Welcome to the ECHO Connector! The Environmental influences on Child Health Outcomes (ECHO) Program is a research program at the NIH with the mission to enhance the health of children for generations to come. The ECHO Connector will keep you informed of program news and our latest research findings.
Message from Matt
A message from the ECHO Director, Matthew W. Gillman, MD
September is Childhood Obesity Awareness Month. Obesity can affect children’s physical and psychosocial health and can lead to substantial health problems later in life, including type 2 diabetes and heart disease.
Obesity is one of ECHO’s five child health outcome areas. This month’s Research Spotlight highlights a recent ECHO study that found that school-age children, on average, gained weight at a higher rate during the first year of the COVID-19 pandemic than they did during the couple of years before.
ECHO researchers also asked what behaviors could explain this excess pandemic-related weight gain. In another recent study of children from before to during the pandemic, they found that screen time—both educational and recreational—increased substantially, whereas sleep duration, diet, and physical activity hardly changed. Screen time takes many forms in kids’ lives these days. Reducing non-productive screen time can lead to less weight gain in children and adolescents.
Both of these studies suggested worse effects among Hispanic or non-Hispanic Black children. Research leading to reducing health disparities and improving health equity are ECHO priorities.
Both of these studies also took advantage of the fact that ECHO began before the pandemic and continues during these many months since it began. That means that ECHO is one of the very few large research programs that has followed individual children over time (“longitudinally”) to see how the pandemic has affected them and their families. Many ECHO researchers are characterizing these wide-ranging effects, and are starting to identify solutions that may offer resilience in the face of hardships.
In addition to my enthusiasm about the burgeoning research coming from ECHO, I am also excited to announce that the next phase of ECHO is within sight. The ECHO Program Office recently released Cohort Funding Opportunity Announcements (FOAs) to invite applications to extend and expand the ECHO Cohort to further investigate the influences of a broad range of early exposures from society to biology, including the preconception period, across ECHO’s five key child health outcome areas among diverse populations.
Frequently Asked Questions and pre-recorded informational webinars regarding these funding opportunities are now available on the NIH ECHO website. I encourage your to use our toolkit to share these FOAs with your networks.
—Matthew W. Gillman, M.D., S.M.
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ECHO Research Spotlight
Changes in BMI During the COVID-19 Pandemic
Collaborative ECHO research led by Emily Knapp, PhD and Aruna Chandran, MD of Johns Hopkins Bloomberg School of Public Health investigates the effects of the COVID-19 pandemic on children’s body mass index (BMI), an estimation of overall body fat. The study looked at the BMI of 1,966 children ages 2 through 18 years old from 38 ECHO cohorts across the United States during the COVID-19 pandemic. The results of this study suggest that, on average, children gained weight at a higher rate during the pandemic. This research, titled “Changes in BMI during the COVID-19 Pandemic,” is published in Pediatrics.
Motivation for Childhood Obesity Research During the Pandemic
"The COVID-19 pandemic is a mass influence on our health, but it's incredibly challenging to study, because everyone is affected. There isn’t an unaffected comparison group. Everything changed all at once, so it's hard to pinpoint a specific cause for these issues. There's an interesting role for more descriptive papers like ours to notice the changing trend and think about societal level changes that could moderate the ill effects of this pandemic,” said Dr. Knapp.
Childhood obesity can affect long-term health and quality of life. At the start of the COVID-19 pandemic, there was concern among researchers and doctors that the closure of schools and the cancellation of recreation and sport activities would cause an increase in childhood obesity.
“Obesity is an epidemic. It's a problem with real consequences, and I think that as a country, we must put in systems level changes that are equitable and fair and appropriate to solve this issue," said Dr. Chandran.
Using ECHO Data to Compare Children’s BMI Data Before and During the Pandemic
To understand the pandemic’s impact on children’s weight, researchers analyzed yearly changes in children’s body mass index (BMI) before and during the pandemic, considering each child’s age and sex. The researchers also investigated whether changes in BMI were different across specific sociodemographic traits including race, ethnicity, pre-pandemic BMI, and household income.
"One of the strengths of ECHO is that we have kids all across the continental United States. This study included kids from 38 of the cohorts, which allows us to have variation in geographic location and means we have kids who were exposed to various COVID-19 mitigation strategies and lockdown procedures in addition to different racial, economic, and educational backgrounds,” said Dr. Knapp. “We're fortunate that with ECHO, we could draw on the data collected both before and during the pandemic, which was a huge strength to have access to this data through the program."
