Flu in pregnancy may quadruple child’s risk for bipolar disorder

NIH-funded study adds to evidence of overlap with Schizophrenia 

Pregnant mothers’ exposure to the flu was associated with a nearly fourfold increased risk that their child would develop bipolar disorder in adulthood, in a study funded by the National Institutes of Health. The findings add to mounting evidence of possible shared underlying causes and illness processes with schizophrenia, which some studies have also linked to prenatal exposure to influenza.

“Prospective mothers should take common sense preventive measures, such as getting flu shots prior to and in the early stages of pregnancy and avoiding contact with people who are symptomatic,” said Alan Brown, M.D., M.P.H, of Columbia University and New York State Psychiatric Institute, a grantee of the NIH’s National Institute of Mental Health (NIMH). “In spite of public health recommendations, only a relatively small fraction of such women get immunized. The weight of evidence now suggests that benefits of the vaccine likely outweigh any possible risk to the mother or newborn.” 

Brown and colleagues reported their findings online May 8, 2013 in JAMA Psychiatry.

Although there have been hints of a maternal influenza/bipolar disorder connection, the new study is the first to prospectively follow families in the same HMO, using physician-based diagnoses and structured standardized psychiatric measures. Access to unique Kaiser-Permanente, county and Child Health and Development Study databases made it possible to include more cases with detailed maternal flu exposure information than in previous studies.

Among nearly a third of all children born in a northern California county during 1959-1966, researchers followed 92 who developed bipolar disorder, comparing rates of maternal flu diagnoses during pregnancy with 722 matched controls.

The nearly fourfold increased risk implicated influenza infection at any time during pregnancy, but there was evidence suggesting slightly higher risk if the flu occurred during the second or third trimesters. Moreover, the researchers linked flu exposure to a nearly sixfold increase in a subtype of bipolar disorder with psychotic features. 

A previous study, by Brown and colleagues, in a related northern California sample, found a threefold increased risk for schizophrenia associated with maternal influenza during the first 

half of pregnancy. Autism has similarly been linked to first trimester maternal viral infections and to possibly related increases in inflammatory molecules. 

“Future research might investigate whether this same environmental risk factor might give rise to different disorders, depending on how the timing of the prenatal insult affects the developing fetal brain,” suggested Brown.

Bipolar disorder shares with schizophrenia a number of other suspected causes and illness features, the researchers note. For example, both share onset of symptoms in early adulthood, susceptibility genes, run in the same families, affect nearly one percent of the population, show psychotic behaviors and respond to antipsychotic medications.

Increasing evidence of such overlap between traditional diagnostic categories has led to the NIMH Research Domain Criteria (RDoC) project, which is laying the foundation for a new mental disorders classification system based on brain circuits and dimensional mechanisms that cut across traditional diagnostic categories.

The research was also funded by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit http://www.nimh.nih.gov.

About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s website at http://www.nichd.nih.gov/.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH…Turning Discovery Into Health® 

Reference 

Gestational Influenza and bipolar Disorder in Adult Offspring. Parboosing R, Bao Y, Shen L, Schaefer CA, Brown AS. JAMA Psychiatry, May 8, 2013.

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Pregnancy and Flu Vaccination

September 15, 2010

Dear Colleague:

Advice from a healthcare provider plays an important role in a pregnant and postpartum woman’s decision to get vaccinated against seasonal influenza. The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Nurse-Midwives (ACNM), American College of Obstetricians and Gynecologists (The College), American Medical Association (AMA), American Nurses Association (ANA), American Osteopathic Association (AOA), American Pharmacists Association (APhA), Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), March of Dimes, and Centers for Disease Control and Prevention (CDC) are asking for your help in urging your pregnant and postpartum patients to get vaccinated against seasonal influenza.

The Advisory Committee on Immunization Practices (ACIP) recommends that pregnant and postpartum women receive the seasonal influenza vaccine this year, even if they received 2009 H1N1 or seasonal influenza vaccine last year. Lack of awareness of the benefits of vaccination and concerns about vaccine safety are common barriers to influenza vaccination of pregnant and postpartum women. To overcome these barriers, some key points have been provided below.

Pregnant women should receive seasonal influenza vaccine.

  1. Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza.
  2. Risk of premature labor and delivery is increased in pregnant women with influenza.
  3. Vaccination during pregnancy has been shown to protect both the mother and her infant (up to 6 months old) from lab-confirmed influenza. Influenza hospitalization rates in infants <6 months of age are more than 10 times that of older children.
  4. Pregnant women represented 5% of 2009 H1N1 influenza deaths in the U.S., while only about 1% of the population was pregnant. Severe illness in postpartum women was also documented. 2009 H1N1 is expected to continue to circulate this influenza season and is included in the seasonal trivalent influenza vaccine this year.

Influenza vaccine is safe.

  1. Influenza vaccines have been given to millions of pregnant women over the last decade and have not been shown to cause harm to women or their infants.
  2. Influenza vaccine can be given to pregnant women in any trimester.
  3. Pregnant women should receive inactivated vaccine (flu shot) but should NOT receive the live attenuated vaccine (nasal spray).
  4. Postpartum women, even if they are breastfeeding, can receive either type of vaccine. Please encourage your pregnant and postpartum patients to get vaccinated against influenza. If you do not offer influenza vaccination, please find out who offers the vaccine in your community and send your pregnant and postpartum patients there. You play a crucial role in helping to prevent influenza in your patients and their infants, which can save their lives. More information can be found at: http://www.cdc.gov/flu/professionals/vaccination/. Free patient education resources (including for pregnant or postpartum patients) are available at www.cdc.gov/flu.
Sincerely,


Lori J. Heim, M.D.
President
American Academy of Family Physicians


Judith S. Palfrey, MD, FAAP
President
American Academy of Pediatrics


Holly Powell Kennedy, CNM, PhD, FACNM, FAAN
President
The American College of Nurse-Midwives


Ralph W. Hale, MD, FACOG
Executive Vice President
The American College of Obstetricians and Gynecologists


Michael D. Maves, MD, MBA
Executive Vice President/Chief Executive Officer
American Medical Association


Marla Weston, PhD, RN
Chief Executive Officer
American Nurses Association


Karen J. Nichols, DO
President
American Osteopathic Association


Thomas E. Meninghan, Pharmacist, BS Pharm, MBA, ScD, FAPhA
Executive Vice President and CEO
American Pharmacists Association


Karen Peddicord, RNC, PhD
Chief Executive Officer
Association of Women’s Health, Obstetric and Neonatal Nurses


Jennifer L. Howse, PhD
President
March of Dimes


Anne Schuchat, MD
RADM, United States Public Health Service Assistant Surgeon General
Director, National Center for Immunization and Respiratory Diseases