and posterior corpus callosum (bregma −1.82 mm). 3D ROIs for DTI metrics were manually drawn based on anatomic landmarks using MIPAV by a researcher familiar with mouse brain neuroanatomy (M.H.). Blinding to the sample’s study group was not performed in this study. Each ROI was drawn on five sequential slices (500 μm) of the rigidly aligned DTI maps  to generate the complete ROI. The manually drawn regions were then converted into binary masks. DTI parameter values for each ROI were obtained by importing the 3D ROI binary masks generated by mipav into TORTOISE and exporting TORTOISE parameter values from the DTI maps.Following MRI, brains were rinsed in PBS while still in the skull and left for 24 hours at 4°C in PBS. The brains were then removed from the skull and cryoprotected using 20% sucrose in PBS then frozen for sectioning. Coronal sections were prepared from the entire cerebrum. Degenerating neurons were visualized using FD Neurosilver kit (FD Neurotechnologies) on 40-μm sections. Immunohistochemical and immunoflorescent stains were performed on 30-μm sections. Axonal damage was detected via anti-amyloid precursor protein  and anti-neurofilament . Myelin sheaths were identified using an antibody against myelin basic protein . Neuroinflammatory cells were detected using antibodies against glial fibrillary acidic protein  and ionized calcium-binding adaptor molecule 1  for astrocytes and microglia, respectively . AntibodSemiquantitative analysis of photomicrographs of the immunohistochemically stained sections was performed with ImageJ . Sectionp < 0.05), immunohistochemistry and DTI measures were analyzed separately using Graphpad Prism statistical software, version 7 (GraphPad Software). For each metric, multiple t tests were performed and p values were corrected for multiple comparisons using the Holm-Šidák multiple comparisons. Both corrected (*) and uncorrected (#) p values are presented.To determine which ROIs were statistically different between groups  and optical density (MBP) were analyzed for the nineteen ROIs included in this study.  and APP . When a Before multiple comparisons correction was applied, both IBA-1 and GFAP immunoreactivity was increased in the CHIMERA group relative to sham samples for the brachium of the superior colliculus and optic tract bilaterally A,B. MBP After multiple comparisons correction, significant increases were seen in the brachium of the superior colliculus for IBA-1 and GFAP and the optic tract for GFAP ; Table 3Visualization of direct relationships between DTI metrics and histopathology in a region known to be injured by several metrics, the left optic tract, is shown by the scatterplots in n = 5) and CHIMERA injured (n = 5). To extend the type of classification process demonstrated by the scatterplots in the previous section to a higher dimensional space including all DTI or histology measures across all ROIs, the random forests analysis classifier algorithm was applied and the results are summarized in Tables 4-The random forests measure of mean decrease accuracy characterizes the relative importance of parameters and regions for classification. The random forests analysis feature results were ranked based on this measure and several ROIs were consistently at the top of the list. The top three ROIs for injury classification are listed alongside the DTI and histology metrics that contributed to their classification ability in To provide a comprehensive visual representation of the random forests analysis results, the mean decrease in accuracy is shown in When all histology markers were investigated, all histology measures of the left optic tract had high importance for the classification. For the left brachium of the superior colliculus, IBA-1 and GFAP are important features for classification, while MBP and APP were less important features for the classification B.ex vivo DTI abnormalities are evident following CHIMERA injury to the mouse brain in several white matter tracts even in the absence of visually detectable abnormalities in conventional structural MRI. Changes in T and reductions in FA were apparent in the optic tract, brachium of the superior colliculus, corpus callosum, and cingulum bundle. Group difference maps also revealed FA decreases in the hippocampus. When careful histologic studies were done on the same tissue, silver staining confirmed the presence of neurodegeneration in the optic tract, brachium of the superior colliculus, corpus callosum, and cingulum bundle. This pattern of silver stain reproduces the findings of This study was designed to explore the relationship between DTI parameters and neuropathology in a DAI mouse model of TBI. The study revealed that Beyond the identification of injured brain regions using DTI, a primary goal of this work was to better understand the cellular alterations that underlie changes in DTI metrics. To accomplish this, the regions demonstrating the greatest level of abnormality across several metrics, the optic tract, brachium and hippocampus, were carefully examined by their qualitative and quantitative ROI values for DTI and histology metrics within the same sample.The optic tract was carefully examined in this study as it demonstrated an abundance of silver stain, as well as having the methodological advantage of high coherence and simple geometry, making it well suited for investigation by DTI. There were no gross abnormalities of the optic tract in the T2 image. Diffusion MRI, however, revealed a slight decrease in optic tract FA and RD, with a significant decreased in AD, WP, and WL anisotropy in the CHIMERA brains relative to sham. The combined decrease in FA and AD has been previously associated with axonal damage , beadingIn addition to changes in FA, AD, and RD, the optic tract had significantly reduced WL and increased WP. These metrics are less commonly used than other DTI metrics, but provide increased information about the shape of the diffusion ellipsoid in tissue with similar FA . A recenWhile the brachium of the superior colliculus demonstrated many of the same histologic features as the optic tract including ample neuroinflammation and axonal disruption, DTI metrics were not as similarly altered as for the optic tract. AD in this region was not altered, but WL anisotropy was decreased, which may suggest greater sensitivity of the linear anisotropy measure compared with AD. Another explanation for the difference in DTI metrics in this region is that partial volume