Direct and indirect interactions of cocaine with childbirth outcomes

Fifty Years of Research on Prenatal Substances: Lessons Learned for the Opioid Epidemic

Current efforts to design research on developmental effects of prenatal opioid exposure can benefit from knowledge gained from 50 years of studies of fetal alcohol and prenatal drug exposures such as cocaine. Scientific advances in neurobiology, developmental psychopathology, infant assessments, genetics, and imaging support the principles of developmental neurotoxicology that guide research in prenatal exposures. Important to research design is accurate assessment of amount, frequency, and timing of exposure which benefits from accurate self-report and biomarkers of exposure. Identifying and control of pre- and postnatal factors that impact development are difficult and dependent on appropriate research design and selection of comparison groups and measurement of confounding, mediating, and moderating variables. Polysubstance exposure has increased due to the number of prescribed and nonprescribed substances used by pregnant women and varying combinations of drugs may have differential effects on the outcome. Multiple experimental and clinical assessments of infant behavior have been developed but predicting outcome before 18-24 months of age remains difficult. With some exceptions, prenatal substance exposure effect sizes have been small, and cognitive and behavioral effects tend to be specific rather than global. Studies require large sample sizes, adequate retention, and support for social services in at-risk samples. The ethical and legal contexts and stigma associated with drug/alcohol use disorder should be considered in order to prevent harm to families in research programs. Recognition of the pervasive use of addictive substances in this nation should lead to broad scientific efforts to understand how substances affect child outcomes and to initiate prevention and intervention where needed.

Prenatal cocaine exposure: An examination of childhood externalizing and internalizing behavior problems at age 7 years

Aim – This study examines the relationship between prenatal cocaine exposure and parent-reported child behavior problems at age 7 years. Methods – Data are from 407 African-American children (210 cocaine-exposed, 197 non-cocaine-exposed) enrolled prospectively at birth in a longitudinal study on the neurodevelopmental consequences of in utero exposure to cocaine. Prenatal cocaine exposure was assessed at delivery through maternal self-report and bioassays (maternal and infant urine and infant meconium). The Achenbach Child Behavior Checklist (CBCL), a measure of childhood externalizing and internalizing behavior problems, was completed by the child's current primary caregiver during an assessment visit scheduled when the child was seven years old. Results – Structural equation and GLM/GEE models disclosed no association linking prenatal cocaine exposure status or level of cocaine exposure to child behavior (CBCL Externalizing and Internalizing scores or the eight CBCL sub-scale scores). Conclusions – This evidence, based on standardized ratings by the current primary caregiver, fails to support hypothesized cocaine-associated behavioral problems in school-aged children with in utero cocaine exposure. A next step in this line of research is to secure standardized ratings from other informants (e.g., teachers, youth self-report).

Declaration of Interest: This research was conducted in the context of an ongoing longitudinal study funded by the National Institutes of Health National Institute on Drug Abuse (R01 DA 06556). Support was also provided by a NIDA career development award (K01 DA 16720), a NIDA research training award (T32 DA 07292), the General Clinical Research Center (MOI RR 16587), and the Health Foundation of South Florida.

Motor and cognitive outcomes through three years of age in children exposed to prenatal methamphetamine

BACKGROUND

Methamphetamine (MA) use among pregnant women is an increasing problem in the United States. The impact of prenatal MA exposure on development in childhood is unknown.

OBJECTIVE

To examine the effects of prenatal MA exposure on motor and cognitive development in children at 1, 2, and 3 years of age.

DESIGN/METHODS

IDEAL enrolled 412 mother-infant pairs at four sites (Tulsa OK, Des Moines IA, Los Angeles CA, and Honolulu HI). MA subjects (n=204) were identified by self report or GC/MS confirmation of amphetamine and metabolites in infant meconium. Comparison subjects (n=208) were matched (race, birth weight, maternal education, and type of insurance), denied amphetamine use, and had a negative meconium screen. Both groups included prenatal alcohol, tobacco and marijuana use, but excluded use of opiates, lysergic acid diethylamide, phencyclidine or cocaine only. The Peabody Developmental Motor Scales (PDMS-2) were administered to the infants at the 1 and 3 year visits. This analysis includes a subsample (n=350) of the IDEAL study with completed 1 and/or 3 year visits (n=330 and 281, respectively). At each annual visit we also conducted the Bayley Scales of Infant Development (BSID-II) as a general evaluation of mental and motor development. The BSID-II analysis includes a subsample (n=356) of the IDEAL study with completed 1, 2, and/or 3 year visits (n=331, 288, and 278 respectively). GLM analysis conducted on the PDMS-2 and BSID-II examined the effects of MA exposure and heavy MA exposure (≥3 days of use/week), with and without covariates. Longitudinal analyses were used to examine the effects of MA exposure on changes in motor and cognitive performance over time.

RESULTS

Heavy MA exposure was associated with significantly lower grasping scores than some and no use at 1 year (P=0.018). In longitudinal analysis, lower grasping scores associated with any MA exposure and heavy exposure persisted to 3 years. There were no effects of MA exposure, including heavy exposure, on the Bayley Mental Development Index (MDI) or Psychomotor Development Index (PDI) at any or across age.

CONCLUSIONS

There were no differences in cognition as assessed by the BSID-II between the groups. There was a subtle MA exposure effect on fine motor performance at 1 year with the poorest performance observed in the most heavily exposed children. By 3 years, no differences in fine motor performance were observed. These findings suggest MA exposure has modest motor effects at 1 year that are mostly resolved by 3 years.

Effects of cocaine use during pregnancy on low birthweight and preterm birth: systematic review and metaanalyses

OBJECTIVE

To review systematically maternal antenatal cocaine exposure and adverse perinatal outcomes.

STUDY DESIGN

Medline, Embase, CINAHL and secondary references in relevant studies were searched. English language studies of antenatal cocaine exposure and pregnancy outcomes published from 1966 to July 2009 were included. Metaanalyses were performed using the random effects model.

RESULTS

Thirty-one studies were included. Cocaine use during pregnancy was associated with significantly higher odds of preterm birth (odds ratio [OR], 3.38; 95% confidence interval [CI], 2.72-4.21), low birthweight (OR, 3.66; 95% CI, 2.90-4.63), and small for gestational age infants (OR, 3.23; 95% CI, 2.43-4.30), as well as shorter gestational age at delivery (-1.47 week; 95% CI, -1.97 to -0.98 week) and reduced birthweight (-492 g; 95% CI, -562 to -421 g).

CONCLUSION

Prenatal cocaine exposure is significantly associated with preterm birth, low birthweight, and small for gestational age infants.

Neurologic aspects of drug abuse

Neurologic aspects of drug abuse vary. This article explains the general nature of drug abuse, identifies the physiologic effects of certain drugs, and briefly describes the neurobiology of addiction. This article also reviews available treatment options for those addicted to substances of abuse, and clarifies common misconceptions, including the differences between tolerance, abuse, and addiction.

