ABSTRACT BACKGROUND Prenatal alcohol exposure (PAE) impacts the neurodevelopment of the fetus, including the infant’s ability to self-regulate. Heart rate variability (HRV), that is, the

beat-to-beat variability in heart rate, is a non-invasive measurement that can indicate autonomic nervous system (ANS) function/dysfunction. METHODS The study consisted of a subset of our

ENRICH-2 cohort: 80 participants (32 PAE and 48 Controls) who had completed three visits during pregnancy. The participants completed a comprehensive assessment of PAE and other substances

throughout pregnancy and assessments for stress, anxiety, and depression in the third trimester. At 24 h of age, infant HRV was assessed in the hospital during the clinically indicated heel

RSA, HF, and low-frequency / high-frequency (LF/HF, _p’s_ < 0.05). CONCLUSIONS Alterations in ANS regulation associated with PAE and maternal stress may reflect abnormal development of

the hypothalamic-pituitary-adrenal axis and have long term implications for infant responsiveness and self-regulation. IMPACT * Previous studies have focused on effects of moderate to heavy

prenatal alcohol exposure (PAE) on autonomic dysregulation, but little is known about the effects of lower levels of PAE on infant self-regulation and heart rate variability (HRV). *

Prenatal stress is another risk factor for autonomic dysregulation. * Mild PAE impacts infant self-regulation, which can be assessed using HRV. * However, the effect of prenatal stress is

stronger than that of mild PAE or other mental health variables on autonomic dysregulation. You have full access to this article via your institution. Download PDF SIMILAR CONTENT BEING

VIEWED BY OTHERS PRENATAL SMOKING AND DRINKING ARE ASSOCIATED WITH ALTERED NEWBORN AUTONOMIC FUNCTIONS Article 19 April 2022 MATERNAL HEART RATE VARIABILITY AT 3-MONTHS POSTPARTUM IS

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EMOTION DYSREGULATION, AND NEWBORN NEUROBEHAVIOR Article 03 August 2024 INTRODUCTION Alcohol use during pregnancy continues to pose a worldwide concern.1,2,3,4,5 From 1984 to 2014, the

prevalence of alcohol use during pregnancy was estimated at 9.8%, with women in the United States having a prevalence of alcohol use of 10.2%.2 More current reports estimate 11.5–15.0% of

pregnant women consume alcohol during pregnancy.6,7,8 The recent COVID-19 pandemic has also resulted in an increase in alcohol consumption.9 Importantly, alcohol can readily cross the

placenta10 and impact the developing fetus. As the fetus is not able to effectively eliminate alcohol, exposure can have a prolonged effect.11,12,13 Therefore, the CDC and researchers

believe that no or only a small amount of alcohol use during pregnancy is considered safe.14 The effect of alcohol on the developing fetus is broad, with multiple organ systems impacted,

including cardiac, endocrine, and immunological.2,10,15,16,17,18,19,20 Most notably, the nervous system is directly impacted by prenatal alcohol exposure (PAE).21,22,23,24,25 Fetal alcohol

spectrum disorder (FASD) is the umbrella term used to describe the long-term impact of PAE, the most serious of which is fetal alcohol syndrome (FAS). Individuals with an FASD experience

difficulties in motor functioning, attention, executive function, cognition, and social skills, as well as exhibiting adverse physical and mental health outcomes.14,23,26,27,28,29,30 One of

the problems in providing services and support for children with FASD and their families is centered around the difficulty in obtaining a diagnosis at an early age, so that early

intervention services can be initiated.31,32,33 Often, the extent of the child’s deficits may not be apparent until middle childhood.33 Thus, identifying markers or measurements that can

provide support for a diagnosis is essential in this population and continues to be a focus of research.31,34 Self-regulation, or the ability to monitor and manage feeling and behaviors, is

critically important in the development and maturation of executive function and is currently being investigated as a possible early marker of altered development in numerous studies.35,36

Indeed, updated guidelines on diagnosing an FASD include neurobehavioral impairment in specific domains, such as global intellectual ability, cognition, behavior and self-regulation, and/or

adaptive skills.32 The behavioral deficits in children with a FASD may present more challenges in daily life than deficits in other domains. Heart rate variability (HRV) can provide insight

into the balance between the sympathetic and parasympathetic nervous system activity and ultimately into emerging self-regulatory skills. Specifically, the variability in heart rate, or the

beat-to-beat differences, results from changing levels of sympathetic and parasympathetic outflow.37,38 HRV signal parameters can be used to provide a noninvasive assessment of the autonomic

nervous system.37,38 Numerous medical conditions in infants, including prematurity, low birth weight, sepsis, necrotizing enterocolitis, and hypoxic ischemic encephalopathy, have been

associated with decreased HRV; thus, measurement of HRV has been useful in indicating developmental alterations.39,40,41,42,43 Interestingly, prior studies of effects of moderate to heavy

PAE, such as ref. 44 reported that the alcohol-exposed infants had _decreased_ HRV in response to heel lancing for the newborn screening compared to unexposed healthy controls, indicative of

reduced behavioral arousal and alteration in self-regulation. Additional studies have reported similarly decreased HRV in infants with PAE and reductions in parasympathetic activity during

infancy that persist into childhood.45,46 To date, no studies of low levels of PAE using HRV have been conducted, making the applicability of these results unknown in milder exposures. While

prenatal substance exposure can impact infant HRV parameters, another important contributing factor is maternal stress, which consists of perceived stress, anxiety, and associated mental

health disorders. Numerous studies have investigated the impact of maternal stress on infant and child self-regulation.47,48,49,50 Specifically, maternal stress has been shown to be directly

associated with lower infant physiological regulation at 6 months of age,50 with an increased risk of self-regulatory difficulties at age 2 years.49 Thus, to better understand the impact of

PAE on HRV, information on maternal stress also needs to be considered. While most prior studies on effects of PAE have been conducted in populations with moderate-to-heavy alcohol use

during pregnancy, little is known about the effects of lower levels of PAE on infant self-regulation and HRV, even though lower levels of drinking are more prevalent. Our aim was, therefore,

to evaluate the impact of low levels of PAE and of maternal stress on autonomic regulation within the first days of life in infants born to a well-characterized prospectively-recruited

cohort. MATERIAL AND METHODS ETHANOL, NEURODEVELOPMENT, INFANT AND CHILD HEALTH (ENRICH-2) STUDY Mothers and infants from the ENRICH-2 longitudinal prospective cohort participated in this

study, following approval by the University of New Mexico (UNM) Health Sciences Center Institutional Review Board (IRB). Enrollment was conducted between 2018 and 2022. The prospective

design spans from the second trimester of pregnancy until 6–9 months after birth and includes four study visits (V1–V4). The study design incorporated maternal structured interviews and

biological sample collection from two prenatal visits, collection of maternal blood and urine samples, placenta, and umbilical cord blood samples at delivery (V3), a comprehensive

developmental assessment at birth/first month of life, and a 6-month follow-up assessment of child development (V4). The first two study visits (enrollment [V1] and third trimester [V2])

were conducted in the antenatal period. At V1, socio-demographic information was collected, including participant age, marital status, education, employment, and ethnic group. Health

information included gravidity, parity, complications during the pregnancy, chronic health conditions, and medications. A short screener using the AUDIT-C questionnaire was used to inquire

about binge drinking episodes (≥4 drinks/occasion) in the periconceptional period (2 weeks before and 2 weeks after the last menstrual period).51,52,53,54,55,56 A Timeline Follow-Back (TLFB)

interview57,58 was used to collect information about alcohol consumption, date of last drinking, maximum number of drinks in a day, and binge drinking episodes at five different time

points: the periconceptional period, and 30 days prior to each of the scheduled visits (V1-V4). One standard drink unit (SDU) was the equivalent of one 12-ounce can or bottle of beer, one

