Neurobehavioral Development in Toddlers and Preschoolers in Relation to Prenatal Exposure of Mild Analgesics
Overview
- Phase
- Not Applicable
- Status
- Enrolling By Invitation
- Sponsor
- Rigshospitalet, Denmark
- Enrollment
- 685
- Locations
- 1
- Primary Endpoint
- Behavior Rating Inventory of Executive Function-Preschool Version (BRIEF-P) (male and female children)
Overview
Brief Summary
Fundamental aspects of both neurological and reproductive function are established in fetal life, and there is a present increased awareness of the potential effects of fetal exposures on neurodevelopmental and reproductive health of offspring. Experimental and epidemiological research studies strongly suggest that paracetamol and NSAID are endocrine disruptive in the fetus, which could increase the risks of some neurodevelopmental, reproductive, and urogenital disorders. In recent years, there has been an increasing rate of neurodevelopmental disorders such as ADHD and autism. The original cohort, the Copenhagen Analgesic Study (COPANA), is the first prospective human study designed primarily to assess the effect of fetal exposure to mild analgesics on male and female reproductive function. If the same children are examined with relevant neurobehavioral testing during mid-childhood, the study design allows the investigators to assess the effect of mild analgesics as well as other EDCs on neurodevelopmental health.
Detailed Description
Detailed Description In Denmark, mild analgesics such as acetaminophen (e.g. paracetamol) and non-steroidal anti-inflammatory drugs, NSAIDs (e.g. ibuprofen and acetylsalicylic acid), are sold over the counter, and up to 56% of pregnant women use mild analgesics during pregnancy. In vivo, in vitro, and ex vivo studies have shown that paracetamol directly perturbs hormone-dependent processes, which leads to disrupted reproductive development and neurodevelopment in both sexes. Fetal exposure in rodents has been shown experimentally to cause reproductive disorders of the male urogenital tract, including abnormalities in testicular function, sperm abnormalities, and sexual behavior. Experiments have shown disruption of female ovarian development resulting in reduced oocyte number and subsequent early ovarian insufficiency and reduced fertility. Fetal paracetamol exposure has been demonstrated to induce changes in neurotransmission in the brain manifesting in altered cognitive function, behavior, and locomotion. The studies have shown that the effect of paracetamol is dependent on the timing of exposure in relation to specific developmental processes, duration, and dose.
Population-based cohort studies have reported associations of prenatal exposure to EDCs and language development, autism spectrum disorder scores, as well as externalizing and internalizing behavior scores. Phthalates are one example of an endocrine disrupter used in a variety of consumer products. Human studies suggest an association between phthalate exposure and cognitive development. However, adverse effects of the recently introduced phthalate substitutes have only been sparsely studied, which will be a focus point in this study.
Animal studies suggest deleterious effects of fetal exposure to mild analgesics on both male and female gonadal development. In rodents, paracetamol administered in a single daily dose of 350 mg/kg at 13.5-21.5 days post coitum (dpc) was associated with reduced prostaglandin synthesis and delayed transition from germ cell mitosis to meiosis, causing fetal germ cell apoptosis in both female and male gonads. The long-term consequence seems to be most severe in the female, who becomes unable to form germ cells postnatally. In two studies, female offspring of mice treated with mild analgesics at 7 dpc to delivery and 13.5-21.5 dpc were born with reduced ovarian weight and with a 40-50% reduction in number of follicles. In adulthood, exposed animals gave birth to fewer pups per litter compared with controls.
Use of acetylsalicylic acid (150-250 mg/kg/day) in early and mid-pregnancy (dpc 13-21) has shown to be antiandrogenic, causing shorter AGD and decreased testosterone production in rodents. Furthermore, studies of rodents suggest that in both males and females, adverse reproductive effects are passed on to the next generations, indicating altered and inherited programming of the genome, i.e., epigenetic. Effects on fetal germ cell development with therapeutically relevant concentrations of analgesics have been confirmed in various experimental animal models.