The results of this study indicated that, on average, children gained weight at an increased rate during the pandemic, and children who had obesity before the pandemic gained weight at a faster rate compared to children who were at a healthy weight pre-pandemic. Additionally, children in higher income households were at a lower risk of excess BMI gain during the pandemic.
Next Steps
“This study highlights the need for interventions to mitigate the physical and mental health consequences of the COVID-19 pandemic,” said Dr. Knapp. “The conditions faced by families during the COVID-19 pandemic may have led to an acceleration of weight gain in children. This study highlights the need to support less resourced families who have borne the worst consequences of the pandemic.”
Future studies can explore strategies to help families and communities thrive amidst the challenges faced during the ongoing COVID-19 pandemic. As the pandemic continues to alter children’s lives, it will be important to monitor changes in health outcomes among children and use these data to build programs to reduce health inequities.
"We hope this study is a step toward addressing one of the things that experts fear, which is that children will experience excess weight gain during the pandemic. We hope our study adds to some of the literature that has started to show these effects. We suggest not only more work in that area, but the kind of work that will allow us to learn more about the underlying causes and vulnerable groups that we hope will then shape action,” said Dr. Chandran.
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News You Can Use
ECHO Researchers Investigate How the COVID-19 Pandemic Affected Children’s Health Behaviors
Collaborative ECHO research led by Traci Bekelman, PhD, MPH of the University of Colorado, Anschutz Medical Campus investigates how the COVID-19 pandemic affected children’s diet, physical activity, screen time, and sleep. The study found that children’s screen time increased significantly during the pandemic, with Hispanic children and non-Hispanic Black children having the most noticeable increase in screen time. The amount of time children spent asleep also increased, but only among children whose sleep time was below the recommended range before the pandemic. The study didn’t find any significant increase in the amounts of sugary drinks and unhealthy snack foods children consumed in the full study sample, but it did find a more noticeable increase among Hispanic children and older children.
This research, titled “Health Behavior Changes during the COVID-19 Pandemic: A Longitudinal Analysis among Children,” is published in the International Journal of Environmental Research and Public Health.
This study included 347 children between the ages of 4 to 12 and their caregivers recruited from ECHO cohorts in California, Colorado, North Dakota, and New Hampshire. Of these participants, 47% percent were female and 62% were non-Hispanic White. ECHO researchers compared children’s diet, physical activity, screen time, and sleep data collected before the pandemic (July 2019 to March 2020) to data collected during the pandemic (December 2020 to April 2021).
For many children, public health measures to mitigate the spread of the COVID-19 pandemic disrupted their daily routines, and prevented them from using community resources, such as parks and organized sports. Changes in children’s health behaviors during the first few months of the pandemic were observed in what they eat, screen time, physical activity, and sleep habits. However, there are limited data on what happened to children’s health behaviors after the earliest, most restrictive lockdown period.
“Our study is one of the first to report that increases in screen time persisted into 2021,” said Dr. Bekelman. “Screen time has been linked to physical and mental health outcomes in children, so it will be important to provide families with more support to help them re-establish healthy routines.”
In the future, researchers will continue to investigate children’s health behaviors at other points in the pandemic to reveal whether changes are sustained, and the pathways by which social and economic disruption impacted children’s behaviors. Future studies can also look at changes in more nuanced measures of health behaviors among more diverse groups of children.
ECHO Researchers Study the Effects of Neighborhood Environmental and Social Conditions on Pregnancy and Infant Health
Collaborative ECHO research led by Sheena Martenies, PhD, MPH of the University of Illinois at Urbana-Champaign investigates the combined effects of environmental hazards and social stressors on pregnancy and infant health. This research included information on more than 13,000 infants born between 2010 and 2019 from 41 ECHO cohorts located throughout the United States. In this study, researchers found that pregnant people living in neighborhoods with higher combined exposures had shorter pregnancies and smaller babies. This research, titled “Associations between combined exposure to environmental hazards and social stressors at the neighborhood level and individual perinatal outcomes in the ECHO-wide cohort,” is published in Health & Place.
