Effect of Maternal Substance Abuse on the Fetus, Neonate, and Child

Trends in cocaine use among United States females of reproductive age, 2005-2019

BACKGROUND AND OBJECTIVES

The prevalence of cocaine use has increased in the United States, with an estimated 5.5 million people have used it at least once in 2019. We report trends in cocaine use for reproductive age females who participated in the National Survey on Drug Use and Health (NSDUH, 2005-2019).

METHODS

Interviewers for NSDUH recruited and assessed a representative sample of the US noninstitutionalized population. The prevalence of cocaine use was estimated annually for females (15-44 years; n = 295,751). Joinpoint regression was then used to test for significant changes in trends.

RESULTS

Approximately 2.4% of females (n = 8136) reported past 12-month cocaine use. Joinpoint regression revealed an initial decline in cocaine use prevalence between 2005 and 2011, followed by a robust increase (2011-2019 annual percent change = 5.2; 95% confidence interval = 2.6, 7.8%). This nonlinear trend was observed for all subgroups, except for adolescent and pregnant females for whom a decrease in cocaine use prevalence was observed.

DISCUSSION AND CONCLUSIONS

Although the prevalence of cocaine use remains scarce among US females, the uptake in use after a period of initial decline is concerning, highlighting the need for continued public health awareness and action.

SCIENTIFIC SIGNIFICANCE

Cocaine use among females of reproductive age is particularly concerning given the increased likelihood of transitioning to disordered use and the risk of use during pregnancy. Previous studies have not reported cocaine use estimates specific to reproductive age females or only reported co-drug use patterns, without detail of specific cocaine use trends.

Non epileptiform abnormal neurologic signs in newborns following in-utero psychotropic medication exposure

BACKGROUND

Post natal adaptation syndrome is well reported but early presentation of neurological symptoms severe enough to warrant detailed neurological work up is rare. Our aim was to evaluate and describe abnormal early neurological symptoms in infants following in-utero exposure to a varying combination of selective serotonin uptake inhibitor medication and other psychotropic medications, with negative seizure work-up.

METHOD

Descriptive case series of infant exposed to selective serotonin uptake inhibitor medication and other psychotropic medications, presenting with early neurologic signs and symptoms within the first 24 hours of life concerning for seizures, who underwent an extensive neurologic evaluation.

RESULTS

Five infants met criteria. Infant #1 : 39-weeks gestational age (GA), with escitalopram, clonazepam, gabapentin, methadone exposure, presented with generalized hypertonia and intermittent back-arching. #2 : 40-weeks GA with escitalopram and hydroxyzine exposure, with bilateral arm stiffening and sucking mouth movements. #3 : 34-weeks GA with fluoxetine, quetiapine and clonazepam exposure, presented with decerebrate posturing. #4 : 38-weeks GA with fluoxetine, clonazepam, clonidine, quetiapine and gabapentin exposure, presented with asynchronous tremoring of all extremities. #5 : 35-weeks GA with citalopram, quetiapine exposure, presented with increased tone and posturing of upper extremities. Electroencephalogram was negative for seizures in all infants.

CONCLUSION

In-utero exposure to selective serotonin uptake inhibitor medication, especially in combination with other psychotropic medications, may be associated with significant abnormal neurological symptoms, which may not represent true seizures.

Parental substance use disorder and risk of intellectual disability in offspring in Sweden: a national register study

Background

Intellectual disability (ID) is a disorder with unknown aetiology in many cases. Maternal alcohol use is a known risk factor for ID, but less is known about the importance of maternal and paternal substance use disorder (SUD) and risk of ID in offspring.

Methods

Data from multiple nationwide registers were used to create a cohort of children born from January 01, 1978 to December 31, 2002. All participants were born in Sweden, had available parental identification information and did not emigrate or die before age 12 (n = 1,940,820). Logistic regression modelling was performed with exposure defined as having a parent who received any SUD diagnosis, including alcohol use disorder (AUD) and drug use disorder (DUD). The outcome was registration of diagnosis of any form of ID. First, we analysed the risk of ID if parental SUD was registered prior to childbirth with stepwise adjustment of multiple covariates. Second, the effect of timing of SUD diagnosis in relation to childbirth was analysed.

