基于人口的瑞典出生队列儿童的剖宫产，神经发育和精神疾病的评估,JAMA Network Open

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基于人口的瑞典出生队列儿童的剖宫产，神经发育和精神疾病的评估
JAMA Network Open ( IF 10.5 ) Pub Date : 2021-03-01 , DOI: 10.1001/jamanetworkopen.2021.0837
Tianyang Zhang _{1,

2,

3} , Gustaf Brander _{1,

2,

4} , Ängla Mantel _{5,

6} , Ralf Kuja-Halkola ₃ , Olof Stephansson _{5,

6} , Zheng Chang ₃ , Henrik Larsson _{3,

7} , David Mataix-Cols _{1,

2} , Lorena Fernández de la Cruz _{1,

2}

Affiliation

重要性 最近的研究表明，剖宫产（CD）与儿童神经发育障碍的风险增加有关，尽管他们无法控制CD的指征或全兄弟姐妹以外的家族性混杂症。

目的探讨儿童CD与神经发育和精神疾病之间的关系。

设计，环境和参与者 这项基于瑞典登记册的队列研究包括1990年1月1日至2003年12月31日之间出生的1 179 341例足月单胎，并随访至2013年12月31日。兄弟姐妹，母亲和父亲的同父异母兄弟姐妹以及母亲的堂兄弟姐妹。从2019年9月26日至2021年1月16日进行统计分析。

出生时按CD记录的出生暴露，分层为计划CD和产前CD。

主要结果和措施已 注册的神经发育障碍的诊断，包括注意缺陷/多动障碍（ADHD），自闭症谱系障碍（ASD），智障，抽动障碍，沟通障碍，学习障碍和任何神经发育障碍；和精神疾病，包括焦虑症，强迫症，抑郁症，进食障碍，躁郁症，精神病和任何精神病。

结果在1 179 341人中，有10 838 838名（533 140名男孩[50.6％]）通过阴道分娩，59 514名（30 138名男孩[50.6％]）通过计划CD送达，还有70 989名（39 191名男孩[55.2％]）。）是通过分娩期CD交付的。阴道分娩的随访平均年龄（SD）为17.7（4.1）岁，计划CD的平均年龄（SD）为16.6（4.2）岁，产后CD的年龄为16.8（4.1）岁。与阴道分娩相比，在控制了测量的协变量（父母和新生儿特征，母亲合并症和妊娠并发症）之后，CD与任何神经发育障碍患儿的风险较高（计划CD，危险比[HR]，1.17； 95）％CI，1.13-1.22；产前CD，HR，1.10； 95％CI，1.05-1.14），ADHD（计划内CD，HR，1.17； 95％CI，1.12-1.23；产前CD，HR，1.10； 95％CI ，1.05-1.15）和智力障碍（计划的CD，HR，1.26；95％CI，1.14-1.39；产时CD，HR，1.17；95％CI，1.06-1.28）。仅计划CD与较高的ASD风险（HR，1.20; 95％CI，1.10-1.31），沟通障碍（HR，1.14; 95％CI，1.02-1.28）和学习障碍（HR，1.15; 95）相关％CI，1.01-1.30）。剖宫产与其余疾病无关。CD与任何神经发育障碍，ADHD，ASD和智力障碍之间的关联在全表亲和父亲同父异母的兄弟姐妹中减弱，并在母亲同父异母的同父异母兄弟姐妹和全兄弟姐妹中进一步减弱（变得不显着）（计划中的全兄弟姐妹任何神经发育障碍的风险） CD，HR，0.93; 95％CI，0.81-1.06;产时CD，HR，1.07; 95％CI，0.96-1.21）。95％CI（1.10-1.31），沟通障碍（HR，1.14; 95％CI，1.02-1.28）和学习障碍（HR，1.15; 95％CI，1.01-1.30）。剖宫产与其余疾病无关。CD与任何神经发育障碍，ADHD，ASD和智力障碍之间的关联在全表亲和父亲同父异母的兄弟姐妹中减弱，并在母亲同父异母的同父异母兄弟姐妹和全兄弟姐妹中进一步减弱（变得不显着）（计划中的全兄弟姐妹任何神经发育障碍的风险） CD，HR，0.93; 95％CI，0.81-1.06;产时CD，HR，1.07; 95％CI，0.96-1.21）。95％CI（1.10-1.31），沟通障碍（HR，1.14; 95％CI，1.02-1.28）和学习障碍（HR，1.15; 95％CI，1.01-1.30）。剖宫产与其余疾病无关。CD与任何神经发育障碍，ADHD，ASD和智力障碍之间的关联在全表亲和父亲同父异母的兄弟姐妹中减弱，并在母亲同父异母的同父异母兄弟姐妹和全兄弟姐妹中进一步减弱（变得不显着）（计划中的全兄弟姐妹任何神经发育障碍的风险） CD，HR，0.93; 95％CI，0.81-1.06;产时CD，HR，1.07; 95％CI，0.96-1.21）。