effects of this very thin structure reduce the sensitivity of the imaging metrics.CHIMERA is primarily a white matter injury; however, DTI values were abnormal within the hippocampus, suggesting that CHIMERA may affect this vulnerable region as well as diffuse white matter tracts. DTI difference maps showed decreased FA in both hippocampi of the CHIMERA-injured samples, and group analysis found a decrease in FA, as well as a slight decrease in WL and WP. This DTI profile is distinct from changes in the white matter for which reduced FA was accompanied by changes in AD. Histology in this region showed an increase in APP immunoreactivity, which is indicative of potentially subtle axonal damage to the hippocampus. The alterations in DTI metrics and qualitative histology is indicative of potentially subtle damage to the hippocampus caused by CHIMERA injury. The damage caused to the hippocampus is not as copious as the damage seen in white matter tracts throughout the CHIMERA mouse brain yet is still detectable via DTI metrics.Several studies have performed Pearson’s correlation analysis or similar statistics to determine the linear relationship between DTI metrics and histology or behavioral measures in studies of neurologic disorders. While this is intuitively attractive, several aspects of this type of analysis precluded the use of such an approach in this study. The study would require a much larger sample of controls and injured brains, to accurately investigate how neurophysiology correlates with DTI metrics in healthy tissue, and then to investigate how TBI neuropathology potentially alters these relationships. Correlation analysis could be useful if enough data were available to determine with high statistical certainty the correlation of metrics in each group and compare correlates in injured tissue to correlates in healthy tissue. Due to our experimental design, i.e., very high-quality MRI and detailed analysis of histology in a small number of animals, this approach would not be feasible here. The inferences made in this study between DTI parameters and histologic features are intended to further elucidate the multiple components of TBI neuropathology that DTI is sensitive to, not to characterize the reproducibility of the CHIMERA lesion in a population of animals. Instead of correlation analysis, the random forests analysis approach was implemented to determine the classification potential of each type of parameter collected in this study along with the importance of each ROI selected to successfully predict TBI status.Perhaps the greatest remaining challenge for the effective use of DTI tools in brain research is the gap in understanding of the neurobiological correlates of DTI measures. Often, general associations between metrics are cited for example, FA being associated with “white matter integrity.” These may be misleading as numerous and distinct biological changes could result in the exact same change to DTI values. For example, a decrease in FA may arise from demyelination, axonal loss, crossing fibers, or infiltrating cells, each having a clearly different impact on the brain despite an identical FA value. Complete characterization of the multiple cellular and molecular components contributing to DTI metrics would require a very large battery of histology markers. Additionally, neuropathology will affect the way a DTI metric behaves in a particular region, especially in a complex neuropathology with multiple secondary injury mechanisms, as is the case in TBI. A study like the one described would require a large sample size and the measurement of multiple parameters. This type of analysis is beyond the scope of the current study; however, within the current study, we propose using a machine-learning algorithm that can handle a multiparametric dataset and show that it can easily extract important parameters for classification free of user bias.The question of which metrics are most affected by TBI and therefore most informative of TBI neuropathology was investigated. Classification of sham versus CHIMERA-injured brains via different DTI and histology metrics was examined via random forests analysis. When all DTI metrics were considered together, DTI was able to classify the majority of sham and CHIMERA samples. When all ROIs were considered for classification, one sham sample was misclassified and one CHIMERA sample was misclassified. When all histology markers were considered together, the same sham sample was misclassified by the histology yet the one CHIMERA-injured sample was correctly classified. DTI metrics were equivalent to histology markers in classifying sham samples. Histology markers, however, more accurately classified injured samples when compared to DTI metric classification.We additionally ran random forests with a subset of DTI metrics as input variables (1) T and FA, (2) AD and RD, and (3) T, WL, WP . Each ofWhen looking at the top three best regions for classification, the algorithm primarily selected data from the ROIs identified as injured by group analyses of DTI metrics and histology markers . The two regions selected as most important for classification in the models, the optic tract and brachium of the superior colliculus, were abundant in silver staining and showed reduced FA on the difference maps. Random forests has shown that it is capable of selecting injured ROIs in a manner unaffected by potential operator-induced bias. The data also shows that random forests can identify metrics that classify injury with 100% accuracy in an injury group which includes different injury severities (0.5J and 0.65J). This tool could prove clinically useful given that the TBI diagnosis results in a heterogeneous population consisting of several injury severities with no useful prognostic tools for separating the population. Other studies have shown the utility of random forests in identifying ROIs with DTI abnormalities in temporal lobe epilepsy  and multn = 5; CHIMERA, n = 5), which affects the statistical power for characterization of the average group outcomes for CHIMERA injury. This also limits the generalizability of the study results. The data presented are intended to introduce a classification approach that is novel to this type of study as well as a comprehensive understanding of the types of neurobiological changes that underlie diffusion metric. The question regarding neurobiological correlates of DTI metrics is a very important point of discussion .