Term-Gestation Low Birth Weight and Health-Compromising Behaviors During Pregnancy

OBJECTIVE

To estimate the association between term-gestation low birth weight (term-LBW) rates and increasing numbers of health-compromising behaviors during pregnancy.

METHODS

Retrospective cohort study of 78,397 term live births in Kansas City, Missouri, 1990-2002. Information on maternal and newborn characteristics was obtained form birth certificate records. Health-compromising behavior, specifically, smoking, alcohol, and drug use, was classified by the numbers and combinations of behaviors engaged in during pregnancy. Covariates included race, age, interconception interval, education, Medicaid status, medical risk factors, adequacy of prenatal care, and marital status.

RESULTS

The cohort was 61% white, 16% less than 20 years of age, 45% on Medicaid, 24% with medical risk factor, and 45% single pregnant women. Overall term-LBW rate was 3.3%, and it increased with numbers of health-compromising behaviors: 2.6% (none), 5.5% (1), 10.8% (2), and 18.5% (3), P < .001. Unadjusted odds ratio (OR) for term-LBW increased with increasing numbers of behaviors (OR 1.0 [none]; 2.3, 95% confidence interval 2.0-2.4 [smoking]; 0.9, 0.6-1.4 [alcohol]; 2.1, 1.5-3.0 [drugs]; 4.6, 3.6-5.8 [smoking + alcohol]; 4.4, 3.6-5.4 [smoking + drugs]; 4.2, 1.5-11.9 [drugs + alcohol]; 8.4, 6.2-11.5 [smoking + alcohol + drugs]). However, on adjusting for covariates, smoking, alone (OR 2.3, 2.0-2.5) or in combinations with other behaviors (OR 4.4, 3.4-5.7 [smoking + alcohol]; 2.0, 1.6-2.6 [smoking + drugs]; and 3.3, 2.2-4.7 [smoking + alcohol + drugs]) remained the major risk factor for term-LBW.

CONCLUSION

Smoking alone or in combination with alcohol and/or drug use is associated with term-LBW among women who engage in health-compromising behaviors. The effect is especially pronounced when smoking is combined with alcohol consumption.

Substance use associated with unintended pregnancy outcomes in the National Longitudinal Survey of Youth

Abortion is known to be associated with higher rates of substance abuse, but no studies have compared substance use rates associated with abortion compared to delivery of an unintended pregnancy. This study examines data for women in the National Longitudinal Survey of Youth whose first pregnancy was unintended. Women with no pregnancies were also used as a control group. Use of alcohol, marijuana, cocaine, and behaviors suggestive of alcohol abuse were examined an average of four years after the target pregnancy among women with prior histories of delivering an unintended pregnancy (n = 535), abortion (n = 213), or those who reported no pregnancies (n = 1144). Controls were instituted for age, race, marital status, income, education, and prepregnancy self-esteem and locus of control. Compared to women who carried an unintended first pregnancy to term, those who aborted were significantly more likely to report use of marijuana (odds ratio: 2.0), with the difference in these two groups approaching significance relative to the use of cocaine (odds ratio: 2.49). Women with a history of abortion also reported more frequent drinking than those with a history of unintended birth. With the exception of less frequent drinking, the unintended birth group was not significantly different from the no pregnancy group. Resolution of an unintended pregnancy by abortion was associated with significantly higher rates of subsequent substance use compared to delivering an unintended pregnancy. A history of abortion may be a useful marker for identifying women in need of counseling for substance use.

Cocaine, anemia, and neurodevelopmental outcomes in children: a longitudinal study

This longitudinal study investigated the rates of iron-deficiency (ID) and iron-deficiency anemia (IDA) among prenatally cocaine-exposed and nonexposed two- and four-year-old children and assessed their relationships to neurodevelopmental outcomes. The sample consisted of 143 two-year-old (70 exposed and 73 nonexposed) and 274 four-year-old (139 exposed and 135 nonexposed) low socioeconomic status children recruited from an ongoing longitudinal study. Hematological assessments included hemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation, and blood lead levels. The neurodevelopmental outcomes consisted of the Bayley Mental (MDI) and Motor (PDI) Development indices at two years, and the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) and the Peabody Developmental Motor Scales (PDMS) at four years. The rate of IDA in four-year-old children was significantly greater among the cocaine-exposed compared to the nonexposed group (p =.026), while the rates at two years were not significant. Exposure to IDA at two years was associated with a significant decrease in concurrent motor scores (p =.011) after adjustment for relevant covariates. Peak exposure to IDA, defined as being anemic at 2 and/or 4 years of age, was associated with a significant (p <.05) decrease in Full Scale IQ after adjustment. Cocaine exposure was not a significant predictor of Full Scale IQ with the inclusion of peak IDA and lead in the model. These findings indicate the need for greater pediatric surveillance of IDA and lead in cocaine-exposed infants, in order to reduce long-term neuropsychological deficits.

Influence of prenatal cocaine exposure on early language development: longitudinal findings from four months to three years of age

The influence of prenatal cocaine exposure on children's language functioning was evaluated longitudinally at six time points from 4 months to 3 years of age. The Miami Prenatal Cocaine Study prospectively enrolled 476 full-term African-American infants at birth, categorized as cocaine-exposed (n = 253) or non-cocaine-exposed (n = 223) by maternal self-report and bioassays (maternal/infant urine, meconium). The Bayley Scales of Infant Development, scored using the Kent Scoring Adaptation for language, was administered at 4, 8, 12, 18, and 24 months. The Clinical Evaluation of Language Fundamentals-Preschool was administered at 3 years. In longitudinal analyses using Generalized Estimating Equations, cocaine-exposed children had lower overall language skills than non-cocaine-exposed children (D = -0.151; 95% CI = -0.269, -0.033; p =.012). Longitudinal findings remained stable after evaluation of potential confounding influences including other prenatal substance exposures and sociodemographic factors. Preliminary evidence also indicated possible mediation through an intermediary effect involving cocaine-associated deficits in fetal growth.

Foster-placed and adopted children exposed in utero to opiates and other substances: prediction and outcome at four and a half years

This article presents a Norwegian prospective, longitudinal study of children prenatally exposed to opiates and other substances under conditions of minimal postnatal social risk. Outcome at 4(1/2) years of age is presented. The study reports on the prediction of later intellectual performance, on the basis of the children's prenatal, perinatal, and early developmental status, as well as the foster or adoptive parents' socioeconomic level. Significant differences were found between the substance-exposed group and the comparison group on the Bayley Scales at age 1 year and on the McCarthy Scales at age 4(1/2) years. The findings showed that although the mean cognitive scores were within normal limits at age 4(1/2) years, a special weakness in the area of visual-motor and perceptual abilities was detected among the substance-exposed children. It is indicated that these areas of performance are especially sensitive to the effect of prenatal adversity. A special vulnerability among the substance-exposed boys, detected at an earlier age, persisted at 4(1/2) years. The study indicates that even if children experience adequate caregiving, the accumulation of biomedical risk factors associated with prenatal substance exposure is still a potential determinant of developmental problems, especially in the area of perceptual-performance functions. The study also hints at differential influences of biomedical and environmental variables on outcome at age 4(1/2) years.

