Prenatal lead exposure modifies the effect of shorter gestation on increased blood pressure in children

Background: High blood pressure (BP) in childhood is frequently renal in origin and a risk factor for adult hypertension and cardiovascular disease. Shorter gestations are a known risk factor for increased BP in adults and children, due in part to a nephron deficit in children born preterm. As nephrogenesis is incomplete until 36 weeks gestation, prenatal lead exposure occurring during a susceptible period of renal development may contribute to programming for later life renal disease. The relationship between shorter gestation and children's BP has not yet been explored to identify i) critical windows using nonlinear piecewise models or ii) combined with other early life risk factors such as prenatal lead exposure. Objectives: (1) To evaluate the nonlinear relationship between lower gestational age and childhood BP measured at 4-6 years of age, and (2) to investigate modification by prenatal lead exposure. Methods: In a prospective longitudinal birth cohort, we assessed 565 children between 4 and 6 years of age (mean: 4.8 years) in the PROGRESS cohort in Mexico City, Mexico. Gestational age at delivery was calculated using maternal report of last menstrual period (LMP) and confirmed with Capurro physical examination at birth. We measured pregnant women's blood lead levels (BLLs) in the second trimester via inductively coupled plasma-mass spectrometry and children's BP using an automated device. We performed both linear and nonlinear piecewise regression analyses to examine associations of gestational age with children's BP adjusting for children's age, sex, height, prenatal exposure to smoke, and maternal socioeconomic status. We stratified to assess modification by prenatal lead exposure, and used a data-adaptive approach to identify a lead cutpoint. Results: Maternal second trimester BLLs ranged from 0.7 to 17.8 mu g/dL with 112 (20%) women above the CDC guideline level of 5 mu g/dL. In adjusted linear regression models, a one week reduction in gestational age was associated with a 0.5 mmHg (95% CI: 0.2, 0.8) increase in SBP and a 0.4mmHg (95% CI 0.1, 0.6) increase in DBP. Our nonlinear models suggested evidence for different magnitude estimates on either side of an estimated join-point at 35.9 weeks' gestation, but did not reach statistical significance. However, when stratified by prenatal lead exposure, we identified a cutpoint lead level of concern of 2.5 mu g/dL that suggested an interaction between gestational age and blood lead. Specifically, for BLLs >= 2.5 mu g/dL, SBP was 1.6 (95% CI: 0.3, 2.9) mmHg higher per each week reduction in gestational age among children born before 37.0 weeks; and among children born after 37.0 weeks, this relationship was attenuated yet remained significant [beta: 0.9, 95% CI (0.2, 1.6)]. At BLLs below 2.5 mu g/dL, there was no appreciable association between lower gestational age and SBP. Conclusions: Our findings suggest that shorter gestation combined with higher prenatal lead exposure contributes to a higher risk of increased SBP at 4-6 years of age, particularly among infants born < 37 weeks gestation. Our results underscore the importance of preventing prenatal lead exposure - even levels as low as 2.5 mu g/dL - especially among pregnant women at risk for preterm birth. Given that high BP in childhood is a risk factor for adult hypertension and cardiovascular disease later in life, these results may have implications that extend across the life span.