5-ounce glass of regular wine, 1.5 ounces of hard liquor, or one mixed drink with 1.5 ounces of hard liquor. The quantity and frequency reported in the TLFB were used to calculate the

absolute ounces of alcohol/day. Biomarkers were obtained at the V1 session. The ethanol biomarkers collected included γ-glutamyltranspeptidase (GGT), carbohydrate-deficient transferrin

(%dCDT), phosphatidylethanol (PEth) and urine ethyl glucuronide and ethyl sulfate (uEtG/uEtS).59,60 In addition, the pregnant participant’s blood and urine samples were collected to

ascertain alcohol and illicit drug use (i.e., cocaine, methamphetamines, heroin, or ecstasy) or medication assisted therapy (e.g., methadone or buprenorphine). Participants were assigned to

the PAE or Control group using a 3-tiered screening process (see Fig. 1). Tier I consisted of the AUDIT-C questionnaire and information about binge drinking episodes in the periconceptional

period. Those participants with an AUDIT-C score of ≥2 and reports of ≥2 binge drinking episodes or >13 drinks around the time of the last menstrual period were provisionally enrolled in

the PAE group; those with no binge drinking and an AUDIT-C score of <2 were provisionally enrolled in the Control group. Tier II focused on alcohol use during pregnancy and required more

than minimal-risk alcohol use (>13 SDU per month) based on the prospective 30-day TLFB interviews. Participants who reported greater than 13 SDU in the four TLFB or at least one binge

episode during pregnancy remained in the PAE group, with the Control group consisting of individuals with no alcohol use beyond the periconceptional period (no binge episodes and no SDUs).

Tier III assessed for ethanol biomarkers; Control participants had all negative biomarkers. To remain in the PAE group, the participant was required to have ≥1 binge episode or >13 drinks

or ≥1 positive biomarker. Alcohol exposure levels required in the PAE group follow greater than “minimal risk” exposure levels recommended for diagnosis of PAE-related disorders.61

Co-exposure to nicotine and marijuana was not considered a reason for exclusion in both PAE and Control groups and were assessed via self-report and urine drug screen both at enrollment (V1)

and delivery (V3). The National Survey on Drug Use and Health questionnaire was used to screen for self-reported drug use. A 7-panel drug test was used to screen for basic opiates

(including codeine, morphine, and heroin), expanded opiates (including oxycodone and hydrocodone), amphetamines, cocaine, phencyclidine (PCP), marijuana, and ecstasy. Those with prenatal use

of cocaine, amphetamines, opioids/medication assisted therapy (methadone, buprenorphine), or ecstasy were excluded based on either self-report, positive drug test, or medical record review.

During the V2 visit, the mothers were administered the following mental health interviews or questionnaires: the Perceived Stress Scale (PSS),62 Generalized Anxiety Disorders-7

questionnaire (GAD-7),63 Edinburgh Depression Scale (EDS),64,65 modified Medical Outcomes Study Social Support (MOSS),66 Posttraumatic Stress Disorder Checklist for Diagnostic and

Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), and Adverse Childhood Experiences (ACEs) questionnaire. Any participant with a serious mental health disorder (e.g., psychosis

or schizophrenia) was excluded from the study. V3 occurred with the infant delivery, at which time the Barratt Simplified Measure of Social Status67 and information on any new major life

events since V2 were collected from the mother. Maternal blood and urine samples were again collected at V3, and dried blood spots (DBS) were collected from the newborns via heel-lancing at

the time of a clinically indicated blood collection to measure the PEth (PEth-DBS).59,68,69 Children with severe fetal/infant anomalies were excluded from the study (e.g., major structural

abnormality or complications requiring surgery or general anesthesia, such as congenital diaphragmatic hernia or gastroschisis) as well as those born <35 weeks gestational age since these

problems may have resulted in similar dysregulatory outcomes unrelated to the focus of the study. Infants with a prolonged hospitalization were excluded retrospectively. Maternal or newborn

administration of corticosteroids or children not living with a biological parent were also exclusionary criteria. A total of 135 participants met all eligibility criteria after V2 and

advanced through the study pipeline. Among those, 3 participants voluntarily withdrew and 1 was lost to follow-up due to delivery at another hospital, resulting in 131 subjects who completed