Previous studies have found that neighborhood conditions can influence pregnancy and infant health, but few have examined the effects of exposure to a combination of environmental and social conditions. It is important to look at multiple exposures simultaneously because this more closely mirrors real-world experiences. There are existing tools for looking at combined exposures to environmental hazards and social stressors in neighborhoods, but they either do not have national coverage or they do not cover the time frames needed.
ECHO researchers developed an exposure index which combined data on multiple environmental hazards and social circumstances—including air pollutants, vehicle traffic, poverty, and crowded housing—into a single measure of neighborhood conditions. Pregnant people were assigned an index score based on where they lived during their pregnancy. Then, the researchers looked at how this index score was associated with birthweight, length of pregnancy, and other pregnancy outcomes.
The researchers found that pregnant people living in neighborhoods with higher combined exposures had shorter pregnancies and smaller babies. For Black pregnant people, there was a higher risk of preterm birth associated with increased combined exposures during pregnancy compared to White pregnant people. The researchers also found that pregnant people living in rural areas had shorter pregnancies and smaller babies compared to pregnant people living in urban areas who had similar index scores.
More research is needed to determine which factors included in the exposure index are most important in pregnancy and child health outcomes. Some members of the research team are currently studying data from two ECHO cohorts (Healthy Start and MADRES) to explore how neighborhood-level exposures might interact to influence obesity later in life.
New ECHO Research Finds Pregnant People are Exposed to Potentially Dangerous Chemicals Found in a Variety of Household Products
Collaborative ECHO research led by Giehae Choi, PhD and Jessie Buckley, PhD, both of Johns Hopkins University, along with Tracey Woodruff, PhD, MPH of the University of California, San Francisco, investigates whether pregnant people are exposed to potentially dangerous chemicals commonly found in a variety of household products, including plastics, disinfectants, and products that contain dyes or pigments. Two of these chemicals, melamine and cyanuric acid, were found in over 99% of study participants, and exposure to four different types of aromatic amines were also found in nearly all participants. Levels of these chemicals were higher among participants of color and those exposed to tobacco smoke. This research, titled “Exposure to melamine and its derivatives and aromatic amines among pregnant women in the United States: The ECHO Program,” is published in Chemosphere.
This research focused on melamine, along with related chemicals like cyanuric acid and aromatic amines. Even though these chemicals are found in a wide variety of household products, their exposures are not regularly monitored in human populations. In general, people can be exposed to harmful chemicals through the air, contaminated food, household dust, water, plastics, products that contain dyes and pigments, tobacco smoke, diesel fumes, and more. Melamine is known to cause health problems in children, but there is limited research on its effects in pregnant people, and in adults in general.
To address this gap, this study used new methods to measure the levels of 45 chemicals in urine samples from 171 pregnant people across nine ECHO cohorts. Of these participants, 40% were Hispanic, 34% were White, 20% were Black, 4% were Asian, and the remaining 2% were from other or multiple racial groups. The researchers also examined data on the participants’ race and ethnicity, age, education, and marital status to determine whether chemical exposure was higher in different sociodemographic groups. Levels of most chemicals were higher among Black and Hispanic women. For example, levels of 3,4-dichloroaniline—a chemical used in the production of dyes and pesticides—were more than 100% higher among Black and Hispanic women compared to White women.
“This is the first national study to reveal that pregnant people in the U.S. are widely exposed to melamine, cyanuric acid, and aromatic amines—chemicals that may be harmful to maternal health and child development,” said Dr. Choi. “This raises concerns for the health of pregnant people and babies.”
Future research will expand this study to include over 1,700 pregnant people and investigate whether higher exposure to these chemicals during pregnancy might be related to negative child health outcomes.
Cross-Cultural Applicability of Eye-Tracking in Accessing Attention to Emotional Faces in Children
Collaborative ECHO research led by Sara Nozadi, PhD, of the University of New Mexico and Andréa Aguiar, PhD of the University of Illinois Urbana-Champaign suggests that eye-tracking technology can be used as a robust measure across diverse populations and settings to assess attention patterns linked to socially withdrawn behavior in preschool children. Their research, titled “Cross-Cultural Applicability of Eye-Tracking in Assessing Attention to Emotional Faces in Preschool-Aged Children” is published in the Emotion Journal.
Humans tend to give more attention to emotional information than neutral information. Past research indicates departures from this pattern typically occur in children with socially withdrawn behaviors. However, most of this research has been very limited and only conducted in controlled settings among primarily White children from urban areas.
