Effects of Aerobic Exercise during Pregnancy

on 1-Month Infant Neuromotor Skills

AMY GROSS MCMILLAN1, LINDA E. MAY2, GEORGEANNA GOWER GAINES1,
CHRISTY ISLER3, and DEVON KUEHN4
1
Department of Physical Therapy, College of Allied Health Sciences, East Carolina University, Greenville, NC; 2Department of
Foundational Sciences and Research, School of Dental Medicine, East Carolina University, Greenville, NC; 3Department of
Obstetrics and Gynecology, Brody School of Medicine, East Carolina University, Greenville, NC; and 4Department of Pediatrics,
Brody School of Medicine, East Carolina University, Greenville, NC
Downloaded from https://journals.lww.com/acsm-msse by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+5UxwP5IFlC46JFfmAbascK+QWR/F0f/gAXUt3BQb38VtyWIoWwcAw== on 07/13/2019

ABSTRACT
MCMILLAN, A. G., L. E. MAY, G. G. GAINES, C. ISLER, and D. KUEHN. Effects of Aerobic Exercise during Pregnancy on 1-Month
Infant Neuromotor Skills. Med. Sci. Sports Exerc., Vol. 51, No. 8, pp. 1671–1676, 2019. Purpose: To determine the effects of exercise during
pregnancy on the neuromotor development of 1-month-old offspring. We hypothesized that aerobic exercise during pregnancy would be as-
sociated with higher neuromotor scores in infants at 1 month of age, based on standard pediatric assessment of neuromotor skills. Methods:
Seventy-one healthy, pregnant women between 18 and 35 yr were randomly assigned to either aerobic exercise intervention or no exercise
(control) group. Women in the exercise group performed 50 min of moderate-intensity, supervised aerobic exercise, three times per week; those
in control group maintained usual activity. Neuromotor skills were measured at 1 month of age using the Peabody Developmental Motor Scales,
2nd Edition (PDMS-2). Unpaired t-tests were used to compare infants’ PDMS-2 subtest percentiles, Gross Motor Quotients, and Gross Motor
Quotient percentile between groups. Results: Infants of women in the exercise group had higher PDMS-2 scores on four of the five variables
analyzed relative to infants of nonexercisers. Female infants tended to have improved scores relative to male infants of controls; this difference
was attenuated in infants of exercisers. Conclusions: Exercise during pregnancy can positively influence developing systems allowing for im-
proved neuromotor development, thus leading to infants who are more adept at movement, and presumably more likely to be active. Because
physical activity is a modifiable risk factor of childhood obesity, these findings suggest that exercise during pregnancy may potentially reduce
childhood risk of obesity. Key Words: OFFSPRING, MOTOR SKILLS, EXERCISE, PREGNANT, DEVELOPMENT

C
hildhood obesity is continuing to increase with nearly
one-third of US children 2–19 yr of age meeting the
criteria for overweight or obese (1,2). This increase in
obesity is associated with decreased physical activity (3), and
poor performance of motor skills in childhood (4). The earliest
intervention to attenuate this trend is in the prenatal period.
Moderate to vigorous aerobic exercise during pregnancy
has been shown to contribute to improved cardiac autonomic
health in offspring (5,6) in addition to its established benefits
including reductions in preterm delivery, gestational weight
gain, and risk of infant macrosomia (7,8). Previous studies also
found 5-d-old offspring from exercised women had slightly
improved neurobehavioral ability relative to same age off-
spring of controls (9). Thus, there is growing support for the
positive influence of exercise at the recommended levels
Address for correspondence: Linda May, M.S., Ph.D., F.A.H.A., 1851
MacGregor Downs Rd, Greenville, NC 27834; E-mail: mayl@ecu.edu.
Submitted for publication June 2018.
Accepted for publication February 2019.
0195-9131/19/5108-1671/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE®
Copyright © 2019 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000001958
during pregnancy on offspring outcomes, according to the
American College of Obstetrics and Gynecology (10). Fur-
thermore, previous work suggests a modest relationship be-
tween earlier gross motor milestone achievement in the first
year and lower adiposity at 3 yr of age (11). Children who de-
velop movement skills earlier may be more likely to move and
remain physically active throughout their childhood (12),
which could decrease their risk of becoming overweight or
obese, obesity-associated comorbidities (e.g., metabolic syn-
drome), improve bone density and mental health (13–15).