结论与相关性 这项研究的结果表明，CD与儿童神经发育障碍风险增加之间的关联最有可能是由无法测量的家族性混杂因素引起的。

"点击查看英文标题和摘要"

Assessment of Cesarean Delivery and Neurodevelopmental and Psychiatric Disorders in the Children of a Population-Based Swedish Birth Cohort

Importance Recent studies suggest that cesarean delivery (CD) is associated with increased risk of neurodevelopmental disorders in children, although they were unable to control for indications for CD or familial confounding beyond full siblings.

Objective To examine the association between CD and neurodevelopmental and psychiatric disorders in children.

Design, Setting, and Participants This Swedish register-based cohort study included 1 179 341 term-birth singletons born between January 1, 1990, and December 31, 2003, and followed up through December 31, 2013. All individuals were linked to their full siblings, maternal and paternal half siblings, and maternal full cousins. Statistical analyses were performed from September 26, 2019, to January 16, 2021.

Exposures Birth by CD recorded at birth, stratified into planned and intrapartum CD.

Main Outcomes and Measures Registered diagnoses of neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD), intellectual disability, tic disorders, communication disorders, learning disorders, and any neurodevelopmental disorder; and psychiatric disorders, including anxiety disorders, obsessive-compulsive disorder, depressive disorders, eating disorders, bipolar disorders, psychotic disorders, and any psychiatric disorder.

Results Of 1 179 341 individuals, 1 048 838 (533 140 boys [50.8%]) were delivered vaginally, 59 514 (30 138 boys [50.6%]) were delived via planned CD, and 70 989 (39 191 boys [55.2%]) were delivered via intrapartum CD. Mean (SD) age at follow-up was 17.7 (4.1) years for vaginal delivery, 16.6 (4.2) years for planned CD, and 16.8 (4.1) years for intrapartum CD. Compared with vaginal delivery, and after controlling for measured covariates (parental and neonatal characteristics, maternal comorbidities, and pregnancy complications), CD was associated with higher risk in children of any neurodevelopmental disorder (planned CD, hazard ratio [HR], 1.17; 95% CI, 1.13-1.22; intrapartum CD, HR, 1.10; 95% CI, 1.05-1.14), ADHD (planned CD, HR, 1.17; 95% CI, 1.12-1.23; intrapartum CD, HR, 1.10; 95% CI, 1.05-1.15), and intellectual disability (planned CD, HR, 1.26; 95% CI, 1.14-1.39; intrapartum CD, HR, 1.17; 95% CI, 1.06-1.28). Only planned CD was associated with a higher risk of ASD (HR, 1.20; 95% CI, 1.10-1.31), communication disorders (HR, 1.14; 95% CI, 1.02-1.28), and learning disorders (HR, 1.15; 95% CI, 1.01-1.30). Cesarean delivery was not associated with the remaining disorders. The associations between CD and any neurodevelopmental disorder, ADHD, ASD, and intellectual disability attenuated in full cousins and paternal half siblings, and further attenuated (became nonsignificant) in maternal half siblings and full siblings (risk of any neurodevelopmental disorder in full siblings, planned CD, HR, 0.93; 95% CI, 0.81-1.06; intrapartum CD, HR, 1.07; 95% CI, 0.96-1.21).

Conclusions and Relevance The findings of this study suggest that the association between CD and increased risk of neurodevelopmental disorders in the children was most likely explained by unmeasured familial confounding.

更新日期：2021-03-05

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