Abstract
Background:
Maternal depression has been linked to healthcare use for asthma in cross-sectional or short-term follow-up studies of school-aged children.
Objective:
To examine whether increased or persistent maternal depressive symptoms over ~5 years are associated with severe asthma exacerbations or worse lung function in youth.
Methods:
Prospective study of 386 youth living in Puerto Rico, aged 6–14 years at a baseline visit and 9–20 years at a second visit. Our exposure of interest was change in or persistence of maternal depressive symptoms, assessed at both visits using the Center for Epidemiologic Studies Depression Scale (CESD-D). Our outcomes of interest were change in percent predicted FEV1 and FEV1/FVC between the first and second visits in all subjects, and ≥1 severe asthma exacerbation in the year prior to the second visit in subjects with asthma.
Results:
In a multivariable analysis, each one-point increment in the CESD score was associated with decrements of 0.15% in percent predicted FEV1 (95% CI= −0.28% to −0.01%; P= 0.03) and 0.10% in percent predicted FEV1/FVC (95% CI= −0.20% to 0.001%; P= 0.05) between visits, as well as with 1.03 times increased odds of ≥1 severe asthma exacerbation at the second visit (95% CI for odds ratio=0.99 to 1.06, P= 0.09). In a multivariable analysis, the presence of maternal depressive symptoms (a CESD score ≥21 points) at the second visit or at both visits was significantly associated with 3.17 to 3.52 times increased odds of ≥1 severe asthma exacerbation in the year prior to the second visit.
Conclusions:
Increasing or persistent maternal depressive symptoms over ~5 years are associated with worse lung function measures and severe asthma exacerbations among Puerto Rican youth, a high-risk population.
Keywords: maternal depression, lung function, asthma attacks, Puerto Rican, children
INTRODUCTION
Asthma affects nearly 6 million children in the United States (U.S.) (1). Compared with non-Hispanic whites, Puerto Ricans share a disproportionate burden of asthma, both in the continental U.S. and in Puerto Rico(2). Indeed, the estimated prevalence of childhood asthma is twice as high in Puerto Ricans (13.6%) as in non-Hispanic whites (6.8%)(1).
In the continental U.S., Puerto Rican adults are more likely to report depressive symptoms than adults in other racial or ethnic groups (e.g., Mexican Americans), particularly in females(3, 4). Among Puerto Ricans, women are most often the primary caregiver of children, commonly to the point of self-sacrifice(5). Puerto Ricans are commonly exposed to risk factors for both depression and morbidity from asthma, including poverty, low educational attainment, and violence(6, 7).
Previous studies have shown that pre- or post-natal maternal depression has been associated with childhood asthma(8–10), and a prior report showed that maternal depression during a child’s school years was linked to emergency department visits for asthma over a six-month period of follow up(11). To date, however, little is known about the relationship between persistent or increasing maternal depressive symptoms over several years on lung function measures or severe asthma exacerbations (encompassing emergency department visits and hospitalizations for asthma requiring treatment with systemic corticosteroids) in children and adolescents.
On the basis of prior findings, we hypothesized that increased or persistent maternal depressive symptoms over a period of approximately 5 years would be associated with worse lung function and severe asthma exacerbations among Puerto Rican youth. We examined this hypothesis in a prospective study of Puerto Ricans followed from ages 6 to 14 years to ages 9 to 20 years.
METHODS
Study population
PR-GOAL:
Subject recruitment and study procedures for the Puerto Rico Genetics of Asthma and Lifestyle Study (PR-GOAL) have been previously described(12). Participants were recruited from March 2009 through June 2010 from randomly selected households in the metropolitan area of San Juan and Caguas (Puerto Rico) using a multistage probabilistic sampling design. Based on this sampling design, 7,073 households were selected and 6,401 (91%) were contacted. Of these 6,401 households, 1,111 had ≥1 child who met inclusion criteria (age 6–14 years, four Puerto Rican grandparents, and residence in the same household for ≥ 1 year). Of these 1,111 households, 438 (39.4%) had ≥1 child with asthma (a case). From these 438 households, one child with asthma was selected (at random if there was more than one such child). Similarly, only one child without asthma (a control subject) was randomly selected from the remaining 673 households. To reach a target sample size of 700 children, we attempted to enroll 783 of the 1,111 eligible children. Parents of 105 (13.4%) of these 783 households refused to participate or could not be reached, leaving 678 study participants (351 cases and 327 controls). There were no significant differences in age, sex, or area of residence between eligible children who did (n=678) and did not (n=105) participate in PR-GOAL.
