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Comment & Response
February 15, 2021

Methodologic Concerns With Concluding a Link Between Epidural and Autism Spectrum Disorder

Author Affiliations
  • 1Columbia University, New York, New York
  • 2Society for Obstetric Anesthesia and Perinatology, Lexington, Kentucky
JAMA Pediatr. 2021;175(5):536. doi:10.1001/jamapediatrics.2020.6686

To the Editor We have strenuous concerns about the conclusions of Qiu et al,1 implying a causal link between maternal labor epidural analgesia (LEA) and an increased risk of autism spectrum disorder (ASD) in children, based on their analysis of a retrospective cohort of women who underwent vaginal delivery between 2008 and 2015 in Kaiser Permanente Southern California hospitals. Autism spectrum disorder is a major public health concern attributed primarily to genetic and environmental risk factors2 but, as the authors mention, has a purported association with general anesthesia for cesarean delivery (CD) and CD itself.3 The ASD incidence was lower than prior reports, possibly suggesting missing cases based on very early screening and loss to follow-up. Information regarding LEA management was omitted; however, the authors speculated that transplacental transfer of epidurally administered local anesthetics may be causal factors. Contemporary practice consists of minimal local anesthetics doses at levels insufficient to cause fetal neurotoxicity.4 Longer labors may reflect inherently more complicated pregnancies, and the incidence of ASD according to duration of labor among the no-LEA group is glaringly absent.

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