V3 at least partially (97%). Among those, 80 (61.1%) had complete HRV data available. During the COVID-19 pandemic, UNM Hospital had restrictions on all in-person clinical research

activities beginning March 17, 2020, with all restrictions being lifted at the end of May 2022, which affected in-hospital collection of HRV data by the research team. The study team was

able to collect at least partial information from V3 for the majority of participants by switching to phone interviews to retain them in the cohort. HEART RATE VARIABILITY During V3, the

infant EKG was administered to obtain HRV measures during the newborn heel-lance performed at 24 h post-delivery. Specifically, a BIOPAC Systems, Inc., MP150 was used to obtain the data.

Three cardiac electrodes were attached to the infant’s chest, with a pneumogram transducer taped midline at the diaphragm level. The tracing was then recorded for 3 min to obtain a baseline

measurement prior to heel lancing (baseline). The acute stressor was comprised of a heel lance used to obtain blood for the routine newborn screening labs and collection of a DBS card for

PEth analysis. The HRV was recorded during this period (heel lance), with at least 3 min of recording obtained during the blood collection procedure. Finally, a recording was obtained for 3 

min after the completion of blood collection (recovery). The time domain measures of HRV quantify the time intervals between QRS complexes, which is the R-R interval (from R-R peaks) or N-N

interval (normal-to-normal intervals between adjacent QRS complexes resulting from sinus node depolarizations). The time domain measures are calculated from the N-N intervals and include the

root mean square of the successive differences (RMSSD).70 The frequency domain measures are used to assess the spectral component of HRV and include low frequency (LF) power (0.04–0.15 Hz),

high frequency (HF) power (0.15–0.40 Hz) and LF/HF ratio. The respiratory sinus arrhythmia (RSA), which measures the variation in heart rate that occur with respiration, was also obtained.

Upon completion of the recordings, the electrodes and pneumogram transducer were removed using a natural oil to minimize skin irritation. The HRV measures were extracted using the

QRSTool/CMETX software (Tucson, Arizona, United States) for data cleaning and Kubios software (v3.4.2; Kuopio, Finland) for analysis of the IBI (inter-beat-interval, consistent with time

interval between successive ECG R-waves) data. STATISTICAL ANALYSIS Demographic and clinical characteristics were summarized using means and standard deviations (SD) for continuous variables

and counts (percentages) for categorical variables. Distributions for HRV measures were reviewed for normality assumptions, and HRV measures utilized in regression analyses, with the

exception of heart rate, were natural log-transformed. Pearson correlation coefficients between PSS, GAD-7, EDS, and PCL-5 scores were examined. Generalized least squares mixed effects

models using maximum likelihood were created for each of the HRV measures. These models accommodate missing values in the response variable by making use of all the available information

(the repeated measures). Models accounted for the repeated HRV measures for each participant, and covariance structures were selected based on the lowest AIC score. The lowest AIC scores

were found for a compound symmetry covariance structure on every HRV measure except Ln LF/HF, for which an unstructured covariance structure was used. Once covariance structures were

selected, restricted error maximum likelihood estimates were used. Separate univariate models were constructed to examine relations between the HRV measures and the effects of group and of

HRV episode, as well as marijuana use and each of the mental health scales. Initial multivariable models for each HRV measure were then constructed to examine the interaction between groups

