Prenatal exposures to chemical and psychosocial stressors can impact the developing brain, but few studies have examined their joint effects. We examined associations between prenatal phthalate exposures and child behavior, hypothesizing that prenatal stressful life events (PSLEs) may exacerbate risks. To do so, we harmonized data from three U.S. pregnancy cohorts comprising the ECHO-PATHWAYS consortium. Phthalate metabolites were measured in single mid-pregnancy urine samples. When children were ages 4–6 years, mothers completed the Child Behavior Checklist (CBCL), from which a Total Problems score was calculated. Mothers additionally provided recall on their exposure to 14 PSLEs during pregnancy. Primary models examined problem behaviors in relation to: (1) phthalate mixtures calculated through weighted quantile sums regression with permutation test-derived p-values; and (2) joint exposure to phthalate mixtures and PSLEs (counts) using interaction terms. We subsequently refitted models stratified by child sex. Secondarily, we fit linear and logistic regression models examining individual phthalate metabolites. In our main, fully adjusted models (n = 1536 mother–child dyads), we observed some evidence of weak main effects of phthalate mixtures on problem behaviors in the full cohort and stratified by child sex. Interaction models revealed unexpected relationships whereby greater gestational exposure to PSLEs predicted reduced associations between some phthalates (e.g., the metabolites of di-2-ethylhexyl phthalate, di-n-octyl phthalate, di-iso-nonyl phthalate) and problem behaviors, particularly in males. Few associations were observed in females. Additional research is needed to replicate results and examine potential mechanisms.

BACKGROUND: Phthalate exposures are ubiquitous during pregnancy and may contribute to racial and ethnic disparities in preterm birth. OBJECTIVES: We investigated race and ethnicity in the relationship between biomarkers of phthalate exposure and preterm birth by examining: a) how hypothetical reductions in racial and ethnic disparities in phthalate metabolites might reduce the probability of preterm birth; and b) exposure-response models stratified by race and ethnicity. METHODS: We pooled individual-level data on 6,045 pregnancies from 16 U.S. cohorts. We investigated covariate-adjusted differences in nine urinary phthalate metabolite concentrations by race and ethnicity [non-Hispanic White (White, 43%), non-Hispanic Black (Black, 13%), Hispanic/Latina (38%), and Asian/Pacific Islander (3%)]. Using g-computation, we estimated changes in the probability of preterm birth under hypothetical interventions to eliminate disparities in levels of urinary phthalate metabolites by proportionally lowering average concentrations in Black and Hispanic/Latina participants to be approximately equal to the averages in White participants. We also used race and ethnicity-stratified logistic regression to characterize associations between phthalate metabolites and preterm birth. RESULTS: In comparison with concentrations among White participants, adjusted mean phthalate metabolite concentrations were consistently higher among Black and Hispanic/Latina participants by 23%-148% and 4%-94%, respectively. Asian/Pacific Islander participants had metabolite levels that were similar to those of White participants. Hypothetical interventions to reduce disparities in metabolite mixtures were associated with lower probabilities of preterm birth for Black [13% relative reduction; 95% confidence interval (CI): formula presented , 8.6%] and Hispanic/Latina (9% relative reduction; 95% CI: formula presented , 0.8%) participants. Odds ratios for preterm birth in association with phthalate metabolites demonstrated heterogeneity by race and ethnicity for two individual metabolites (mono-n-butyl and monoisobutyl phthalate), with positive associations that were larger in magnitude observed among Black or Hispanic/Latina participants. CONCLUSIONS: Phthalate metabolite concentrations differed substantially by race and ethnicity. Our results show hypothetical interventions to reduce population-level racial and ethnic disparities in biomarkers of phthalate exposure could potentially reduce the probability of preterm birth. https://doi.org/10.1289/EHP12831.