To date, research has not evaluated the neuromotor out-
comes of offspring exposed to supervised maternal aerobic ex-
ercise at the recommended levels in a controlled randomized
trial. The purpose of this study was to determine the effects
APPLIED SCIENCES
of supervised moderate-intensity aerobic exercise during
pregnancy on the early neuromotor development of offspring.
We hypothesized that aerobic exercise during pregnancy
would be associated with higher neuromotor scores in infants
at 1 month of age, based on standard pediatric assessment of
neuromotor skills.
METHODS
We conducted a randomized controlled study designed to
investigate the effects of exercise during pregnancy on infant

1671

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 neuromotor outcomes. All procedures were approved by Uni-
versity and Medical Center Institutional Review Board at East
Carolina University and in accordance with the Code of Ethics
of the World Medical Association (Declaration of Helsinki)
for experiments involving human participants. Women were
recruited via study fliers at local obstetric clinics between
July 2015 and January 2018. Pregnant women were screened
and enrolled between 13 and 16 wk gestation. All participants
signed informed consent.
Participants. We focused recruitment on low-risk,
healthy women, 18 to 40 yr of age, with a prepregnancy body
mass index (BMI) between 18.5 and 34.9 kg·m−2 with a sin-
gleton pregnancy. All women were healthy, nonsmokers, with
no history of alcohol or drug use during the pregnancy, and no
current medication use (e.g., antidepressants, blood pressure).
Participants with any contraindications to exercise during
pregnancy, according to American College of Sports and
Medicine (16), American College of Obstetricians and Gy-
necologists (17), and Society for Obstetricians and Gyne-
cologists of Canada (18) were excluded, as were those with
preexisting diabetes mellitus, hypertension, cardiovascular
disease, or other comorbidities known to effect fetal well-bring
(e.g., systemic lupus erythematous).
Procedures. After written informed consent and physi-
cian clearance for exercise was obtained, participants were
randomized into control or aerobic exercise intervention
group using GraphPad software random sequence generator
(GraphPad, San Diego, CA) that was concealed prior to
group assignment. Study personnel (A.G.M., C.I., D.K.)
were blinded to participant group assignment; however,
due to the nature of an exercise intervention, participants and
trainers could not be blinded to group assignment.
Before 16 wk gestation, each participant performed a mod-
ified Balke submaximal treadmill testing to determine target
HR for moderate intensity exercise intervention, 40% to 59%
HR reserve (HRR), as previously published (19). Heart rate
(POLAR FS2c, Polar Electro Inc., Bethpage, NY) and 12 to
14 rating of perceived exertion (6–20 scale) was monitored be-
fore, during, and after each training session.
Aerobic exercise sessions were supervised by at least two
staff members (1:3 maximum trainer-to-participant ratio)
who were ACSM, First Aid, and CPR certified and occurred
at one of two approved university exercise facilities. Partici-
pants exercised, individually, 3 d·wk−1, with each session in-
cluding a 5-min warm-up, 45- to 50-min exercise, and 3- to
APPLIED SCIENCES
5-min cool down. Based on individual preference, aerobic
exercise modality included treadmill, stationary bicycle, el-
liptical, or aerobics. Participants in the control group did not
receive an exercise intervention; however, they were asked
to engage in a 50-min supervised stretching and breathing
routine, three times to per week. Control participants wore
a HR monitor throughout each session to ensure their HR
did not exceed light intensity (<40% HRR).
Data collection. The validated and reliable Modifiable
Physical Activity Questionnaire (20–22) was provided at en-
rollment and after delivery to confirm compliance based on
1672 Official Journal of the American College of Sports Medicine
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
group assignment. This questionnaire also provided partici-
pant demographic information (age, prepregnancy weight,
number of pregnancies, number of live children, breastfeeding,
highest degree obtained, race) (20,21,23). Results from the
Modifiable Physical Activity Questionnaire after delivery was
used to verify participants activity levels respective of their
assigned group (18,20). Importantly, participants in the control
group were excluded from the analysis if their activity levels
outside of their stretching/breathing routine exceeded the PA
recommendations (i.e., 150 min·wk−1 of moderate activity).
Height was measured in inches to the nearest 0.25 inch using
a stadiometer and converted to meters. Using the standard
formula for females, body mass index (BMI, kg·m−2) was
calculated using height, and self-reported prepregnancy
weight (24). At 36 wk gestation, weight was measured
using a calibrated scale. Gestational weight gain was calcu-
lated by subtracting the participant’s prepregnancy weight
from the weight taken at 36-wk visit.