EVA-PR:
Subject recruitment and study procedures for the Epigenetic Variation and Childhood Asthma in Puerto Ricans study (EVA-PR) were similar to those in PR-GOAL and have been previously described(13). In brief, subjects were recruited from the metropolitan area of San Juan and Caguas (Puerto Rico) from February 2014 through May 2017. Of the 1,111 households that were randomly selected for PR-GOAL (see above), 1,045 still had current and correct contact information and were thus screened for EVA-PR. Of these 1,045 households, 180 were unreachable despite several efforts. Of the 865 households that were contacted, 720 had at least one child who met the following inclusion criteria: age 9 to 20 years, four Puerto Rican grandparents, and living in the same residence for at least one year. To reach a sample size of ~550 subjects, we attempted to enroll 638 of the 720 eligible children. Of the 638 children and adolescents whom we attempted to enroll, 543 (85.1%) agreed to participate. There were no significant differences in age, sex, or area of residence between subjects who did (n=543) and did not (n=95) agree to participate in EVA-PR.
Participants included in the current analysis:
Please see Figure 1. Of the 543 participants in EVA-PR, 406 had previously participated in PR-GOAL. Of these 406 subjects, 386 (95.1%) had complete data on maternal depressive symptoms and other covariates of interest for both EVA-PR and PR-GOAL), and were thus included in the current analysis.
Figure 1.
Study diagram for selection of the participants included in the current analysis
Study Procedures
All 386 participants included in this analysis completed a protocol including administration of questionnaires and spirometry at both study visits (i.e. for both the PR-GOAL and EVA-PR studies). One parent of each participant (more often [>93%] the mother) completed a questionnaire adapted from that used in the Collaborative Study of the Genetics of Asthma(14). Data obtained from this questionnaire included information regarding the child’s overall and respiratory health status, family history, demographics, and socioeconomic status. The Center for Epidemiologic Studies Depression Scale (CESD), a 20-item widely employed and validated questionnaire, was used to assess maternal depressive symptoms(15, 16). The total CESD score was calculated by summation of the scores for each item, leading to a total score ranging from 0 to 60 points.
Spirometry was conducted with an EasyOne spirometer (NDD Medical Technologies, Andover, Mass) according to the American Thoracic Society and European Respiratory Society recommendations(17). The best results for forced expiratory volume-one second (FEV1) and Forced vital capacity (FVC) were selected for data analysis.
Our outcomes of interest were change in percent predicted FEV1 and change in percent predicted FEV1/FVC between the first and second visits (with percent predicted values at each visit calculated using the Global Lung Function Initiative [GLI] equations, which account for age, sex, race/ethnicity, and height)(18), and severe asthma exacerbations at the second visit (defined as at least one hospitalization for asthma or at least one visit to the emergency department [ED] or urgent care for asthma, requiring treatment with systemic corticosteroids in the previous year; or one or more courses of systemic steroids for asthma(19) in the previous year).
Our exposure of interest was maternal depressive symptoms, which we analyzed as both a continuous variable (defined as change in the CESD score between the first and the second visits) and as a categorical variable (presence of maternal depressive symptoms at neither visit, at the first visit, at the second visit, or at both visits) Maternal depressive symptoms were defined as a CESD score ≥21 points, which has been deemed an adequate threshold for significant depressive symptoms in Puerto Rican adults, as well as an indicator of severe depressive symptoms in a general population of adults(15, 16).
Written parental consent was obtained for participating children, from whom written assent was also obtained. PR-GOAL was approved by the Institutional Review Boards of the University of Puerto Rico (San Juan, PR), Brigham and Women’s Hospital (Boston, MA) and the University of Pittsburgh (Pittsburgh, PA). EVA-PR was approved by the institutional review boards of the University of Puerto Rico (San Juan) and the University of Pittsburgh (Pittsburgh, PA, USA).
