Gender-specific effects of exposure to maternal prenatal smoking on gross motor skills and movement behaviors in 3-5 year-old children: findings from the 2012 National Youth Fitness Survey

doi:10.21203/rs.3.rs-4283363/v1

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Gender-specific effects of exposure to maternal prenatal smoking on gross motor skills and movement behaviors in 3-5 year-old children: findings from the 2012 National Youth Fitness Survey

https://doi.org/10.21203/rs.3.rs-4283363/v1

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Background: Smoking during pregnancy has been associated with various health and behavioral problems in offspring throughout their lifespan. In addition, studies have shown that these health and behavioral problems following maternal prenatal smoking exposure (MPSE) are likely gender-dependent, i.e. the outcomes are divergent between male and female offspring. However, studies on whether MPSE affects gross motor skills in 3-5 year-old children in a gender-specific manner are lacking. The first aim of this project is to examine the effects of MPSE on gross motor skills in 3-5 year-old boys and girls. The second aim is to identify factors that are associated with gross motor skills in children with MPSE.

Methods: The data used in this project are from the 2012 National Youth Fitness Survey (NNYFS) conducted by the Centers for Disease and Prevention National Center for Health Statistics (NCHS). Out of the 368 children aged 3-5 surveyed by NCHS, 329 had locomotor skills standard score (LSSS), object control skills standard score (OCSSS), and gross motor quotient (GMQ) along with demographic data, body measurement data early childhood questionnaire data movement behavior questionnaire data and were selected for this study.

Results: Boys with MPSE had significantly lower LSSS, OCSSS, and GMQ compared to those without MPSE, while no significant differences in LSSS, OCSSSS, and GMQ for girls were detected, indicating a gender-specific effect of MPSE on GMQ in 3-5 year-old children. MPSE was associated with low ratio of family income to poverty (RFIP) in girls but not in boys, suggesting a gender-specific inverse relationship of MPSE with parity. MPSE was associated with having no physical activity outside of school for the past 7 days in boys but not in girls, watching TV for >2 hours in the past 30 days and having 2 or fewer days with physical activity at least 60 min in the past 7 days in girls but not in boys, suggest that MPSE is associated with movement behaviors that confer less physical activity in boys and more sedentary state in girls.

Conclusion: MPSE negatively impacts gross motor skills in 3-5 year-old boys.

maternal prenatal smoking exposure

gross motor skills

gender-specific

movement behaviors

parity

NNYFS

Smoking during pregnancy has been associated with various health and behavioral problems in offspring, from low birth weight and high irritability in infants^1–3, increased obesity and attention-deficit/hyperactivity disorder and delayed puberty in adolescence^4–6, to increased risk of tobacco smoking/dependence and susceptibility to metabolic diseases in adulthood^7,8. In addition, studies have shown that these health and behavioral problems following maternal prenatal smoking exposure (MPSE) are likely gender-dependent, i.e. the outcomes are divergent between male and female offsprings^9,10. For example, multiple investigations demonstrated a greater reduction in lung function in boys with MPSE compared to girls aged from 6 to 13 years old¹⁰, while adolescent women whose mothers smoked during pregnancy display more pronounced deficits in visual and auditory attention than male counterparts⁹. However, findings on the gender-specific effects of MPSE in children aged 3–5 years old are inconsistent. For instance, some studies have demonstrated that boys with MPSE are more vulnerable to the development of conduct problems while others have found no gender differences⁹. More investigations are certainly needed to determine whether MPSE differentially affects the health and behavior of 3–5 year-old children.

The age range of 3–5 years is considered as a critical period in developing and learning gross motor skills involving the large muscles of the body that enable major body movements including locomotor skills such as walking, running, and jumping and object control skills such as throwing, striking, and catching¹¹. It is important to understand the factors that influence motor skill competence because adequate motor skills have been shown to be critical for cardiovascular fitness, healthy weight status, language development and academic performance in children^12–14. In 2012, the National Youth Fitness Survey (NNYFS) was conducted on a representative sample of US children aged 3–15 years¹⁵. The survey provided the first nationally representative data on locomotor and object control skills among 3–5 year-old children together with demographic, health, physical activity, and nutrition information about the child, providing a unique opportunity to investigate factors that influence motor skill competence including the gender-specific effects of MPES on gross motor skills and movement behaviors in these children.