Background and aim: Studies suggest prenatal exposure to polycyclic aromatic hydrocarbons (PAHs) may inuence wheezing or asthma in preschool-aged children. However, the impact of prenatal PAH exposure on asthma and wheeze in middle childhood remain unclear. We investigated these associations in diverse participants from the ECHO PATHWAYS multi-cohort consortium. Methods We included 1,081 birth parent-child dyads across ve U.S. cities. Maternal urinary mono-hydroxylated PAH metabolite concentrations (OH-PAH) were measured during mid-pregnancy. Asthma at age 8-9 years and wheezing trajectory across childhood were characterized by caregiver reported asthma diagnosis and asthma/wheeze symptoms. We used logistic and multinomial regression to estimate odds ratios of asthma and childhood wheezing trajectories associated with ve individual OH-PAHs, adjusting for urine specic gravity, various maternal and child characteristics, study site, prenatal and postnatal smoke exposure, and birth year and season in single metabolite and mutually adjusted models. We used multiplicative interaction terms to evaluate effect modication by child sex and explored OH-PAH mixture effects through Weighted Quantile Sum regression. Results The prevalence of asthma in the study population was 10%. We found limited evidence of adverse associations between pregnancy OH-PAH concentrations and asthma or wheezing trajectories. We observed adverse associations between 1/9-hydroxyphenanthrene and asthma and persistent wheeze among girls, and evidence of inverse associations with asthma for 1-hydroxynathpthalene, which was stronger among boys, though tests for effect modication by child sex were not statistically. Conclusions In a large, multi-site cohort, we did not nd strong evidence of an association between prenatal exposure to PAHs and child asthma at age 8-9 years, though some adverse associations were observed among girls.

Objectives. To characterize the trends in degree conferrals, degree-associated debt, and employment outcomes among undergraduate public health degree (UGPHD) graduates. Methods. We reported administrative data on degree conferrals from 2001 to 2020 from the National Center for Education Statistics (NCES). For alumni graduating from 2015 to 2019, we also reported degree-associated debt and earnings 1 year after graduation compiled by NCES. Finally, we utilized a data set on 1-year postgraduation employment outcomes for graduates from 2015 to 2020 from the Association of Schools and Programs of Public Health. Results. As of 2020, more than 18 000 UGPHDs were awarded each year, more than 140 000 in total over the past 20 years. UGPHD graduates are highly diverse, with more than 80% being women and 55% being individuals from communities of color. We find alumni worked mostly in for-profit organizations (34%), health care (28%), nonprofits (11%), academic organizations (10%), government (10%), and other (6%). Degree-associated debt was $24 000, and the median first-year earnings were $34 000. Conclusions. While growth in UGPHD conferrals has slowed, it remains among the fastest-growing degree in the nation. However, the limited pathways into government remains a significant challenge. (Am J Public Health. 2023;113(1):115-123. https://doi.org/10.2105/AJPH.2022.307113).

Prior work developed a shortened 16-item version of the Social Responsiveness Scale (SRS), a quantitative measure of social communication and autism spectrum disorder (ASD)-related traits. However, its properties for use in risk factor estimation have not been fully tested compared to the full SRS. We compared the associations between gestational age (previously established risk factor for ASD) and the 65-item “full” and 16-item “short” versions of the SRS to test the shortened version’s ability to capture associations in epidemiologic analyses of ASD risk factors. We used data from participants in the Environmental influences on Child Health Outcomes (ECHO) Program (n = 2,760). SRS scores were collected via maternal/caregiver report when children were aged 2.5–18 years. We compared estimates of associations between gestational age and preterm birth between the full and short SRS using multivariable linear regression, quantile regression, and prediction methods. Overall, associations based on full and short SRS scores were highly comparable. For example, we observed positive associations between preterm birth with both full ( $$\beta$$ =2.8; 95% CI [1.7, 4.0]) and short ( $$\beta$$ =2.9; 95% CI [1.6, 4.3]) SRS scores. Quantile regression analyses indicated similar direction and magnitude of associations across the distribution of SRS scores between gestational age with both short and full SRS scores. The comparability in estimates obtained for full and short SRS scores with an “established” ASD risk factor suggests ability of the shortened SRS in assessing associations with potential ASD-related risk factors and has implications for large-scale research studies seeking to reduce participant burden.