Findings

Of 37,410 offspring with parental SUD registered prior to birth, 3.0% (n = 1110) had any form of ID compared to 1.2% (n = 23,168) of those 1,903,410 individuals without parental SUD prior birth. Parental SUD prior birth was associated with an increased risk of any form of ID (Odds Ratio [OR]: 2.3 [2.2-2.5]), with ORs similar for maternal (OR: 2.3 [2.1-2.5]) and paternal SUD (OR: 2.3 [2.1-2.5]). These ORs were reduced but remained statistically significant after adjusting for parental education, migration, psychiatric comorbidity, and co-parent SUD (OR parental SUD: 1.6 [1.5-1.8]; OR maternal SUD: 1.4 [1.2-1.5]; OR paternal SUD: 1.6 [1.5-1.7]). Parental SUD was associated with increased risk of ID in offspring irrespective of timing of diagnosis, but if mothers or fathers were diagnosed with AUD during pregnancy (OR maternal AUD: 5.0 [3.1-8.2]; OR paternal AUD: 2.8 [2.2-3.6]), the risk was significantly greater than if the AUD diagnosis was first registered after childbirth (OR maternal AUD: 1.9 [1.8-2.0]; OR paternal AUD: 1.6 [1.6-1.7]).

Interpretation

Both paternal and maternal SUD were associated with an increased risk of ID in offspring, with greatest risk observed when AUD was diagnosed during pregnancy. Possible mechanisms may involve shared genetic and environmental factors, including toxic effects from alcohol intake. These findings have clinical implications in suggesting that parental SUD in either parent represents a possibly modifiable risk factor to consider when developing prevention, diagnostics and treatment programs for children with ID.

Funding

Stockholm County Council, the Research Council of the Swedish Alcohol Retailing Monopoly, Fredrik and Ingrid Thurings stiftelse, Academy of Finland, the Swedish Research Council and the Swedish Research Council for Health, Working Life and Welfare, Nordforsk by the Nordic Council of Ministers and the Polish Medical Research Agency.

Congenital anomalies and risk factors in Africa: a systematic review and meta-analysis

OBJECTIVE

To evaluate the pooled prevalence and identify risk factors of congenital anomalies among neonates in Africa.

METHODS

The pooled birth prevalence of congenital anomalies was the first outcome of this review, and the pooled measure of association between congenital anomalies and related risk factors in Africa was the second. We conducted a thorough search of the databases PubMed/ Medline, PubMed Central, Hinary, Google, Cochrane Library, African Journals Online, Web of Science and Google Scholar up to 31 January 2023. The JBI appraisal checklist was used to evaluate the studies. STATA V.17 was used for the analysis. The I² test and Eggers and Beggs tests were used to measure study heterogeneity and publication bias respectively. The pooled prevalence of congenital anomalies was calculated using DerSimonian and Laird random-effect model. Subgroup analysis, sensitivity analysis and meta-regression were also performed.

RESULT

This systematic review and meta-analysis includes 32 studies with a total of 626 983 participants. The pooled prevalence of congenital anomalies was 23.5 (95% CI 20 to 26.9) per 1000 newborns. Not taking folic acid (pooled OR=2.67; 95% CI (1.42 to 5.00)), history of maternal illness (pooled OR=2.44, 95% CI (1.2 to 4.94)), history of drug use (pooled OR=2.74, 95% CI (1.29 to 5.81)), maternal age (>35 years.) (Pooled OR=1.97, 95% CI (1.15 to 3.37)), drinking alcohol (pooled OR=3.15, 95% CI (1.4 to 7.04)), kchat chewing (pooled OR=3.34, 5% CI (1.68 to 6.65)) and urban residence (pooled OR=0.58, 95% CI (0.36 to 0.95)) were had significant association with congenital anomalies.