Statistical Analysis
Bivariate analyses were conducted using two-tailed t tests or analysis of variance for categorical and continuous variables, Chi-square tests for categorical variables, and Spearman correlation coefficients for pairs of continuous variables. The multivariable analysis of severe asthma exacerbations in cases was always adjusted for age and sex (this was not necessary for the analysis of percent predicted lung function measures, which already accounted for age and sex), and use of inhaled corticosteroids in the six months prior to the second study visit. The multivariable analysis of lung function was always adjusted for case-control (asthma) status. The time interval between the study visits and the following covariates (assessed at the second study visit) were considered for inclusion in the multivariable models, as either potential confounders or mediators of the relation between change in or persistent maternal depressive symptoms and lung function measures or severe asthma exacerbations: type of health insurance (private vs. others), annual household income (< vs. ≥$15,000/year, based on census data), maternal education (less than high school, completed high school, and college and above), maternal asthma, current exposure to second-hand smoke (SHS, defined as smoking by anybody in the child’s household), and body mass index (BMI) z-score. Of these covariates, the only ones to be significantly associated or correlated with either change in CESD score between study visits or maternal depressive symptoms at study visits were three indicators of socioeconomic status (SES) and/or healthcare access: type of health insurance, household income, and maternal education status (Table 1 and Figure E1). However, only type of health insurance was also significantly associated with change in lung function measures or severe asthma exacerbations (see Table 1 and tables E2-E3). Thus, all models for lung function or severe asthma exacerbations were additionally adjusted for type of health insurance. In addition, we conducted a mediation analysis based on a counterfactual framework to estimate the total, direct, and indirect effects of any covariate to be a potential mediator of the relation between maternal depressive symptoms and lung function of severe asthma exacerbation (20, 21). In this analysis, no covariate was shown to be a significant mediator. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC).
Table 1.
Participant characteristics by changes in CESD score or presence of maternal depressive symptoms at second study visits
| Change in CESD scorea | Maternal depressive symptomsb | ||||
|---|---|---|---|---|---|
| All participants (n=386) | At neither study visit (n=251) | At the first study visit only (n=41) | At the second study visit only (n=41) | At both the first and second study visits (n=53) | |
| Asthma status | |||||
| Control | 0 (−5, 3) | 119 (68.8) | 13 (7.5) | 15 (8.7) | 26 (15.3) |
| Case | 0 (−7, 5) | 132 (62.0) | 28 (13.2) | 26 (12.2) | 27 (12.7) |
| Sex | |||||
| Male | 0 (−6, 4) | 136 (67.0) | 25 (12.3) | 17 (8.4) | 25 (12.3) |
| Female | 0 (−7, 5) | 115 (62.8) | 16 (8.7) | 24 (13.1) | 28 (15.3) |
| Type of health insurance | |||||
| Private insurance | 0 (−5, 4) | 103 (77.4) | 13 (9.8) | 9 (6.0) | 8 (6.0)* |
| Others | −1 (−7, 5) | 148 (58.5) | 28 (11.1) | 32 (12.7) | 45 (17.8) |
| Annual household income | |||||
| <$15,000 | −1 (−6.5, 5) | 136 (54.2) | 29 (72.5) | 30 (73.2) | 37 (71.2)* |
| ≥$15,000 | 0 (−5, 4) | 115 (45.8) | 11 (27.5) | 11 (26.8) | 15 (28.9) |
| Maternal education | |||||
| Less than high school | 0 (−6, 6) | 45 (17.9) | 7 (17.1) | 12 (29.3) | 11 (29.3)* |
| High school graduate | −1 (−8, 7) | 66 (26.3) | 13 (31.7) | 16 (39.0) | 22 (41.5) |
| College and above | 0 (−5, 4) | 140 (55.8) | 21 (51.2) | 13 (31.7) | 20 (37.7) |
| Maternal asthma | |||||
| Yes | 0 (−8, 7) | 80 (58.0) | 17 (12.3) | 19 (13.8) | 22 (15.9) |
| No | 0 (−6, 4) | 169 (69.0) | 24 (9.8) | 22 (9.0) | 30 (12.2) |
| BMI z-scorec | 0.038 | 0.63 ± 1.08 | 0.64 ± 1.18 | 0.84 ± 0.94 | 0.87 ± 1.03 |
| Current second-hand smoke exposure | |||||
| Yes | 0 (−7, 6) | 84 (62.2) | 14 (10.4) | 12 (8.9) | 25 (18.5) |
| No | 0 (−6, 4) | 166 (66.4) | 27 (10.8) | 29 (11.6) | 28 (11.2) |
| Use of inhaled corticosteroids in the previous six months | |||||
| Yes | 0 (−8, 6) | 34 (58.6) | 9 (15.5) | 9 (15.5) | 6 (10.3) |
| No | 0 (−6, 4) | 214 (66.3) | 31 (9.6) | 31 (9.6) | 47 (14.6) |
| Children with asthma (cases, n=213) | |||||
| Severe asthma exacerbations in the previous year | |||||
| Yes | 3 (−4.5, 9.5) | 15 (41.7) | 6 (16.7) | 8 (22.2) | 7 (19.4)* |
