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New ECHO Research Investigates Increase in Screen Time for Children During the Pandemic

Posted on by Jodi Snare

Collaborative ECHO research led by Monique Hedderson, PhD and Assiamira Ferrara, MD, PhD, of the Division of Research at Kaiser Permanente Northern California, investigates the changes in screen time habits of children during the COVID-19 pandemic. The study found that total screen time among children ages 4 to 12 increased between December 2020 and April 2021 when school closures and lockdowns were widespread and remained even after several restrictions were lifted. The research, titled “Trends in screen time use among children during the COVID pandemic, July 2019 through August 2021,” is published in JAMA Network Open.

The study included 228 parent-child pairs from three ECHO cohorts across the United States (Colorado, California, and South Dakota). Parents reported their children’s screen time. The geographically, racially, and ethnically diverse participants ranged in age from 4 to 12 at the start of the study. ECHO researchers surveyed parents about their children’s media use before, during the early, and later periods of the pandemic. The study assessed total, educational (not including remote school), and recreational screen time and examined trends in screen use before and at two points during the pandemic.

Excessive screen time is associated with obesity-promoting health behaviors and adverse mental health. The COVID-19 pandemic initially led to widespread school closures, shelter-in-place laws, closures of recreational facilities and cancellation of youth sports, increases in parents working from home, and social distancing recommendations, all of which may have impacted screen time among children.

“Our findings can help inform clinical guidelines that could aid parents and their children in re-establishing healthy media use habits,” said Dr. Hedderson. “Pediatricians can help parents reset family media use priorities and limits that may have relaxed during the early stages of the COVID-19 pandemic using tools like the American Academy of Pediatrics Family Media Plan.”

Prior studies have reported screen time levels during the pandemic but were unable to document changes in screen time because most lacked pre-pandemic assessments. This study is among a handful of ECHO COVID-19 studies to include pre-pandemic assessments of screen use in order to document changes during the pandemic.

More studies are needed to determine whether the increases in screen time among children during the pandemic impacted longer term obesity and mental health outcomes in children. Future studies can also clarify whether there were specific types of screen time that adversely impacted children’s health during the pandemic.

Read the research summary.

ECHO Researchers Investigate the Effect of the Healthy, Hunger-Free Kids Act on the Body Mass Index of School-aged Children

Posted on by Jodi Snare

Collaborative ECHO research led by Aruna Chandran, MD, MPH and Emily Knapp, PhD of the Johns Hopkins Bloomberg School of Public Health, examines how the body mass index (BMI) trends of school-aged children have changed following the implementation of the 2010 Healthy, Hunger-Free Kids Act (HHFKA). Researchers analyzed height and weight data from over 14,000 children in the ECHO Program and found an overall decrease in BMI following the implementation of the HHFKA. These results suggest a reversal of the pre-implementation trends, which indicated that BMI was increasing from year to year, particularly among adolescents and children from lower-income families. This research, titled “Changes in Body Mass Index Among School-Aged Children Following Implementation of the Healthy, Hunger-Free Kids Act,” is published in JAMA Pediatrics.

“The National School Lunch Program and School Breakfast Program (NSLP) provides free or low-cost meals to over 30 million children annually, providing an estimated 50% of students’ caloric intake each school day,” said Dr. Chandran. “The Healthy, Hunger-Free Kids Act was the first legislation in nearly 3 decades aimed at improving the nutritional quality of breakfast, lunch, and snacks sold at schools.”

Childhood obesity is a serious health concern, affecting nearly 1 in 5 children in America, that has long-term consequences for health and quality of life. While many studies have already shown the success of the HHFKA in improving the quality of school meals, there are still gaps in understanding the effect of this policy on childhood BMI.

For this study, researchers analyzed height and weight measurements collected between January 2005 and March 2020 from children ages 5 to 18 years across 50 ECHO cohorts in the United States. They used these measurements to calculate each child’s BMI, then adjusted those measurements based on the child’s age and sex. Using this data, the researchers compared yearly BMI trends from before and after the implementation of the HHFKA.