P = 0.047; PNN50: P = 0.021; HF: P = 0.041), systolic  and diastolic (PNN50: P = 0.030) blood pressure levels. On the other hand, there were consistent positive correlations between the HRV parameters and birth weight . To determine the effect of birth weight on HRV parameters, we perform multivariate linear regression analysis adjusted for potentially confounding factors . These findings were preserved even after adjusting for these confounders. Our results suggested that impaired cardiac autonomic modulation characterized by a reduction in the parasympathetic activity occurs in children with low birth weight. One possible interpretation for these data is that a vagal withdrawal, rather than a sympathetic overactivity, could precede the development of hypertension and other cardiometabolic diseases in children with low birth weight. However, long-term studies should be performed to investigate this possibility.Several studies indicate that the fetal environment plays a significant role in the development of cardiometabolic disease later in life. However, a few studies present conflicting data about the correlation between birth weight and the impairment of cardiac autonomic modulation. The purpose of the present study was to provide further knowledge to elucidate this contradictory relationship. One hundred children aged 5 and 14 years had anthropometric parameters, body composition and blood pressure levels determined. Heart rate variability (HRV) was evaluated by heart rate monitoring, including measurements of both the time and frequency domains. The results showed inverse correlation between the HRV parameters with BMI (RMSSD:  Birth weight has been considered an important measure for assessing fetal growth and is an indicator of neonatal morbidity, survival, and development in children –3. It isIt is known that the two ends of the birth weight spectrum, low and high birth weight, are associated with an increased risk of cardiovascular events in childhood –8 and adThis study was a cross-sectional survey conducted in a representative group of children identified in the Youth Healthcare Centre located near the Federal University of São Paulo . A total of 100 children were identified during the study period. No child had any clinical signs of endocrine, renal or cardiovascular disease. Personal and family medical histories were obtained using a questionnaire completed during an interview with the parents. The prenatal data from the mother’s recall was confirmed with medical records. The Ethics Committee of the Federal University of São Paulo approved the study protocol (Number: 214.956). All parents and children signed written informed consent/assent forms. All children were evaluated twice on different days. On the first day, the Baecke questionnaire was administered and body composition was assessed. On the second day, anthropometric measures, blood pressure, and HRV were evaluated. All procedures were conducted in a quiet room with minimum disturbance between 9:00 and 11:00 am. All participants sat still for at least 5 minutes to assess blood pressure and heart rate at rest. All measurements were made by the same trained researcher who was blinded to the clinical data.The physical activity level was evaluated by the total score obtained with the Habitual Physical Activity Questionnaire proposed by Baecke et al.  and valiBody weight and height were measured in light clothing without shoes using a standard balance beam scale. Waist and hip circumferences were measured using inextensible tape. Waist circumference (WC) was recorded at a level midway between the lower rib margin and the iliac crest at the end of normal expiration. Hip circumference (HP) was measured at the maximum circumference of the buttocks. For both measurements, the tape was positioned at a level parallel to the floor, and the waist-to-hip ratio was calculated. Body mass index (BMI) was computed using the formula weight (kg)/height (m2). Children were classified as overweight (+1 SDS) or obese (+2 SDS) according to BMI-for-age following the cut-off parameters of the WHO growth standards .Body composition was evaluated using bioelectrical impedance (BIA) with a single-frequency hand-to-foot  . ChildreBlood pressure (BP) levels were measured twice in the right arm with the child in a seated position using an automated oscillometric device  with an appropriate cuff size. The blood pressure value was the average of three measurements made at 2-min intervals . After tThe HRV indices were calculated as previously described , 28. BriP<0.05.Statistical analyses were conducted using SPSS version 21.0 for Windows . All continuous variables were examined for normality with the Shapiro-Wilk test and expressed as the mean ± Standard Deviation (SD). Categorical variables were expressed as percentage. Pearson’s correlation and multiple linear regression analyses were performed to verify the relationship between HRV parameters and independent factors. Multicollinearity was evaluated using variance inflation factor (VIF) and significance level was set at r = 0.603, P< 0.001). Preterm delivery occurred in ten pregnancies. We also found that 33% of children have excess weight and 16% of them were already obese. General characteristics of the children are listed in The present study was conducted on 100 children (63 boys and 37 girls) with a mean age of 8.85 years . The mean BW was 3008 g  with birth length 47.1 cm . For entire cohort, we found a positive correlation between BW and birth length  or frequency-domain  indices; therefore, analyses were performed considering boys and girls together. For the entire cohort, inverse correlations were observed between the HRV parameters with BMI , systolic  and diastolic  BP levels. On the other hand, resting HR values were positive correlated with BMI  and blood pressure levels .Considering the HRV analysis, there was no significant gender effects with respect to the time-domain   was not influenced by BW in these children (2 = 0.15) (2 = 0.23) (2 = 0.16)  . Meanwhichildren . Intereschildren  and freqchildren , suggestchildren . In the  = 0.15) . On the  = 0.15) . These i = 0.23) . Finally = 0.16) .It is known that the ANS development begins in fetal life and persists after birth , 31. TheIt has been reported that low birth weight is related to modulation of both the sympathetic and parasympathetic function from the prenatal period through childhood and adult life , 34–38. It is well known that lower HRV parameters are associated with increased mortality due to heart failure, coronary heart disease and ischemic cardiomyopathy during adulthood . There iThe limitations of this study include the small sample size based on a cross-sectional analysis, which prevent us from establishing causal relationships. Despite these, our study was able to replicate findings reported in individuals from developed countries. In conclusion, our study revealed that children born with low weight presents detriment of the cardiac vagal autonomic modulation. Therefore, the high risk of cardiometabolic diseases among these children could be attributed, at least in part, to a reduction in the protective actions of the cardiac vagal tone. The interaction between low birth weight and reduction in parasympathetic regulation observed in the present study occurs independently of prematurity, gender, age, BMI, physical activity index and SBP levels.


Testing whether familial socioeconomic status (SES) in childhood is a predictor of mortality has rarely been done on historical cohorts.The birth certificates of 4,805 individuals born 1914–1916 in 16 districts of the Paris region were retrieved. The handwritten information provided the occupation of parents, the legitimacy status, life events , and the precise date of death when after 1945 (i.e. age 31 years (y) in the cohort). We used the median age at death (MAD) as a global measure of mortality, then studied separately survival to and after 31 y. Multivariate Imputation by Chained Equations (MICE), Generalized Additive Models (GAMs) and mixed effect Cox models were used.MAD showed large variations according to paternal occupation. The lowest MAD in both sexes was that of workers’ children: it was 56.3 y (95% CI: [48.6–62.7]) in men and 67.4 y (95% CI: [60.8–72.7]) in women, respectively (95% CI: 13.4 y [5.7–21.3]) and 12.3 y (95% CI: [4.0–19.2]) below the highest MAD attained. MAD experienced by illegitimate children was 18.9 y (95% CI: [13.3–32.3]) shorter than of legitimate children. The multivariate analysis revealed that in both sexes survival to age 31 y was predicted independently by legitimacy and paternal occupation. Paternal occupation was found significantly associated with mortality after age 31 y in females only: accordingly difference in life expectancy at age 31 y was 4.4 y (95% CI: [1.2–7.6]) between upper class and workers’ daughters.Paternal occupation and legitimacy status were strong predictors of offspring longevity in this one-century historical cohort born during World War One. The French civil registration system is organized so that all major life events  are systematically notified on birth certificates, wherever these events occur. This has previously provided us with the opportunity to study the adult mortality of orphans who lost their father during World War One WW1) [ [1]. TheThe effect of SES in early life on health across the lifespan has recently raised a growing interest among epidemiologists –4. ParenA global assessment of the effect of parental SES on mortality requires the study of quasi-extinct cohorts. Obviously, data on such cohorts are very difficult to obtain, so that most studies about childhood SES have examined adult mortality on short age spans, typically below 30 years. One notable exception is the recent analysis by Juárez et al. of a Swedish cohort born 1915–1929 in Uppsala, whose analysis was restricted to individuals for which at least one of the two parental occupations was known, and was stratified by age. Low SES at the time of the birth, defined by parental occupation , and marital status (i.e. legitimacy of the birth), was associated with an increase in mortality at all ages . We repost 1914 and December 31st 1916 in 16 administrative districts of the Paris region (14 “arrondissements” (boroughs) of Paris and two suburban cities, Neuilly-sur-Seine and Le Kremlin-Bicêtre). Though they were matched to the “pupilles de la Nation”, we anticipate the results obtained on this cohort may be generalized to the population of all Parisian births of the time. The following pieces of information were collected on the handwritten birth registers in each district’s city hall: date of birth, sex, parental age (precision: year) and occupation (see below) at the time of the birth, legitimacy status, date of death and date of the other life events notified in the margin of birth certificates  born between August 1ificates .The National Commission on Information Technology and Liberties  grantedth 1945, at occurrence of death, the civil registration service at the place of death systematically notifies the civil registration service at the place of birth, so that the birth certificate is updated in a few weeks at most. For individuals who died abroad, information is transmitted to the place of birth by the local French consulate. Given that data collection took several months, all dates of death were checked at the end (Sept. 29 –Oct. 8 2015) to avoid differences in the time period covered between districts due to different data collection dates. Because observation of death was available from 1945 onward, there was a 29-month difference in the age period on which individuals born in early August 1914 and those born at the end of 1916 were observed.  years is the age range on which all dates of death are known.By law, since March 29th 1945 or still be alive. An individual who was never observed after March 29th 1945  was considered dead before age 31 y. In the analyses of life expectancy at 31 y , the longevity L31 of those alive at age 99 y  was set to 99 + er, where er is the life expectancy remaining at age 99 as given by the Human Mortality Database  (with known age at death), alive at 99 y. Any survival function S(t) is thus known at age 0 and on . This enables the computation of the median age at death in groups defined by legitimacy status, paternal occupation or maternal occupation. Bootstrap 95% confidence intervals (95% CI) were computed by first bootstrapping the data (with B = 500 bootstrap samples), and then performing multiple imputation on each bootstrap sample, as recommended by recent work .Probability of survival to age 31 y was modelled with a Generalized Additive Model (GAM) , 16. A s31 is the probability to survive to age 31 y, PO the paternal occupation at the time of the birth, DB the date of birth (time since August 1st 1914), AM the age of the mother at birth, MO the maternal occupation, Illeg a dummy variable taking value 1 if the birth is illegitimate, and Arr a normally distributed random effect controlling for the district of birth. Smooth functions f1 and f2 are represented as penalized cubic regression splines with respectively 100 and 8 degrees of freedom and evenly spaced knots. The smoothing parameters determining the effective degree of freedom of f1 and f2 are both selected to minimize the unbiased risk estimator score.