INTRODUCTION Birth hospitalization length of stay (LOS) is extended for infants with neonatal opioid withdrawal syndrome (NOWS) [1], raising health care costs and complicating efforts to promote maternal-infant bonding [1, 2]. However, many infants exposed to opioids do not develop NOWS. The overall costs of intrauterine opioid exposure may be significantly greater if infants who do not develop withdrawal symptoms also have an increased LOS due to observation for the emergence of NOWS or other medical or social complications. Using data from the Environmental influences on Child Health Outcomes (ECHO)-wide cohort study funded by the National Institutes of Health, we evaluated whether opioid exposure not resulting in NOWS was associated with a longer LOS. We also performed similar evaluations of tobacco, alcohol, and cannabis, and considered the effect of combined exposures. METHODS Study population The current analysis used previously collected data to evaluate the association between intrauterine substance exposure and postnatal hospital LOS among neonates without NOWS. The analytic sample included infants from eight cohorts with complete data on intrauterine substance exposure and postnatal hospital LOS. Cohorts exclusively enrolling very low birthweight or preterm infants were excluded. Infants diagnosed with and/or receiving treatment for NOWS (parent report of opioid or drug withdrawal in the infant, or one or more NOWS screening tools administered, with either a positive score on that measure or pharmacological treatment for NOWS administered); 14 of the 5989 participants) were removed from analyses. Measures The primary exposure was prenatal maternal opioid use, defined as any use of opioid medications or heroin during pregnancy, other than those administered during labor and delivery, as indicated by self-report, medical record abstraction, or maternal toxicology, all of which were taken from cohort study records. Prenatal maternal use of other substances was defined in the same way. The primary outcome was postnatal LOS, calculated as a continuous variable from medical record abstraction data on the date of discharge from the hospital (or final placement if discharged to a different level of care) and date of birth. Covariates were selected based on known or theoretical associations with either polysubstance exposure or LOS, and included maternal age, race, ethnicity, education, calendar year of pregnancy; and infant sex, race, and ethnicity. Statistical analyses To reduce confounding, we estimated propensity scores for exposure to opioids, alcohol, cannabis, and tobacco using maternal covariates. We used the parameter estimates to calculate propensity scores for exposed and non-exposed infants. The inverse probability weights were stabilized by the marginal probability of the actual infant exposure level. Generalized Estimating Equations (GEE), accounting for clustering of participants in original cohort, models were used to examine associations between each prenatal substance use measure and continuous LOS in days, controlling for infant-level covariates. Sensitivity analyses also controlled for con-comitant substance use. R 4.1.0 was used for all analyses, [3] and Multiple Imputation by Chained Equations (MICE) [4] was used to impute missing data (<10% for race, and 4% for all others). RESULTS The analytic sample included 5975 infants (from 5913 pregnancies) who were not selected from NICU-enriched cohorts and did Journal of Perinatology 1234567890();,: not have a diagnosis of NOWS (n = 14) at birth. For this analysis, among observations with data, maternal race was primarily White (3488; 63%) and other race/multiple races (1730; 31%), with 324 (5.8%) describing themselves as Black, and 1057 (18%) reporting Hispanic ethnicity; 4642 pregnant people (80%) reported at least some college education. Among infants, 5315 (90.9%) were not admitted to the NICU, 4326 (74.9%) were of appropriate weight for gestational age, and 198 (3.3%) tested positive for opioid exposure. No significant differences were detected in postnatal LOS for any of the intrauterine exposure groups, in either unadjusted or adjusted analyses (Table 1). Prenatal substance exposure (other than tobacco) was not associated with NICU admission. Sensitivity analyses controlling for other prenatal substance use or evaluating the effect of LOS outliers were also not significant (results not presented). DISCUSSION Our sample included many infants with intrauterine exposure to opioids who were not diagnosed with or treated for NOWS, a finding that is consistent with differences in the prevalence of opioid use vs. opioid use disorders. Although NOWS is associated with extended LOS, our aggregated data for substance-exposed neonates from a variety of United States (U.S.) hospital settings suggest no differences in duration of birth hospitalization based on exposure history alone when NOWS does not manifest. This could be positive news, and-as with evidence that the negative effects of other substances are restricted to those with higher exposure [5]-suggests that harm cannot be inferred solely on the basis of self-reported use or a positive drug screen. Alternatively, these findings may also mean that some infants with intrauterine opioid exposure are discharged before NOWS manifests (up to 5 days after birth), which would present clear risks. Although current clinical practice guidelines suggest observing infants with intrauterine opioid exposure for 3-7 days after birth, [6] there is significant variability in hospital policy and even in NOWS definitions-particularly during the period in which most original data in this study were collected. Unfortunately the available data do not contain information about readmission for NOWS. Further research should clarify how frequently infants are discharged prior to the emergence of withdrawal symptoms.

