Twins and maternal smoking: ordeals for the fetal origins hypothesis? A cohort study

BMJ 1999;318:897 (full) ( 3 April )

Papers

Four papers appear in the print BMJ this week in abridged form. The full and abridged versions are both available here on our website. The editorial by Delamothe et al explains why we are doing this, and we welcome readers' reactions. The paper by Whitehead (p. 908) appears in two abridged versions, one much shorter than the other; again we welcome readers' reactions on which they prefer, and why.

Twins and maternal smoking: ordeals for the fetal origins hypothesis? A cohort study

Editorial by Delamothe et al

Sheila Williams, senior research fellow, ^a Richie Poulton, senior research fellow. ^b

^a University of Otago, Box 913, Dunedin, New Zealand, ^b Department of Preventive and Social Medicine

Correspondence to: Ms Williams sheila.williams{at}stonebow.otago.ac.nz

Objective: To assess the direct and indirect effectsof being a twin, maternal smoking, birth weight, and mother'sheight on blood pressure at ages 9 and 18years.
Design: Longitudinalstudy.
Subjects: Cohort born in 1972-3.
Setting: Dunedin, NewZealand.
Main outcome measure: Blood pressure at ages 9 and 18years.
Results: Compared with singletons, twins had a systolicblood pressure 4.55 (95% confidence interval 1.57 to 7.52) mmHg lower at age 9 after adjustment for direct and indirect effectsof sex, maternal smoking, mother's height, socioeconomic status,and birth weight, as well as concurrent height and body mass index.Blood pressure in children whose mothers had smoked during pregnancywas 1.54 (0.46 to 2.62) mm Hg higher than in those whose mothersdid not. The total effect of birth weight on systolic blood pressureat age 9 was $-$ 0.78 ( $-$ 1.76 to 0.20) mm Hg and that for mother'sheight was 0.10 (0.06 to 0.14) mm Hg. Similar results were obtainedfor systolic blood pressure at age 18. The total effect of twins,maternal smoking, and birth weight on diastolic blood pressurewas not significant at eitherage.
Conclusions: Twins had lower birth weight and lower systolicblood pressure at ages 9 and 18 than singletons. This findingchallenges the fetal origins hypothesis. The effect of maternalsmoking was consistent with the fetal origin hypothesis in thatthe infants of smokers were smaller and had higher blood pressureat both ages. This may be explained by pharmacological ratherthan nutritional effects. The total effect of birth weight onsystolic blood pressure, after its indirect effect working throughconcurrent measures of height and body mass index was taken intoaccount, wassmall.

Key message

Twins have lower systolic blood pressure at age 9 and 18 years than singletons
Children of mothers who smoke in pregnancy have a lower mean birth weight and a higher mean systolic blood pressure at age 9 and 18.
When the indirect effects of birth weight on current height and body mass index are taken into account the effect of birth weight on blood pressure is small at ages 9 and 18

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