One month after birth, each participant brought her infant
for neurodevelopmental assessment using the Peabody Devel-
opmental Motor Scales, 2nd edition (PDMS-2) (25). The
PDMS-2 is a standardized, norm-referenced tool used to as-
sess gross motor skills. For infants up to 12 months of age,
the PDMS-2 includes three subtests: Reflexes, Stationary,
and Locomotion. Normalized standard score and percentile
ranks can be calculated for each subtest. A composite score,
the Gross Motor Quotient (GMQ), and a percentile ranking
for this overall score, can also be calculated (25). The
PDMS-2 was performed by an experienced pediatric physi-
cal therapist (A.G.M.) blinded to group classification and
scored according to the standardized protocol.
Data analysis. Maternal and infant 1-month descriptive
measures and infant PDMS-2 subtest percentiles, GMQ, and
GMQ percentiles were summarized as means ± SD, and com-
pared using independent t-tests to determine group differences;
if data were not normally distributed, then the Mann–Whitney
U test was used to analyze group differences. Research sug-
gests breastfeeding may have positive influences on infant
neurodevelopment (26), thus, data analyses were repeated
with only breastfed infants; there were too few formula-fed in-
fants to compare with breastfed infants. Pearson correlations
were performed to determine relationships between maternal
and infant variables. ANCOVA analyses were performed to
determine differences between groups on neuromotor scores
controlling for sex and breastfeeding. All statistical analyses
were performed using the Statistical Package for Social Sci-
ences (SPSS version 19.0, Chicago, 2009) with α < 0.05.
RESULTS
A total of 116 participants were enrolled; after excluding
participants (Fig. 1), our final analysis included 60 participants
(33 aerobic exercisers, 27 nonexercisers/controls). The aver-
age participant was 30.6 yr old, 23.9 BMI (healthy weight),
had a bachelor’s degree, gained 29 pounds, were in their first
pregnancy, and breastfed their child. We found no differences
http://www.acsm-msse.org
FIGURE 1—Study participants.

between group in regard to maternal demographic variables: prepregnancy BMI, gravida, parity, gestational weight gain,
age, BMI, number of pregnancies, number of live children, and education) and infant BMI with infant neuromotor out-
maternal years of education (Table 1). There were near signif- comes (data not shown).
icant differences between groups in gestational weight gain Since males and females may develop at different rates (27),
(P = 0.05) and prevalence of breastfeeding (P = 0.08) we repeated infant analyses between sexes within groups and
(Table 1). All infants included in the study were born healthy, found males infants of controls did significantly better than fe-
full-term, and with no congenital abnormalities. One-month male infants of controls on Reflex percentile, Locomotion per-
infants had similar gestational age, height, weight, and BMI centile, GMQ, and GMQ percentile scores. Female infants of
between groups (Table 2). For exercisers, average exercise in- exercisers did slightly better than males in Reflex, Stationary,
tervention compliance was 83%, but ranged from 29% to and GMQ scores, whereas male infants of exercisers did
100%. Most exercisers (81%) had compliance greater than slightly better in Locomotion scores (Table 4). With differ-
70% throughout the pregnancy. ences between sex, we then compared within sexes between
All infants scored within the range of typical gross motor groups and noted female infants of exercises did significantly
development on the PDMS-2. The PDMS-2 Stationary and better on most scores (Stationary percentile, GMQ, GMQ per-
Locomotion percentiles, GMQ, and GMQ percentiles were centile) compared with females of controls (Table 4). Con-
all higher for infants of aerobic exercisers compared to infants versely, male controls had significantly higher (P = 0.02)
of controls (Table 3). This difference was significant for the Reflex scores than male exercisers; except for Reflex scores,
Locomotion subtest percentile score (Table 3). Based on male infants of exercisers tended to have higher scores than
previous literature (26), comparisons were repeated with male and female infants of controls (Table 4). With ANCOVA
only infants breastfed and findings are similar between we found a significant effect of exercise–sex interaction on
groups (data not shown). Pearson correlation analysis found 1-month Reflex scores after controlling for breastfeeding
no significant associations between maternal measures (age, (F(1,65) = 5.819, P = 0.02). The effect was almost significant
for exercise group on 1-month Stationary scores after control-
TABLE 1. Maternal participant demographics.