Diastolic filling abnormalities by color kinesis in newborns exposed to intrauterine cocaine

Because cocaine crosses the placenta, we prospectively evaluated global and segmental systolic and diastolic cardiac function by color kinesis in clinically asymptomatic newborns who were exposed to cocaine in utero (group 1, n = 82). Their data were compared with normal controls (group 3, n = 87) and newborns exposed to drugs other than cocaine (group 2, n = 108). During left ventricular filling, newborns exposed to cocaine, compared with groups 2 and 3, had significantly (P <.05) higher global fractional area change (%) (76 +/- 10.3 vs 72 +/- 9.4 and 72 +/- 9.1, respectively), regional fractional area changes (%) for the anterior, septal, inferior, and lateral wall, and in the index of asynchrony (at 50% filling 13.2 +/- 5.8 vs 11.3 +/- 4.1 and 11.6 +/- 4.2, respectively). There were no significant differences in systolic function among the 3 groups. Prenatal cocaine exposure in asymptomatic infants leads to higher global and segmental fractional area changes and asynchrony during diastole. The significance and course of these alterations require further investigation.

The Maternal Lifestyle Study: drug exposure during pregnancy and short-term maternal outcomes

OBJECTIVE

Reports of maternal effects resulting from drug exposure during pregnancy are inconsistent. The Maternal Lifestyle Study (MLS) is a multicenter, prospective, observational study that was initiated to better define the effects of exposure to illicit drugs during pregnancy on the mother, fetus, and infant.

METHODS

Between May 1993 and May 1995, of 19,079 mother-infant dyads that were screened after delivery for cocaine and opiate exposure at four clinical centers (Brown University, University of Miami, University of Tennessee, Memphis, and Wayne State University), 16,988 (89%) met eligibility criteria and 11,811 (70%) of those eligible agreed to participate in the study. Exposure was defined as an admission of use of cocaine or opiates or both or the presence of cocaine or opiate metabolites in meconium as determined by use of gas chromatography-mass spectroscopy assay. Nonexposure was defined as a negative drug use history by interview and a negative immunoassay screen. When exposure could not be confirmed, such as when meconium was not obtained or was inadequate for confirmatory analysis, the mother-infant dyad was excluded (n = 3184).

RESULTS

Of the mothers who consented to participate, 50% were African American, 38% were married, 64% were Medicaid recipients, and 95% had at least one prenatal care visit (median, 10 visits). Significant differences (P <.01) between cocaine-opiate exposed (n = 1185) and nonexposed (n = 7442) mothers included race (African American: 74.6% and 47.0%, respectively), mean age (29.6 and 26.1 years, respectively), and polydrug use including any combination of alcohol, tobacco, and/or marijuana (93% and 42%, respectively). Odds ratios (99% CI) indicate that exposed mothers had a significantly higher risk(P <.001) of medical complications including syphilis 6.7 (4.8-9.6), gonorrhea 1.9 (1.3-3.0), and hepatitis 4.8 (2.6-8.91); psychiatric, nervous, and emotional disorders 4.0 (2.2-7.4); and abruptio placenta 2.3 (1.4-3.9). The odds of a positive test for human immunodeficiency virus were higher (available on 28% of the cohort) in the exposed group 8.2 (14.3-15.4). Seventeen cases of maternal acquired immunodeficiency syndrome (AIDS) were identified. Opiate exposure with its attendant needle use significantly increased the risk of hepatitis and AIDS. The number of hospitalizations during pregnancy did not differ between the exposure groups because 11% of patients in each group were hospitalized at least once. However, violence as a cause of hospitalization was more common in the cocaine-exposed group, 19.6 (2.7-144.7).

CONCLUSION

This observational study confirmed many of the reported adverse social and serious medical perinatal complications of mothers exposed to cocaine or opiates during pregnancy. The overall prevalence of these risk outcomes was lower than has been reported previously.

Effects of cocaine/polydrug exposure and maternal psychological distress on infant birth outcomes

To assess teratogenic effects of cocaine exposure and maternal psychological distress on birth outcomes, we conducted a longitudinal prospective study of 415 infants (218 cocaine-exposed--CE, 197 nonexposed--NE). Drug exposure was determined through a combination of maternal self-report, urine, and meconium screens. Maternal psychological distress postpartum was evaluated through a standardized, normative, self-report assessment. An extensive set of confounding variables was controlled, including severity of exposure to alcohol, tobacco, marijuana and other drugs, maternal age, race, parity, number of prenatal care visits, educational, marital, and socioeconomic status, and verbal and nonverbal intelligence. CE infants were smaller on all birth parameters and more likely to be preterm, small for gestational age, and microcephalic than NE infants. Forty-one percent of cocaine users had clinically significant psychological symptoms, compared to 20% of a high-risk comparison group of noncocaine users. Consistent with a teratologic model, cocaine exposure independently predicted offspring birthweight, length, and head circumference. Maternal psychological distress self-reported postnatally also independently predicted head circumference. Tobacco, alcohol, and marijuana exposures were also significant independent predictors of some fetal growth parameters. In addition, maternal distress symptoms, which may be reflective of maternal mental health disorders or responses to stress, added significantly to the risk for poorer fetal growth.

Prenatal drug exposure and the conceptualization of long-term effects

This paper discusses several factors affecting the development of children prenatally exposed to drugs. In the "first generation" of research in this field a main factor model of disease formed the basis for a belief in the feasibility of detecting the direct pharmacological or teratogenic effects of drug exposure on long-term child development. However, the clustering of confounding variables has constituted a major problem in identifying these effects. In the last few years a "second generation" of research in this field has emerged, and investigators have moved beyond simple main-effect models. The importance of controlling for confounding variables has been underscored. However, prenatal substance exposure is still often studied within a teratology model where the main goal is the search for unique effects of a specific drug or substance. Based on this review it is suggested that an appropriate model for understanding the development of drug-exposed children cannot be based on a main-effect perspective. Rather, such a model must evolve from a contextual perspective, and it is suggested that a transactional model, where both potential risk factors and protective factors are considered, should replace the traditional teratology model in this field.

