Episode #93 Epidural and Autism, Part 2

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. This is the exciting Part 2 for our discussion about the relationship between epidurals and autism. Have you taken care of a pregnant patient in labor who asked you if epidurals cause autism? The answer is No, and we have more important points to discuss related to this topic.

Before we dive into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Our featured article today is once again, “Do Epidurals Cause Autism? (No.) A Review of the Controversy and What Patients and Providers Need to Know” by Caroline Thomas and Jennifer Banayan from the February 2022 APSF Newsletter. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is Current Issue. Then, scroll down until you see our featured article today. I will include a link in the show notes as well.

I hope you tuned in last week for Part 1 on Episode #92. For a recap, the link between epidural exposure and autism development in children because an important patient safety concern after the publication of an article in JAMA Pediatrics in 2020 that reported an association between lumbar epidural exposure and duration of epidural exposure for labor analgesia and the development of autism in children. There were immediate concerns about this publication including the clinical implications as well as the methodology in the paper given that there were significant limitations in the study and that an association between a treatment and an outcome does not imply causation. We also reviewed three other studies published afterwards that addressed some of the limitations of the JAMA Pediatrics study. The later studies included more covariates to decrease the impact of residual confounding and used multiple sensitivity analyses to evaluate for potential bias and reported no association or that there was not enough evidence for an association between labor epidural exposure and the development of autism.

Let’s get back into the article. The authors highlight an important finding in these studies. While the studies were looking at the association between autism and epidurals, the results displayed baseline differences in the groups of women who received an epidural and those that did not. These differences included the following:

• Maternal age
• Race
• Ethnicity
• Education level
• Household income
• Maternal diabetes
• Pre-eclampsia
• And gestational age.

These differences are important since it appears that women who receive an epidural during labor are a different group of women at baseline than those that do not receive an epidural. Residual confounding is likely to be present as a limitation in all of these studies since it is challenging to control for other variables of maternal health including general mental state, nutrition, self-care, and prenatal care. Another important consideration is that one explanation for a possible association between epidural exposure and autism is that there are several maternal conditions and pregnancy disorders that are associated with epidural analgesia  that are also associated with autism. This is difficult to study and quantify, but it may be the maternal conditions and pregnancy disorders that are associated with autism and this group of women are more likely to receive epidural analgesia during labor.

Wong and Stevens published an editorial in JAMA in October 2021 called, “Labor Epidural Analgesia and Autism Spectrum Disorder Is There an Association?” In this piece, the authors point out that when evaluating an association between epidural analgesia exposure and autism, it is important to consider the pathophysiology as well. Lumbar epidural analgesia does lead to placental transfer of local anesthetics and lipid-soluble opioids, but in very low concentrations, and there is limited evidence related to any direct effects on neuronal, glial, and microglial development. In addition, any direct effects of these very low concentrations would be further limited by short duration of exposure, timing of exposure (third trimester compared to first trimester) and short duration of action of the medications used for epidural analgesia.

When discussing options for labor analgesia with patients and obtaining consent, it is important to include a discussion of the benefits of epidural analgesia as well as the risks. So, let’s talk about the benefits now. Benefits include improved pain control during labor when compared to IV opioids and nitrous oxide. Another benefit of having an epidural catheter in place is that you have an epidural catheter in place in case an urgent or emergent c-section is required which helps by avoiding general anesthesia and the associated increased risks, improved post-C-section pain scores, and maternal bonding in the theatre immediately following delivery.  An important consideration for anesthesia professionals and patient regarding the JAMA Pediatrics study is the assertion of a relationship between labor epidural analgesia and autism leading to increased anxiety and guilt for pregnant patients when deciding on analgesia for labor. There are further reaching effects from this, if more patients avoid epidurals during labor, there is the potential for increased rates of general anesthesia for emergent-section delivery leading to increased neonatal exposure to maternal medications and increased maternal morbidity. The conclusion to the article is that more research on the safety of epidural analgesia on neurodevelopmental outcomes in children is needed and this statement along with the title of the article, “Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring” and a quick read of the abstract raises an alarm even though the article does state that there is no causal relationship between labor epidural analgesia and autism. Noncausal associations may be a threat to patient safety and are important to recognize. The now retracted 1998 Lancet article that reported an association between vaccines and autism created a vaccine hesitancy movement around the world which is one of the top 10 threats to global health according to the World Health Organization. It is critical to have an informed discussion with patients regarding the risks and benefits of labor epidural analgesia to reinforce the safety of epidurals and clear up any inaccuracies or misunderstandings.

So, what do patients and anesthesia professionals need to know? Here are the bullet points:

• Follow-up studies with improved methodology revealed no evidence of association or correlation between labor epidural analgesia and autism.
• Epidurals are safe for pregnant patients for labor analgesia.
• And finally, these are important concerns that should not be dismissed, but it is clear with the available literature to date that there is not a correlation between labor epidural analgesia and autism and that epidurals do not cause autism.

Before we wrap up for today, we are going to hear from Thomas again. I asked her, “What do you hope to see going forward?” Here is her thoughtful response.

[Thomas] “Last year, a joint statement from SOAP, ASA, SPA, ACOG, and SMFM was released reinforcing the fact that labor epidurals do not cause autism. It is not everyday that a statement of this magnitude is released, and I felt it was important to share this information with as many providers as possible so that they could distribute this info to their patients so that they could make the best decisions for themselves and their children. I hope that in the future, the thought of whether an epidural might cause autism does not come into play when patients are making decisions about whether or not to get an epidural. Going forward, I hope to see a that our clinical practice will reinforce the safety profile of epidurals, and I hope that as anesthesia providers we advocate for the rights of women to have safe and effective pain control during labor.”

[Bechtel] Thank you so much to Thomas for contributing to the show today and for helping to share the critical message that labor epidurals do not cause autism. This is important information for anesthesia professionals, obstetricians, nurses, our patients, and other members of the obstetric healthcare team. We hope that you will share this podcast with your colleagues and join the conversation on twitter.

The Society for Neuroscience in Anesthesiology and Critical Care 50^th Annual Meeting is going to be in Seattle on September 8-10^th. The online submission site for abstracts is open now. but you need to get your abstract in soon because the deadline to submit 11:59pm US Eastern Time on Monday, May 2^nd, which is coming up! Abstract categories include the following:

• Basic Science
• Clinical Science
• Medically-challenging Case
• Education
• Neuromonitoring
• Neuroprotection
• Cerebral Ischemia
• Patient Safety
• Quality Assessment
• Cerebrovascular and/or Subarachnoid Hemorrhage
• Stroke
• Delirium
• Cognition
• EEG Monitoring
• Clinical Trial
• Other

One of the annual award categories is the APSF Patient Safety Abstract Award of $500. That’s right, so go ahead and submit your patient safety related abstract for the annual SNACC Meeting and you could win this award and present your patient safety related abstract at the meeting. I will include a link to the submission site in the show notes. What are you waiting for… click on the link and submit your Patient Safety Abstract for the SNACC Annual Meeting now!

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation