Ivan L Hand

The effects of intrauterine cocaine exposure on the respiratory status of the very low birth weight infant.

OBJECTIVES: This study examined the effects of intrauterine cocaine exposure on very low birth weight infants with respect to their surfactant requirement and need for ventilatory support.STUDY DESIGN: A retrospective cohort study was conducted on infants with birth weight between 750 and 1500 g admitted to the neonatal intensive care unit between January 1992 and January 1995.RESULTS: Of the 149 infants studied, 48 infants were exposed only to cocaine and 101 infants had no drug exposure. There were no significant differences between the two groups for gestational age, sex, abruptio placenta, prolonged rupture of membranes, and antenatal steroid usage. The cocaine-exposed group had a significantly greater birth weight (1190 vs. 1109, p<0.02), less prenatal care (48% vs. 14%, p<0.00007), older maternal age (30 vs. 24, p<0.00002), more black race (79% vs. 57%, p<0.01), and more rapid plasma reagin (RPR) positivity (25% vs. 2%, p<0.00006). There were no significant differences in median APGAR scores, or incidence of necrotizing enterocolitis, retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), and bronchopulmonary dysplasia (BPD) between the two groups. Cocaine-exposed infants received surfactant treatment less often (73% vs. 48%, p<0.0035), received fewer mean doses of surfactant (0.4 vs. 10.0, p<0.0014), and were intubated less frequently (44% vs. 65%, p<0.012). There was no significant difference between groups for intubation at 24 and 48 hours and for the development of bronchopulmonary dysplasia.CONCLUSION: Perinatal cocaine exposure appears to have some significant short-term effects on the need for surfactant replacement therapy and need for initial intubation in respiratory distress syndrome (RDS) but no overall effect on the development of BPD.

Aerosolized pentamidine for prophylaxis of Pneumocystis carinii pneumonia in infants with human immunodeficiency virus infection.

Aerosolized pentamidine is widely used in adult patients with human immunodeficiency virus as both prophylaxis and therapy for Pneumocystis carinii pneumonia. The aim of this study was to evaluate the safety of a monthly regimen of aerosolized pentamidine in human immunodeficiency virus-infected infants. Seven human immunodeficiency virus-infected infants, ages 3.5 to 11 months, were given a total of 45 monthly treatments of aerosolized pentamidine. The infants dose of pentamidine was based on an adult dosage of 300 to 600 mg/month, adjusted for minute ventilation and weight. There were no discernible clinical side effects in 62% (28 of 45) of the treatments. Observed toxicity included mild to moderate coughing, mild wheeze and transient arterial desaturation as measured by pulse oximetry. Pulmonary function data revealed an increased tidal volume (P < 0.005) and an increased pulmonary resistance (P < 0.02) post-pentamidine treatment. Urinary pentamidine concentrations were obtained and pentamidine was detected in all tested samples suggesting pulmonary deposition and systemic absorption. In conclusion aerosolized pentamidine appears to be a relatively safe, well-tolerated treatment in infants, with side effects similar to those seen in adults.

DRUG USE IN PREGNANT ADOLESCENTS: A COMPARISON BETWEEN SELF-REPORT AND TOXICOLOGY SCREENING. 13

DRUG USE IN PREGNANT ADOLESCENTS: A COMPARISON BETWEEN SELF-REPORT AND TOXICOLOGY SCREENING. 13

Human immunodeficiency virus seropositivity in critically ill neonates in the South Bronx

Cord blood was anonymously screened to determine the prevalence of human immunodeficiency virus (HIV) seropositivity in neonates admitted to the neonatal intensive care unit (NICU) at the Bronx Lebanon Hospital Center, located in the South Bronx. We speculated that factors leading to admission to the NICU such as low birth weight, prematurity and being small for gestational age would also be associated with an increased prevalence of HIV seropositivity. During the study period the prevalence of HIV seropositivity was 11.6% in the NICU population. There was no significant difference in maternal age, gravidity, race and sex in HIV-seropositive vs. HIV-seronegative newborns. There was a significantly increased incidence of maternal drug use (P < 0.01), babies small for gestational age (P < 0.005) and microcephaly (P < 0.02) in seropositive vs. seronegative NICU babies. The results of this study suggest that the NICU population may comprise a significant number of infants of HIV-infected mothers.

