Research has shown that infants born to adolescent mothers are more likely to have

B Children of Adolescent Mothers

Children of adolescent mothers are at risk for a host of developmental problems. Without adequate prenatal care adolescent mothers often experience a large number of complications during delivery (Broman, 1981). Hence, their newborns are more likely to manifest developmental problems such as prematurity or low birth weight (Field, 1980). Even with adequate prenatal care and normal deliveries, children of teen mothers remain at risk for later development delays. For instance, data from the Perinatal Longitudinal Project of Broman, Nichols, Shaughnessy, and Kennedy (1987), which analyzed the outcomes of over 35,000 high-risk births, showed a higher percentage of mild retardation in the offspring of teen mothers versus adult mothers from similar SES and educational backgrounds. The actual percentage of retardation—attributable apparently to nonorganic causes—may be up to three times higher among teens. Similarly striking data have come from the Baltimore project of Brooks-Gunn and Furstenberg (1986). They found that up to one-half of the children of teen mothers showed behavioral and school-achievement problems, especially during their early teen years. These two important, longitudinal projects suggest that the social and psychological consequences of early pregnancy and teenage parenting are considerable, particularly for the children themselves and the society that helps guide their future development.

Belmont, Cohen, Dryfoos, Stein, and Sayac (1981) attempted to separate the effects of economic, social, and demographic disadvantages and maternal immaturity (mother’s age) on children’s cognitive development (WISC). The data were drawn from two large samples of the Health Examination Survey and from the Collaborative Perinatal Project, involving 12 medical centers and over 26,000 subjects. Children of mothers in the younger maternal age groups (≤ 19) had significantly lower IQ scores than children of mothers who were age 20 or older. When the effects of social variables such as family income, parental education, family size, and one- or two-parent families were controlled, maternal age continued to show a small, but significant, relationship with the children’s cognitive abilities. Mean IQ scores for several samples ranged from 91.36 to 94.41 for the children of young teens (14–17 years old), from 95.31 to 97.87 for children of older teens, and from 97.81 to 101.23 for children of adults.

Dramatic developmental changes for children living in poverty have been described in more recent and extensive longitudinal studies. Both the North Carolina Abecedarian and the Milwaukee projects have found that cognitive development declines over time for the children of low-IQ adult mothers. For instance, children in the control group of the Milwaukee Project declined up to 20 IQ points by age 10, provided they did not receive early intervention. Children of very low IQ mothers in the Abecedarian Project showed a dramatic decline in IQ, up to 25 points, by age 10. In both projects, the intervention and control children were very similar on early measures of cognitive development, with most children appearing to be functioning within the normal range of development. In the Abecedarian Project, children in the control condition were 3.5 times as likely to have cognitive-educational deficits (i.e., IQs below 85). Older siblings of the target sample were also evaluated on the Wechsler scale (Ramey & Campbell, 1981); the mean IQ for older siblings was found to be 87.4. These findings support the general conclusion that IQs continue to decline for children in poverty who do not receive early intervention.

We propose three reasons to explain why adolescent mothers tend to have children who experience cognitive-academic problems during early and middle childhood: (1) direct, genetic transmission of retardation; (2) poor quality of maternal teaching style, emotional instability, and impoverished home environments, factors sometimes independent of maternal IQ; and (3) genetic and environmental factors that interact to determine a mother’s parenting skills (Plomin, Loehlin, & DeFries, 1985). Thus, the development of cognition and intelligence in children of teenage mothers may be affected directly via genetic factors and indirectly through inadequate parental cognitive and emotional readiness, which combine to produce unstable and unstimulating childrearing environments. Some of these relationships, especially those dealing with environmental, social, and personal factors, are captured in a model of parenting and infant development, as described in the next section.

Pregnancy in obese adolescents

The evolving problem of childhood and adolescent overweight and obesity, coupled with the rising rates of adolescent child-bearing, has culminated into a third emerging issue of pregnancy among obese adolescents [2].

Adolescent mothers are particularly vulnerable to developing obesity due to faulty eating behaviors in that age group along with higher weight gain during pregnancy. This is further aggravated by depression associated with pregnancy in adolescence [45,46]. These adolescents also face difficulties in losing weight after the pregnancy and have lower rates of breastfeeding [47]. Various studies have linked excess weight gain during pregnancy to retaining excess weight after pregnancy for more than 15 years [48].