Longitudinal investigation of task persistence and sustained attention in children with prenatal cocaine exposure

The present study estimates the longitudinal effects of prenatal cocaine exposure on indicators of sustained attention processing at 3, 5 and 7 years of age in an urban sample of full-term African-American children (235 cocaine-exposed, 207 noncocaine-exposed). The sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview, urine and meconium toxicology assays. Sustained attention was measured at age 3 years using a standardized measure of task persistence during a challenging task [G.A. Morgan, N.A. Busch-Rossnagel, C.A. Maslin-Cole and R.J. Harmon, Individualized Assessment of Mastery Motivation: Manual for 15-36 Month Old Children, 1992.], and at ages 5 and 7 years using omission error scores from computerized continuous performance tasks (CPT) [L. Greenberg, R. Leark, T. Dupuy, C. Corman, C. Kindschi, M. Cenedela, Test of Variables of Attention (T.O.V.A. and T.O.V.A.-A.), 22, Universal Attention Disorders, Los Alamitos, CA, 1996; C.K. Conners, Conners' Continuous Performance Test (CPT), second ed., Multi-Health Systems, Canada, 1995.]. Findings from longitudinal GLM/GEE analyses of the three measured time points support a stable influence of prenatal cocaine exposure on indicators of sustained attention, after controlling for prenatal exposure to alcohol, marijuana, tobacco and over 20 additional medical and social-demographic covariates drawn from potentially confounding influences assessed at birth and later assessment visits (D=0.21; 95% CI=0.04, 0.38; P=.017). This effect was not mediated by fetal growth or gestational age and remained highly stable with increasing levels of covariate control. Separately, using the age 7 data, a structural equations model (SEM) was constructed combining all available self-report and bioassay data to measure magnitude of cocaine exposure in relationship to attention task performance. Results indicated a gradient of influence, with each standard deviation increase in the level of prenatal cocaine exposure relating to a 16% standard deviation increase in omission error scores at age 7. Overall findings support a stable cocaine-specific effect on indicators of sustained attention processing during the early childhood years. Results are discussed within the context of neurobiological and behavioral research linking prenatal cocaine exposure to long-lasting disruption of the brain systems subserving arousal and attention.

Influence of prenatal cocaine exposure on full-term infant neurobehavioral functioning

This study investigated infant neurobehavioral functioning during the newborn period in 334 full-term, African American neonates (187 cocaine exposed, 147 non-cocaine exposed) enrolled prospectively at birth, with documentation of drug exposure status through maternal interview and urine and meconium toxicology assays. Infants were assessed using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) during the newborn period (0-6 postnatal days). Findings from multivariate profile analyses support a consistent, modest effect of prenatal cocaine exposure on neurobehavioral functioning in full-term neonates. All of the BNBAS cluster scores, with the exception of abnormal reflexes, were similarly affected, sharing a common slope (D=-0.14; 95% CI=-0.27, -0.003; P=.046) representing a -0.14 point difference between cocaine-exposed and non-cocaine-exposed infants after controlling for prenatal exposure to alcohol, tobacco, and marijuana (ATM); maternal age, education, employment, primigravida status, and prenatal care visits; and infant sex and postnatal age in days. Fetal growth was also related to neurobehavioral functioning and, in part, mediated the relationship between cocaine exposure and the BNBAS cluster scores. Cocaine exposure during each trimester similarly influenced infant neurobehavioral profiles, with cocaine-associated deficits most pronounced in infants with exposure in all three trimesters. Results from qualitative and quantitative urine and meconium bioassay indicators further substantiated these results. Findings, while significant, represent modest effect sizes in full-term infants.

Heart rate variability in cocaine-exposed newborn infants

BACKGROUND

Infants born to cocaine-using mothers have a 3- to 8-fold increase in sudden infant death syndrome. Its underlying cause, in part, may be attributed to abnormal autonomic function. We proposed to study heart rate variability, reflecting autonomic control of the heart, in cocaine-exposed infants.

METHODS

From 1997 to 2000, we studied 217 asymptomatic, term infants, of whom 68 had intrauterine cocaine exposure (group I). Their data were compared with infants exposed to drugs other than cocaine (group II, n = 77) and no drugs (group III, n = 72). Twenty-four-hour heart rate variability was measured within 72 hours of birth.

RESULTS

Cocaine-exposed infants, as compared with the 2 control groups, had an overall significant decrease (P <.05) in global heart rate variability and a lower standard deviation of all valid N-N intervals in the recording (41.9 +/- 1.4 ms vs 47.6 +/- 1.3 ms and 46.9 +/- 1.3 ms, respectively). Vagal parameters such as high-frequency power and the square root of the mean of the squared differences between adjacent N-N intervals were also lower in newborns with heavy in utero cocaine exposure.

CONCLUSIONS

Decreased heart rate variability was seen in cocaine-exposed infants. Whether low heart rate variability is a marker for increased risk of sudden death in infants (as it is in adults with structural heart disease) is unknown and requires further investigation.

Developmental outcomes and environmental correlates of very low birthweight, cocaine-exposed infants

Fetal cocaine exposure may have differentially adverse effects on developmental outcomes of very low birthweight (VLBW) infants. As part of a longitudinal study, 31 cocaine-positive very low birthweight infants, and age, race and socioeconomic status matched VLBW controls enrolled at birth were followed. Neonatal maternal-child interactions, concurrent maternal psychological characteristics and environmental factors conceptualized as important for child outcome were assessed as well as standard developmental outcomes at 3 years. In the neonatal period, cocaine-exposed VLBW infants who remained in maternal custody tended to be rated as less responsive and their mothers as less nurturing, less emotionally available and with a tendency to use more maladaptive coping mechanisms than nonexposed VLBW infants. At follow-up, cocaine-exposed VLBW children were delayed in cognitive, motor and language development compared to controls. Almost half (45%) of the exposed children scored in the range of mental retardation compared to 16% of the comparison VLBW children. The persistent cognitive, motor and language delays of the cocaine-exposed VLBW children, combined with the poorer behavioral interactions of cocaine-using women with their infants in the neonatal period, indicate a need for increased developmental surveillance of cocaine-exposed VLBW infants with a focus on maternal drug treatment and parenting interventions.

Fetal effects of cocaine: an updated meta-analysis

BACKGROUND

A very large number of women in the reproductive age group consume cocaine, leading to grave concerns regarding the long term health of millions of children after in utero exposure. The results of controlled studies have been contradictory, leading to confusion, and, possible, misinformation and misperception of teratogenic risk.

OBJECTIVE

To systematically review available data on pregnancy outcome when the mother consumed cocaine.

METHODS

A meta-analysis of all epidemiologic studies based on a priori criteria was conducted. Comparisons of adverse events in subgroups of exposed vs. unexposed children were performed. Analyses were based on several exposure groups: mainly cocaine, cocaine plus polydrug, polydrug but no cocaine, and drug free.