Using the NNYFS data, Kit et al. reported that gross motor development among 3–5 year-old children generally did not differ by demographic or weight status¹⁶. In addition, neither the percentage of body fat nor sum of skinfolds was associated with gross motor skills¹⁷. Furthermore, neither lean muscle mass nor fat mass was related with any motor skill measure¹⁷. However, Kwon et al. found that 3–5 year-old children living below the poverty threshold were more likely to have a higher gross motor quotient (GMQ) determined using the Test of Gross Motor Development-Second Edition (TGMD-2)¹⁸, indicating an inverse association between family income and gross motor development in NNYFS participants. In addition, children engaging in gross motor-related physical activity or living with other child(ren) ≤ 5 years old had significantly higher GMQ¹⁸. Moreover, girls were more likely to have a higher locomotor score than boys, indicating a gender difference in locomotor skills in 3–5 year-old children¹⁸. In a more recent meta-analysis using data from 39 studies in children aged 3–6 years, Zheng et al. showed that boys had significantly higher proficiency in gross motor skills and object control skills than girls, while gender differences in locomotor skill proficiency approached significance, trending in favor of girls¹⁹. These studies revealed gender differences in gross motor skills including locomotor and object control skills in 3–5 year-old children.

Studies on whether MPSE affects gross motor skills in 3–5 year-old children in a gender-specific manner are lacking. The first aim of this project is to examine the effects of MPSE on gross motor skills in 3–5 year-old boys and girls. The second aim is to identify factors that are associated with gross motor skills in children with MPSE.

Data collection: The data used in this project are from the 2012 NNYFS conducted by the Centers for Disease and Prevention National Center for Health Statistics (NCHS) and publicly available at https://wwwn.cdc.gov/nchs/nhanes/search/nnyfs12.aspx. Detailed survey design and methods including sampling strategy and measurement procedures are described elsewhere^15,20. Out of the 368 children aged 3-5 surveyed by NCHS, 329 had locomotor skills standard score, object control skills standard score, and gross motor quotient available and were selected for this study. Three types of data were used in this study: 1. Demographics data included age, gender, race, the ratio of family income to poverty (RFIP), and the number of children 5 years or younger in household; 2. Questionnaire data included early childhood variables (mother smoked when pregnant (MPSE) and weight at birth (WAB)) and movement behavior variables (days physically active at least 60 mins for the past 7 days, days with physical activities outside of school for the past 7 days, hours watching TV or videos during the past 30 days); 3. Examination data included body mass index (BMI), locomotor skills standard score (LSSS), object control skills standard score (OCSSS), and gross motor quotient (GMQ) which is calculated using LSSS and OCSSS.

In addition, individual scores for tests assessing different aspects of locomotor skills, i.e. run, gallop, hop, leap, horizontal jump, slide, and object control skills, i.e. striking a stationary ball, stationary dribble, kick, catch, overhand throw, and underhand roll, were also evaluated in these 329 children. All data were compiled into a single file available at https://docs.google.com/spreadsheets/d/11N54nUwBjtyVv3W07bOy1g3pHZzoFbh-/edit?usp=sharing&ouid=109765623934484658518&rtpof=true&sd=true

Statistical analysis: All statistical analyses were performed using GraphPad Prism version 9.0.0 (GraphPad Software, San Diego, California USA, www.graphpad.com). For all analyses, the alpha value was set for 0.05 as statistically significant.

For continuous variables including LSSS, OCSSS, GMQ, BMI, RFIP, and WAB, data were first stratified by gender and then by MPSE status. Data distribution and equality of variance of each group were then determined using Shapiro-Wilk normality test (SW test) and F-test, respectively. For data that are normally distributed with equal variance, two-sample t-test was performed to determine whether there is a significant difference in these variables between boys and girls. For data that are normally distributed but with unequal variance, Welch’s t-test was performed. For data that are not normally distributed, Mann-Whitney U test was incorporated to assess any significant between-groups differences.