Other medications, such as glucocorticoids and azoles, have previously been suggested to affect fetal germ cell development and will therefore also be incorporated in this study to adjust for possible effects when analyzing final data. Aniline is an organic compound found in many industrial products, pesticides, rubber, textiles, and tobacco smoke. The general population is inevitably exposed to aniline in daily life, and in vivo aniline is converted to paracetamol. In fact, studies have shown that paracetamol can be measured in urine samples of the general human population even with no prior intake of paracetamol, and similar to paracetamol, aniline has shown to exhibit similar anti-androgenic effects in male mice.
To date, no prospective human studies have assessed the effect of analgesic exposure on neurobehavioral development. COPANA is the first prospective human study designed primarily to assess the effect of fetal exposure to mild analgesics on male and female reproductive function. By inviting the same families to participate in the present study, unique information about essential prenatal exposure patterns of analgesics as well as other potential EDCs (e.g., fungicides and phthalates) is already available. Furthermore, essential parameters for the gonadal function of the children have been established in the previous study. These parameters can be directly included in analyses of associations to neurobehavioral development.
The primary objective of this study is to evaluate whether analgesic exposure during fetal life affects neurodevelopmental health in male and female toddlers and preschool children. Prenatal exposure to other potential endocrine-disrupting chemicals (e.g., fungicides and phthalates) on brain development will also be assessed. The families will be asked to complete inventories designed and validated to evaluate language development, ADHD and autism-like behavior, and gender-typical behavior-disorders that are more prevalent in gender-incongruent children and possibly linked with hormone-mediated brain development.
To elucidate underlying mechanisms, the study includes an analysis of the children's epigenetic profile and genetic variation in specific genes/promoter regions affecting prostaglandin action in parents, boys, and girls.
Study Design
- Study Type
- Observational
- Observational Model
- Cohort
- Time Perspective
- Prospective
Eligibility Criteria
- Ages
- 2 Years to 6 Years (Child)
- Sex
- All
- Accepts Healthy Volunteers
- Yes
Inclusion Criteria
- •\- Participant in the COPANA project
Exclusion Criteria
- •Premature birth
- •Postterm birth
- •Twin birth (gemelli)
- •Severe disease in the child
- •Stillbirth
- •Late abortion
Arms & Interventions
The mothers and fathers of the children
The parents, i.e., the mother and father, of the healthy children. The parents will answer the inventories regarding the neurobehavioral development of the child and the general health questionnaire including parental educational level etc.
Children
Healthy children originally recruited specifically for COPANA will be reinvited for follow up, including a child examination.
Outcomes
Primary Outcomes
Behavior Rating Inventory of Executive Function-Preschool Version (BRIEF-P) (male and female children)
Time Frame: 2-5 years of age
Parents will complete the BRIEF-P to assess their child's executive functioning, and the Global Executive Composite score will be used in the analysis.
BRIEF-P Emergent Metacognition Index (male and female children)
Time Frame: 2-5 years
The EMI score reflects the child's ability to sustain ideas and activities in working memory and to plan and organize problem-solving approaches. It is composed of the Working Memory and Plan/Organize subscales and is critical for developing systematic metacognitive strategies.
Child Behavioral and Emotional Functioning - Child Behavior Checklist (CBCL) - (male and female children)
Time Frame: 2-5 years of age
Behavioral and emotional functioning will be assessed using the Child Behavior Checklist (CBCL), a validated parent-report questionnaire. The CBCL provides a Total Score as well as multiple subscale scores reflecting specific behavioral and emotional domains. The questionnaire is completed electronically by the child's mother or father when the child is between 2 and 4 years of age. Unit of Measure: CBCL standardized score (T-score)
BRIEF-P Global Executive Composite (GEC) (male and female children)
Time Frame: 2-5 years of age
The Global Executive Composite (GEC) score is derived from the BRIEF-P questionnaire, which includes 63 items assessing executive functioning in preschool-aged children. The GEC score reflects the overall level of executive function difficulties and is calculated from the five clinical subscales: Inhibit, Shift, Emotional Control, Working Memory, and Plan/Organize.
CBCL Total Problem Score (TPS) (male and female children)
Time Frame: 2-5 years of age
The Total Problem Score (TPS) from the Child Behavior Checklist for Ages 1½-5 (CBCL/1½-5) is derived by summing responses of all items. The possible TPS ranges from 0 to 200, with higher scores representing more severe behavioral and emotional problems. According to standardized CBCL norms. Raw scores are converted to age- and sex-adjusted T-scores for interpretation.
CBCL Internalizing Score (male and female children)
Time Frame: 2-5 years of age
The Internalizing Score is based on 24 items assessing emotional symptoms such as anxiety, depression, and withdrawal. The score range is 0-48.
CBCL Externalizing Score (male and female children)
Time Frame: 2-5 years of age
The Externalizing Score is based on 36 items assessing behaviors such as aggression and rule-breaking. The score range is 0-72.
Danish MacArthur-Bates Communicative Development Inventories (MB-CDI) (male and female children)
Time Frame: 2-4 years
Using the validated Danish MacArthur-Bates Communicative Development Inventories (MB-CDI) "Words and Sentences", which consists of a vocabulary check list (part I) and questions regarding sentences and grammar (part II). Distributed electronically to the mother of the child at age 2-4 years.
MB-CDI Vocabulary Size (Words Understood and Produced) (male and female children)
Time Frame: 2-4 years
Assessed using Part I of the validated Danish version of the MacArthur-Bates Communicative Development Inventories (MB-CDI) "Words and Sentences". This section consists of a vocabulary checklist completed by the child's mother. Unit of Measure: Number of words understood and/or produced
Preschool Activities Inventory - Gender-typical behavior (male and female children)
Time Frame: 3-5 years
Using the "Preschool Activities Inventory "(PSAI). This includes 24 items about the child's toy and activity preferences. The inventory holds 12 typical masculine and 12 typical feminine activities. The parents will score each activity on a likert scale which creates a composite score on the childs preferences.
Inattention symptom load - Measured by the ADHD Rating Scale (male and female children)
Time Frame: 5 years of age
The ADHD Rating Scale Inattention Subscore is based on 9 items rated on a 4-point scale (0 = never, 3 = very often). Scores range from 0 to 27, with higher scores indicating greater severity of inattention symptoms.
Hyperactivity/Impulsivity symptom load - Measured by the ADHD Rating Scale (male and female children)
Time Frame: 5 years of age
The ADHD Rating Scale Inattention Subscore is based on 9 items rated on a 4-point scale (0 = never, 3 = very often). Scores range from 0 to 27, with higher scores indicating greater severity of inattention symptoms.
MB-CDI Sentence and Grammar Use (male and female children)
Time Frame: 2-4 years of age
Assessed using Part II of the Danish MB-CDI "Words and Sentences", which includes questions about the child's use of sentences and grammatical structures. The questionnaire is distributed electronically to the mother. Unit of Measure: Parental report of sentence complexity and grammatical usage (qualitative and/or categorical scoring)
Attention deficit hyperactivity disorder (ADHD) symptom load - Measured by the ADHD Rating Scale (male and female children)
Time Frame: At 5 years of age
The ADHD Rating Scale (ADHD-RS) assesses ADHD symptom severity based on 26 items rated on a 4-point scale (0 = never, 3 = very often). The total score ranges from 0 to 78, with higher scores indicating greater symptom severity. The total score is calculated by summing all item scores.