(PAE vs. Control) and HRV episode (baseline as the reference episode). Following this, separate multivariable mixed effects models were constructed with group (PAE vs. Control), HRV episode

(baseline as the reference episode), marijuana use, and each of the mental health scales. Least squares estimates from the multivariable models were used to estimate Bonferroni-adjusted

pairwise comparisons between each time measurement (i.e., baseline, heel lance, recovery). SAS statistical software (version 9.4; Cary, North Carolina, United States) was used for

statistical analyses. Analyses were two-tailed, and statistical significance was determined with an alpha level of 0.05; _p_ < 0.10 representing significance at a trend level are also

reported. RESULTS No significant differences between the groups were observed in the maternal sociodemographic characteristics, which included maternal age, marital status, ethnic group,

education level, employment status, income, and medical insurance type (Table 1, _p_ > 0.05). The average maternal age was slightly less than 30 years. Just over half the women identified

as Hispanic/Latina (56%); the majority were married or cohabitating (~70%). Over 60% of women were employed and 28% had some college or vocational school education, while about 39% had a

college degree. No differences were observed between groups for income, with only 28.1% of PAE and 41.7% of Controls earning less than $30,000 per year. No significant between group

differences were found for the infant characteristics and birth outcomes, including gestational age at delivery, birth weight, sex, mode of delivery, and preterm status, (Table 1, _p_ > 

0.05). As shown in Table 2, the average amount of alcohol per day across the pregnancy was found to be 0.12 ± 0.11 ounces for the PAE group with the average amount of alcohol per drinking

day during pregnancy 0.51 ± 0.27 ounces. This is considered low exposure71 or less than 1 drink/day on average. The prevalence of marijuana use was higher among participants in the PAE than

the Control group (_p_ < 0.01). For all mental health measures except the ACEs, significant differences were observed between the PAE and Control groups (all _p_’s < 0.05, Table 3).

Women in the PAE group had higher scores for PSS, GAD-7, EDS, and PCL-5, indicating greater levels of stress, anxiety, depression, and trauma experience. PSS, GAD-7, EDS, and PCL-5 were all

highly correlated (all _r’_s > 0.7, all _p_’s < 0.01), with EDS (depression) having the highest correlation values with the other measures (_r_ = 0.79 with GAD-7, _r_ = 0.77 with PSS,

and _r_ = 0.74 with PCL-5). Figure 2 summarizes average HRV values for infants at the three HRV episode points—baseline, heel lance, and recovery. Of the 80 participants, RSA values were

missing for 5 participants (5.9%). All participants had sufficient data quality (despite infant movement) to assess HRV variables including measurement for heart rate, RMSSD, LF, and HF, for

at least 1 episode. The baseline episode had the most complete data (>85% for all measures), while during the heel-lance episode HR signal quality was the lowest (75–79%). HRV measures

for all three episodes were available for 61.2% of participants, 24.7% had measures for two episodes, and 14.9% had measures for one episode. There were no significant differences between

the PAE and Control groups for missing HRV measures at each HRV episode, nor were differences observed between the PAE and Control groups for the baseline or heel-lance HRV measures (all

_p_’s > 0.05). At the recovery episode, infants in the PAE group had higher mean heart rate and lower Ln RMSSD, Ln LF, Ln HF, and Ln RSA values (all _p_’s < 0.05). The univariate

associations between PAE, prenatal marijuana use, maternal stress, and mental health outcomes with HRV measures are presented in Tables 5 and 6 in the Appendix. In univariate analyses, there

were significant negative effects of PAE on Ln RSA and Ln HF (both _p_’s < 0.05), as well as a trend for a negative effect that fell short of conventional levels of statistical

significance for Ln RMSSD (_p_ < 0.10). There was also a positive effect of PAE on Ln LF/HF that fell just short of statistical significance (_p_ = 0.06). Significant negative

associations were observed for each unit increase in PSS score and Ln RSA, Ln HF, and Ln LF/HF (all _p_’s < 0.05). The direction of effects for GAD-7 and EDS were similar to PSS, and