πThe hazard ratio (HR) on the age span  was regressed on explicatory variables using a mixed effects Cox proportional hazards model:The notations are the same as above.31) by parental occupation, we fitted GAMs with Gaussian errors, identity link and the same predictors as in model (1), with smoothing parameters selected by generalized cross validation.To give adjusted estimates of life expectancy at 31 y , and those died on  only. Analyses were performed in R, using the following packages: putation , mgcv foressions , and coxd models . All conSurvival varied strongly with paternal occupation . The higMAD of illegitimate children was 18.9 y [13.3–32.3] years below that of legitimate children . MAD also varied according to maternal occupation in both sexes .−6; maximum p = 5.3 x 10−4). This was largely due to low survival in worker’s offspring: indeed, the pooled adjusted odds ratio  was 0.77 [0.63–0.94] for those born to a worker. Though not significant, there was a trend for higher survival for those born to a middle class father (OR = 1.33 [0.89–2.00]) and upper class father (OR = 1.23 [0.87–1.74]). The offspring of craftsmen, employees and shopkeepers experienced intermediate survival  = 7.8 x 10survival . ConsistSurvival to age 31 y was also strongly decreased in illegitimate children: the adjusted OR with legitimate children was 0.54 [0.46–0.62] .2 after penalization ≈1). There was a 1.09 [1.02–1.16] fold increase in survival associated with each 5-year increase in the age of the mother.Maternal occupation had no effect . The age of the mother was found to be linearly associated with survival in all datasets (effective degree of freedom of f−4), again due to low survival in worker’s offspring . In the by-sex analysis, the effect of paternal occupation was found to be significant for females (median p = 5.2 x 10−4), not for males (median p = 0.73). As shown on The hazard ratio (HR) was associated with paternal occupation (median p = 9.0 x 10−3), but not in males  and illegitimacy were independently associated with a strong excess risk of death before 31 y. We observed no effect of maternal occupation on survival to 31 y after adjustment for paternal occupation. It is likely that most of the differences in survival to 31 y according to paternal occupation and legitimacy relate to early life mortality, since the main contributors to the probability of death before 31 y in our study were infant (0–1 y) and child (1–5 y) mortalities, and to a lesser extent World War II (WW2)  and access to healthcare. About 20% of infants were left to wet-nurses mainly residing outside Paris . QualityLack of effect of maternal occupation on survival to 31 y was unexpected. Our interpretation is that it is due to the fact that 43% of mothers are recorded on birth certificates as “housekeeper” or “housewife”, a status that may indeed mask heterogeneous socioeconomic conditions and wealth. This is evidenced by the diversity of paternal occupations associated with a “housekeeper” or a “housewife” see . InteresFor those people who survived WW2, knowledge of the exact date of death after 1945 allowed classical survival analysis through two different approaches to study mortality after 31 y . Both approaches showed an association between paternal occupation at birth and mortality for females, but not for males. Neither legitimacy nor maternal occupation showed an association with mortality after 31 y.Loose classification or loose imputation of paternal occupations cannot account for this absence of differences among men after 31 y, given that we do find differences according to paternal occupation for both sexes before 31 y, and among women after 31 y. Moreover, results were not changed when the analysis was restricted to legitimate children alone. One hypothesis is that the men of the cohort encountered in adulthood risk factors that were strong enough to overcome the effects of paternal SES. Indeed, smoking and stress are likely to have been stronger mortality “equalizers” among males than among females. In 1953, 72% of French men (only 17% of women) were regular smokers , therebyAlthough the current study allows no identification of its causes, we wondered if the sexual dimorphism observed for mortality after 31 y could relate in part to the wartime conditions at the time of the birth. Most young women had their husband called to arms in the early months of the conflict. These women had to face loneliness during pregnancy, fear for husband’s death and the day-to-day challenges of single life, exposing their offspring to socially dependent degree of early life adversity and childhood stress. Altered perinatal maternal behavior is known to modify the offspring’s stress response durably , 33, andth century translated in decreased longevity in offspring of those unprivileged, nobody can predict how these findings can be extrapolated to children born in contemporary countries. Some of the signals generated by the lowest SES situations may still act on infants in contemporary societies through biological, educational, or behavioral pathways comparable to that which prevailed for those born in 1914 France. In contrast, newly appeared conditions that have today strong links with SES, such as obesity  is the age range on