The researchers found that increasing BMI trends from the decade before the HHFKA was implemented were reversed after the law was implemented. This effect was also observed in adolescents, who tend to have more autonomy in purchasing their own meals and snacks during the school day but still benefited from HHFKA implementation.

“School meals and snacks represent a key opportunity for intervention to combat the childhood obesity epidemic, given the high rates of participation in school meal programs and the significant proportion of caloric intake that children receive at school,” said Dr. Knapp. “This is particularly important for children in lower-income families, who are more likely to participate in the NSLP and are at higher risk of obesity.”

In the future, researchers should continue to the examine the effects of improving the nutritional quality of school meals on childhood obesity. Results from this study can also help policymakers evaluate future policies related to improving school meals and snacks.

Read the research summary.­­

ECHO Researchers Investigate Whether Prenatal Chemical Exposures Affect the Development of Autism-related Traits in Children

Posted on by Jodi Snare

Collaborative ECHO research led by Jennifer Ames, PhD of the Kaiser Permanente Northern California Division of Research and Ghassan Hamra, PhD of Johns Hopkins Bloomberg School of Public Health, investigates whether exposures to per- and polyfluoroalkyl substances (PFAS) during pregnancy were associated with the development of autism-related traits in children. The researchers looked at data from 1,224 mother-child pairs and found that prenatal exposure to one specific PFAS chemical, perfluorononanoic acid (PFNA), may be associated with an increase in autism-related traits in children. Prenatal exposure to the mixture of all PFAS chemicals combined was not associated with increased autism-related traits in children. This research, titled “Prenatal exposure to per- and polyfluoroalkyl substances and childhood autism-related outcomes,” is published in Epidemiology.

PFAS are widely used, long lasting chemicals, the components of which break down very slowly over time. Previous studies that have investigated the association between prenatal PFAS exposure and childhood autism spectrum disorder (ASD) have been inconsistent and mostly involved small sample sizes. This study leveraged the large, diverse ECHO-wide cohort to evaluate how prenatal PFAS exposure affects the development autism-related traits, even when a child does not receive a clinical ASD diagnosis.

This study included children born between 2011 and 2018 from 10 racially and ethnically diverse ECHO cohorts across the United States, including one cohort that enrolls children from families with an increased likelihood of ASD. The researchers measured the levels of eight different PFAS in blood samples collected from mothers during pregnancy. Later, when their children were aged 2.5 years or older, researchers asked caregivers to report on their child’s autism-related traits using a questionnaire called the Social Responsiveness Scale (SRS). The research team tracked the associations between these data to examine child SRS scores in relation to each individual PFAS as well as the combination of the PFAS.

“In the U.S. population, exposures to perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) have dropped substantially since the industry voluntarily phased out these chemicals in the early 2000s,” said Dr. Ames. “However, other PFAS exposures have increased over time, including thousands with unknown toxicity. These so-called ‘forever chemicals’ continue to pose risks to health even after they are phased out because they persist in the environment and inside people’s bodies and don’t break down easily.”

These results underscore the need for more research on whether PFAS chemicals might have more significant effects on child neurodevelopment, and whether factors such as genetics, underlying health conditions, or nutritional status may change the effect of PFAS exposure on brain development.

Read the research summary.­­

New ECHO Study Investigates the Relationship Between a Mother’s Oxidative Stress Levels and Preterm Birth

Posted on by Jodi Snare

A collaborative research study led by Stephanie Eick, PhD, MPH of Emory University’s Rollins School of Public Health and Rachel Morello-Frosch PhD, MPH of the University of California, Berkeley found an association between elevated levels of oxidative stress and higher risk of preterm birth. This study examined data from 1,916 racially, ethnically, and demographically diverse pregnant participants from four ECHO cohorts across the United States and Puerto Rico. This research titled, “A pooled analysis of four birth cohorts examining urinary oxidative stress biomarkers and preterm birth,” is published in the American Journal of Obstetrics and Gynecology.

Oxidative stress is a process that can trigger cell damage and may contribute to poor prenatal health outcomes. “This is the largest study to date looking at the relationship between oxidative stress and preterm birth,” said Dr. Eick. “Previous research on this topic has involved fairly small, primarily White populations, which is not reflective of diversity in the US.”