The Hering-Breuer Reflex and Sleep State in the Premature Infant ♦ 1663

Objective: The Hering-Breuer reflex is an important reflex in the control of breathing and a critical component in the measurement of passive respiratory mechanics in the newborn. There is conflicting data however, on the strength of this reflex in different sleep states. The aim of this study was to determine the effects of sleep states on the Hering-Breuer reflex.

No Increase in Developmental Delay in Very Low Birth Weight Cocaine Exposed Infants: A Two Year Follow-Up † 1306

Objective: Published studies reveal conflicting data on the effect of in-utero cocaine exposure on infant development, with little data on VLBW infants. The aim of this study was to measure the effect of cocaine and other variables on the VLBW infant.

Cocaine Attenuates Neonatal Withdrawal in Methadone-Maintained Mothers† 1226

There is conflicting data about the effect of cocaine on the withdrawal of newborns from methadone. We reviewed 85 consecutive cases of newborns born at Bronx Lebanon Hospital Center from January 1993 till February 1996 to mothers in methadone maintenance programs. The age range of the mothers was 18-41 years (mean 30.4± 5.1) with 75% Latino and 22% African-American. Sixty-four women (91%) had prenatal care during the pregnancy and 7% had extramural deliveries. The overall prevalence of illicit drug use within one month prior to delivery was 55%. This was determined by history or a positive infant urine toxicology screen. The mothers were divided into 4 groups: 1. methadone alone (methadone) 38 mothers (45%), 2. cocaine + methadone (cocaine) 13 (15%), 3. opiates + methadone (opiates) 13 (15%), 4. methadone +cocaine+opiates (poly-drug) 21 (25%). There were no significant differences between the groups in birth weight, gestational age, length, head circumference, neonatal morbidity, blood pressure, and exposure to smoking or alcohol. There were several important differences between the groups. The daily dose of methadone was significantly higher in the cocaine group than in the methadone group (76 vs 56 mg, p=0.0036) or the opiate group (55mg, p=0.0050). In addition, mothers using cocaine were enrolled in a methadone program significantly longer than the methadone users (60 vs 25 months, p=0.0015) or opiate users (13 months, p=0.0011). However, the peak total withdrawal score(modified Finnegan 1975) was significantly lower in the cocaine-exposed group than the methadone-exposed group (12 vs 16, p=0.0111) or the opiate-exposed group (16, p=0.0220). The number of hospital days spent withdrawing was also significantly lower with cocaine than methadone (22 vs 34, p=0.0235) or opiate(39, p=0.042). Despite the use of illicit drugs, 44% (20/45) of these newborns were discharged home to their mothers. We conclude that while methadone maintenance programs are hailed as an effective method of preventing illicit drug use, concomitant drug use is still very high and continues to place the newborn at risk both in the immediate neonatal period as well upon discharge home. Cocaine use attenuates the neonatal withdrawal syndrome from methadone, whereas opiate use does not.