which the deaths of all the members of the cohort were observed. Those with no date of death on their birth certificate may have died before March 29th 1945 or be alive at the end of the observation period. Those with no life event  after March 29th 1945 were considered dead before March 29th 1945. Conversely, those with no date of death but at least one life event after March 29th 1945 were considered alive at age 99 y. To test the effect of this indirect means of classification, the analysis of life expectancy at 31 y was performed on all those considered alive at 31 y (black) and was then restricted to those who died on  (grey), with hardly any difference in the results. These results are in line with those obtained from the modeling of the hazard ratio on the age span : increased variability according to paternal occupation is found among females. Estimated effects are given ± standard error.The life expectancy at 31 y was modeled with a Generalized Additive Model separately for each sex on each completed dataset and then combined. Since March 29(TIFF)Click here for additional data file.S1 File(CSV)Click here for additional data file.S1 TableBoth paternal and maternal occupations are available on the birth certificate of virtually all legitimate children. 0.93% of all legitimate children (N = 32) with at least one missing or unclassified parental occupation were excluded from the contingency table. Cramer’s V is 0.29.(DOCX)Click here for additional data file.


The gut microbiome is established in the newborn period and is recognised to interact with the host to influence metabolism. Different environmental factors that are encountered during this critical period may influence the gut microbial composition, potentially impacting upon later disease risk, such as asthma, metabolic disorder, and inflammatory bowel disease. The sterility dogma of the foetus in utero is challenged by studies that identified bacteria, bacterial DNA, or bacterial products in meconium, amniotic fluid, and the placenta; indicating the initiation of maternal-to-offspring microbial colonisation in utero. This narrative review aims to provide a better understanding of factors that affect the development of the gastrointestinal (GI) microbiome during prenatal, perinatal to postnatal life, and their reciprocal relationship with GI tract development in neonates. Humans are holobionts, a complex ecosystem of host-derived cells together with transient and stable microbial symbionts . A typicThe association between the development of the gut microbiota and the host’s genotype and phenotype has received increasing attention as technological advances in culture-independent techniques  have facilitated the detection of a greater diversity of microbes . These sIt is clear that under “normal” circumstances, the gut microbiota has a symbiotic relationship with the host during which, among other things, it contributes to: the storage and harvesting of energy ; developDespite our awareness of the significance of maintaining the mutual relationship between the host and gut microbiota across the life-span, conclusive evidence of the factors that affect the development of the microbiome are not yet available. Various factors have been proposed to affect the early-life development of the microbiota, including: the composition of the maternal microbiome ; mode ofThe human gastrointestinal tract or alimentary canal starts from the mouth, extending through well-defined anatomical regions—the oesophagus, stomach, small intestine, colon, rectum—and ending at the anus . The funThe maturation of the human GI tract starts in utero but continues after birth with some functions, such as epithelial barrier mechanisms, accessory structures , and the intestinal immune system, only becoming fully developed several months or years after birth . The priComparative studies have identified abnormalities in gut-associated lymphoid tissue development and decreased antibody production in germ-free mice . SimilarWe have long assumed that the gut is sterile before birth ,40,41,42In order for the microbiome to affect GI development in utero, there must be a mechanism to ensure the selection and exposure of the appropriate microbial population or factors. The obvious medium for such a system is the amniotic fluid that bathes the developing fetus. Notably, the composition of amniotic fluid varies over the course of gestation . AmniotiOne of the potential route for the exposure of the developing GI to microbes/microbial products within the amniotic fluid can be mediated by swallowing. The human fetus begins swallowing amniotic fluid as early as 10 weeks post-conception . This coData from human infants born with gut abnormalities, such as gastroschisis and intestinal atresia, suggest that despite nutrition being obtained through the placenta, fetal gut development affects fetal growth in utero . Babies Enterococcus fecium to pregnant mice resulted in this organism being isolated from the meconium of the newborn pups but not from the control group [It remains to be determined if it is the act of swallowing or specific components of the amniotic fluid that are responsible for the observed impacts on development. However, oral administration of labelled ol group , as consol group ,44 and tol group . HoweverThe complexity and richness of the microbial community progress through a series of developmental stages that range from the neonatal period before there is an apparent stabilisation after weaning. There are several crucial interrelated factors, together with individuality, which play an important role in shaping the