Warshak et al. reported a higher risk of stillbirths in adolescents than in adults (20% higher), and further increased risk in obese adolescents than those with a normal weight (70%) [22]. Studies have also shown that excess weight gain in pregnant adolescents resulted in higher incidence of operative deliveries and macrosomia in the fetus compared to pregnancy in adulthood [49]. Another study by Salihu et al. reported that obesity in pregnant adolescents was associated with a higher incidence of medically indicated preterm birth (for gestational hypertension and eclampsia) rather than spontaneous preterm birth [50]. The hypothesis to explain this finding is that obesity and the resulting longer cervical length confers protection from spontaneous preterm births [50]. Another study found that obesity conferred some protection against preterm delivery and low birth weight in adolescents [51].

Children born to obese adolescents also show a predilection toward becoming obese like their mothers. The causes for this are often closely related to lower breast-feeding rates among adolescent mothers and the maternal faulty eating habits influencing children [52].

Depression

About 10% of women develop clinical depression during pregnancy. New mothers (10–20%) develop depression after giving birth to their babies. These rates double in low-income mothers and in adolescent mothers.

Although the symptoms of depression in pregnancy are the same as the symptoms that occur in depression at other phases in life, they often go unrecognized because normal pregnancy changes cause similar symptoms such as difficulties in sleeping, tiredness, changes in body weight, and strong, emotional reactions.

Clinical depression in pregnancy can pose formidable problems for the mother and baby to be. A mother who becomes depressed during pregnancy may fail to seek out prenatal care. In addition, she may not eat properly, lose weight, and increase her use of addictive substances, particularly smoking and alcohol use. If a mother develops suicidal thoughts as part of her depression, there is a risk that she may overdose on medications, posing a substantial risk for herself and her fetus.

There is growing evidence that depression in pregnancy can negatively affect fetal and infant well-being. Untreated maternal depression in pregnancy has been associated with premature labor and with low infant birth weight. Maternal smoking and substance abuse can all exert a negative effect on fetal and infant development. Pregnant mothers who are depressed also experience high levels of stress. Their babies, in turn, show high levels of activity during pregnancy and high stress hormone levels after birth.

Recognizing factors that increase the chances that a pregnant woman will develop depression can help in preventing depression in this critical phase of life. Table 1 lists several factors that increase the risk that a pregnant mother will develop depression.

Table 1. Factors that increase risk of clinical depression during pregnancy

Postpartum depression is not the same as the postpartum ‘blues’, which is a normal experience for many women in the immediate postpartum period. Women experience the blues within the first 10 days after birth. They alternate between feeling irritable, having an elated mood, and having increased crying spells. Women who develop postpartum depression, by contrast, experience sleep and appetite disturbances, impaired concentration, feelings of inadequacy, and a sad mood. These symptoms occur within 6 months after a woman has given birth to her child.

Postpartum depression can greatly affect how a mother feels about herself as a parent and how she perceives and responds to her newborn baby. A mother who becomes clinically depressed after giving birth may develop a negative attitude toward her baby or harbor negative feelings and thoughts about her ability and desire to parent. She may be emotionally unavailable to her baby and have difficulties in responding to her baby’s cues. Some mothers feel that their baby hates them. Most women with postpartum depression feel guilty about these thoughts and are anxious about their ability to parent.

The exact etiology of postpartum depression is unknown, but the lack of sleep, stress, and new responsibilities that are part of having a baby can contribute to its development. Table 2 summarizes factors that increase the risk that a woman will develop depression in the postpartum period.

Table 2. Factors that increase the risk for postpartum depression

Depression in the postpartum period often remains unrecognized by mothers, family members, and mental health professionals alike. In about 50% of cases, however, episodes of postpartum depression are continuations of a depressive episode from pregnancy. Mothers may be reluctant to acknowledge that they are depressed after giving birth to their child because it may seem incongruous with the happiness they feel they should experience in the mothering role. Given the negative repercussions that it can have on parenting, recognizing symptoms of depression in the postpartum period as early as possible and helping mothers to seek treatment is essential.

There is some evidence that prolonged interventions may be needed to achieve positive outcomes for parenting. A significant proportion of women who are vulnerable to postnatal depression, however, refuse to engage in treatment. Understanding the barriers to engaging in services is therefore essential for achieving better outreach and care for these women and their babies.