For categorical variables such as race, more than 2 days physically active at least 60 mins for the past 7 days, any physical activities outside of school for the past 7 days, and watching TV or videos for more than 2 hours during the past 30 days, data were stratified by MPSE into two groups for each gender and a contingency table was then constructed. Considering the sample sizes of some groups are small, two-sided Fisher’s exact test was performed to determine whether there is a significant association between either of these categorical variables with MPSE. For each gross motor skill tested, specific performance criteria in TGMD-2 procedures manual (https://www.cdc.gov/nchs/data/nnyfs/tgmd.pdf) were evaluated with two separate trials. The number of trials, i.e. 0, 1 or 2, that a child performed correctly based on the criteria was recorded.

Finally, a multiple linear regression analysis was performed to determine the relationship between GMQ as a dependent variable and all other continuous variables except LSSS and OCSSS and categorical variables as independent variables. Specifically, analysis of variance (ANOVA) is used to determine the overall significance of the regression model, as well as the significance of each independent variable included in the model.

MPSE is associated with low LSSS, OCSSS and GMQ in boys but not in girls

Statistical tests based on data normality and equality of variance were chosen to compare the means of two groups as described in the methods section (Table 3). Boys exposed to maternal prenatal smoking had significant lower LSSS, OCSSSS, and GMQ compared to those without MPSE, while no significant differences in LSSS, OCSSSS, and GMQ for girls with or without MPSE were detected (Fig. 1), indicating a gender-specific effect of MPSE on GMQ in 3–5 year-old children. For other variables tested, MPSE only associated with low RFIP in girls (Table 3 and Fig. 1), suggesting a gender-specific inverse relationship of MPSE with parity.

Table 1

Descriptive statistics, distribution and variance tests for LOSSS, OCSSS and GMQ
Gender		Boys (n = 166)		Girls (n = 163)
MPSE Status		Yes (n = 17)	No (n = 149)	Yes (n = 17)	No (n = 146)
LSSS	Mean (95% CI)	8.0 (6.2–9.3)	9.7 (9.3–10.3)	11.0 (10.1–11.9)	10.4 (9.9–10.9)
	Range (min-max)	11 (2–13)	18 (2–20)	8 (7–15)	17 (3–20)
	SD	3.0	3.3	1.8	3.2
	SEM	0.7	0.3	0.4	0.3
	SW Test	p = 0.74	p = 0.03	p = 0.04	p = 0.17
	F-test	p = 0.69		p = 0.013
OCSSS	Mean (95% CI)	7.1 (5.8–8.5)	8.8 (8.3–9.2)	8.5 (7.6–9.5)	8.6 (8.2-9.0)
	Range (min-max)	10 (2–12)	14 (1–15)	7 (5–12)	12 (3–15)
	SD	2.6	2.6	1.8	2.3
	SEM	0.6	0.2	0.5	0.2
	SW Test	p = 0.84	p = 0.06	p = 0.73	p = 0.004
	F-test	p = 0.90		p = 0.36
GMQ	Mean (95% CI)	84.6 (76.8–92.5)	95.5 (93.0-97.8)	98.2 (93.6-102.9)	96.9 (94.6–99.2)
	Range (min-max)	51 (61–112)	87 (49–136)	36 (85–121)	84 (61–145)
	SD	15.3	15.0	9.1	14.2
	SEM	3.7	1.2	2.2	1.2
	SW Test	p = 0.77	p = 0.49	p = 0.46	p = 0.14
	F-test	p = 0.82		p = 0.04