transitioning human GI microbial composition. These factors include age ,56, dietThe shape of the developing microbial composition is also affected by technical variation . For exa® Soil DNA Isolation Kit  [Culture-independent techniques, typically use high throughput sequencing or array technologies to analyse the extracted nucleic acids from the community. These techniques are subject to variation due to processing, the kits that are used to prepare the DNA for analysis, and the computational analyses themselves. Commercially available kits including the PowerLyzer PowerSoil DNA Isolation Kit  ,59, QIAaCA, USA) , and FasCA, USA)  have beeDespite the use of commercial kits for DNA preparation, sample processing methods, including different amounts of starting material , alsThe mode of birth determines the microbial population that infants are exposed to during birthing. For instance, vaginal birth exposes infants to the microbes that are currently colonising the mother’s birth canal. This direct form of inheritance during birth results in infants who are born by vaginal delivery having a similar microbiota to that of their own mother when compared to other mothers ,63. By cLactobacillus in the infant’s GI tract. Lactobacillus is highly abundant in, and specific to, the maternal vagina with an IndVal index of 0.922 [Lactobacillus as part of their microbiome profile, but that infants born by C-section do not [Lactobacillus genus in the microbiome profile of infants born by C-section (n = 17) versus vaginal (n = 134) (Detection rate of 6% vs. 37%) [Lactobacilli in the intestinal discharge of the C-section infants persisted for the first six months after birth in contrast to vaginally born infants, who had higher and increased detection rates throughout the first six months after birth [Lactobacilli detection rates vanished by three years of age [A good example of the effect of birth mode on the gut microbiota comes from the impact of birth mode on the acquisition of of 0.922 . It has n do not . These evs. 37%) . Notablyer birth . Howevers of age .Bacteroides and Clostridium genera  within an individual’s microbiota are also associated with birth mode [n = 1032), real-time quantitative PCR assays were used to enumerate different bacterial species from stool samples collected at one month of age [n = 826) had relatively high numbers of B. fragilis and a reduced number of C. difficile compared to C-section infants [n = 108) showed the inverse relationship [C. difficile could be linked to environmental factors rather than the mother, as C. difficile was detected on the hands and in the stools from healthy hospital personnel [C. difficile has been considered as a microorganism that exists exclusively in hospitals [C. difficile identified in hospital-born and C-section infants [The levels of bacteria in the rth mode ,63,69,70h of age . Infants infants . By conttionship . The souersonnel ,71. Notaospitals  and has ospitals ,74. This infants . Bacteroidetes (p = 0.002) was also observed in infants born by C-section (n = 9) when compared to vaginally born infants in a study of 24 infants conducted in south-eastern Sweden [Bacteroidetes persisted for the first two years after birth [Bacteroides in C-section infants in the first six months [Bacteroides genus are highly specific to the maternal stool  [Bacteroides in the infant’s microbial profile. At the phylum level, a low abundance of n Sweden . Notablyer birth . This isx months  and one x months . Notablyf 0.943) . CollectBacteroidetes); a less diverse microbiota [Not all studies have found an association between mode of birth , the inheritance and development of the GI microbiota. For example, a study of 21 infants found that mode of birth did not affect microbial population in preterm babies throughout the first three months after birth . The inccrobiota ,61; delacrobiota ; and, thcrobiota  more freStreptococcus thermophilus, Staphylococcus epidermidis, and Bifidobacterium longum) has also been identified in human breast milk and infants’ faecal samples [p < 0.001) [Bifidobacterium longum rDNA sequences can be co-detected in infant’s faeces, maternal blood, maternal faeces and breast milk collected between one and four weeks post-birth [Milk is the first food that is introduced into the GI tract postpartum and the composition of the milk is believed to directly impact on shaping the early GI microbiota ,4. This  samples . This re< 0.001) . Furtherst-birth . Collectst-birth . Bifidocbacterium longum, Streptococcus salivarius, Strepotococcus lactarius, Streptococcus pseudopneumoniae, and Lactobacillus gasseri). Lee et al. (2015) argued that the presence of these species in the intestines of these babies must be independent of feeding type, and thus these species constitute common commensal bacteria that are present in four-week-old Korean infants [B. longum, S. pseudopneumoniae, and L. gasseri having a greater abundance and S. salivarius, and S. lactarius having a lesser abundance in breast-fed infants when compared to formula-fed infants. These results are consistent with the hypothesis that the relative abundance of common commensal bacteria is altered by exposure to different feeding patterns, formula or breast milk.Culture-based techniques have identified more diverse microbiomes in formula-fed infants when compared to breast-fed infants . Culture infants . Howevern = 107) reported that the continuation of breast milk feeding after the introduction of solid food suppresses the diversification of the microbiota associated with the introduction of solid food [Collectively, formula-fed infants tend to have relatively stable and diverse GI microbial communities that contain higher levels of facultative anaerobes and strict anaerobes when compared to breast-fed infants ,37,82,83lid food . The effThe nutritional composition of human milk varies as lactation progresses. Besides nutrients, breast milk also contains hormones , growth Lactobacillus, Streptococcus, Enterococcus, Peptostreptococcus, Staphylococcus, Corynebacterium, and Escherichia species [Escherichia species, found specifically  in the six week old infant gut, may have originated from breast milk. This is consistent with the observed low abundance, and hence low transfer possibility, of this species from other maternal body sites  [Breast milk that was aseptically-collected from lactating mothers, who birthed at term, contained members of the  species . It can d stool) . The micd stool) . By contd stool) . For exad stool) . These dd stool) . Bifidobacteria species [Bacteroidetes, but not pathogenic bacteria, such as Enterobacteriaceae [Bifidobacteria predominate in both formula- and breast-fed infants [Bifidobacteria species from the mother, but not all Bifidobacteria species are able to degrade HMOs [Bifidobacteria that are able to break down the individual specific HMOs that are present in the breast milk are most likely to predominate in the infant’s GI tract during early development [Bifidobacteria over other bacteria [Human milk oligosaccharides (HMOs) are the third largest component of breast milk. The types and amounts of HMOs produced from mothers who gave birth to preterm and term infants differ . HMOs ar species ,92 and B infants ,79, the  infants ,80,93,94elopment ,95. A hiThe use of antibiotics is more prevalent in infants born via C-section  and in tStreptococcus during labour to reduce the risk of early-onset neonatal infections [Actinobacteria and Bacteroidetes were lower in IAP-exposed infants in two different studies that performed 16s rRNA amplicon sequencing using the Illumina [Bifidobacteriaceae were also observed in IAP-exposed infants [Firmicutes [Proteobacteria [p < 0.05 and p < 0.062, respectively) in IAP-exposed infants. Intrapartum antimicrobial prophylaxis (IAP) is believed to be the most frequent source of antibiotic exposure in neonates . IAP  and timing of the exposure is yet to be determined. Despite this, we know that the impact on certain bacterial counts within faecal samples from neonates in early life is affected by the combined effect of IAP exposure, postpartum feeding mode ,106, andExposure to different extra uterine environments during early gut development contributes to the colonisation and evolution of the infant GI microbiota. Infants born by C-section are speculated to be more susceptible to environmental factors ,91. ThisAcinetobacter baumannii strain also led to an outbreak in a NICU in Tunis. 31 neonates  developed MDR A. baumannii associated pneumonia and there were 10 deaths due to infection after the MDR A. baumannii was transferred from a neonate in the epidemic-associated surgical ward of another hospital [Bifidobacterium breve for the prevention of sepsis and necrotising enterocolitis in 1310 preterm babies born between 23 and 30 weeks’ gestation from 24 hospitals in the southeast England found that the probiotic strain of Bifidobacterium breve could be detected in the stool of 37% of babies in the placebo arm, as compared with 85% of the intervention arm, indicating that environmental-related factors resulted in significant cross-colonisation of B. breve in babies in this study [The route of microbial transfer from the immediate environment to infants is hard to verify but studies have shown that microbes from the immediate environment can be isolated from infant faecal samples ,108. Crohospital ,82. Howeis study . Interesis study .It is possible that the hospital environment, handling, feeding, and treatment regimes enhance microbial transmission to neonates . HoweverK. pneumoniae and C. difficile) [Enterobacteriaceae [Enterococcaceae [Bifidobacterium, Bacteroides, and Atopobium [The microbiota of children born preterm tend to more frequently contain detectable levels of pathogenic microorganisms  ,92,111, eriaceae  and Enteoccaceae ,41, and topobium ,41. Enterobacteriaceae, Enterococcus, and Streptococcus) [Staphylococci, Escherichia coli, Enterococcus fecalis, and faecium, Klebsiella, Enterobacter, and, infrequently Aeromonas, Pseudomonas, and Acinetobacter) [Bifidobacterium, Clostridium, Bacteroides, Veillonella, Eubacterium, and Ruminococcus species) [Newborn infants have an aerobic intestine at birth . The higococcus) ,113,114.obacter) . These especies) ,92,113. species) ,113.Differences in oxygen levels exist between infants born term and preterm . HoweverGastrointestinal and gut microbiota maturation is an intricate, lengthy, and complicated process which starts in utero and continues after birth. Currently, there is no standardised definition of the composition of a “healthy” GI microbiota at different developmental stages and the main factors that contribute to the establishment of the GI microbiota in the early life remain elusive . SeedingAlbeit clear that environmental and extrinsic factors affect gut microbiota development, a lack of statistical power limits current studies with preterm infants. This is particularly relevant because nearly 15 million babies are born preterm each year worldwide and the rate of preterm birth is increasing . Thus, tCrosstalk between host cells  and the colonising microbiota is likely to be critical for metabolic development and the programming of body immune system in infants ,120. Alt