CONCLUSION

The pooled prevalence of congenital abnormalities in Africa was found to be substantial, with significant regional variation. Appropriate folate supplementation during pregnancy, proper management of maternal sickness, proper antenatal care, referring healthcare personnel before using drugs, avoiding alcohol intake and kchat chewing are all important in lowering the occurrence of congenital abnormalities among newborns in Africa.

Effects of ketamine-induced H3K9 hypoacetylation during pregnancy on cardiogenesis of mouse offspring

BACKGROUND

Prenatal exposure to adverse factors can cause congenital heart defects. Ketamine, a widely used anesthetic drug, produces several adverse reactions such as tachycardia, hypertension, and laryngospasm, especially in pediatric patients. This study aimed to detect the effects of ketamine exposure during pregnancy on the cardiogenesis of mouse offspring and the potential mechanisms.

METHODS

In this study, ketamine at an addictive dose (5 mg/kg) was administered to mice during early gestation to explore the epigenetic mechanism of its causing cardiac dysplasia. The cardiac morphology of the mouse offspring was observed through hematoxylin-eosin staining and transmission electron microscopy. The heart function of one-month-old neonates was detected by echocardiography. The expression of cardiomyogenesis-related genes was detected by western blot and RT-qPCR. The acetylation level of histone H3K9 at the Mlc2 promoter and its deacetylase level and activity were detected by CHIP-qPCR, RT-qPCR, and ELISA, respectively.

RESULTS

Our data revealed that ketamine exposure during pregnancy could cause cardiac enlargement, myocardial sarcomere disorganization, and decreased cardiac contractile function in mouse offspring. Moreover, ketamine reduced the expression of Myh6, Myh7, Mlc2, Mef2c, and cTnI. The histone H3K9 acetylation level at the Mlc2 promoter was down-regulated by increasing the histone deacetylase activity and HDAC3 level upon ketamine administration.

CONCLUSIONS

Our work indicates that H3K9 acetylation is a vital player in cardiac dysplasia in offspring caused by prenatal ketamine exposure and HDAC3 is a key regulatory factor.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.

Evaluating the relationship of in utero nicotine exposure with hypoglycemia after delivery: An observational study

BACKGROUND

Hypoglycemia in neonates is common and contributes to 4.0-5.8% of neonatal intensive care unit (NICU) admissions. In utero nicotine exposure is underexplored as a potential contributor to neonatal hypoglycemia. Rat models have shown that in utero nicotine exposure can be associated with a reduction in pancreatic beta cell mass, leading to glucose dysregulation. The primary aim of this work is to study the risk of developing hypoglycemia after birth in a population of in utero nicotine-exposed neonates.

METHODS

We conducted a retrospective matched cohort study that augmented an existing dataset of neonates admitted to a level IV NICU with household-based in utero nicotine exposure (N = 335). Neonates in the control group parents denied household smoking (N = 325), were born within a 6-month timeframe, and were within a birthweight of 50 grams of a nicotine-exposed neonate. Data reviewed included gestational age, growth parameters, maternal history of diabetes, and glucose levels within the first three hours of life per unit protocol.

RESULTS

660 neonates were included in the analysis. In utero nicotine exposure demonstrated a 94.3% posterior probability (PP) for greater hypoglycemia risk (RR = 1.185, 95% CrI = [0.953, 1.445]). A 94.6% PP was demonstrated when neonates who were small for gestational age, intrauterine growth-restricted, and born to diabetic mothers were excluded (n = 482; RR = 1.271, 95% CrI = [0.946, 1.669]).

CONCLUSION

Nicotine exposure in utero was found to be a potential risk factor for developing hypoglycemia after birth. Mechanisms of action should be explored, and additional research on in utero nicotine exposure risks should follow.