Table 2

Descriptive statistics, distribution and variance tests for RFIP, WAB and BMI
Gender		Boys		Girls
RFIP	MPSE Status	Yes (n = 17)	No (n = 139)	Yes (n = 17)	No (n = 129)
	Mean (95% CI)	1.34 (0.81–1.86)	2.05 (1.78–2.32)	0.85 (0.62–1.07)	2.19 (1.92–2.45)
	Range (min-max)	3.30 (0.00-3.30)	5.00 (0.00–5.00)	1.39 (0.43–1.82)	5.00 (0.00–5.00)
	SD	1.02	1.60	0.44	1.53
	SEM	0.25	0.14	0.11	0.13
	SW Test	p = 0.22	p < 0.0001	p = 0.0047	p < 0.0001
	F-test	p = 0.13		p < 0.0001
WAB (oz)	MPSE Status	Yes (n = 17)	No (n = 147)	Yes (n = 16)	No (n = 144)
	Mean (95% CI)	119 (106–133)	122 (119–125)	113 (104–121)	113 (109–116)
	Range (min-max)	103 (66–169)	134 (34–168)	59 (83–142)	140 (26–166)
	SD	26	20	16	21
	SEM	6	2	4	2
	SW Test	p = 0.95	P = 0.0001	p = 0.99	p < 0.0001
	F-test	p = 0.11		p = 0.22
BMI	MPSE Status	Yes (n = 17)	No (n = 149)	Yes (n = 17)	No (n = 146)
	Mean (95% CI)	16.7 (15.6–17.9)	16.6 (16.3–16.9)	16.9 (15.7–18.1)	16.2 (15.8–16.5)
	Range (min-max)	8.0 (13.6–21.6)	11.8 (13.4–25.2)	8.1 (13.7–21.8)	12.2 (11.9–24.1)
	SD	2.2	1.9	2.4	2.0
	SEM	0.5	0.2	0.6	0.2
	SW Test	p = 0.090	p < 0.0001	p = 0.27	p < 0.0001
	F-test	p = 0.37		p = 0.29

Table 3

Detection of significant differences between means for LSSS, OCSSS, GMQ, RFIP, WAB, and BMI
Variable	Gender	Test	P	Variable	Gender	Test	P
LSSS	Boys	Mann-Whitney U	0.022	RFIP	Boys	Mann-Whitney U	0.13
LSSS	Girls	Mann-Whitney U	0.29	RFIP	Girls	Mann-Whitney U	0.0002
OCSSS	Boys	Two sample t	0.015	WAB	Boys	Mann-Whitney U	0.49
OCSSS	Girls	Mann-Whitney U	0.90	WAB	Girls	Mann-Whitney U	0.82
GMQ	Boys	Two sample t	0.0054	BMI	Boys	Mann-Whitney U	0.71
GMQ	Girls	Welch's t	0.60	BMI	Girls	Mann-Whitney U	0.18

Multiple gross motor skills were negatively affected by MPSE in boys but not in girls

To determine the specific motor skills differentially affected by MPSE in boys and girls, we evaluated the distribution of test scores for 48 individual criteria measured in NNFYS, including run (4 criteria), gallop (4 criteria), hop (5 criteria), leap (3 criteria), horizontal jump (4 criteria) and slide (4 criteria) for locomotor skills and striking a stationary ball (5 criteria), stationary dribble (4 criteria), kick (4 criteria), catch (3 criteria), overhand throw (4 criteria), and underhand roll (4 criteria) for object control skills. Out of these criteria, 8 showed statistically significant lower frequencies of low scores in boys with MPSE compared to those without MPSE determined by Fisher’s exact test or chi-square test (Table 4). These criteria measure skills in hop, jump, leap, stationary dribble, catch, and underhand roll, suggesting that MPSE negatively affects different aspects of gross motor skills in boys. In contrast, the distribution of scores that correspond to these criteria were not statistically different in girls with MPSE compared with those without MPSE, suggesting that MPSE influences these individual motor skills in a gender-dependent manner.