ling for breastfeeding (F(1,65) = 3.235, P = 0.08). The effect
was significant for sex (F(1,65) = 8.895, P = 0.004) and almost
APPLIED SCIENCES
Maternal Variables Control Exercise P
Age (yr) 29.5 ± 4.4 30.7 ± 3.4 0.24
for exercise group (F(1,65) = 3.752, P = 0.057) on 1-month
Prepregnancy BMI (kg·m−2) 25.7 ± 4.8 24.8 ± 5.2 0.48 Locomotion scores after controlling for breastfeeding. With
Gestational weight gain (lb) 21.3 ± 12.6 33.9 ± 25.4 0.05 ANCOVA we found a significant effect of exercise–sex inter-
No. pregnancy* 1 (1,5) 2 (1,4) 0.90
No. children* 1 (1, 3) 2 (1, 3) 0.72 action on 1-month GMQ scores (F(1,65) = 4.509, P = 0.04)
Breastfeeding 86.7% 97.2% 0.08
Education 16.7% High school 2.8% High school
53.3% College degree 52.8% College degree TABLE 2. Infant participant descriptors.
30% Graduate degree 44.4% Graduate degree
Maternal education (yr) 17.3 ± 2.8 18.1 ± 2.2 0.18 1-Month Variables Control Exercise P
Race 77% White 78% White Gestational age at birth (wk) 38.9 ± 1.2 39.5 ± 1.5 0.14
23% Minority 22% Minority Height (cm) 53.7 ± 3.1 53.9 ± 3.9 0.82
Weight (kg) 4.22 ± 0.64 4.46 ± 0.59 0.16
*Represented as median (minimum, maximum); two-sided P value. Minority—African −2
BMI (kg·m ) 14.7 ± 2.5 15.4 ± 1.8 0.22
American and Asian.

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 TABLE 3. PDMS-2 gross motor quotient (GMQ) and subtest scores.
PDMS-2 Scores Control Exercise
Reflex percentile 66.2 ± 9.1 63.1 ± 11.8
Stationary percentile 39.5 ± 10.3 45.5 ± 14.0
Locomotion percentile 50.0 ± 9.9 55.7 ± 10.3
GMQ 101.0 ± 3.3 102.6 ± 4.7
GMQ percentile 52.5 ± 8.6 56.3 ± 11.3
*P < 0.05.
and GMQ percentiles (F(1,65) = 5.063, P = 0.03) after control-
ling for breastfeeding.
DISCUSSION
The purpose of this study was to determine the effects of
maternal exercise during pregnancy on the early neuromotor
development of offspring. We hypothesized that exercise dur-
ing pregnancy would be associated with higher neuromotor
scores in infants at 1 month of age, based on standard assess-
ment of infant motor skills. The data show, in support of our
hypothesis, that infants of mothers who exercised during preg-
nancy scored higher on Stationary and Locomotion skills and
on overall Gross Motor Quotient at 1-month relative to infants
of mothers who did not exercise during pregnancy. Significant
differences were also found in neuromotor skills within like
sexes associated with the exercise intervention. This is the first
evidence of its kind from a randomized control study of super-
vised exercise intervention in pregnancy and adds to the growing
body of knowledge supporting the positive effects of maternal
exercise on infants’ outcomes.
The findings of this study are consistent with previously re-
ported positive effects of maternal exercise on neurobehavior
in newborns and at 1 yr of age (9,28). Clapp et al. (29) reported
higher scores in neuromotor skills in 5-yr-olds exposed to
maternal aerobic exercise, ≥90 min of moderate intensity
throughout the entire pregnancy, compared to 5-yr-olds of
women in control group (29). Although Hellenes et al. (30) re-
ported no difference in motor skills of 18-month-olds whose
mothers had/had not exercised during pregnancy, the moder-
ate intensity exercise was less than three times per week,
whereas duration and type of exercise for each session was
not reported, which may explain the lack of differences be-
tween groups. Overall, improved neuromotor skills in infancy
may be related to later physical activity and performance, as
has been reported previously (31–33). Sanchez et al. (31) re-
ported that delays in gross motor development were related
APPLIED SCIENCES
and suggest exercise during pregnancy as a potential modifier
P of childhood and adult obesity risk.