RESULTS

Thirty three studies met our inclusion criteria. For all end points of interest (rates of major malformations, low birth weight, prematurity, placental abruption, premature rupture of membrane [PROM], and mean birth weight, length and head circumference), cocaine-exposed infants had higher risks than children of women not exposed to any drug. However, most of these adverse effects were nullified when cocaine exposed children were compared to children exposed to polydrug but no cocaine. Only the risk of placental abruption and premature rupture of membranes were statistically associated with cocaine use itself.

CONCLUSIONS

Many of the perinatal adverse effects commonly attributed to cocaine may be caused by the multiple confounders that can occur in a cocaine using mother. Only the risk for placental abruption and PROM could be statistically related to cocaine. For other adverse effects, additional studies will be needed to ensure adequate statistical power.

Developing language skills of cocaine-exposed infants

OBJECTIVE

To assess whether there is an association of level of fetal cocaine exposure to developmental precursors of speech-language skills at 1 year of age, after controlling for confounding factors.

DESIGN

In a prospective, longitudinal, quasi-experimental, matched cohort design, 3 cocaine exposure groups were defined by maternal self-report and infant meconium assay: nonexposure (n = 131), heavier exposure (n = 66), >the 75th percentile for maternal self-report and >the 70th percentile of benzoylecgonine concentration, and all others as lighter exposure (n = 68). At 1 year of age, the Preschool Language Scale-3 was administered by examiners unaware of infant drug status.

RESULTS

Independent of confounding drug, medical, and environmental factors, more heavily exposed infants had lower auditory comprehension scores than nonexposed infants and lower total language scores than lighter and nonexposed infants. More heavily exposed infants were also more likely to be classified as mildly delayed by total language score than nonexposed infants. There were positive linear relationships between the concentration of benzoylecgonine in meconium and all outcomes and between maternal report of severity of prenatal cocaine use with poorer auditory comprehension indicating a relationship between amount of exposure and poorer outcomes.

CONCLUSIONS

This study documents significant behavioral teratogenic effects of fetal cocaine exposure on attentional abilities underlying auditory comprehension skills considered to be precursors of receptive language. Pediatricians are in a unique position to monitor early development of cocaine-exposed infants and make timely referrals for intervention.

Cocaine: effects of in utero exposure on the fetus and neonate

In North America, an increasing number of babies are prenatally exposed to cocaine, yet the implications of cocaine use during pregnancy are not fully understood. The effects of cocaine are exerted primarily by its influence on aminergic receptors in the central and peripheral nervous systems. Developmental, physiological, and behavioral problems in infants and children are likely outcomes of maternal cocaine abuse, but these findings are confounded by concomitant use of other drugs such as marijuana and cocaine and by factors such as time, dosage, and route of cocaine intake. Different screening options exist for cocaine and its metabolites, including sampling of neonatal urine, hair and meconium need to be considered, as do the sensitivity and the ethical implications of such testing. Clinical management of cocaine-exposed infants requires attention to several issues, including: central nervous system irritation, cardiac anomalies, apnea, and feeding difficulties, as well as infant safety and follow-up postdischarge. Early detection and intervention remain the primary objectives of caring for cocaine-exposed infants.

Teacher-assessed behavior of children prenatally exposed to cocaine

OBJECTIVE

Prenatal cocaine exposure has been associated with alterations in neonatal behavior and more recently a dose-response relationship has been identified. However, few data are available to address the long-term behavioral effects of prenatal exposures in humans. The specific aim of this report is to evaluate the school-age behavior of children prenatally exposed to cocaine.

METHODS

All black non-human immunodeficiency virus-positive participants in a larger pregnancy outcomes study who delivered singleton live born infants between September 1, 1989 and August 31, 1991 were eligible for study participation. Staff members of the larger study extensively screened study participants during pregnancy for cocaine, alcohol, cigarettes, and other illicit drugs. Prenatal drug exposure was defined by maternal history elicited by structured interviews with maternal and infant drug testing as clinically indicated. Cocaine exposure was considered positive if either history or laboratory results were positive. Six years later, 665 families were contacted; 94% agreed to participate. The child, primary caretaker (parent), and, when available, the biologic mothers were tested in our research facilities. Permission was elicited to obtain blinded teacher assessments of child behavior with the Achenbach Teacher's Report Form (TRF). Drug use since the child's birth was assessed by trained researchers using a structured interview.

RESULTS

Complete laboratory and teacher data were available for 499 parent-child dyads, with a final sample size for all analyses of 471 (201 cocaine-exposed) after the elimination of mentally retarded subjects. A comparison of relative Externalizing (Aggressive, Delinquent) to Internalizing (Anxious/Depressed, Withdrawn, Somatic Complaints) behaviors of the offspring was computed for the TRF by taking the difference between the 2 subscales to create an Externalizing-Internalizing Difference (T. M. Achenbach, personal communication, 1998). Univariate comparisons revealed that boys were significantly more likely to score in the clinically significant range on total TRF, Externalizing-Internalizing, and Aggressive Behaviors than were girls. Children prenatally exposed to cocaine had higher Externalizing-Internalizing Differences compared with controls but did not have significantly higher scores on any of the other TRF variables. Additionally, boys prenatally exposed to cocaine were twice as likely as controls to have clinically significant scores for externalizing (25% vs 13%) and delinquent behavior (22% vs 11%). Gender, prenatal exposures (cocaine and alcohol), and postnatal risk factors (custody changes, current drug use in the home, child's report of violence exposure) were all related to problem behaviors. Even after controlling for gender, other prenatal substance exposures, and home environment variables, cocaine-exposed children had higher Externalizing-Internalizing Difference scores. Prenatal exposure to alcohol was associated with higher total score, increased attention problems, and more delinquent behaviors. Prenatal exposure to cigarettes was not significantly related to the total TRF score or any of the TRF subscales. Postnatal factors associated with problem behaviors included both changes in custody status and current drug use in the home. Change in custody status of the cocaine-exposed children, but not of the controls, was related to higher total scores on the TRF and more externalizing and aggressive behaviors. Current drug use in the home was associated with higher scores on the externalizing and aggressive subscales.

CONCLUSIONS

Results of this study suggest gender-specific behavioral effects related to prenatal cocaine exposure. Prenatal alcohol exposure also had a significant impact on the TRF. Postnatal exposures, including current drug use in the home and the child's report of violence exposure, had an independent effect on teacher-assessed child behavioral problems. (ABSTRACT TRUNCATE

The effects of neonatal ethanol and/or cocaine exposure on isolation-induced ultrasonic vocalizations

Isolation-induced ultrasonic vocalizations (USVs) are emitted by young rat pups when isolated from their dam and conspecifics. These USVs play an important role in maternal/offspring interactions, and have been used as an indicator of response to stress and isolation. This study examined the effects of neonatal ethanol and/or cocaine exposure on USVs in neonatal rats. The neonatal exposure paradigm serves as a model for the "human third trimester of pregnancy" in terms of CNS development. There were five treatment groups including an artificially reared (AR) ethanol-exposed group (6 g/kg/day), an AR cocaine-exposed group (60 mg/kg/day), an AR ethanol- and cocaine-exposed group (6 g/kg/day+60 mg/kg/day), an AR isocaloric control, and a normally reared control. Both groups that received ethanol took longer to vocalize, and displayed fewer vocalizations than non-ethanol-exposed pups when tested on clean bedding (Experiment 1) or on chips from the nest of a lactating dam (Experiment 2). These results suggest that neonatal ethanol exposure alters the pup's immediate response to isolation. This could have direct effects on maternal/infant interactions, and might help explain some of the long-term effects of ethanol exposure on social behaviors.