Maternal Methamphetamine Exposure Influences Behavioral Sensitization and Nucleus Accumbens DNA Methylation in Subsequent Generation

The deleterious effects of methamphetamine (METH) exposure extend beyond abusers, and may potentially impact the vulnerability of their offspring in developing addictive behaviors. Epigenetic signatures have been implicated in addiction, yet the characteristics to identify prenatal METH abuse to offspring addiction risk remains elusive. Here, we used escalating doses of METH-exposed mouse model in F0 female mice before and during pregnancy to simulate the human pattern of drug abuse and generated METH-induced behavioral sensitization to investigate the addictive behavior in offspring mice. We then utilized whole genome-bisulfite sequencing (WGBS) to investigate the methylation signature of nucleus accumbens (NAc) in male METH-sensitized mice. Interestingly, male but not female offspring exhibited an enhanced response to METH-induced behavioral sensitization. Additionally, the METH-exposed group of male mice underwent a more comprehensive wave of epigenome remodeling over all genomic elements compared with unexposed groups due to drug exposure history. 104,219 DMCs (METH-SAL vs. SAL-SAL) induced by prenatal METH-exposure were positively correlated with that of postnatal METH-exposure (38,570, SAL-METH vs. SAL-SAL). Moreover, 4,983 DMCs induced by pre- and postnatal METH exposure (METH-METH vs. SAL-METH) were negatively correlated with that of postnatal METH exposure, and 371 commonly changed DMCs between the two comparison groups also showed a significantly negative correlation and 86 annotated genes functionally enriched in the pathways of neurodevelopment and addiction. Key annotated genes included Kirrel3, Lrpprc, and Peg3, implicated in neurodevelopmental processes, were down-regulated in METH-METH group mice compared with the SAL-METH group. Taken together, we render novel insights into the epigenetic correlation of drug exposure and provide evidence for epigenetic characteristics that link maternal METH exposure to the intensity of the same drug-induced behavioral sensitization in adult offspring.

Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults, and Families

Pediatricians across the United States encounter infants, children, adolescents, young adults, and families affected by substance use disorders in their daily practice. For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame; however, as addiction became understood as a medical disorder, clinical terminology has shifted along with a growing awareness of harm of stigmatizing language in medicine. In issuing this policy statement, the American Academy of Pediatrics (AAP) joins other large organizations in providing recommendations regarding medically accurate, person-first, and nonstigmatizing terminology. As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of infants, children, adolescents, young adults, and families. In this policy statement, the AAP provides 3 specific recommendations, accompanied by a table that presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and explanations for each. Pediatricians have an important role in advocating for the health of children and adolescents in the context of families affected by substance use and are optimally empowered to do so by avoiding the use of stigmatizing language in favor of medically accurate terminology that respects the dignity and personhood of individuals with substance use disorders and the children and adolescents raised in families affected by substance use.

Neonatal Hypertension

Neonatal hypertension is uncommon but is becoming increasingly recognized. Normative blood pressure data are limited, as is research regarding the risks, treatment, and long-term outcomes. Therefore, there are no clinical practice guidelines and management is based on clinical judgment and expert opinion. Recognition of neonatal hypertension requires proper blood pressure measurement technique. When hypertension is present there should be a thorough clinical, laboratory, and imaging evaluation to promptly diagnose causes needing medical or surgical management. This review provides a practical overview for the practicing clinician regarding the identification, evaluation, and management of neonatal hypertension.