0.24 A possible explanation for the neuromotor improvements in
0.06
0.02* infants exposed to exercise in utero could be the release of
0.12 growth hormone as well as intrauterine growth factor-1
0.14
(IGF-1) associated with maternal exercise (34). Although ma-
ternal growth hormone and IGF-1 do not cross the placenta,
they can enhance fetal growth and development via improved
fetal nutrient supply (35). Additionally, exercise during
pregnancy may directly impact brain and nervous system
development in utero by improving overall blood flow and
oxygenation, decreasing inflammatory factors and oxidative
stress (36), and increasing serum levels of growth factors
(i.e., brain derived neurotrophic factor, IGF-1) (37). Newborn in-
fants of mothers who exercised during pregnancy had enhanced
cerebral maturation compared to infants whose mothers were inac-
tive (38). Cerebral maturation is associated with myelination and
motor skills. Newborn infants of mothers who exercised during
pregnancy had enhanced cerebral maturation compared to infants
whose mothers were inactive (38). Cerebral maturation is associ-
ated with myelination and motor skills (38–40). Conversely,
studies of maternal obesity report infant motor milestones are de-
layed and associated with long-term consequences of cognitive
function when mothers are classified as obese (41). Conversely,
studies of maternal obesity find infant motor milestones are de-
layed and associated with long-term consequences of cogni-
tive function when mothers are classified as obese (41).
An intriguing finding of this study was the sex dimorphism
in the effects of prenatal exercise on neuromotor skills. Sex di-
morphism during fetal and neonatal growth and development
is common given the dramatic differences in growth rates,
concentrations of sex hormones secreted (e.g., testosterone)
and accretion of bodily tissues (e.g., lean body mass) between
males and females. In this study, we found that male infants of
nonaerobically trained mothers exhibited higher neuromotor
skills at 1-month of age compared to their female counterparts,
which is consistent with previous literature (42). At birth, male
brain volume, especially in the motor cortex region, is larger
compared with females. This accelerated growth is suggested
to be consequent to the “masculinization” of the male brain
via the heightened secretion of testosterone. Interestingly,
when comparing male and female infants of aerobically-trained
mothers, the sex differences in neuromotor skills disappeared.
TABLE 4. PDMS-2 GMQ and subtest scores for males between groups.

Control Exercise P
to decreased time in moderate-to-vigorous physical activity, Female PDMS-2 scores
and increased sedentary time, at 7 yr of age. Ridgway et al. Reflex percentile 62.9 ± 6.9 66.9 ± 12.9 0.60
(32,33) reported that earlier attainment of gross motor skills Stationary percentile 38.2 ± 10.4 48.3 ± 11.8 0.04*
Locomotion percentile 45.4 ± 9.5 52.6 ± 7.3 0.06
predicted increased sports participation at 14 yr of age, and GMQ 99.4 ± 2.4 103.2 ± 4.5 0.02*
greater muscle strength, muscle endurance, and aerobic fitness GMQ percentile 48.6 ± 6.4 58.1 ± 11.2 0.02*
Male PDMS-2 scores
at 31 yr of age. Infants and children with higher motor compe- Reflex percentile 69.5 ± 10.2** 60.5 ± 10.5 0.04
tence will likely enjoy movement more and thus participate Stationary percentile 40.9 ± 10.5 43.6 ± 15.3 0.56
more in gross motor activities. Increased physical activity will Locomotion percentile 54.6 ± 8.2** 57.7 ± 11.6 0.78
GMQ 102.5 ± 3.5** 102.1 ± 4.8 0.80
contribute to a decreased risk for obesity and cardiovascular dis- GMQ percentile 56.4 ± 8.8** 55.1 ± 11.4 0.72
ease later in life. The current findings further support the posi- *P < 0.05 between exercise and control groups; **P < 0.05 between males and females
tive influence of maternal exercise on fetal neurodevelopment within same group.

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This observation offers a few speculations given its novelty. First,
it is possible that the advanced development of male brain
in utero presents a ceiling effect, whereby the documented
augmentation of cerebral blood flow and oxygenation and
subsequently maturation consequent to prenatal exercise, did
not further enhance brain development in male fetuses. Relat-
edly, prenatal exercise may accelerate cerebral maturation in
female fetuses, potentially resulting in increased motor skills,
equivalent to that of males. Specific mechanisms for this hy-
pothesis are not clear, requiring further investigation.
The clinical implications of this study relate to the promo-
tion of healthy neuromotor development in infants, and poten-
tially the prevention of childhood overweight and obesity.