Neurobehavioral outcomes of cocaine-exposed infants

The present study investigated the neurobehavioral outcomes of fetal cocaine exposure. Attempts were made to control, by design or statistical analysis, for significant confounders. Timing and amount of drug exposures were considered, and biologic measures of exposure were quantified to classify exposure severity. One hundred sixty-one non-cocaine and 158 cocaine-exposed (82 heavily and 76 lightly exposed) infants were seen at a mean-corrected age of 43 weeks post-conception and administered the Neurobehavioral Assessment (NB Assessment). Heavily cocaine-exposed infants had more jitteriness and attentional problems than lightly and non-exposed infants. They also had more movement and tone abnormalities, and sensory asymmetries than non-exposed infants. Heavily exposed infants were more likely to be identified with an abnormality than non-exposed infants and there was a trend toward heavily exposed infants being more likely to be identified with an abnormality than lightly exposed infants. Furthermore, there was a trend for heavily exposed infants to be less likely to be testable than non-exposed infants. After the confounding and mediating factors were considered, heavily cocaine-exposed infants were four times as likely to be jittery and nearly twice as likely to demonstrate any abnormality than lightly and non-exposed infants, but all other effects were no longer significant. Higher concentrations of the cocaine metabolites of cocaine, cocaethylene, and benzoylecgonine (BZE) were related to higher incidence of movement and tone abnormalities, jitteriness, and presence of any abnormality. Higher cocaethylene levels were related to attentional abnormalities and higher meta-hydroxybenzoylecgonine (m-OH-BZE) was related to jitteriness. Drug effects on attention were mediated by maternal psychological distress, suggesting that this factor should be considered in future studies of drug exposure effects.

Teratogenic effect of ketamine and cocaine in CF-1 mice

Pregnant CF-1 mice were used to study the teratogenic effect of ketamine and cocaine, alone and in combination. The dose of ketamine was 50 mg/kg and that of cocaine was 20 mg/kg, given intravenously (tail) once daily (these doses of ketamine and cocaine are comparable to doses used by addicted humans). Treatment was started from day 6 to day 15 of gestation, and dams were sacrificed on day 18. There were significant decreases in the fetal weight and length in the combined group. Skeletal defects such as incomplete ossification of skull bones and vertebrae were observed in both the cocaine and combined group, compared with the control. An increased frequency of cerebral and abdominal hemorrhages as well as hydrocephalus and hydronephrosis was observed in the combined group. This study showed that fetal exposure to ketamine and cocaine in combination was more teratogenic than each drug alone in CF-1 mice.

Prenatal heroin exposure. Effects on development, acoustic startle response, and locomotion in weanling rats

The purpose of this study was to investigate the effects of prenatal heroin exposure on the offspring in postnatal behavioral development. Pregnant Sprague-Dawley rats were injected daily (s.c.) with 10mg/kg of heroin from gestational day 8 to 20. The control dam received saline injections and the pair-fed dam received saline and was yoked to a weight-matched heroin-treated dam. Litters were culled to eight to ten pups and weighed at postnatal day (PND) 1, 8, 15, and 22. Acoustic prepulse inhibition and habituation were parameters used for evaluating the sensorimotor gating and simple form of learning respectively. Locomotor activity and rearing were assessed using the photobeam activity system. All behavioral tests were performed on the offspring at PND 21 to 23. Results showed that heroin treatment significantly reduced maternal food intake, water consumption, and weight gain. Both heroin-exposed and pair-fed groups showed a marked reduction in birth weight in both male and female pups when compared with controls; however the postnatal weight gain in heroin-exposed pups was significantly lower than the pair-fed group by 3 weeks postnatally, particularly in the female pups. These female pups also showed a significant increase in ambulation and rearing when compared to the pair-fed pups. The habituation rate in both types of behavioral tests was also decreased in these female pups as compared to control and pair-fed groups. The present study indicated that prenatal heroin exposure could result in a marked retardation of postnatal development and learning. These effects are sex related.

The triad of substance abuse, violence, and depression are interrelated in pregnancy

A study group of 271 registrants had their medical and social history taken by a nurse-interviewer and were requested to take the Substance Abuse Subtle Screening Inventory. If the nurse interviewer felt that the patient needed social service assessment, referral was made, and a social worker completed the the Social Service Review Questionnaire. The patients who were reported as positive for substance abuse did not respond differently from their negative counterparts for issues of demographics, pregnancy, social support, and career. They were highly likely to have had a history of severe depression and/or have been a victim of physical and/or sexual abuse. On the basis of these data we recommend that the prenatal patient who responds positively in her personal history regarding any of these three experiences should be carefully evaluated for problems related to the other two.

Effectiveness of comprehensive services for crack-dependent mothers with newborns and young children

This article presents an outcome study of the Family Rehabilitation Program (FRP), a unique network of community-based programs in New York City that provides comprehensive services to families with drug-dependent parents, most caring for prenatally cocaine-exposed newborns. An admission sample of 173 mothers in 17 FRP sites was studied for one year; substance use was assessed by hair analysis and self-report. Mean length of retention was 10 months; half the clients were still active in the program at follow-up. Mothers completing or still active in FRP had higher rates of abstinence and substantially lower average levels of cocaine in their hair at follow-up than those exiting prematurely. The percent of families with children out of their homes did not increase significantly between admission and follow-up, and completing or remaining active in the program were associated with less out-of-home placement at follow-up.

Why screen newborns for cocaine: service patterns and social outcomes at age one year

OBJECTIVE

To compare baseline characteristics, service provision, and child placement for infants exposed to cocaine in utero based on postnatal screening results.

METHODS

We studied a retrospective cohort of 40 consecutive drug-exposed, but seemingly healthy term infants who underwent urine drug screening in the newborn nursery of a community hospital. Using clinical and service agency data, two cocaine-exposed cohorts were compared (a) screen-positive at birth (n = 22) versus (b) screen-negative at birth (n = 18).