| No | −1 (−8, 4.5) | 108 (65.9) | 22 (13.4) | 16 (9.8) | 18 (11.0) |
Median (interquartile range) and mean ± SD for BMI z-score
Center for Epidemiologic Studies Depression (CESD) score ≥ 21 points
Analyzed by Spearman correlation for change in CESD score and ANOVA for maternal depressive symptom
P< 0.05
RESULTS
Table E1 shows a comparison of the main baseline characteristics of the 386 subjects who participated in PR-GOAL (the first timepoint or study visit for our analysis) and were included in the current analysis against the 292 subjects who participated in PR-GOAL but were not included in this study because they did not participate in EVA-PR (n=272) or had missing data (n=20), separately for asthma cases and non-asthma control subjects. Compared with non-asthma controls included in the current analysis (n=173), those excluded (n=n=154) were slightly older. There were no significant differences in maternal CESD score, maternal depressive symptoms, lung function measures, or any other characteristic at the first study visit between non-asthma controls who were and were not included in the current analysis. Compared with asthma cases included in the current analysis (n=213), those excluded (n=138) had a lower BMI z-score and were more likely to be slightly older and exposed to SHS. There were no significant differences in maternal CESD score, maternal depressive symptoms, lung function measures, or having had ≥1 severe asthma exacerbation in the year prior to the first or baseline visit between asthma cases who were and were not included in this analysis.
A comparison of the baseline characteristics of the asthma cases and non-asthma control subjects included in the current analysis are shown in Table 2. Children with asthma (cases) had higher BMI z-score, lower FEV1 percent predicted and FEV1/FVC percent predicted than controls. There were no significant differences in age, sex, type of health insurance, CESD score, or the presence of maternal depressive symptoms (a CESD score ≥21 points) between asthma cases and non-asthma controls at the baseline (first) study visit. Moreover, the time interval between the two visits was similar between asthma cases (4.85 (1.04) years) and non-asthma controls (4.91 (0.90) years). Of the 213 asthma cases, 70 (33%) had used inhaled corticosteroids in the previous six months and 109 (51%) had at least one severe asthma exacerbation in the previous year.
Table 2.
Participant characteristics at the baseline (first) study visit
| All participants (n=386) | Subjects without asthma (Controls, n=173) | Subjects with asthma (Cases, n=213) |
|---|---|---|
| Age (years) | 10 (8, 13) | 10 (8, 12) |
| Male sex | 84 (49) | 119 (56) |
| Private health insurance | 64 (37) | 74 (35) |
| Annual household income ≥ $15,000 | 60 (36) | 77 (37) |
| Maternal education | ||
| Less than high school | 57 (33) | 64 (30) |
| High school graduate | 72 (42) | 91 (43) |
| College and above | 43 (25) | 57 (27) |
| Maternal asthma | 32 (19.1) | 98 (46.2)** |
| BMI z-score | 0.61 ± 1.12 | 0.90 ± 1.12* |
| Current second-hand smoke exposure | 61 (35.3) | 83 (39.2) |
| Use of inhaled corticosteroids in the previous six months | -- | 70 (33) |
| Maternal Depression | ||
| CESD scorea | 10 (5, 19) | 12 (6, 21) |
| Depressive symptomsb | 39 (23) | 55 (26) |
| Lung function measures | ||
| FEV1 percent predicted | 97.3 ± 15.6 | 91.7 ±14.9** |
| FEV1/FVC percent predicted | 94.2 (87.3, 99.5) | 91.8 (85.6, 97.4)* |
| Severe asthma exacerbations in the previous year | − | 109 (51%) |
Values are presented as n (%) for binary variables, mean ± SD for normally distributed continuous variables, or median (interquartile range) for non-normally distributed variables.
Center for Epidemiologic Studies Depression score (CESD)
Depressive symptoms: CESD score ≥ 21 points
P<0.05;
P<0.01 for comparison between non-asthma controls and asthma cases
Figure 2 and Table E2 show the results of the unadjusted and adjusted analyses of change in CESD score between the two study visits and the change in percent predicted lung function measures between the two study visits. In a multivariable analysis adjusting for asthma status and type of health insurance, each one-point increment in the CESD score was associated with a 0.15% decrement in percent predicted FEV1 (95% confidence interval [CI]= −0.28% to −0.01%, P= 0.03) and a 0.10% decrement in percent predicted FEV1/FVC (95%CI= −0.20 to 0.001, P=0.05). We found no significant association between the presence of maternal depressive symptoms at either visit or at both visits and change in percent predicted FEV1 or FEV1/FVC (see Table E3).