Fetotoxicity

Exposure to cannabis during pregnancy and its adverse effects on the fetus are difficult to assess, for several reasons. Concentrations of the psychoactive agents in cannabis sold on the street vary widely, from a trace of THC to as much as 20%. The amount of drug use by expectant mothers and duration of use are also difficult to determine.

A study of altered neurobehavior in term neonates with prenatal cannabis exposure within 24–72 hours of life has been reported (16C). Between July 2001 and November 2002, 928 (25%) of 3685 infants at a hospital in Brazil were born to adolescent mothers; 26 infants (4.6%) of 561 infants who met the study criteria had marijuana exposure detected by maternal hair and neonatal meconium analysis for marijuana and cocaine metabolites. Neonates who had prenatal exposure to tobacco, alcohol, or cocaine were excluded. The infants were assessed with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). Infants exposed to marijuana scored significantly higher in variables of arousal, regulation, and excitability than non-exposed infants. Only one of 26 mothers who used cannabis during pregnancy revealed this during the interview.

Research on cannabis use in adolescent pregnancy is complicated by a number of variables (17r). Adolescent mothers frequently have poor nutrition, use other substances, and have poor mental health. The parenting environment of an infant born to an adolescent mother is likely to have a number of psychosocial stressors.

A systematic review of studies on neurobehavioral and cognitive outcomes associated with cannabis in utero exposure has been published (18M). To date, there have been only two longitudinal studies, the Ottawa Prenatal Prospective study (2002) and the Maternal Health Practices and Child Development Study (1998). The consequences of heavy prenatal exposure to cannabis appear to be subtle, with the prefrontal brain region negatively affected by prenatal cannabis use. There have been no studies focused on moderate or low cannabis use during pregnancy.

A small fMRI study has suggested that prenatal cannabis exposure may have effects on neural activity during tasks involving visuospatial working memory in young adults (19c). In this study, 16 prenatally exposed and 15 unexposed individuals (aged 18–22) performed a task involving visuospatial working memory while being imaged by fMRI. While there was no difference in performance between the two groups, there were differences in the neural networks that were activated during the task. Those exposed to cannabis had more activity in the left inferior and left middle frontal gyri, the left parahippocampal gyrus, the left middle occipital gyrus, and the left cerebellum, whereas they had less activity in the right inferior and right middle frontal gyri.

Targeting populations and care

Government targets for improving child health include communicable disease prevention, addressing malnutrition, focusing on maternal health, and providing adequate sanitation. The effects of poverty are being stemmed with increased prenatal care. Since 1995, poor municipalities have been targeted specifically according to a national agenda. Despite these efforts, there remains low attendance and a lack of appointments for adolescent mothers seeking prenatal care. A synergistic effect of poverty, adolescent pregnancy, and low levels of education has been suggested to explain undesirably high IMRs in urban settings. Of note, fertility rates have been diminishing in all age groups except the 10–19 years category. Teenage birth may ‘transmit’ poverty, as young mothers are more likely to drop out of school, have less potential for finding well-paying employment, and will be less able to provide necessary educational opportunities for their children.

Delays in care additionally depend on geographical and cultural situations. Travel time and distance are major determinates for the utilization of medical services. Language barriers between rural communities and service areas can also deter families from seeking healthcare. Within remote communities, traditional healing methods may also be sought instead of evidenced-based medical interventions. This may be compounded by economic factors whereby families with sick children perceive the children as ‘doomed’ and are less likely to seek costly medical assistance. To remedy these actions, fusing western beliefs into traditional practices has been suggested.

Case Study 2

LS is a 24-month-old female born at 39 weeks gestational age with a birth weight of 3700 g. Her Apgar score at 5 minutes was 7, the delivery was long, and LS was lethargic for 24 hours after birth. She eventually perked up, and was discharged in 8 days. LS resides in a low socioeconomic status household with a single, adolescent mother with no extended family close by. On the 21–24 BINS item set, LS received non-optimal scores (0) on Names Four Pictures (Item 3), Identifies Four Pictures (Item 4), Names Three Objects (Item 6), Produces Two-word Utterances (Item 11), and Speaks Intelligibly (Item 12). Her overall score was 8/13, placing her in the moderate-risk range (see Figure 7.1).