RESULTS

Both cocaine-exposed groups had similar infant birth weights, levels of paternal involvement, maternal ages, gravidity, parity, and lengths of gestation. Mothers in both groups had similar histories of prostitution, poor home environment, drug use, and prenatal drug rehabilitation. Mothers of screen-positive infants were more likely than mothers of screen-negative infants to have other children in foster care (27% vs. 6%, p = .07), to have experienced previous interventions by child protective services (CPS) (55% vs. 17%, p < .01), to have had no prenatal care (32% vs. 6%, p = .09), and fewer prenatal visits (4.7 vs. 8.6, p = .02). Compared to screen-negative infants, more screen-positive infants were referred to a high-risk infant tracking program (91% vs. 6%), referred to CPS (100% vs. 33%), placed outside the mother's home (50% vs. 22%), and had their mothers referred to drug rehabilitation (36% vs. 11%), (p < .01 for each). By 1 year of age, support services differed little between exposed cohorts. However, 6 of 22 screen-positive infants were in foster care and 3 were placed for adoption, while only 1 of the 18 screen-negative infants was in foster care and only 1 had been placed for adoption. There were no services available in this community to provide coordinated or comprehensive services or drug treatment specific to the needs of drug using mothers and drug exposed infants.

CONCLUSIONS

Despite similarities between cocaine-exposed infants cared for in a normal newborn setting (with and without positive urine drug screens at birth), differences in referral services were noted. More striking than these differences was that services for families with drug-exposed infants are inadequate to even meet the needs of those families in our setting deemed to be at highest risk. Neonatal drug screening needs to be paired with effective services.

Motor development of cocaine-exposed children at age two years

OBJECTIVE

This article was designed to investigate effects of prenatal cocaine exposure on motor development of young children from a predominately underprivileged, urban population.

METHODOLOGY

A total of 260 infants and young children were initially recruited from either the newborn nursery or the at-risk pediatric clinic of an urban teaching hospital. Prenatal history and birth outcomes were collected from medical records. Demographic characteristics and additional drug histories were obtained from the mothers. The 199 subjects (98 cocaine-exposed and 101 unexposed) who returned at age 2 years were assessed by examiners blinded to drug exposure status using the Peabody Developmental Motor Scales.

RESULTS

Compared with control subjects, the cocaine-exposed group performed significantly less well on both the fine and the gross motor development indices. Mean scores for both groups were within the average range on the gross motor index, but greater than 1 standard deviation below average on the fine motor index. Differences were significant on the balance and the receipt and propulsion subscales of the gross motor scale, and on the hand use and the eye-hand coordination subscales of the fine motor scale. Cocaine status independently predicted poorer hand use and eye-hand coordination scores. There also was an effect of alcohol exposure on the receipt and propulsion subscale.

CONCLUSIONS

Findings indicate that deficiencies in motor development remain detectable at 2 years of age in children exposed to drugs prenatally. Although other environmental variables may influence motor development, children exposed to cocaine and to alcohol in utero may encounter developmental challenges that impede later achievement.

Detection of drug use during pregnancy

Several methods of drug testing are efficacious in identifying and monitoring drug use during pregnancy. Urine screening remains the most commonly used method despite the limited period during which drugs can be detected. Hair has been recognized as a possible alternate test specimen, but wider acceptance of hair testing must await better understanding of drug disposition in hair, answers to the issues relating to interpretation, and the development of less demanding laboratory techniques. Regardless of the matrix used, proper interpretation of the results of drug testing requires familiarity with the sensitivity, specificity, and limitations of the laboratory methodologies employed. Moreover, unconfirmed positive results may actually be false-positives and must be interpreted with caution, particularly if they are the basis for major clinical decisions.

Birth outcome from a prospective, matched study of prenatal crack/cocaine use: I. Interactive and dose effects on health and growth

OBJECTIVE

This prospective, longitudinal project was designed to determine the effects of prenatal cocaine use on the pregnancy outcomes of women from a historically understudied rural public health population.

METHODOLOGY

We interviewed over 2500 women prenatally, identified 154 cocaine users, and matched 154 controls on race, parity, socioeconomic status, and location of prenatal care (that related to level of pregnancy risk). Drug testing was required at enrollment and at delivery; detailed demographic, psychosocial, and drug histories were taken at each available trimester and follow-up visit. After birth, neonatal nurse practitioners, blinded to maternal history of drug use, examined infants to assess gestational age and take growth measurements. Medical charts were reviewed and the Hobel Risk Scale was completed.

RESULTS

Compared with controls, the cocaine users had significantly higher Hobel Prenatal and Total Risk Scores and more preterm infants (28 vs 14), but not a significantly greater number of fetal deaths (3 vs 1). After controlling for the effects of marijuana, alcohol, and tobacco use, the following results remained. There was no difference in gestational age, Ponderal Index, birth weight, or length between infants born to cocaine users and controls. There was a significant interaction effect such that infant head and chest circumference were smaller in cocaine users who also smoked tobacco. Significant correlation coefficients demonstrated the effects of the amount of drug usage on fetal growth during each trimester of pregnancy. The average cocaine use per day for trimesters one and three and for the entire pregnancy was negatively related to birth length. The mean amounts used in trimesters two and three were negatively related to head circumference. Amounts of tobacco and alcohol use in pregnancy were also inversely related to fetal growth measures. When the effects of marijuana, alcohol, and tobacco were partialed out, there continued to be a negative relationship between the amount of cocaine used in the third trimester and infant length and head circumference.

CONCLUSIONS

The observed decrement in fetal growth, especially head circumference, among cocaine-exposed neonates raises concerns about later growth and development. Follow-up of these infants will reveal if these disadvantages continue. These early results also emphasize the importance of considering amount and time of drug exposure as well as the interactive effects of drug exposure and other risk variables.

Dopamine transporter development in postnatal rat striatum: an autoradiographic study with [3H]WIN 35,428

The dopamine transporter mediates the reinforcing effects of cocaine, thus playing a central role in human cocaine addiction, and perhaps providing the mechanism for inducing the effects of prenatal cocaine exposure. This possibility has stimulated growing interest in the normal and abnormal development of this transporter. [3H]WIN 35,428 is a cocaine analog that is useful for studying the distribution and density of the dopamine transporter in striatum and other brain regions. The postnatal development of the dopamine transporter in the rat striatum was measured by quantitative autoradiography with [3H]WIN 35,428. Dopamine transporter levels were low at birth, increased through day 15, followed by much more rapid growth in late postnatal development. The majority of the transporter sites appeared after day 15. Lateral to medial and anterior to posterior gradients in transporter density were established early during development, and there was also an early concentration of transporter in striosomes that became difficult to identify by day 15. Differences between the developmental patterns described here and studies using other ligands for the dopamine transporter suggest there are significant differences in the transporter binding sites for these drugs. These differences in transporter ligand binding characteristics may reflect developmental changes in post-translational modification of the transporter and/or changes in the functional activity rather than simply the presence of the transporter.