The researchers measured oxidative stress biomarkers in urine samples from participants collected during the second and third trimesters of pregnancy. Then, they calculated the association between the oxidative stress biomarkers concentration for each participant and all preterm births (delivery prior to 37 weeks).

Results from this study showed a strong association between higher levels of oxidative stress biomarkers and preterm birth.  This association was particularly true for participants who experienced preterm birth that was sudden and unexpected or occurred prior to 34 weeks.

Future research will investigate how the chemicals involved in oxidative stress may lead to preterm birth and identify what risk factors lead to higher oxidative stress during pregnancy.

Read the research summary.

ECHO Researchers Investigate How Changes in Family Situations Due to the COVID-19 Pandemic are Linked to Children’s Behaviors

Posted on by Jodi Snare

Collaborative ECHO research led by Traci Bekelman, PhD, MPH and Katherine Sauder, PhD of the University of Colorado, Anschutz Medical Campus, investigates whether parents’ coping strategies, stress, and financial strain affected their children’s health behaviors during the first seven months of the COVID-19 pandemic. The researchers found that children with parents who were able to change their work schedules to care for their children during the pandemic had less screen time and slept longer at night, while children with parents who were unable to adjust their work schedules due to stress about money and access to food drank more sugary drinks, were less active, and slept less at night. This research, titled “Sociodemographic Variation in Children’s Health Behaviors During the COVID-19 Pandemic,” is published in Childhood Obesity.

This study included 3,315 children between 3 and 17 years old from 50 ECHO cohorts across the United States. Parents answered questions about their child’s diet, physical activity, screen time, and sleep during the first seven months of the COVID-19 pandemic. Additionally, the parents reported how they personally coped with the pandemic and what their largest sources of stress was.

The COVID-19 pandemic significantly changed many families’ routines and financial situations, causing an increase in parents’ stress and affecting children’s diet, physical activity, and sleep behaviors. “Parents stressed about money may need additional resources to help their children to eat healthier, increase their physical activity and sleep, and decrease their screen time,” said Dr. Bekelman. “Going forward, we will continue to look at how financial stress and parents’ work schedules affect children’s health behaviors to help guide the design of future interventions that can encourage healthy behaviors among children, especially during stressful times like a pandemic.”

Read the research summary.

New ECHO Research Links Neighborhood Opportunity and Social Vulnerability to Children’s Body Mass Index (BMI)

Posted on by Jodi Snare
Izzuddin M. Aris, PhD
Izzuddin M. Aris, PhD

Collaborative ECHO research led by Izzuddin M. Aris, PhD of Harvard Medical School, investigates associations between neighborhood-level opportunity and social vulnerability and children’s body mass index (BMI) and obesity risk. The study evaluated over 20,000 children and found that children who lived in higher opportunity or less vulnerable neighborhoods early in life had lower average BMI and lower risk of obesity from childhood to adolescence. Children’s BMI and obesity risk was most strongly linked with the conditions of the neighborhoods they lived in at birth compared to those they lived in later in childhood. Additionally, these associations were not affected by individual and family sociodemographics or by prenatal characteristics that are considered risk factors for childhood obesity. This research, titled “Associations of Neighborhood Opportunity and Vulnerability with Trajectories of Child Body Mass Index and Obesity Among U.S. Children,” is published in JAMA Network Open.

Childhood BMI—an estimation of their overall body fat—and childhood obesity are significant risk factors for cardiovascular disease-related morbidity and mortality later in adulthood. To understand how neighborhood-level conditions can affect a child’s risk for these health outcomes, this study looked at children from 54 ECHO cohorts located across the United States. ECHO researchers collected each child’s home address and weight at birth, infancy (6 months‒1.5 years), early childhood (2‒5 years), and mid-childhood (5‒10 years). The researchers linked children’s addresses throughout childhood to data from the Child Opportunity Index and Social Vulnerability Index to examine links between neighborhood conditions and children’s BMI and obesity over time.