In this case, most of the non-optimal scores are in the verbal expressive (E) and, to a lesser degree, verbal receptive (R) areas. Other areas of neurodevelopmental function appear adequate. In general, language skills are more developed by age 2 years, allowing for better detection of problems. Conversely, language is strongly influenced by environment. The specific deficit in the expressive language cluster (and one receptive item) with optimal scores in other areas is not particularly congruent with what may have been mild hypoxic-ischemic encephalopathy. Hence, environment may be a strong factor, and early intervention services in speech/language would be recommended.

C Parents’ memory

To date, only one study has examined associations between parents’ attachment-relevant memory processes and their children's attachment (Dykas, Woodhouse, Ehrlich, & Cassidy, 2010). The principal purpose of this study was to examine memories about previous conflictual adolescent–parent interactions, one component of which examined the links of parents’ memories to adolescent attachment security. To this end, parents and adolescents were asked to engage in a 10-min structured laboratory task in which they discussed three topics previously identified as areas of disagreement in the relationship (e.g., chores, curfew, homework). There were separate mother–adolescent and father–adolescent conflict interactions. Immediately following each interaction, parents completed a questionnaire about their emotional responses to the discussion, including the extent to which they perceived the interaction as positive and negative; parents also rated the extent to which they felt they had been treated with hostility by their children. Six weeks later, parents were asked to recall the laboratory discussion and then to complete the same questionnaire, this time providing reports of their memories for the previous discussions. Mothers’ (but not fathers’) memories of the conflict discussion were associated with adolescents’ attachment security, such that mothers of insecure adolescents remembered the discussion less favorably over time than they had initially perceived it. In contrast, mothers of secure adolescents remembered the interactions more favorably over time relative to their initial reports. These findings are striking because it is possible that mothers of insecure adolescents will feel, think, and act in ways that are congruent with their negatively biased memories rather than in ways associated with their original perceptions of the interaction.

10.3.4 Other beverages based on whey and whey components

Technical literature contains many marketing-type articles on whey protein-based nutritional drinks, as well as on dietary supplements and specialised high protein-containing formulas. Whey protein is one of the more easily digestible proteins and thus may be ideally suited as the basis for a high-protein ‘liquid meal drink’ intended for persons under stress or in high-anxiety situations, such as those faced by the top competitive sportspeople during the high anxiety pre-competition period.

Products resembling flavoured drinkable yogurts but formulated from reconstituted WPC or WPI keep appearing with increasing regularity at food product exhibitions and in the literature, often promoted as sources of high-quality protein or as nutritional specialities for targeted consumer groups (lactating mothers, adolescents, senior citizens, etc.).

Conversely, UF permeates from milk or whey processing are essentially solutions of a relatively easily digestible carbohydrate (lactose, especially if it has been pre-hydrolysed) and some important electrolytes in almost isotonic concentrations. Thus these permeates, essentially devoid of protein, should be ideal for development of sport drinks offering high energy and proper mineral replenishment. Indeed, several such whey beverages referred to as ‘isotonic fruit drink’ or ‘multi-mineral sport drink’ were described in the review by Riedel (1994).

Products resembling sparkling wine, based on fermentation of whey lactose and/or other carbohydrates added to whey or UF permeates have been described in the literature and are reported to be popular in certain national markets (e.g. Poland). Ideas for many other drinkable foods containing whey and/or whey components have been published, and undoubtedly many more tried in the industrial product development laboratories. In many cases, whey has served as an inexpensive component in fruit juice drinks to gain marketing advantage. One such notorious example is the case of the product named Frusighurt, an ‘official drink’ of the 1984 Winter Olympic Games in Sarajevo, produced by an orange juice manufacturer. The product was essentially a fruit juice-type whey drink (see Section 10.3.1) based on orange juice with a very small addition of yogurt (thus the ‘catchy name’). The product life after the games was relatively short, but most likely the venture was still worth the effort.

Entry into Prenatal Care

Teenage mothers have a higher rate of presenting late for prenatal care compared to mothers in their twenties. In 2008, Mary Aruda and colleagues found that teenagers overall present late for prenatal care, and that younger adolescents enrolled in care significantly later than their older counterparts. Another study in 2009 by Sina Haeri and colleagues in a predominantly African American community in Washington, DC showed that the youngest adolescents (<16 years old) enrolled in prenatal care significantly later than older adolescents (at 19.7 vs. 16.2 weeks gestation). In a 25-year analysis reported in 2008 by William Hueston and colleagues of timing of entry into prenatal care among adolescents in the United States, those females who received no prenatal care or waited until their third trimester of pregnancy were significantly more likely to be preteens (10–14 years) or young adolescents (15–16 years). The preteens and young adolescent mothers were more likely to delay accessing care in each year that was examined during the 25-year study period. Being unmarried, living in poverty, and being of a minority group were also associated with a delay of initiation of prenatal care.