GAD-7, EDS, and PCL-5 were significantly associated with Ln LF/HF (_p_ < 0.05). Marijuana use was not associated with any HRV measure. Initial multivariable regression models were first

constructed that included the group (PAE vs. Control), time (HRV episode), and the group-by-time interaction. The interaction terms were non-significant for all HRV measures (all _p_’s > 

0.05) and were dropped from subsequent analyses. With respect to differences between episodes, there were significant differences for heart rate in Bonferroni adjusted pairwise comparisons

between baseline and heel lance episodes (_p_ < 0.001) and between heel lance and recovery episodes (_p_ = 0.002). For Ln RSA, significant differences between heel lance and recovery (_p_

 = 0.032) were also found. Table 4 summarizes the multivariable models that include PSS. In these models, PAE status was no longer a significant factor for any HRV measure (_p_ > 0.05).

There was a significant association between PSS and Ln HF (_p_ = 0.04) as well as PSS and Ln LF/HF (_p_ = 0.002); while the effect for PSS and Ln RSA showed a marginal trend that fell short

of conventional levels of statistical significance (_p_ = 0.096). Results of multivariable analyses with respect to other mental health scales are summarized in the Appendix (Table 5). In

these models, no significant relations between mental health scales and HRV measures were noted; though relations were observed for GAD-7 and EDS with Ln LF/HF ratio of borderline

statistical significance (_p_ = 0.06). DISCUSSION In this cohort of infants with mild PAE, there was a significant association between the alcohol exposure and HRV measures during the

recovery phase from an acute noxious stimulus (heel lance). Specifically, mean heart rate was higher and RMSSD, LF, HF, and Ln RSA values were all lower in infants with PAE than in unexposed

Controls. As RMSSD reflects the integrity of vagus nerve-mediated autonomic healthy control of the heart,72 and LF and HF reflect the activities of the autonomic nervous system,37 these

results indicate an alteration in the ability of infants with PAE to return to a normal baseline within the timeframe needed by unexposed Controls. Importantly, the autonomic nervous system

acts in a coordinated manner with the HPA axis to mediate the overall response to stressors. Indeed, these two systems are highly interconnected: they are reciprocally innervated, interact

through a feed-forward mechanism (activity in either system increases activity in the other), and are both under the inhibitory healthy control of the same brain areas (prefrontal cortex and

limbic system structures such as the hippocampus).73 Thus, it is possible that the altered activity and regulation of the autonomic nervous system demonstrated here reflects the fact that

PAE is known to alter both autonomic and HPA activity and regulation, which would result in altered interactions between these systems. It is possible that a change in the balance between

autonomic and HPA activity may be key to increasing risk for adverse health outcomes.73 Thus, our findings have important implications for the long-term consequences of PAE on stress

reactivity and regulation as well as behavior, adaptive function, and health following PAE.73,74,75,76,77,78 Interesting future directions would include: (a) assessing any differences in the

time needed for the autonomic nervous system to recover fully to baseline, to determine whether or not the altered activity following PAE is a delay is return to baseline function; (b)

measuring cortisol levels pre- and post-stress to assess possible differences in HPA responsiveness to the stressor; and (c) examining associations/interactions between these systems. The

ability to diagnose FASD following PAE remains a challenge, as the alcohol exposure may not be documented, women may be reluctant to admit alcohol use during pregnancy or forget consumption

of low levels,58,79 and the developmental impact may not be apparent very early in life. The criteria for a diagnosis of full FAS can be based on short stature and the characteristic FAS

facial features and neurobehavioral impairment, which can include impairment in self-regulation.32 Thus, the utilization of HRV in the newborn period may serve as a type of biomarker to

provide additional important information in diagnosing FASD. Our study also demonstrated significant effects of maternal stress and mental health on infant autonomic regulation. Stress has

been shown to impact overall health, and the PSS is a widely used survey which can be used to assess perceived stress.62 Maternal prenatal stress impacts fetal brain development, emotional

regulation, and infant mental disorders and increases the risk of infant mortality.77,78,80 The PSS has been shown to be appropriate for both English- and Spanish-speaking individuals in the