“Our findings suggest that living in a high opportunity or low vulnerability neighborhood is an important resilience factor that may promote favorable BMI patterns which, in turn, could reduce future chronic disease risk,” said Dr. Aris. “This study bolsters the need for a focus on investments that address the structures that consistently compromise the health of marginalized communities.”

Neighborhood indices, such as the ones used in this study, could be used to target the development of place-based programs or policies that directly address the disparate contexts of neighborhoods, reduce barriers and improve access to essential resources and provide families with the environments needed to support optimal child health and well-being.

Future research should explore whether programs or policies that change specific aspects of neighborhood environments would be effective in preventing excess weight and obesity in children.

 

Read the research summary.

ECHO Researchers Investigate the Mental Health Effects of Life Changes Related to the COVID-19 Pandemic

Posted on by Jodi Snare

Collaborative ECHO research led by Tracy Bastain, PhD, MPH of the University of Southern California and Amy Margolis, PhD of Columbia University, investigates the mental health impacts of the COVID-19 pandemic on mothers in the United States. The study found that mothers who reported more life changes during the pandemic also reported more symptoms of traumatic stress. This research, titled “COVID-19 Pandemic Experiences and Symptoms of Pandemic-Associated Traumatic Stress Among Mothers in the US,” is published in JAMA Network Open.

This study included 11,473 mothers from 62 ECHO cohorts across the U.S. and Puerto Rico and investigated the potential impacts of the COVID-19 pandemic on maternal mental health from April 2020 through August 2021.  ECHO researchers examined patterns of pandemic-associated changes in maternal health and health behaviors, healthcare visits, work and finances, and coping strategies. The researchers used cluster analysis to group the mothers based on their pandemic experiences and then examined whether these groups reported higher or lower symptoms of traumatic stress related to the pandemic.

“As compared to fathers, during the COVID-19 pandemic more mothers have been affected by job and income losses, taken on more childcare burdens related to remote schooling, and have made major adjustments to their daily routines,” said Dr. Margolis.

The mothers who fell into the group that experienced more changes and reported more symptoms of traumatic stress tended to be women with higher incomes and higher education, and these women were more likely to report financial concerns as a cause of that stress. In contrast, mothers who had lower education and lower income were more likely to report fewer pandemic-related changes.

“Our study found that mothers who had the most changes to their work, health, and social support systems also reported the highest amount of traumatic stress due to the pandemic,” said Dr. Bastain.

The study results suggest that the association between sociodemographic, stressful life events and mental health should be considered in future studies examining the long-term outcomes of the COVID-19 pandemic. Future research could examine how changes over the course of the pandemic affect mothers’ stress and well-being.

Read the research summary.

ECHO Researchers Find Connection Between Mothers’ Food Quality During Pregnancy and their Duration of Breastfeeding

Posted on by Jodi Snare
Emily Zimmerman
Emily Zimmerman, PhD, CCC-SLP

Collaborative ECHO research led by Emily Zimmerman, PhD of Northeastern University investigates the relationship between mothers’ food sources and preparation during pregnancy and the length of time they breastfed. Pregnant participants who reported eating the least processed food and take-out, tended to breastfeed for an average of 41 weeks (10 months), while pregnant participants who reported eating the most processed food and take-out breastfed for an average of 16 weeks. This research, titled “Association Between Quality of Maternal Prenatal Food Source and Preparation and Breastfeeding Duration in The Environmental influences on Child Health Outcome (ECHO) Program,” is published in Nutrients.

This study included 751 mothers who were at least 18 years old and their infants from 12 ECHO cohorts located across the United States. Mothers reported on their food source and preparation during pregnancy and were placed in one of three groups: high, moderate, or low food source quality. Mothers also reported on their breastfeeding duration.

“This is the first time that maternal food source during pregnancy has been examined and linked to breastfeeding duration in such a large and diverse cohort,” said Dr. Zimmerman. “Our findings are in line with our hypothesis that mothers who reported eating more processed and fast foods and less food prepared at home breastfed for a shorter duration.”