Total Difficulties Score derived from the "Strengths and Difficulties Questionnaire" (SDQ) (male and female children)
Time Frame: 2-5 years
The Strengths and Difficulties Questionnaire (SDQ) is a 25-item behavioral screening tool that assesses emotional and behavioral problems in children. The Total Difficulties Score is calculated by summing four subscales: Emotional Symptoms, Conduct Problems, Hyperactivity-Inattention, and Peer Problems (20 items in total). The Total Difficulties Score ranges from 0 to 40, with higher scores indicating greater emotional and behavioral difficulties. According to standardized norms, scores can be interpreted depending on age- and sex-specific cutoffs. The SDQ also includes a separate Prosocial Behavior subscale, which is not included in the Total Difficulties Score.
Secondary Outcomes
- Length (male and female children)(2-4 years)
- Weight (male and female children)(2-4 years)
- Head circumference (male and female children)(2-4 years)
- Gross motor development (Parent reported)(1-2 year)
- Serum concentration of progesterone (male and female children)(2-4 years)
- Serum concentration of dehydroepiandrosterone (DHEA) (male and female children)(2-4 years)
- Serum concentration of 21-deoxycortisol (male and female children)(2-4 years)
- Serum concentration of estrone sulfate (male and female children)(2-4 years)
- Serum concentration of luteinizing hormone (male and female children)(2-4 years)
- Serum concentration of Sex hormone Binding Globulin (SHBG) (male and female children)(2-4 years)
- Childhood Infections (Parent-Reported and Registry-Based Assessment)(1-6 years old)
- Waist circumference (male and female children)(2-4 years)
- Hip circumference (male and female children)(2-4 years)
- Digit length (male and female children)(2-4 years)
- Biceps skinfold (male and female children)(2-4 years)
- Triceps skinfold (male and female children)(2-4 years)
- Scapula skinfold (male and female children)(2-4 years)
- Serum concentration of brain-derived neurotrophic factor (BDNF) (male and female children)(2-4 years)
- Serum concentration of 17-hydroxypregnenolone (male and female children)(2-4 years)
- Serum concentration of corticosterone (male and female children)(2-4 years)
- Serum concentration of cortisol (male and female children)(2-4 years)
- Serum concentration of dihydroxytestosterone (male and female children)(2-4 years)
- Serum concentration of 11-deoxycorticosterone (male and female children)(2-4 years)
- Serum concentration of 11-deoxycortisol (male and female children)(2-4 years)
- Serum concentration of dehydroepiandrosterone sulfate (DHEAS) (male and female children)(2-4 years)
- Serum concentration of 17α-hydroxyprogesterone (male and female children)(2-4 years)
- Serum concentration of androstenedione (male and female children)(2-4 years)
- Serum concentration of aldosterone (male and female children)(2-4 years)
- Serum concentration of IGF-binding protein 3 (male and female children)(2-4 years)
- Serum concentration of cortisone (male and female children)(2-4 years)
- Serum concentration of anti-müllerian hormone (AMH) (male and female children)(2-4 years)
- Serum concentration of Insulin-like growth factor-I (male and female children)(2-4 years)
- Medical history (male and female children)(2-4 years)
- Penile measurements (male children)(2-4 years)
- Plasma serotonin (male and female children)(2-4 years)
- Serum concentration of estradiol (male and female children)(2-4 years)
- Serum concentration of inhibin B (male and female children)(2-4 years)
- Serum concentration of follicular stimulating hormone (FSH) (male and female children)(2-4 years)
- Anogenital distance (AGD) (male and female children)(2-4 years)
- Presence of Selected Genetic Variants Related to Hormone Regulation -Targeted SNP analyses (male and female children)(2-4 years)
- Serum concentration of testosterone (male and female children)(2-4 years)
- Assessment of Tanner stages (male and female children)(2-4 years)
- Flank skinfold (male and female children)(2-4 years)
- Medical history (mother)(2-4 years)
- Assessment Palpable Breast Tissue in female participants(2-4 years)
- DNA methylation patterns (male and female children)(2-4 years)
- Urine sample (male and female children)(2-4 years)
- Testes volumen (male children)(2-4 years)
Investigators
Casper Hagen
Associate Professor
Rigshospitalet, Denmark