Neurologic manifestations of in utero cocaine exposure in near-term and term infants

Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas 75235-9063, USA.
Pediatrics (Impact Factor: 5.47). 09/1995; 96(2 Pt 1):259-64.
Source: PubMed


To determine whether the incidence of neurosonographic and neurologic abnormalities is higher in cocaine-exposed infants at birth.
In utero exposure to cocaine was investigated in 39 term and near-term infants with positive urine screens for cocaine only and 39 matched control infants without drug exposure admitted to the regular term newborn nursery. Serial evaluations were performed on each infant on postnatal days 1 and 2 and included a cranial sonogram, a neurologic and behavioral assessment for drug withdrawal, and Doppler interrogation of the anterior and middle cerebral arteries.
There were no differences between groups in neurosonographic abnormalities. Grade I or II intraventricular hemorrhage occurred in 11% of cocaine-exposed and 11% of control infants. There were no cases of grade III intraventricular hemorrhage, cystic periventricular leukomalacia, or neonatal stroke. Head size was smaller in cocaine-exposed infants, ie, 32.7 +/- 0.1 cm versus 33.8 +/- 0.1 cm. The neurologic examination was similar between groups with regard to tone, reflexes, and cranial nerves. Behavioral scores were higher on both days, in cocaine-exposed versus control infants, ie, 4.4 +/- 0.5 versus 2.7 +/- 0.03 on day 1 and 5.0 +/- 0.5 versus 1.71 +/- 0.31 on day 2. Cerebral blood flow velocity measurements in the anterior cerebral artery were similar between groups on both days of examination. However, cocaine-exposed infants demonstrated a significant increase in flow velocity from day 1 to day 2, ie, 0.48 +/- 0.03 to 0.57 +/- 0.04. There was a concomitant decrease in the pulsatility index from day 1 to day 2 in the cocaine-exposed, ie, 0.74 +/- 0.02 to 0.69 +/- 0.02, but not in the control infants. No differences were noted in the flow velocities in the middle cerebral arteries between groups.
Term and near-term infants admitted to a regular nursery who are exposed to cocaine in utero: (1) do not exhibit an increased incidence of neurosonographic abnormalities; (2) do exhibit altered behavior consistent with drug withdrawal; and (3) do demonstrate changes in flow velocity in the anterior cerebral artery consistent with the vasoconstrictive effects of the drug. However, these changes were not accompanied by changes in the neurologic examination or altered care. The long-term neurodevelopmental implications of these subtle abnormalities in the neonatal period remain to be determined.

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    • "Of the studies cited above, most reported mild to moderate signs of what they called withdrawal [2] [7] [14] [15] [21] [24] [30] [31] [35] [37] [48] [50] [51], two noted only some tone and movement differences not thought to be connected with narcotic-like withdrawal signs [8] [40] and a few saw no evidence of withdrawal in cocaine-exposed infants [22] [29] [44]. Of the four controlled studies using blinded observers [8] [22] [24] [51], two reported no evidence of withdrawal signs [8] [22] and two reported mild signs, including jitteriness, irritability, brisk or excessive reflexes and some poor feeding , that did not require treatment and were not related to neurologic problems [24] [51]. "
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    ABSTRACT: The literature on prenatal cocaine exposure is unclear whether immediate postpartum effects on the infant are transient, related to either acute toxicity of cocaine, or to a withdrawal effect as cocaine is metabolized, or whether they might persist. This prospective, longitudinal study was designed to test the hypotheses that newborns urine-positive for cocaine metabolites, compared to those exposed but urine-negative, and to nonexposed controls would (1) have poorer neurobehavioral scores (toxicity effect) and (2) worsen or demonstrate less improvement over the first week (withdrawal effect). We approached over 2500 pregnant women designated to deliver at our referral hospital from public health clinics; 85% consented to participate in a longitudinal study. We excluded women <18 years old with major chronic illness and prenatal drug use except cocaine, marijuana, alcohol and tobacco. From positive urine toxicologies or admissions in private, thorough interviews, 154 were identified as prenatal cocaine users; 154 were selected from noncocaine users matched on socioeconomic status (SES), race, parity and location of prenatal care (that related to perinatal risk), for a total sample size of 308. Included in this article are the 155 surviving infants who were full-term, delivered vaginally and were well and available for testing over the first week postpartum. Infant urine specimens were collected, and neurobehavorial testing was performed by certified, blinded examiners using the Neonatal Behavioral Assessment Scale on days 1, 2-4 and 5-7 postpartum. In toxicity analyses, controlling for amount of prenatal drug exposures, only autonomic regulation demonstrated significant overall and cocaine drug group effects. Urine-positive newborns had the poorest scores (i.e., more startles, tremors). However, given that planned comparisons were not significant, these data provided little support for acute toxicity effects. In withdrawal analyses, only one significant change over time varied among exposure groups. Those infants exposed and positive for cocaine metabolites increased their scores on regulation of state on days 2-4 and decreased them on days 5-7 (when withdrawal might be evident). However, their scores on days 5-7 were not significantly lower than their initial scores, nor different from the days 5-7 scores of the exposed negatives or control infants, lending little support for withdrawal effects. Our data support those of other controlled studies in failing to demonstrate devastating early effects of prenatal cocaine exposure. They add to our understanding that effects observed do not appear to be related to acute toxicity nor to cocaine withdrawal. The uncertainty of persistent effects of cocaine exposure warrants long-term follow-up.
    Full-text · Article · Sep 2001 · Neurotoxicology and Teratology
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    • "The authors statistically controlled for other drug exposures. While controlling for confounding variables, King et al. (1995) found neurobehavioral abnormalities (increased jitteriness, hyperactive moro response, and excessive sucking) on day 1 and 2 of life using the standardized Finnegan method for evaluation among 39 term or near term infants prenatally cocaine-exposed. The authors suggested these results were consistent with withdrawal. "
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    ABSTRACT: Maternal cocaine use during pregnancy continues to be of great concern for health care professionals. Research in this area has increased as investigators examine the effects of prenatal cocaine exposure in the infant/young child. This paper will critically review the literature, identify the primary care needs of infants and young children with a known history of prenatal cocaine exposure, and present guidelines for the primary care practitioner to monitor the infant's physiologic and developmental sequelae during the first 3 years of life. Findings in the literature demonstrate inconsistencies in regard to the physiologic and developmental outcomes of infants/young children prenatally exposed to cocaine. Further research is warranted, as it is evident from studies that not all investigators are controlling for confounding variables such as poly-drug use, which is necessary in isolating cocaine's effects. Subtle effects, however, have been reported from well-controlled studies and, thus, particular attention needs to be paid to early identification and interventions by primary care practitioners to prevent negative health outcomes. The guidelines proposed assist the practitioner with a thorough and focused approach to assessing the physiologic and developmental effects that are currently known to occur in the infant/young child prenatally exposed to cocaine.
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    ABSTRACT: Substance abuse among pregnant women remains a national health issue. The incidence of infants born addicted to licit and illicit substances is increasing. The long-term outcomes have not been consistently documented. These appear to include mild to severe developmental and cognitive problems, depending upon the substance used. Central nervous system problems, behavioral dysfunction, and safety issues are major parental concerns for these children as they grow. Interventions must be aimed at thorough assessments, including an accurate maternal history, use of supports for positive neurodevelopment, parent education about infant/child cues, and encouragement of educational environments that are highly structured and safe. Consistent, long-term follow-up is essential to optimize long-term outcomes.
    Full-text · Article · Aug 1997 · Journal of Obstetric Gynecologic & Neonatal Nursing
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