Developmental immunotoxicity of cocaine and ethanol in postnatal Lewis rats

The immunomodulatory effect of cocaine (COC), ethanol (EtOH) and their combination was investigated in the developing immune system of postnatal Lewis rats. To simulate the route of exposure during lactation, newborn rats were orally treated with either saline, 20 mg COC/kg, and 0.6 g EtOH/kg or the coadministration of COC and EtOH from day 1 to 21 of life. Rat pups were sacrificed thirty minutes following the last treatment. Total lymphocytes and spleen/body weight ratios were decreased in animals exposed to COC. These immunotoxic effects were not enhanced by the coadministration of EtOH. However, pups exposed to both drugs had significantly decreased levels of serum immunoglobulin M (IgM) when compared to saline-treated rats. Plasma and tissue distribution studies revealed that the combination treatment group had a higher COC content in the brain and spleen as well as an increase in the metabolites benzoylecognine (BE) and norcocaine (NC) in the spleen. Ethylcocaine (EC) formation was not demonstrated in this model.

Prenatal cocaine exposure effects on arousal-modulated attention during the neonatal period

The organization of arousal and attention as a function of intrauterine cocaine exposure was investigated in 180 normal nursery infants prior to hospital discharge and at 1 month of age. This was done by studying visual looking preferences when infants were in three arousal conditions: less aroused (after feeding); more aroused-endogenous (before feeding); and more aroused-exogenous (after feeding but including 8-Hz visual stimulation prior to each visual preference trial). The stimuli were light panels illuminated at three temporal frequencies between 1 and 8 Hz presented in pairs using a balanced presentation series of trials. Infants not exposed to cocaine demonstrated strong arousal-modulated attention, preferring faster frequencies when less aroused and slower frequencies when more aroused in both endogenous and exogenous conditions. In contrast, cocaine-exposed infants showed a lack of arousal-modulated attention and preferred faster frequencies of stimulation regardless of arousal condition. Similar differences in arousal-modulated attention as a function of cocaine exposure were obtained at 1 month after birth, indicating that these effects lasted longer than would be reasonable to attribute to the active presence of cocaine or its metabolites. This form of stimulus-seeking behavior was shown to be independent of confounding factors associated with prenatal cocaine exposure such as the absence of prenatal care, alcohol use, minority status, or gender, as well as mediating factors associated with growth such as birthweight. A direct and more chronic effect of intrauterine cocaine exposure on arousal-modulated attention and presumably on the developing CNS therefore was supported.

Cocaine exposure during the brain growth spurt failed to produce cerebellar Purkinje cell loss in rat pups

Previous studies in our laboratory indicated that cocaine exposure during the brain growth spurt period, a developmental stage vulnerable to various teratogens, did not produce microencephaly (gross brain weight measures). However, neonatal cocaine exposure has been shown to affect motor coordination and balance, which are both sensitive to cerebellar damage. The purpose of this study was to investigate whether cocaine exposure during the brain growth spurt period could result in the loss of cerebellar Purkinje cells, a neuronal population known to be vulnerable to other teratogenic insults. Sprague-Dawley rat pups were randomly assigned to either cocaine-treated groups (40, 80 mg/kg s.c.) or a gastrostomy control group, and were reared using an artificial-rearing method from postnatal days (PDs) 4 through 9. On PD 10, these animals were perfused and the cerebella were extracted and processed for cell counts. Estimates of Purkinje cell numbers were obtained using a 3-dimensional optical dissector method. The results using this stereological method demonstrated no significant Purkinje cell loss in response to cocaine treatment, even at a dose which has been shown to result in high mortality. The failure of cocaine to produce significant Purkinje cell loss (present finding) or microencephaly (previous finding) odds to the evidence indicating that cocaine is not a potent neuroteratogen.

Fetal Cocaine Exposure: Neurologic Effects and Sensory-Motor Delays

Research on animal models demonstrates that fetal cocaine exposure results in neurologic deficits in memory and learning. Although drug effects on human infants are difficult to separate from other environmental influences of a drug-using lifestyle, studies suggest that infants exposed to cocaine in utero have reduced growth, delays in sensory-motor development, attentional deficits, and depressed responsivity to social stimulation. Standard interventions to promote behavioral state regulation in affected infants may be helpful when parents are capable of participating.

Natural history of somatic growth in infants born to women infected by human immunodeficiency virus. Women and Infants Transmission Study Group

OBJECTIVE

To evaluate the nature and magnitude of the effect of congenitally or perinatally acquired human immunodeficiency virus (HIV) infection on somatic growth from birth through 18 months of age.

STUDY DESIGN

Anthropometry was performed serially in 282 term infants born to HIV-infected women in a multicenter prospective natural history cohort study. Repeated measures analysis was used to compare z-score anthropometric indexes of weight-for-age, length-for-age, weight-for-length, and head circumference-for-age between infected and uninfected infants, with adjustment for covariates including infant gender; maternal education; prenatal alcohol, tobacco, and/or illicit drug exposure; and mean prenatal CD4+ T-lymphocyte count. A separate repeated measures model was used to assess the effect of infant zidovudine treatment on growth.

RESULTS

Infants infected with HIV were an estimated average 0.28 kg lighter and 1.64 cm shorter than uninfected infants at birth, were 0.71 kg lighter and 2.25 cm shorter by 18 months of age, and had a sustained estimated average decrement of 0.70 to 0.75 cm in head circumference. Patterns of growth were similar in male and female infants. Infected infants had a progressive decrement in body mass index from birth through 6 months of age. Infection with HIV was associated with significant decrements across all standardized growth outcome measures after adjustment for covariates. Mean z scores were lower for weight by 0.612 (p < 0.001), for length by 0.735 (p < 0.001), for weight-for-length by 0.255 (p = 0.02), and for head circumference by 0.563 (p < 0.001) SD units compared with uninfected infants. Zidovudine treatment was not associated with improved growth.

CONCLUSION

The effect of congenitally or perinatally acquired HIV infection on infant growth is one of early and progressive decrements in attained linear growth and growth in mass, early and sustained decrements in head growth, and marked early decrements in body mass index.

Increased psychological distress in post-partum, cocaine-using mothers

This study investigated psychological symptoms, self-reported postpartum by poor, primarily African American women who used cocaine during pregnancy. Ninety-nine cocaine-using mothers (COC+) were compared to 44 noncocaine-using mothers (COC-) on standardized measures of psychological distress and verbal comprehension. Mothers were interviewed to determined extent of drug involvement. COC+ mothers reported using alcohol, marijuana, and tobacco at two to three times the rate of comparison mothers during pregnancy and reported earlier initiation of marijuana use. COC+ women were more likely to admit to interpersonal difficulties and to report phobic anxiety and paranoid ideational symptoms. The COC+ group was also more likely to have clinically elevated scores on subscales indicating feelings of personal inadequacy, phobic anxiety, and paranoia. The use of cocaine, in combination with either alcohol or marijuana, was the best predictor of psychoticism, hostility, and total number of distress symptoms.