Maternal exercise has many positive effects on the offspring,
as is shown in this and previous studies (6,43–46). The finding
of consistently higher scores on the PDMS-2 stationary and lo-
comotor subtests, and on overall GMQ, suggests improved
ability of the infants in the exercise group to use sensory input,
cognitive motivation, and muscular strength and coordination
to voluntarily control head, trunk and extremities. Since poor
neuromotor skills are associated with decreased physical activ-
ity of infants and children, which is a risk factor for obesity,
the promotion of exercise during pregnancy may positively in-
fluence childhood health outcomes.
Limitations. Although our sample is relatively small, the
fact that we found differences between two healthy, typically
developing groups of infants is encouraging and suggests fur-
ther research should be done in this area. Though we had a di-
verse population of women (BMI, race, education, etc.), all
were healthy with a singleton pregnancy, therefore, these re-
sults may not be generalizable to all pregnant women, espe-
cially those considered high risk due to multiple gestation,
comorbidities, etc. We did not control for other factors, such
as maternal diet, sleep, sedentary behavior, or occupation,
nor for postnatal infant environment and stimulation which
may influence fetal/infant nervous system development. It is
possible that women who exercised during pregnancy may
be more likely to provide a stimulating postnatal environment;
this and other potential confounding factors will need to be
considered in future studies. Finally, this study reports only
on gross motor skills at 1 month, and only on effects of aerobic
exercise intervention compared to no exercise. The benefits of
specific types of exercise (e.g., aerobic, resistance, circuit),
REFERENCES
1. Fryar C, Carroll MD, Ogden CL. Prevalence of overweight and
obesity among children and adolescents: United States, 1963–1965
through 2011–2012. In: Surveys NHaNE, ed. CDC National Center
for Health Statistics: CDC/NCHS, National Health and Nutrition Ex-
amination Survey, 2014: 6 pages.
2. Ogden C, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and
adult obesity in the United States, 2011–2012. JAMA. 2014;311:8–14.
3. Steele RM, Brage S, Corder K, et al. Physical activity, cardiorespira-
tory fitness, and the metabolic syndrome in youth. J Appl Physiol.
2008;105:342–51.
MATERNAL EXERCISE & INFANT NEUROMOTOR SKILLS
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
and effects beyond 1 month of age, will need further study.
A significant strength of this study was the high compliance
to the exercise intervention (~89%), a common challenge in
most prenatal exercise studies. We recommend employing
similar compliance strategies used in this study, in future inter-
ventions including supervised exercise sessions, continuous
tracking of maternal HR during exercise, individual exercise
training sessions (dependent on the culture), and flexibility in
training regimen (e.g., scheduling, equipment).
CONCLUSIONS
The current findings of greater neuromotor development in
1-month old infants of exercising women add to the growing
body of evidence suggesting that exercise during pregnancy
positively influences multiple body systems in the developing
infant. Our study demonstrated distinct neurodevelopmental
differences between male and female infants that require fur-
ther investigation. We found that female, but not male infants,
benefit from exercise exposure in utero, as evidenced by im-
proved Stationary and Locomotion skills. The improved ca-
pacity for movement in female infants of exercisers is an
important clinically relevant finding suggesting these children
may be more physically active as they continue to grow and
develop, potentially preventing childhood obesity, osteoporo-
sis, and noncommunicable diseases (e.g., type 2 diabetes
mellitus and cardiovascular disease) (47). Thus, exercise dur-
ing pregnancy may be the earliest intervention to help reduce
the prevalence of common morbidities among children and ad-
olescents and improve the quality of life (15,48).
This study was funded, in part, by the American Heart Association
(AHA grant 15GRNT24470029 to LEM) and by East Carolina University
for funds to collect the data. The authors would like to acknowledge all
the women who agreed to participate in this study. The authors are very
grateful for their time. The authors would further like to thank the ECU
Fitness, Instruction, Testing and Training (FITT) facility staff and stu-
dents, and Department of Physical Therapy students, for their assis-
tance in various tasks throughout the completion of this project.
The authors have no potential, perceived, or real conflict of interest
to disclose in regards to professional relationships with companies or
manufacturers. The study sponsors had no influence on the study de-
sign, interpretation of data, writing of the manuscript, nor decision to
submit the manuscript. The results of the present study do not consti-
tute endorsement by ACSM. The results of the study are presented
clearly, honestly, and without fabrication, falsification, or inappropriate
data manipulation.
APPLIED SCIENCES
4. Loprinzi PD, Davis RE, Fu YC. Early motor skill competence as a me-
diator of child and adult physical activity. Prev Med Rep. 2015;2:833–8.