Future studies are needed to understand the relation between breastfeeding duration and maternal food quality over time. These studies can also provide more specific information on maternal diet, food source, and preparation during pregnancy while considering other important factors, like socioeconomic status, that may affect the types of foods mothers have access to.

Read the research summary.

New ECHO Study Finds Prenatal Antidepressant Use Does Not Increase Risk for Child Autism-related Traits

Posted on by Jodi Snare
Patricia Brennen, PhD

Collaborative ECHO research led by Patricia Brennan, PhD of Emory University, investigates whether maternal prenatal antidepressant use affects a child’s risk for autism spectrum disorder (ASD) or autism-related traits. The study included over 3,000 mothers and their children and found no correlation between the use of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), during pregnancy and child autism-related traits. This research, titled “Prenatal Antidepressant Exposures and Autism Spectrum Disorder or Traits: A Retrospective, Multi-Cohort Study,” is published in Research on Child and Adolescent Psychopathology.

Previous research has not offered conclusive findings on the effect of prenatal antidepressants on child autism-related traits. It is important that pregnant women and the physicians that treat them have the data they need to make informed treatment decisions.

For this study, researchers looked at a large sample of mothers and their children from ECHO cohorts across the United States, collecting data on prenatal antidepressant use and autism-related traits when the children were between 1 and 12 years of age. About 5% of the mothers who participated took antidepressants during pregnancy, according to medical records and self-reported measures. Mothers also reported on whether their child received an ASD diagnosis and completed rating scales about their child’s behavior, including social, language, and other autism-related traits.

“Depression is common during pregnancy, and pregnant women and the physicians who treat them must weigh multiple risks when making treatment decisions,” said Dr. Brennan. “This study suggests that the use of antidepressants and SSRIs during pregnancy does not increase a child’s risk for autism-related outcomes.”

Future studies may consider evaluating if the dose or timing of antidepressant use during pregnancy modifies the effect on child health outcomes.

Read the Research Summary.

ECHO Study Examines Characteristics Associated with Opioid Use During Pregnancy

Posted on by Jodi Snare

Collaborative ECHO research led by Ruby Nguyen, PhD of the University of Minnesota and Monica McGrath, ScD of Johns Hopkins University Bloomberg School of Public Health, described characteristics that were associated with opioid using during pregnancy. The study included over 20,000 pregnant participants from across the United States and found that the majority of individuals who used opioids during pregnancy were non-Hispanic White and college educated. The researchers also found that opioid use was more common among people who used tobacco or illegal drugs and those who had a history of depression or anxiety. This research, titled “Characteristics of Individuals in the U.S. who Used Opioids during Pregnancy,” is published in the Journal of Women’s Health.

Opioids are a class of drugs commonly used as prescription pain relievers that can cause dependence or addiction. Opioid use has disproportionally impacted pregnant women and their fetuses and previous studies of opioid use during pregnancy have been limited in size and scope. The stigmatization of this population has also affected the collection of data on maternal opioid use during pregnancy. This study utilized a large, geographically diverse group of pregnant participants from 32 ECHO cohorts across the U.S. to investigate rare exposures and factors that may affect an individual’s risk for opioid use during pregnancy.

During this study, the researchers analyzed data from pregnant participants who were enrolled in ECHO cohorts between 1991 and 2021. They used medical records, laboratory tests, and self-reported information to assess opioid use and potentially related factors. Of the 21,905 pregnancies evaluated, only 591 (2.8%) involved opioid use. The majority of opioid use during pregnancy originated from a prescription.

“This was among the largest observational studies of opioid use in pregnancy, and the diverse sample of pregnant women better represents the U.S. population than previous studies,” said Dr. Nguyen. “These findings will help to inform further research on screening tools for opioid use during pregnancy, and the finding that most opioid use originates from prescriptions reinforces the need to better monitor the amount of circulating prescription drugs, particularly in pregnant women.”

Further research is needed to understand the factors that contribute to the use of multiple substances during pregnancy and the interrelationship between substance use and depression or anxiety. The results of this study can contribute to the development of screening tools and procedures for identifying individuals who are potentially at-risk for opioid use during pregnancy.

Read the research summary.