Table 4

Individual gross motor skills differentially affected by MPSE in boys and girls
Gender	Boys		Girls
MPSE Status	Yes (n = 17)	No (n = 149)	Yes (n = 17)	No (n = 146)
Hop: Arms flexed and swing forward to produce force
0 or 1 correct trial	16	92	7	85
2 correct trials	1	57	10	61
Statistical test	Two-sided Fisher		Chi-square
P value	0.0066		0.18
Hop: Takes off and lands 3 consecutive times on preferred foot
0 or 1 correct trial	13	62	5	54
2 correct trials	4	87	12	92
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.0089		0.60
Leap: for a period where both feet are off the ground longer than running
0 or 1 correct trial	10	48	5	55
2 correct trials	7	101	12	91
Statistical test	Chi-square/Fisher		Two-sided Fisher
P value	0.029/0.057		> 0.99
Horizontal jump: Takes off and lands on both feet simultaneously
0 or 1 correct trial	12	52	4	36
2 correct trials	5	97	13	110
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.0071		> 0.99
Stationary dribble: Ball contacts surface in front of or to the outside of foot on the preferred side
0 or 1 correct trial	15	87	15	105
2 correct trials	2	62	2	41
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.018		0.24
Catch: Arms extend while reaching for the ball as it arrives
0 or 1 correct trial	14	77	11	91
2 correct trials	3	72	6	55
Statistical test	Two-sided Fisher		Chi-square
P value	0.020		0.85
Catch: Ball is caught by hands only
0 or 1 correct trial	17	113	13	89
2 correct trials	0	36	4	39
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.022		0.78
Underhand roll: Bend knees to lower body
0 or 1 correct trial	10	47	8	50
2 correct trials	7	102	9	96
Statistical test	Chi-square		Chi-square
P value	0.025		0.30

MPSE is differentially associated with movement behaviors in boys and girls

To determine the association between MPSE and movement behaviors, contingency tables were constructed for days physically active at least 60 min in the past 7 days, hours watching TV or videos in the past 30 days, and days with any physical activity outside of school in the past 7 days (Table 5). MPSE was significantly associated with having no physical activity outside of school in boys but not in girls. In addition, MPSE was significantly associated with watching TV for more than 2 hours in the past 30 days and having 2 or fewer days with physical activity at least 60 min in the past 7 days in girls but not in boys (Table 5). These observations suggest that MPSE is associated with movement behaviors that confer less physical activity in boys and a more sedentary state in girls.

Table 5

Determination of association between MPSE and movement behavior and race
Days physically active at least 60 min
	Boys		Girls
MPSE Status	Yes (n = 17)	No (n = 149)	Yes (n = 17)	No (n = 146)
<=2days	0	10	4	9
> 2days	17	139	13	137
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.61		0.033
Hours watch TV or videos past 30 days
<=2 hour	13	119	8	111
> 2 hour	4	30	9	35
Statistical test	Two-sided Fisher		Chi-square
P value	0.75		0.019
Any physical activities past 7 days
Yes	10	126	12	125
No	7	22	5	21
Statistical test	Chi-square		Chi-square
P value	0.014		0.15
Race/Hispanic origin
	Yes (n = 16)	No (n = 139)	Yes (n = 17)	No (n = 128)
non-Hispanic	15	90	13	89
Hispanic	1	49	4	39
Statistical test	Two-sided Fisher		Two-sided Fisher
P value	0.022		0.78

MPSE is significantly associated with GMQ independent of other variables

Our multiple linear regression on MPSE and GMQ models included age, race, BMI, RFIP, number of sibling(s) younger than 5 years old, and whether having any physical activities outside of school in the past 7 days. We chose these variables because either they are significantly associated with MPSE in boys based on our analyses above (race and any physical activities outside of school in the past 7 days) or they have been shown to significantly associated with gross motor skills in this cohort of children in a previous study by Kwon et al. (RFIP, number of sibling(s) younger than 5 years old)¹⁸ or other pre-school cohorts in previous studies (age, BMI)^21,22. The analysis revealed that both MPSE (β = -13.2, p = 0.0013) and RFIP (β = -1.965, p = 0.0306) were significant predictors of GMQ independent of other variables (Table 6), and the model has p-value of 0.037 accounting for 10% (R² = 0.10) of the variance in GMQ.