5. May LE, Glaros AG, Gustafson KM, Suminski RR. Maternal exer-
cise dose response effect on fetal heart rate and variability. FASEB
J. 2010;24:629.7.
6. May LE, Scholtz SA, Suminski R, Gustafson KM. Aerobic exercise
during pregnancy influences infant heart rate variability at one month
of age. Early Hum Dev. 2014;90:33–8.
7. da Silva SG, Ricardo LI, Evenson KR, Hallal PC. Leisure-time
physical activity in pregnancy and maternal–child health: a
Medicine & Science in Sports & Exercise® 1675
 systematic review and meta-analysis of randomized controlled
trials and cohort studies. Sports Med. 2017;47:295–317.
8. Wiebe HW, Boule NG, Chari R, Davenport MH. The effect of super-
vised prenatal exercise on fetal growth: a meta-analysis. Obstet
Gynecol. 2015;125:1185–94.
9. Clapp JF 3rd, Lopez B, Harcar-Sevcik R. Neonatal behavioral profile
of the offspring of women who continued to exercise regularly
throughout pregnancy. Am J Obstet Gynecol. 1999;180:91–4.
10. Gynecologists ACoOa. Physical activity and exercise during
pregnancy and the postpartum period. ACOG Committee Opinion.
2015;650:8.
11. Benjamin Neelon SE, Oken E, Taveras EM, et al. Age of achieve-
ment of gross motor milestones in infancy and adiposity at age
3 years. Matern Child Health J. 2012;16:1015–20.
12. Telama R, Yang X, Viikari J, et al. Physical activity from childhood
to adulthood: a 21-year tracking study. Am J Prev Med. 2005;28:
267–73.
13. Brage S, Wedderkopp N, Ekelund U, et al. Features of the metabolic
syndrome are associated with objectively measured physical activity
and fitness in Danish children: the European youth heart study
(EYHS). Diabetes Care. 2004;27:2141–8.
14. Welten DC, Kemper HC, Post GB, et al. Weight-bearing activity dur-
ing youth is a more important factor for peak bone mass than calcium
intake. J Bone Miner Res. 1994;9:1089–96.
15. Ahn S, Fedewa AL. A meta-analysis of the relationship between chil-
dren’s physical activity and mental health. J Pediatr Psychol. 2011;
36:385–97.
16. Practice ACoO. Physical activity and exercise during pregnancy and
the postpartum period. Obstet Gynecol. 2015;650:8.
17. ACOG Committee Opinion No. 650. Physical activity and exercise
during pregnancy and the postpartum period. Obstet Gynecol.
2015;126:e135–42.
18. Davies GA, Wolfe LA, Mottola MF, et al. Joint SOGC/CSEP clinical
practice guideline: exercise in pregnancy and the postpartum period.
Can J Appl Physiol. 2003;28:330–41.
19. Mottola MF, Davenport MH, Brun CR, et al. VO2peak prediction
and exercise prescription for pregnant women. Med Sci Sports Exerc.
2006;38:1389–95.
20. Kriska AM, Knowler WC, LaPorte RE, et al. Development of ques-
tionnaire to examine relationship of physical activity and diabetes in
Pima Indians. Diabetes Care. 1990;13:401–11.
21. Cramp AG, Bray SR. A prospective examination of exercise and bar-
rier self-efficacy to engage in leisure-time physical activity during
pregnancy. Ann Behav Med. 2009;37:325–34.
22. Cramp AG, Bray SR. Pre- and postnatal women’s leisure time phys-
ical activity patterns: a multilevel longitudinal analysis. Res Q Exerc
Sport. 2009;80:403–11.
23. Bauer PW, Broman CL, Pivarnik JM. Exercise and pregnancy
knowledge among healthcare providers. J Womens Health. 2010;
19:335–41.
24. Moyer C, Livingston J, Fang X, May LE. Influence of exercise mode
on pregnancy outcomes: ENHANCED by Mom project. BMC Preg-
nancy Childbirth. 2015;15:133.
APPLIED SCIENCES
25. Folio M, Fewell RR. Peabody Developmental Motor Scales-2
(PDMS-2). Austin, TX: Pro-Ed; 2000.
26. Bar S, Milanaik R, Adesman A. Long-term neurodevelopmental ben-
efits of breastfeeding. Curr Opin Pediatr. 2016;28:559–66.