Neonatal NMDA blockade alters the LTP, LTD and cognitive functions in male and female Wistar rats

There is compelling evidence that neonatal blockade of NMDA receptors by phencyclidine (PCP) is associated with cognitive impairment in adulthood but little is known about the effects of early life PCP treatment on synaptic function later in life. Here, we sought to determine whether early life exposure to PCP alters the electrophysiologic function of hippocampal CA1 neurons in adult rats. To this end, male and female Wistar rats received either saline or PCP (10 mg/kg) on postnatal days (PND) 7, 9, and 11, and then underwent separate behavioral and electrophysiology tests in adulthood. Neonatal PCP treatment did not alter basic synaptic transmission and had only a modest effect on frequency following (FF) capacity but significantly decreased the paired-pulse facilitation (PPF) in the Schaffer collateral (SC)-CA1 pathway. We found that PCP treatment significantly attenuated the long-term potentiation (LTP) and long-term depression (LTD) in CA1 neurons accompanied by pronounced alteration in complex response profile in adult rats. The electrophysiology data were comparable in male and female rats and reliably associated with impaired spatial reference and working memories in these animals. Overall, this study suggests that blockade of NMDA receptors during early life deteriorates the short-term and long-term synaptic plasticity and complex response profile of CA1 neurons in adulthood.

Why the Maternal Medication List Matters: Neonatal Toxicity From Combined Serotonergic Exposures

Serotonergic medications are used for the prevention and treatment of depression during pregnancy. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs) can cause poor neonatal adaptation, which has been attributed to withdrawal versus toxicity. Bupropion, a norepinephrine-dopamine reuptake inhibitor, is often used as an adjunctive agent to selective serotonin reuptake inhibitors or SNRIs for refractory depression. Quetiapine, an atypical antipsychotic, may also be used in more complex cases. When combined with serotonergic drugs, bupropion and quetiapine are associated with increased risk of serotonin syndrome in adults. We describe a neonate exposed to venlafaxine (an SNRI), bupropion, and quetiapine in utero who presented nearly immediately after birth with encephalopathy and abnormal movements. The severity and rapidity of symptoms may be attributable to potentiation of venlafaxine's serotonergic effects by bupropion and quetiapine. Neonatal providers should be aware of maternal medications and prepare for possible adverse effects, particularly from common psychotropic exposures.

Independent risk factors for chronic illicit substance use during pregnancy

OBJECTIVE

We aimed to determine the incidence of chronic illicit substance use during pregnancy and to identify associated risk factors.

DESIGN

A 2-year time-matched retrospective maternal quality control database (n = 4,470) analysis of parturients with chronic illicit substance use compared to controls.

SETTING

A tertiary academic medical center located in a rural setting.

RESULTS

The rate of chronic illicit substance use was 1.95 percent. Demographic factors associated with chronic illicit substance use in pregnancy-included lower body mass index (BMI; OR: 0.93; 95 percent CI: 0.89-0.96, p < 0.0001), higher gravidity (OR: 1.24; 95 percent CI: 1.13-1.36, p < 0.0001), higher parity (OR: 1.38; 95 percent CI: 1.22-1.57, p < 0.0001), and more live births (OR: 1.30; 95 percent CI: 1.16-1.46, p < 0.0001). A history of smoking (OR: 10.51; 95 percent CI: 5.69-19.42, p < 0.0001), alcohol use (OR: 48.98; 95 percent CI: 17.33-138.40, p < 0.0001), anxiety (OR: 1.88; 95 percent CI: 1.16-3.05, p = 0.01), depression (OR: 2.44; 95 percent CI: 1.55-3.85, p = 0.0001), transfer on admission (OR: 2.12; 95 percent CI: 1.16-3.87, p = 0.01), payor insurance (OR: 2.12, 95 percent CI: 2.10-5.04, p < 0.0001), and Apgar scores < 7 at 1 minute (OR: 0.50; 95 percent CI: 0.25-1.00, p = 0.049) were significant. Multiple variable logistic regression-revealed BMI, smoking, alcohol use, and Apgar score <7 at 1 minute as significant factors.

CONCLUSIONS

Awareness of these factors can assist in identifying and treating parturients with chronic illicit substance use.