United States,81 both of whom were included in our study. A higher score indicates higher perceived stress. Within our cohort, an increase in the maternal PSS score was associated with a

decrease in infant HRV measures, indicating that the level of maternal stress may impact the autonomic nervous system of the infant. Indeed, maternal stress has been shown to negatively

impact the child’s ability to self-regulate.49 Moreover, the fetal HPA axis has been shown to be highly susceptible to programming following PAE.82 Thus, in addition to its effects on infant

autonomic regulation, maternal stress can more directly impact fetal HPA development, with its significant long-term consequences, as noted.74,75,76,83 The Generalized Anxiety Disorder

module 7 (GAD-7) is a survey that has been shown to be reliable in screening, diagnosing, and determining severity of anxiety.84 We found an association between the GAD-7 results and LF/HF

ratio, which provides additional evidence that maternal stress and anxiety during pregnancy can result in alterations in the infant’s ability to self-regulate at 24 h of age. We also found

an association between the maternal scores on the Edinburgh Depression Scale (EDS), a brief self-rating scale which screens for depression and has been validated in women and men,64,85 and

the infant’s LF/HF. Finally, we can view our data through the lens of the stress-diathesis model. It is known that alcohol, in addition to its teratogenic effects, can program developing

neurobiological systems, altering brain development and increasing vulnerability to later life deficits in cognitive, behavioral, and adaptive function, as well as altered stress

responsiveness, self-regulatory abilities, and physical and mental health problems.50,82,86,87,88,89 Furthermore, children with PAE are often at increased risk for exposure to adverse and/or

stressful environments during postnatal life. In the context of the stress-diathesis model, we suggest that fetal programming of stress systems by PAE may alter neuroadaptive mechanisms

that play a role in mediating the stress response, thus sensitizing the organism to stressors encountered later in life, and underlying, at least partly, the increased vulnerability to

deficits and disorders in multiple domains. For example, children with PAE who then experience trauma in childhood are more likely to have deficits in language, attention, memory,

intelligence, and have more severe behavioral problems compared to those experiencing trauma but without PAE.90 Thus, children with PAE are at high risk of altered neurodevelopment at birth,

which places than at higher risk of further deviations from normal development when faced with later insults. Limitations of this study include relatively overall small sample size, which

can result in an inability to detect smaller effect sizes or to further examine dose-response/timing of the PAE, and challenges in collecting high quality HRV data from neonates leading to

missing HRV metrics across episodes. However, despite the small sample size, changes were nonetheless observed following exposure to low doses of alcohol during pregnancy. The mixed effects

modeling used may have allowed for missing repeated measures data to be analyzed, thereby helping to optimize the use of the available data. While many studies focus on higher-dose exposures

(such as 7.8 drinks per occasion 1–2 days per week44), many women report drinking low levels of alcohol in pregnancy because they believe that “only ‘strong’ alcohol and alcohol in large

quantities is harmful”.91 Thus, investigating the impact of low dose exposure is both important and clinically relevant. This cohort is unusual since it represents a largely Hispanic/Latina

population, with the overall educational level of the mother higher (less than a college degree) than that seen in many previous studies where the mothers had less than a high school degree

for education.44,92 CONCLUSIONS PAE, even at low doses, can negatively impact the development of the fetus, often with lifelong consequences. This study found differences in HRV in infants

prenatally exposed to alcohol, which indicated significant alterations in autonomic regulation. HRV measure alterations were also strongly associated with maternal stress, with implications

for programming of fetal HPA development. Alterations in overall regulation of the stress system will have long-term consequences for infant development. The datasets generated during and/or

analyzed during the current study are not publicly available due to the lack of such data sharing acknowledgment in the consent and IRB protocol. The request for data sharing can be