27. Saraiva L, Rodrigues LP, Cordovil R, Barreiros J. Motor profile of
Portuguese preschool children on the Peabody developmental motor
Scales-2: a cross-cultural study. Res Dev Disabil. 2013;34:1966–73.
28. Clapp JF 3rd. Exercise during pregnancy. A clinical update. Clin
Sports Med. 2000;19:273–86.
1676 Official Journal of the American College of Sports Medicine
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
29. Clapp JF 3rd. Morphometric and neurodevelopmental outcome at age
five years of the offspring of women who continued to exercise reg-
ularly throughout pregnancy. J Pediatr. 1996;129:856–63.
30. Hellenes OM, Vik T, Lohaugen GC, et al. Regular moderate ex-
ercise during pregnancy does not have an adverse effect on the
neurodevelopment of the child. Acta Paediatr. 2015;104:285–91.
31. Sánchez GFL, Williams G, Aggio D, et al. Prospective associations
between measures of gross and fine motor coordination in infants
and objectively measured physical activity and sedentary behavior
in childhood. Medicine (Baltimore). 2017;96:e8424.
32. Ridgway CL, Ong KK, Tammelin T, et al. Birth size, infant weight
gain, and motor development influence adult physical performance.
Med Sci Sports Exerc. 2009;41:1212–21.
33. Ridgway CL, Ong KK, Tammelin TH, et al. Infant motor develop-
ment predicts sports participation at age 14 years: northern Finland
birth cohort of 1966. PLoS One. 2009;4:e6837.
34. Kraemer WJ, Ratamess NA. Hormonal responses and adaptations to
resistance exercise and training. Sports Med. 2005;35:339–61.
35. Tung E, Roberts CT, Heinemann GK, et al. Increased placental nutri-
ent transporter expression at midgestation after maternal growth hor-
mone treatment in pigs: a placental mechanism for increased fetal
growth. Biol Reprod. 2012;87:126.
36. Denison FC, Roberts KA, Barr SM, Norman JE. Obesity, preg-
nancy, inflammation, and vascular function. Reproduction. 2010;140:
373–85.
37. Marques AH, Bjorke-Monsen AL, Teixeira AL, Silverman MN. Ma-
ternal stress, nutrition and physical activity: impact on immune func-
tion, CNS development and psychopathology. Brain Res. 2015;1617:
28–46.
38. Labonte-Lemoyne E, Curnier D, Ellemberg D. Exercise during preg-
nancy enhances cerebral maturation in the newborn: a randomized
controlled trial. J Clin Exp Neuropsychol. 2017;39:347–54.
39. Spann MN, Bansal R, Rosen TS, Peterson BS. Morphological fea-
tures of the neonatal brain support development of subsequent
cognitive, language, and motor abilities. Hum Brain Mapp. 2014;35:
4459–74.
40. Deoni SC, Dean DC 3rd, Remer J, et al. Cortical maturation and
myelination in healthy toddlers and young children. Neuroimage.
2015;115:147–61.
41. Murray GK, Jones PB, Kuh D, Richards M. Infant developmental
milestones and subsequent cognitive function. Ann Neurol. 2007;
62:128–36.
42. Richter J, Janson H. A validation study of the Norwegian version of
the ages and stages questionnaires. Acta Paediatr. 2007;96:748–52.
43. May L, Suminski RS. Amount of physical activity in pregnancy and
infant heart outcomes. J Neonatal Biol. 2014;3:160.
44. May LE, Allen JJ, Gustafson KM. Fetal and maternal cardiac re-
sponses to physical activity and exercise during pregnancy. Early
Hum Dev. 2016;94:49–52.
45. May LE, Glaros A, Yeh HW, et al. Aerobic exercise during preg-
nancy influences fetal cardiac autonomic control of heart rate and
heart rate variability. Early Hum Dev. 2010;86:213–7.
46. May LE, Suminski RR, Langaker MD, et al. Regular maternal exer-
cise dose and fetal heart outcome. Med Sci Sports Exerc. 2012;44:
1252–8.
47. Andersen LB, Harro M, Sardinha LB, et al. Physical activity and
clustered cardiovascular risk in children: a cross-sectional study (the
European Youth Heart Study). Lancet. 2006;368:299–304.
48. Poitras VJ, Gray CE, Borghese MM, et al. Systematic review of the
relationships between objectively measured physical activity and
health indicators in school-aged children and youth. Appl Physiol
Nutr Metab. 2016;41:S197–239.
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