State of the Mind: Growing up with HIV

Human immunodeficiency virus (HIV) is a neurotropic virus that has a detrimental impact on the developing central nervous system (CNS) of children growing up with perinatal HIV (PHIV) due to a combination of pathophysiological processes related to direct viral cytopathic effects and immune activation. This leads to a spectrum of neurocognitive impairment ranging from severe encephalopathy to subtle domain-specific cognitive impairments, as well as psychological disorders that are compounded by HIV-related stigma and sociodemographic factors that disproportionately affect PHIV children. Early commencement and consistent use of combination antiretroviral therapy (cART) has resulted in a dramatic improvement in neuropsychological outcomes for PHIV children; however, they remain vulnerable to cognitive impairment and psychological disorders, as evidenced by imaging findings, randomised clinical trials and observational studies. An optimal neuroprotective cART regimen remains elusive in children, but systemic viral suppression, regular neurocognitive and psychological screening and ready access to neuropsychological management strategies are key components for optimising neuropsychological outcomes. However, a lack of standardised and validated screening tools, particularly in resource-limited settings, hinders a precise understanding of the nature, prevalence and associations between neuropsychological symptomatology and HIV health. This article reviews the natural history, cellular pathophysiology and structural and functional imaging findings for children growing up with HIV, as well as summarising management strategies related to antiretroviral therapy, screening tools and specific interventions for neurocognitive impairments and psychological disorders.

Mothering, Substance Use Disorders and Intergenerational Trauma Transmission: An Attachment-Based Perspective

Background: A growing body of research underlines that interpersonal trauma in childhood leads to heightened susceptibility for substance use disorders (SUDs) in later life. Little research has been conducted on parenting experiences of mothers in recovery from substance use, taking into account their own upbringing as a child and the potential aftermath of interpersonal childhood trauma. Methods: Through in-depth qualitative interviews, 23 mothers with SUDs reflected on parenting experiences and parent-child bonding, related to both their children and parents. Interviews were transcribed verbatim and data were analyzed adopting thematic analysis. Results: Throughout the narratives, consequences of trauma on mothers' sense of self and its subsequent impact on parenting arose as salient themes. Five latent mechanisms of intergenerational trauma transmission were identified: 1) early interpersonal childhood trauma experiences in mothers; 2) trauma as a precursor of substance use; 3) substance use as a (self-fooling) enabler of parental functioning; 4) continued substance use impacting parental functioning; and 5) dysfunctional parental functioning and its relational impact upon offspring. Discussion: Findings suggest disruptive attachment can increase the vulnerability for SUDs on the one hand, but can be an expression of underlying trauma on the other, hence serving as a covert mechanism by which trauma can be transmitted across generations. Results indicate the need for preventive, attachment-based and trauma-sensitive interventions targeted at disruptive intergenerational patterns.

Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges

For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.

Cannabinoid toxicity in pediatrics

PURPOSE OF REVIEW

The advent of legalized cannabis in multiple regions of the United States has rendered the drug more accessible to pediatric patients. Pediatricians and Pediatric Emergency Medicine Providers face new challenges in counseling both patients and their parents, diagnosing exploratory ingestions of cannabinoids in toddlers, and managing complications of prolonged, heavy cannabis use in adolescents. The purpose of this review article is to provide clinicians a succinct summary of recent literature regarding tetrahydrocannabinol (THC) pharmacokinetics, pharmacodynamics, impacts on development, as well as presentations of acute and chronic toxicity.

RECENT FINDINGS

Many young children being admitted to the hospital for cannabis toxicity have been exposed to high concentration products, such as edibles, resins, or vaping fluid. These products contain extremely high concentrations of cannabinoids, and lead to sedation, respiratory depression, and other adverse effects. Chronic toxicity associated with cannabis consumption includes neurocognitive changes and cannabinoid hyperemesis syndrome.

SUMMARY

Clinicians should provide guidance for pediatric patients and their caregivers to reduce the risk of accidental cannabis exposure, particularly with high concentration products. In addition, clinicians should consider chronic cannabis exposure when evaluating certain complaints, such as chronic vomiting or educational performance at school.