Table 6

Multiple linear regression analysis of selected independent variables and GMQ
Variable		SE	95% CI	\|t\|	P value	Summary
Intercept	97.6	15.1	67.8 to 127.4	6.5	< 0.0001	Rows in table	166
Physical activity	4.3	5.2	-5.9 to 14.5	0.8	0.41	Missing data (skipped)	11
Race	-1.8	3.0	-7.8 to 4.1	0.6	0.54	Rows analyzed	155
Age	-1.6	1.5	-4.6 to 1.4	1.0	0.3	Parameter Estimates	8
RFIP	-2.0	0.9	-3.7 to -0.2	2.2	0.031	Degrees of freedom	147
BMI	0.4	0.7	-0.9 to 1.7	0.6	0.55	Regression P value	0.037
Sibling(s)	-1.2	2.6	-6.2 to 3.9	0.5	0.65	R squared	0.10
MPSE	-13.2	4.0	-21.1 to -5.3	3.3	0.0013	Adjusted R squared	0.05

Deficits in motor control have been reported in children with maternal prenatal exposure to smoking for more than two decades. For example, smoking in pregnancy was associated with a small, but demonstrable adverse effect on the child's balance at 5 years using the Peabody Developmental Motor Scales (PDMS) test in a cohort of 362 Scandinavian children²³. In addition, prenatal tobacco exposure predicted significantly slower performance on the Grooved Pegboard task, a measure of eye-hand coordination, in 10-year-olds²⁴ and worse visual-motor coordination in 16-year-old adolescents in a computerized bimanual coordination test²⁵. Moreover, heavy smoking during pregnancy was statistically significantly associated with poor coordination performance in 11-year-olds, particularly among boys²⁶, suggesting a gender difference of maternal smoking on motor performance. Our study is the first to demonstrate the gender-specific effects of MPSE on gross motor development in 3–5 year-old children. MPSE is an independent predictor of low GMQ in boys when other confounders are adjusted, underscoring the importance of MPSE on the gross motor development of preschool-aged boys. A previous study showed that prenatal second-hand smoke exposure reduced gross motor development at 18 months of age in both boys and girls²⁷, suggesting the gender-specific effects of MPSE may take 3–5 years to manifest.

Mechanistically, prenatal smoke exposure may elicit adverse effects on children by altering offspring’s epigenetic and genetic profiles such as DNA methylation and telomere length^28–30, resulting in weak muscle tone and reduced cardiovascular and lung functions as well as impaired neurodevelopment such as smaller brain volume^2,31–35. The extent of alterations has been shown to be gender-dependent in some cases. For instance, prenatal second-hand smoke exposure was associated with shorter telomere length in boys than in girls³⁰, indicating that similar molecular mechanisms may underlie the gender-specific effects of MPSE on GMQ observed in this study. Although there is robust evidence for DNA methylation alterations associated with maternal smoking during pregnancy, there are no conclusive studies about the effects of exposure to low doses of maternal smoking or smoking during the preconception period on DNA methylation³⁶. In addition, studies using tissues other than the placenta and blood are scarce³⁶. Moreover, further investigations are needed to better understand the biological consequences of DNA methylation and telomere length changes and how they affect motor development in children.

Since the prevalence of maternal tobacco smoking during pregnancy is estimated to be 8%³⁷ and approximately 360,000-500,000 smoke-exposed infants are born yearly³⁸, it is important to educate parents on the consequences of smoking during pregnancy and offer help to women to quit smoking before pregnancy or when pregnancy is known. A population-based study of 113 6–8 year-old children with MPSE and 113 age and gender-matched controls without MPSE found that brain development in offspring of mothers who quit smoking when pregnancy was known resembled that of nonexposed controls (no smaller brain volumes and no thinning of the cortex)³⁹, suggesting that quit smoking will help protect brain development of offspring, which in turn, will potentially prevent reduced motor skill development and behavioral and emotional problems. The US Preventive Services Task Force has recommended that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco⁴⁰. The results of this study provide further rationale to support this recommendation.