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PubMed Central  Google Scholar  Download references ACKNOWLEDGEMENTS The authors would like to thank Dominique Rodriguez, Laura Stacy, Sandra Beauman, Conra Lacy, Elizabeth Kuan, and Nicole

Salazar for their help with data collection and data management. FUNDING Funding Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism

of the National Institutes of Health under Award Number R01AA021771. The content is solely the responsibility of the authors and does not necessarily represent the official views of the

National Institutes of Health. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Pediatrics, University of New Mexico, Albuquerque, NM, Mexico Jessie R. Maxwell * Department of

Neurosciences, University of New Mexico, Albuquerque, NM, Mexico Jessie R. Maxwell * Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico,

Albuquerque, NM, Mexico Jared DiDomenico, Melissa H. Roberts, Lidia Enriquez Marquez, Rajani Rai & Ludmila N. Bakhireva * Department of Cellular & Physiological Sciences, University

of British Columbia, Vancouver, BC, Canada Joanne Weinberg * Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA Sandra W.

Jacobson * The Mind Research Network, a Division of Lovelace Biomedical Research Institute, University of New Mexico, Albuquerque, NM, Mexico Julia Stephen Authors * Jessie R. Maxwell View

author publications You can also search for this author inPubMed Google Scholar * Jared DiDomenico View author publications You can also search for this author inPubMed Google Scholar *

Melissa H. Roberts View author publications You can also search for this author inPubMed Google Scholar * Lidia Enriquez Marquez View author publications You can also search for this author

inPubMed Google Scholar * Rajani Rai View author publications You can also search for this author inPubMed Google Scholar * Joanne Weinberg View author publications You can also search for

this author inPubMed Google Scholar * Sandra W. Jacobson View author publications You can also search for this author inPubMed Google Scholar * Julia Stephen View author publications You can

also search for this author inPubMed Google Scholar * Ludmila N. Bakhireva View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS J.M.:

substantial contributions to acquisition of data and interpretation of data; drafting the manuscript; final approval of the version for publication. M.R.: substantial contributions to

analysis and interpretation of data; Revising the manuscript critically for important intellectual content; final approval of the version for publication. L.E.M.: substantial contributions

to acquisition of data; revising the manuscript critically for important intellectual content; final approval of the version for publication. R.R.: substantial contributions to acquisition

of data; revising the manuscript critically for important intellectual content; final approval of the version for publication. J.D.: substantial contributions to analysis and interpretation

of data; revising the manuscript critically for important intellectual content; final approval of the version for publication. J.W.: revising the manuscript critically for important

intellectual content; final approval of the version for publication. S.J.: contributions to acquisition of data; revising the manuscript critically for important intellectual content; final

approval of the version for publication. J.S.: substantial contributions to conception and design and interpretation of data; revising the manuscript critically for important intellectual

content; final approval of the version for publication. L.B.: substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; Revising the

manuscript critically for important intellectual content; final approval of the version for publication. CORRESPONDING AUTHOR Correspondence to Jessie R. Maxwell. ETHICS DECLARATIONS

COMPETING INTERESTS The authors declare no competing interests. INFORMED CONSENT Informed participant consent was obtained prior to initiation of study activities. ADDITIONAL INFORMATION

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ARTICLE CITE THIS ARTICLE Maxwell, J.R., DiDomenico, J., Roberts, M.H. _et al._ Impact of low-level prenatal alcohol exposure and maternal stress on autonomic regulation. _Pediatr Res_ 95,

350–358 (2024). https://doi.org/10.1038/s41390-023-02799-5 Download citation * Received: 28 February 2023 * Revised: 07 June 2023 * Accepted: 09 August 2023 * Published: 06 September 2023 *

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