Psychiatric Symptoms In Postpartum Adolescent and Adult Women 68

The object of this study was to evaluate post-partum women for psychiatric symptomatology, including cognitive disturbances, anxiety, depression, and anger in order to better meet their needs for support and involve them in the care of their infants. We interviewed 52 post-partum women at The Bronx Lebanon Hospital Center, 17 adolescents (age≤19 yrs, mean age 17.5 yrs.) and 35 adults (mean age 26.6 yrs.). The presence of psychiatric symptoms were measured by using the 29-item Psychiatric Symptom Index (Ilfeld 1976) on mothers within 5 days of delivery. There were no significant differences between the adolescents and the adults for maternal race, prenatal complications, type of delivery, cigarette smoking, drug use, current employment status, or infant health. Adults were more likely to have planned the pregnancy(41.2% vs. 11.8%, p=.003), received prenatal care (100% vs. 87.5%, p=.033), and report feeling happy upon learning they were pregnant(71.4% vs 29.4%, p=.010). Despite the fact that adult mothers were less likely to be worried about the health of their babies (25.7% vs. 52.9%, p=.003) and more likely to report that they would be better off a year from now (90.0% vs. 62.5%, p=.025), they demonstrated higher depressive symptomatology, higher amounts of anger, and greater overall psychiatric symptomatology than adolescent mothers. Physicians need to be aware of the high levels of depression and anger among adult mothers to provide appropriate support. Adolescent mothers may not realize the gravity of their situation and may not seek adequate intervention. Table

Adolescent Pregnancy Correlates with Educational Underachievement in an Urban Setting 27

In order to better understand the factors leading to teenage pregnancy in our high risk population, we interviewed 119 adolescent females ≤ age 21; 102 postpartum mothers and 17 hospitalized control adolescents (mostly PID and asthma). In addition to direct questioning, the WRAT for reading and Gillmore Reading Comprehension Test were administered to assess educational level. The two groups did not differ for race, citizenship, economic situation or employment. When those sexually active were asked about contraception method, 70% reported using condoms, 7% oral contraceptives, 6% other methods and 17% no method. Of the teens who used some form of contraception, 17% use it every time, 23% most of the time, 45% sporatically and 15% rarely. Information about contraception was obtained primarily from health clinics (45%), with only 14% from schools and 11% from parents. Male partners rarely play a primary role in the decision to use contraception, with only 15% raising the issue first vs 49% of the females. 70% of the pregnancies were unplanned and 30% of the mothers were using contraception at the time of conception. The postpartum group were older when they first had sexual intercourse (15±2 vs 11±6, p=0.0000). Educational underachievement was based on the difference between the expected grade level based upon age and the grade level performed on the reading tests. Teen mothers were academic underachievers, both on the WRAT (4.5±2.8 vs 1.8±2.5, p=0.0006) and on the Gillmore (4.8±2.6 vs 2.4±2.5, p=0.0008). In addition, teen mothers were in a significantly lower percentile on the WRAT than the control teens (12.3±17.6 vs 26.8±29.6, p=0.0060). We conclude that adolescents who are pregnant score lower in academic tests. These findings suggest that better intervention in terms of general education as well as education geared to preventing teenage pregnancy needs to be targeted towards this high risk population.

COCAINE AND WITHDRAWAL. 447

There continues to be controversy about whether cocaine causes withdrawal symptoms in newborn infants. Some of the controversy arises because many of these mothers abuse multiple drugs. We prospectively studied 444 consecutive mother-infant pairs. Detailed histories, including drug use were obtained by structured interviews on the post-partum floor. Concurrently, maternal and infant urine and meconium samples were obtained, numerically coded and matched to interview data to insure anonymity. Symptoms of withdrawal were obtained by researchers blinded to the toxicology data. 148 of the 444 (32%) were proven to have abused drugs during the pregnancy by history or toxicology data. 82 were proven to abusing cocaine alone (18%). 131 of our newborns had symptoms of withdrawal (29.5%). 40 of the cocaine group (49%) had withdrawal symptoms which was statistically greater than the number in the drug-free group (26%, p=.000). The symptoms among the cocaine using group were consistent with withdrawal as they started within the first few days of life and resolved within a few days. Most of the withdrawal cases were mild, with the most common symptoms being decreased sleep, tremors, increased tone, high pitched cry, hyperactive Moro, and sneezing. 2 of the babies (5%) had withdrawal severe enough to require treatment. In conclusion, cocaine does produce withdrawal which is usually mild, but occasionally requires therapy.