Women’s social experiences can have long-term implications for their offspring’s health, but little is known about the potential independent contributions of multiple periods of stress exposures over time. This study examined associations of maternal exposure to adversity in childhood and pregnancy with children’s anxiety and depression symptoms in a large, sociodemographically diverse sample. Participants were 1389 mother-child dyads (child age M = 8.83 years; SD = 0.66; 42% Black, 42% White; 6% Hispanic) in the ECHO-PATHWAYS Consortium’s three U.S. pregnancy cohorts. Women reported their exposure to childhood traumatic events (CTE) and pregnancy stressful life events (PSLE). Children self-reported on their symptoms of anxiety and depression at age 8–9 years. Regression analyses estimated associations between maternal stressors and children’s internalizing problems, adjusting for confounders, and examined child sex as a modifier. Exploratory interaction analyses examined whether geospatially-linked postnatal neighborhood quality buffered effects. In adjusted models, PSLE counts positively predicted levels of children’s anxiety and depression symptoms ([ßAnxiety=0.08, 95%CI [0.02, 0.13]; ßDepression=0.09, 95%CI [0.03, 0.14]); no significant associations were observed with CTE. Each additional PSLE increased odds of clinically significant anxiety symptoms by 9% (95%CI [0.02, 0.17]). Neither sex nor neighborhood quality moderated relations. Maternal stressors during pregnancy appear to have associations with middle childhood anxiety and depression across diverse sociodemographic contexts, whereas maternal history of childhood adversity may not. Effects appear comparable for boys and girls. Policies and programs addressing prevention of childhood internalizing symptoms may benefit from considering prenatal origins and the potential two-generation impact of pregnancy stress prevention and intervention.

Although many disciplines saw increases in manuscript submissions coinciding with lockdown measures, numerous studies have documented widening gender gaps in academic productivity. Chi-squared anal...

There is a growing demand for methods to determine the effects that chemical mixtures have on human health. One statistical challenge is identifying true “bad actors” from a mixture of highly correlated predictors, a setting in which standard approaches such as linear regression become highly variable. Weighted Quantile Sum regression has been proposed to address this problem, through a two-step process where mixture component weights are estimated using bootstrap aggregation in a training dataset and inference on the overall mixture effect occurs in a held-out test set. Weighted Quantile Sum regression is popular in applied papers, but the reliance on data splitting is suboptimal, and analysts who use the same data for both steps risk inflating the Type I error rate. We therefore propose a modification of Weighted Quantile Sum regression that uses a permutation test for inference, which allows for weight estimation using the entire dataset and preserves Type I error. To minimize computational burden, we propose replacing the bootstrap with L1 or L2 penalization and describe how to choose the appropriate penalty given expert knowledge about a mixture of interest. We apply our method to a national pregnancy cohort study of prenatal phthalate exposure and child health outcomes.

