March 11, 2021

Consensus Statement Regarding the Purported Association Between Epidural Analgesia During Labour and Risk of Autism Spectrum Disorders in Children

The Singapore Society of Anaesthesiologists (SSA) would like to reassure pregnant women that a recent article “Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring”, published in JAMA Pediatrics on October 12th, 2020, does not provide credible scientific evidence that labour epidurals for pain relief cause autism in children. This consensus statement is written in consultation with Obstetric and Paediatric Anaesthesiologists from Kandang Kerbau Women’s and Children’s Hospital, Singapore General Hospital and National University Health System.

The study is a retrospective longitudinal cohort study from approximately 150,000 electronic medical records from a single integrated healthcare system in the United States of America. The study aimed to determine the association between maternal labour epidural analgesia (LEA) exposure and risk of autism spectrum disorders (ASD) in offspring born vaginally between 1 January 2008 to 31 December 2015. The study concluded that maternal exposure to LEA was associated with a 37% increased risk of ASD in children and that a longer duration of epidural exposure was associated with greater risk of ASD. (1)

Despite the large cohort numbers, the paper does not provide credible scientific evidence for the following reasons:

Nature of study

  • Due to the retrospective nature of the study, it cannot prove a causal relationship.

Missing information in the study

  • The study did not include any information on whether there were any complications during the pregnancy, delivery or peripartum period; complications during this time have been shown to have a significant influence on whether a child may develop ASD in life.
  • A family history of ASD was not accounted for or examined in the study despite ASD having a genetic link.
  • Follow up duration of the children may not be adequate. Based on the Centers for Disease Control and Prevention recommendations on ASD diagnosis, many children do not receive a diagnosis until after 2 years of age. The study also does not mention the mean age of ASD diagnosis within the study population.

Significant populations excluded from the study

  • Only children enrolled as part of a specific health insurance plan (the Kaiser Permanente Southern California health plan) from 1 year of age were included in the study. It is possible that certain patient characteristics (e.g. lower socioeconomic status) may have been excluded from the study, another factor linked with ASD. (2)
  • Women requiring a Caesarean delivery were also excluded, and they may have had medical indications that may lead to a higher risk of developing ASD in their offspring.

Pathologic processes in ASD are not known

  • The underlying pathologic processes that lead to ASD is not known, therefore the potential mechanisms suggested in the paper, such as maternal fever and the exposure of the foetal brain to local anaesthetics cannot fully explain the link between LEA and the development of ASD.

LEA is still considered the gold standard of labour pain relief and has been shown to safely provide significant benefits for both the mother and newborn. For example, obstetric conditions such as pre-eclampsia and parturients with certain heart conditions can benefit from LEA. A reduction in the need for general anaesthesia in the presence of LEA also helps to improve the safety of caesarean delivery for both the mother and newborn. (2-4)

The SSA will continue to encourage research and education in anaesthesia care to ensure the safety of pregnant women and their newborns. We will closely monitor the latest developments to further improve the standards of care for pregnant women and their newborns in Singapore. In the absence of a medical contraindication, maternal request for pain relief is a sufficient medical indication for pain relief during labour with appropriate care from qualified specialists. Pregnant women should continue to consider labour pain relief, including LEA, as part of the birthing experience.

References:

  1. Qiu C, Lin JC, Shi JM, Chow T, Desai VN, Nguyen VT, et al. Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring. JAMA Pediatr. 2020;174(12):1168-75.
  2. No Evidence that Labour Epidurals Cause Autism [press release]. RCoA, 13 Oct 2020 2020.
  3. Anesthesiologists ASo. Labor Epidurals Do Not Cause Autism; Safe for Mothers and Infants, say Anesthesiology, Obstetrics, and Pediatric Medical Societies. Joint Statement of the Society for Obstetric Anesthesia and Perinatology, American Society of Anesthesiologists, Society for Pediatric Anesthesia, American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. 2020.
  4. McKeen DM, Zaphiratos V, the Canadian Anesthesiologists’ S. Lack of evidence that epidural pain relief during labour causes autism spectrum disorder: a position statement of the Canadian Anesthesiologists’ Society. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2021;68(2):180-2.