In this study, ECHO researchers wanted to determine the extent to which two eye-tracking–based measures could be used cross-culturally to assess attention biases and how these biases might relate to socially withdrawn behaviors in children.
The researchers leveraged ECHO’s large sample size and diverse population to compare information from children in two ECHO cohorts that were very different demographically, geographically, racially and culturally. They analyzed data from 125 children aged 3.5 to 5.5 years from the Navajo Birth Cohort Study (NBCS) and 70 children aged 3.8 to 4.0 years from the Illinois Kids Development Study (IKIDS). NBCS is a cohort of indigenous children who live in rural Tribal lands across New Mexico, Utah, and Arizona and tend to have relatively low socioeconomic status (SES). In contrast, children from IKIDS are primarily Non-Hispanic White and high-SES, living around the University of Illinois at Urbana-Champaign campus in central Illinois. Children in the NBCS historically have not been included in developmental studies, including those investigating attention biases, whereas the IKIDS sample closely resembles the children assessed in most of the previously published eye-tracking studies of attention bias toward emotional stimuli.
Researchers had both groups of children complete two eye-tracking tasks that measured their attention to photos of human faces with positive, negative, and neutral expressions. Indigenous children were assessed in different locations in the Navajo territory, whereas IKIDS children came to a research laboratory in the University campus. Mothers also reported on their child’s socially withdrawn behaviors using the Child Behavioral Checklist (CBCL)—a standardized survey commonly used in research and clinical settings to evaluate risk for behavioral and emotional problems in children.
Attention patterns were similar across the two samples of children irrespective of differences in their cultures, demographics, or assessment settings. Overall, children paid more attention to emotional faces compared to neutral faces, and they were particularly quick to detect angry faces—because this expression may signify a threat. These findings replicate results of previous research with both adults and children. Indigenous children with socially withdrawn behaviors were more likely than other children in the study to avoid emotional faces—a response that has been observed in children with higher levels of socially withdrawn behaviors.
“This work shows that eye tracking can be used to measure patterns of attention towards emotional facial cues—both adaptive patterns and those that underlie socially withdrawn behaviors—in young children,” said Dr. Nozadi. “Because eye tracking technology does not rely on limited clinical observations or parents’ reports, it can be used as a more objective and less biased measure across various settings and communities.”
Moving forward, the researchers will look at how the responses they see in these young children change with age and determine whether eye tracking continues to be an unbiased tool for assessing attention throughout development.
The ECHO Program Office has released the following Funding Opportunity Announcements (FOAs)
All information related to FOAs is available on the NIH ECHO website:
Funding Opportunity Announcements
- ECHO Pregnancy and Pediatric Cohort Study Sites (Limited Competition)
- ECHO Pediatric Cohort Study Sites (Limited Competition)
- ECHO Pregnancy Cohort Study Sites
- ECHO Coordinating Center
- ECHO Data Analysis Center
- ECHO Measurement Core
- ECHO Laboratory Core
Frequently Asked Questions and pre-recorded informational webinars regarding these funding opportunities are now available on the NIH ECHO website.
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ECHO is Hiring
ECHO Program Office Health Scientist Administrator
The ECHO Program Office is seeking to hire a Health Scientist Administrator. The incumbent will be responsible for contributing to the planning, organization, and scientific direction of the ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN), among other duties.
Delegated Examining (Open to the Public)
Merit Promotion (Open to Status Candidates)
The announcements will be open through September 30, 2022.
Please share this opportunity with anyone in your networks who might be interested. If you have any questions, please feel free to reach out to Erin Luetkemeier, ECHO Chief of Staff, at luetkemeieres@mail.nih.gov.
Director for Data Coordinating and Operations Center, ECHO IDeA States Pediatric Clinical Trials Network
The University of Arkansas for Medical Sciences is recruiting an individual at the Associate or Full Professor rank to serve as one of the Multiple Principle Investigators (MPI) of the Data Coordinating Center of the ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN). The incumbent will serve as the MPI responsible for general administration and clinical operations. Learn more: https://www.academicpeds.org/job-listing/director-for-data-coordinating-and-operations-center/
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ECHO Discovery
ECHO Discovery is a monthly webinar series with educational presentations for the ECHO community, stakeholders, and the public.
September ECHO Discovery
Developmental Exposure to PFAS and Childhood/Adolescent Obesity and Cardiometabolic Risk
On September 14, Joseph Braun, PhD, MSPH, RN of Brown University and Kristen E. Boyle, PhD of the University of Colorado, Anschutz Medical Campus presented for ECHO Discovery on the effects of prenatal exposures to per- and polyfluoroalkyl substances (PFAS) on childhood and adolescent obesity risk and related health outcomes.
PFAS are long-lasting chemicals found in some consumer products—like certain types of packaging and cookware—that can contaminate food, water, and air. Virtually all Americans have detectable levels of these substances in their blood with over 100 million Americans having levels above the Environmental Protection Agency’s (EPA) current advised limit. As such, it is critically important for doctors and policymakers to understand what the health effects of PFAS exposure may be for adults and children.
During this presentation, Dr. Braun and Dr. Boyle discussed the ongoing work ECHO is doing to investigate the effects of prenatal PFAS exposures on childhood and adolescent health outcomes. Emerging evidence from ECHO research suggests that prenatal exposure to PFAS may increase a child’s long-term risk for developing obesity and related health conditions. Going forward, these results can help to inform ongoing and future regulatory efforts aimed at defining exposure limits and safe drinking water standards.
View the presentation slides and recording.
August ECHO Discovery
Prenatal Mental Health and Lifestyle Exposures in Association with Child Growth and Neurodevelopment
On August 16, Monique Hedderson, PhD, MPH, Lyndsay Avalos, PhD, MPH, and Assiamira Ferrara, MD, PhD of Kaiser Permanente Northern California presented for ECHO Discovery on how a mother’s mental health and lifestyle during pregnancy may affect her child’s growth and neurodevelopment.
Maternal Prenatal Diet Quality and Infant Growth
Dr. Hedderson presented on recent ECHO research investigating how the quality of a mother’s diet during pregnancy may affect their infant’s size at birth. Infants born smaller or larger than average for their gestational age, as well as infants who gain weight rapidly after birth, are at increased risk for developing obesity later in life. Previous research has found that maternal diet during pregnancy affects fetal growth, but most studies focus on select foods or nutrients rather than overall diet quality.
Dr. Hedderson and her team used dietary assessment data from multiple ECHO cohorts to rate the quality of mothers’ diets during pregnancy and evaluate the relationship between prenatal diet quality and infant size at birth.
Maternal Prenatal Depression and Autism-related Traits in Children
Dr. Avalos presented on recent ECHO research evaluating the effects of prenatal depression on a child’s risk for autism-related traits. Previous research has found a link between prenatal depression and Autism Spectrum Disorder (ASD) diagnosis in children, but those studies often leave out children who don’t meet the ASD-diagnosis criteria but still have autism-related social behaviors.
Dr. Avalos’s team found that prenatal depression was associated with more autism-related traits, especially in boys. They also looked at how the severity of a mother’s depression affected this relationship and found that mothers who experienced more severe depression during pregnancy had children with more autism-related traits.
View the presentation slides and recording.
July ECHO Discovery
Newborn Neurobehavior Predicts 2 Year Developmental Outcome in Preterm Infants
On July 13, Barry M. Lester, PhD of Brown University’s Alpert Medical School presented for ECHO Discovery on using neurobehavioral assessments to predict a preterm infant’s risk for developing behavioral or developmental disorders.
Infants born prematurely are at higher risk for developmental and behavioral disorders, but early detection and treatment can prevent or reduce the severity of these disorders. Doctors and researchers can perform neurobehavioral assessments on newborn infants that evaluate a variety of neurological and behavioral indicators (e.g., attention, movement, response to stress, excitability). Neurobehavioral assessments conducted shortly after birth can identify which infants are most at risk for developmental disorders later in childhood.
During his presentation, Dr. Lester discussed the set of neurobehavioral assessments that he and his team developed to predict long-term developmental outcomes in preterm infants. This collaborative ECHO research took place in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants (NOVI) cohort, as well as other preterm birth cohorts participating in ECHO.
Dr. Lester also emphasized that these neurobehavioral assessments can be conducted before the infants are discharged from the hospital. Because infants’ brains are still highly malleable during this early period, doctors and researchers have a better chance of designing effective interventions that can prevent developmental disorders later in childhood.
View the presentation slides and recording.
Learn More about ECHO Discovery
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