Lower extremity lymphedema (LEL) can result in detriments to quality of life (QOL) and impose a significant economic burden on patients and payers. A common component of treatment is pneumatic compression, which requires patients to&nbsp;remain immobile. We investigated a novel non-pneumatic compression device (NPCD) that allows patients to remain active during compression treatment, to see if it reduces swelling and improves QOL. We conducted a non-randomized, open-label, 12-week pilot study of adult patients with primary or secondary unilateral LEL, and measured changes in limb edema and QOL using the Lymphedema Quality of Life Questionnaire (LYMQOL). Twenty-four subjects were enrolled; the majority were female (17) with secondary lymphedema (21). Eighteen completed the study. Statistically significant improvements were observed in overall QOL, aggregated LYMQOL total score, and three of four LYMQOL subscales (Function, Appearance, Mood). The fourth (Symptoms) trended toward significant improvement (p = 0.06). The average reduction in affected limb edema was 39.4%. The novel NPCD produced statistically significant improvements in QOL, functioning, and edema volume of patients with LEL. Innovations in devices to manage LEL can be effective while allowing patients to maintain mobility and physical activity during treatment.

Accumulating evidence suggests that maternal exposure to objectively stressful events and subjective distress during pregnancy may have intergenerational impacts on children’s mental health, yet evidence is limited. In a multisite longitudinal cohort (N = 454), we used multi-variable linear regression models to evaluate the predictive value of exposure to stressful events and perceived distress in pregnancy for children’s internalizing problems, externalizing problems, and adaptive skills at age 4. We also explored two- and three-way interactions between stressful events, distress, and child sex. Both objective and subjective maternal stress independently predicted children’s behavior, with more stressful events and higher distress predicting more internalizing and externalizing problems and worse adaptability; stress types did not significantly interact. There was some evidence that more stressful events predicted higher externalizing behaviors only for girls. Three-way interactions were not significant. The current findings highlight the importance of considering the type of stress measurement being used (e.g., counts of objective event exposure or subjective perceptions), suggest prenatal stress effects may be transdiagnostic, and meet calls for rigor and reproducibility by confirming these independent main effects in a relatively large group of families across multiple U.S. regions. Results point to adversity prevention having a two-generation impact and that pre- and postnatal family-focused intervention targets may help curb the rising rates of children’s mental health problems.

We examined the knowledge and attitudes of reproductive-age women toward environmental chemicals and determined how these affect consumer behaviors. At the 2018 Minnesota State Fair, a large community sample of reproductive-age women was recruited to complete a survey on environmental health attitudes and behaviors. Descriptive statistics, chi-square tests, and logistic regression models were used to characterize current attitudes about chemicals. Multivariable logistic regression models examined how sociodemographic characteristics predict knowledge, attitudes, and consumer behaviors. A total of 871 women completed the survey; 74% strongly agreed that chemicals in the environment are dangerous, and 44% of women reported having heard of phthalates, while only 29% reported always practicing at least one environmentally healthy behavior (such as consuming food and beverages from safe plastics). Older age (35&ndash;39 versus 18&ndash;24: aOR 2.3, 95% CI 1.3, 4.3; 40&ndash;44 versus 18&ndash;24; aOR 2.0, 95% CI 1.2, 3.2) and working in a healthcare profession (aOR: 1.7, 95% CI: 1.2, 2.5) were associated with strong agreement that chemicals in the environmental are dangerous. Women who strongly agreed chemicals are dangerous were more likely to practice consumer behaviors to reduce their exposure. Interventions targeting knowledge and attitudes towards environmental chemicals could be an effective strategy for reducing harmful exposures.