The amount of variance in GMQ explained by the multiple linear regression model combining potential predictors including MSPE is low but significant and comparable with results from previous studies on the effects of smoking exposure on motor development. For instance, the R² for multivariant analysis between associations of fine and gross motor skill test scores with age, gender, BMI, blood lead, and magnesium levels as well as serum cotinine level that reflect recent exposure to nicotine in tobacco smoke ranges from 0.08 to 0.25⁴¹. The low R² in our study is partly due to the small sample size of MPSE children which can be attributed to the inherited limitations of questionnaire-based investigation, i.e. underreporting of smoking by mothers. The small sample size may also reduce the ability to detect small effects of MPSE on the health and behaviors of children 3–5 year-old. For example, lower birth weight associated with MPSE reported in other studies was not detected in this cohort. Another contributing factor to the low amount of variance explained by the potential predicting factors of GMQ is that the development of gross motor skills in children is a complex process that is affected by a variety of factors such as child’s sleeping time and position^42,43, exposure to formal aquatic activities⁴⁴, and maternal moderate-to-vigorous intensity physical activity during pregnancy⁴⁵. Moreover, MPSE-associated factors such as duration of breastfeeding may also contribute to differential gross motor skills in children with or without MPSE⁴⁶. Information on these factors is not available in the NNYES survey, making it impossible to take them into account for modeling. Further studies using biomarkers such as urine cotinine²⁷ may be helpful to accurately assess the prevalence of MPSE exposure and its effects on the health and development of preschool children including gross motor development. In addition, large-scale studies including as many factors that may affect gross motor development as possible will help to build robust predictive models for preschool children.

Smoking during pregnancy negatively impacts the gross motor skills of 3–5 year-old boys but not girls. It is also associated with movement behaviors that confer less physical activity in boys and a more sedentary state in girls. More efforts in educating parents on the consequences of smoking during pregnancy and helping women to quit smoking before and during pregnancy are needed to ensure the well-being of preschool-aged children, especially boys.

ANOVA: Analysis of variance

BMI: Body mass index

GMQ: Gross motor quotient

LSSS: Locomotor skills standard score

MPSE: Maternal prenatal smoking exposure

OCSSS: Object control skills standard score

NCHS: National Center for Health Statistics

NHANES: National Health and Examination Survey

NNYFS: National Youth Fitness Survey

RFIP: Ratio of family income to poverty

SW: Shapiro-Wilk

TGMD-2: Test of Gross Motor Development-Second Edition

WAB: Weight at birth

Ethical Approval and consent to participate

No ethics approval and consent to participate is required for this study.

Consent for Publication

Not applicable

Data Availability statement

Raw data were downloaded from https://wwwn.cdc.gov/nchs/nhanes/search/nnyfs12.aspx. Compiled data file is available at https://docs.google.com/spreadsheets/d/11N54nUwBjtyVv3W07bOy1g3pHZzoFbh-/edit?usp=sharing&ouid=109765623934484658518&rtpof=true&sd=true

Conflict of interest

There are no competing interests from authors.

Funding

All authors are funded by the Department of Urology at Stanford University.

Acknowledgment

We thank Mr. Josh Kuo for helpful discussions on various topics related to this study.

Author contribution

A.Z and C.A.Z designed the study and developed the overall research plan. A.Z. and Z.Q collected the data and performed the statistical analyses. A.Z drafted the manuscript. Z.Q and C.A.Z revised the manuscript.

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No competing interests reported.

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Gender-specific effects of exposure to maternal prenatal smoking on gross motor skills and movement behaviors in 3-5 year-old children: findings from the 2012 National Youth Fitness Survey

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Abstract

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Background

Methods

Results

MPSE is associated with low LSSS, OCSSS and GMQ in boys but not in girls

Multiple gross motor skills were negatively affected by MPSE in boys but not in girls

MPSE is differentially associated with movement behaviors in boys and girls

MPSE is significantly associated with GMQ independent of other variables

Discussion

Conclusions

Abbreviations

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References

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Supplementary Files

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Version 1