Figure 2.
Results of the regression fit plots for changes in CESD score* and: change in percent predicted FEV1 (left panel) and change in percent predicted FEV1/FVC (right panel).
Footnote: The multivariable models were adjusted for case-control (asthma) status and type of health insurance (private vs. others).
*Change in CESD score= total CESD score at the second study visit minus total CESD score at the first study visit
In the multivariable analysis of severe asthma exacerbations in the 213 asthma cases, each one-point increment in CESD score between the two study visits was associated with 1.03 times increased odds of ≥1 severe asthma exacerbations in the year prior to the second visit (95% CI for OR= 0.99 to 1.06; P= 0.09, see Table E4). Table 3 shows the results of the unadjusted and adjusted analyses of maternal depressive symptoms at the first visit, at the second visit, or at both visits and ≥1 severe asthma exacerbation in the year prior to the second visit. In a multivariable model adjusting for age, sex, type of health insurance, and use of inhaled corticosteroids in the previous six months, the presence of maternal depressive symptoms at the second visit and at both visits was significantly associated with 3.17 times and 3.52 times increased odds of ≥1 severe asthma exacerbation in the year prior to the second visit, respectively.
Table 3.
Multivariable analysis of the relation between presence of maternal depressive symptoms at study visits and severe asthma exacerbations in the year prior to the second study visit, among 213 asthma cases
| Variable | Unadjusted | Adjusteda | ||
|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Private health insuranceb | 0.40 (0.17, 0.97) | 0.04 | 0.46 (0.18, 1.17) | 0.10 |
| Use of inhaled corticosteroids in the previous six monthsb | 4.31 (2.03, 9.18) | <0.01 | 4.33 (1.88, 9.95) | <0.01 |
| Maternal depressive symptomsc | ||||
| At neither study visit | 1.0 | 1.0 | ||
| At the first study visit only | 2.05 (0.72, 5.85) | 0.18 | 1.64 (0.51, 5.27) | 0.41 |
| At the second study visit only | 3.50 (1.30, 9.42) | 0.01 | 3.17 (1.03, 9.72) | 0.04 |
| At both the first and second study visits | 2.75 (0.99, 7.60) | 0.05 | 3.52 (1.10, 11.32) | 0.03 |
Model adjusted for all variables listed in the column.
At the second study visit
Total CESD score ≥21 points
Because maternal asthma has been previously shown to interact with maternal depression on childhood asthma, we tested for such interaction in the final multivariable models. There was no significant interaction on any of the outcomes of interest (P ≥0.20 in all instances).
Of the 386 study participants, 28 (7.2%) had a change in asthma status between the two study visits (15 control subjects were classified as having asthma at the second study visit and 13 cases could be classified as being control subjects at the second study visit). We thus conducted a sensitivity analysis after excluding these 28 subjects, obtaining similar results.
DISCUSSION
To our knowledge, this is the first study of change or persistence in maternal depressive symptoms over time and lung function or severe asthma exacerbations in children and adolescents. In a study of Puerto Rican youth followed from ages 6–14 years to ages 9–20 years, increased maternal depressive symptoms between the first and second study visits were associated with decrements in FEV1 percent predicted and FEV1/FVC percent predicted over time. Although increased maternal symptoms were also associated with severe asthma exacerbations at the second study visit, such association was not significant at P <0.05. In this study, the presence of maternal depressive symptoms at the second study visit or at both study visits was significantly associated with more than threefold increased odds of severe asthma exacerbations at the second study visit. Our overall findings suggest that increased or persistent maternal depressive symptoms over time are associated with poorer asthma control or worse asthma severity in Puerto Rican children and adolescents.
Two previous studies in Latin American children showed no association between depressive symptoms in a child’s mother or caretaker and asthma hospitalizations(22) or asthma control(23), but those null findings could be explained by limited statistical power due to small sample size. In contrast, a study of 339 pairs of Puerto Rican twins followed up to age 3 years showed that maternal depressive symptoms in the child’s first year of life were associated with asthma hospitalizations between ages 1 and 3 years (adjusted OR=1.26, 95% CI=1.01 to 1.58)(24). Consistent with our findings, a study of 158 inner-city school-aged children with asthma reported that a high level of maternal depressive symptoms was associated with 1.3 times increased odds of emergency department visits for asthma after six months of follow up (95% CI=1.1 to 5.0)(11). Our results for increased maternal depressive symptoms and negative changes in lung function over time are partly consistent with those of a prior study in children with asthma, which demonstrated a lower FEV1 among children of caregivers with depression or anxiety, albeit in unadjusted analyses.17 Compared with those prior reports, the current study has larger sample size, longer duration of follow up, and an analytical approach that accounted for potential confounders such as type of health insurance and use of inhaled corticosteroids.
Maternal depression may be linked to worse asthma or lung function in youth through various pathways(25). First, depression may negatively impact a mother’s memory, executive function, and motivation, affecting knowledge and management of her child’s asthma, including adherence with prescribed treatments. Second, maternal depression may lead to negative parenting and thus increased stress or depression in the child, ultimately leading to autonomic and immune dysregulation and worse asthma24. Third, psychosocial stressors correlated with maternal depression (e.g., violence, racism) may also worsen a child’s asthma. Fourth, although our analysis was adjusted for ICS use and type of health insurance, greater asthma morbidity or severity in the child may have led to or worsened maternal depressive symptoms(25). Indeed, a growing body of evidence suggests that the relationship between maternal depression and asthma control or asthma severity in youth is likely to be bi-directional and multifactorial.
Both maternal depression and childhood asthma are common and often co-occur in Puerto Ricans, emphasizing the public health importance of our findings. “Machismo” is observed in Puerto Rico families, in which a “macho” is a male who is characteristically willful, dominant over wife and family, authoritarian, not visibly affected by tender emotions, nor given to contribute to child-rearing or household chores. Thus, in traditional Puerto Rican culture, mothers frequently place the needs of the family above their own and typically serve as the primary caregiver to children, often to their own detriment (5). Further, as Puerto Ricans are disproportionately represented among the poor, they may have limited access to mental health services(25). Moreover, Puerto Rican women may present with somatic complaints rather than classical symptoms of depression25, leading to potential underestimation of an already high prevalence of depression among Puerto Rican women.
Our study has additional limitations. First, our sample size -albeit larger than that of prior studies- may have limited our statistical power to detect modest associations between the persistence of maternal depressive symptoms and lung function. Second, we lack data on maternal depressive symptoms or asthma in pre- or early post-natal life, when a child’s immune system is more susceptible to external stimuli. Third, selection bias is possible in any observational study. However, such bias is an unlikely explanation for our results because there were no significant differences in the exposure (maternal depressive symptoms) or outcomes of interest between children who were and were not included in the current analysis. Fourth, we cannot exclude residual confounding by unmeasured variables such as paternal depression, maternal diet, or adherence with ICS.
Our findings support screening mothers of Puerto Rican children with asthma for depression. Further longitudinal studies are needed to better understand potential mediators and mechanisms of the link between maternal depression and morbidity from asthma.
Supplementary Material
Highlight Box.
1. What is already known about this topic?
Little is known about the relationship between persistent or increasing maternal depressive symptoms over several years and lung function measures or severe asthma exacerbations in children and adolescents..
2. What does this article add to our knowledge?
In this prospective study, increasing or persistent maternal depressive symptoms were associated with worse lung function measures (FEV1 and FEV1/FVC) and severe asthma exacerbations in Puerto Rican youth, a high-risk population.
3. How does this study impact current management guidelines?
Physicians caring for children with asthma should be aware of potential maternal depression, which -if suspected- should be appropriately addressed.
Acknowledgments
Funding: This work was supported by grants HL079966, HL117191, and MD011764 from the U.S. National Institutes of Health (NIH). Dr. Stevens was supported by grant T32 HL129949 from the U.S. NIH. The sponsor had no role in the design or implementation of the study, or the drafting and submission of the manuscript.
Dr. Celedón has received research materials from GSK and Merck (inhaled steroids) and Pharmavite (vitamin D and placebo capsules), to provide medications free of cost to participants in NIH-funded studies, unrelated to this work. Dr. Celedón is the President of the American Thoracic Society.
Abbreviations:
- CESD
The Center for Epidemiologic Studies Depression Scale
- CI
confidence interval
- FEV1
forced expiratory volume-one second
- FVC
forced vital capacity
- OR
odds ratio
Footnotes
Conflicts of interest: The other authors have no conflicts of interest to declare.
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