Speculated reasons for delayed entry into prenatal care among teenagers include unfamiliarity with available services, lack of understanding about what type of care is needed during pregnancy, a desire to conceal the pregnancy, and delayed recognition of the pregnancy state. Having previously delivered a child, however, is not associated with earlier entry into prenatal care. Girls who had a prior delivery appeared to be actually at higher risk for not obtaining early prenatal care. In the preteen population (younger than 15 years old), white adolescents appear to be at high risk for delaying prenatal care, whereas among teenagers 15 years old and older, white adolescents are less likely to delay care.

Of note, overall, access to prenatal health-care services has improved for teenagers in the United States in the past 2 decades, with a notable decrease in the rates of late or no prenatal care occurring when Medicaid expanded funding for pregnant women to obtain care (between 1988 and 1993).

Teenage childbearing is associated with adverse health outcomes. Adolescent birth has been associated with increased risk for low birth weight, preterm delivery, and neonatal mortality. These infants have been shown to have lower 5-min Apgar scores at birth (the utility of the Apgar score in predicting neonatal morbidity and mortality has not been well established, however, although it is widely used). During pregnancy, these teenagers are also at higher risk for developing pregnancy-induced hypertension. These perinatal risks also support the belief that prompt entry into prenatal care is important for pregnant adolescents.

Nutrition

Current knowledge implies that maternal nutrition affects the developing fetus. Malnutrition substantially impacts maternal, gestational, and pregnancy outcome leading to spontaneous, noninfectious preterm birth [63]. Of particular importance seems to be the time window. A mismatch between needs and supplies can occur preconception or during early or late pregnancy with different effects for mother and fetus. Malnutrition includes (1) poor food resources, more commonly seen in developing countries, (2) overweight due to poor diet, a problem with increasing incidence in the Western world, or (3) lack of essential food components like micronutrients. Various maternal conditions like age, height, weight, and interpregnancy duration influence the nutritional status. Adolescent mothers are shorter, lighter, and have a reduced energy and micronutrients availability, much like women with short interpregnancy durations. This results in less fetal access to nutrients, impaired placental and fetal growth, and shorter gestational duration [64].

Low nutrient availability and energy is correlated with lower pregnancy duration. Rayco-Solon and coworkers reported shorter gestational duration in Gambian women who conceived between September and November, which was correlated with reduced maternal nutrients and energy due to annual food fluctuation, compared to pregnancies that started when more food and energy was available [80]. However, not only a lack of prepregnancy nutrients but excess nutrient supply may be associated with lower pregnancy duration. Even though the data for the effect of maternal overweight on preterm birth are inconclusive, Han and coworkers reported that a high maternal body mass index before pregnancy increases the risk for preterm birth [81]. Collectively, these studies indicate that maternal food consumption and weight preconception during the early stages of pregnancy impact fetal development and is associated with lower pregnancy duration and preterm birth.

In addition to the impact of quantitative nutritional supply and nutrition quality, dietary pattern also impacts the fetus and gestational duration. Evaluating associations between maternal dietary patterns before conception and preterm delivery, Grieger and coworkers reported that protein- and fruit-rich diets increased gestational duration, while diets consisting of high fat, sugar, and takeaway food are associated with shorter gestational duration and preterm birth [64]. While elevated preconceptional homocysteine levels are associated with preterm birth, the supplementation of various micronutrients seems to be preventive. Increased vitamin B 12 serum levels and preconceptional folate supplementation have been reported to prevent preterm birth. Furthermore, recommended vitamin supplementation for pregnant women reduces the risk for preterm birth.

In summary, there is evidence supporting that qualitative and quantitative maternal nutritional status impacts placental growth and the developing fetus with direct influence on pregnancy outcome and preterm birth. Of particular importance seems to be the duration of nutritional effects. While lack of nutrients both during preconception and early pregnancy is associated with preterm birth, an excessive supply in late pregnancy results in macrosomia and also preterm birth. Furthermore, there are emerging concerns regarding maternal overweight and obesity.