Marylou Behnke

Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus

Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician’s role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine.

Effect of Nonnutritive Sucking On Behavioral State In Preterm Infants Before Feeding

To describe the effect of nonnutritive sucking (NNS) on behavioral state (BSt) in preterm infants before feedings 24 preterm infants were randomly assigned and studied before each of their first 16 bottle feedings. Twelve received NNS by pacifier for 5 minutes; 12 did not receive a pacifier. BSt was measured with a 12-category scale for 30 seconds before the 5-minute period (BSt1) and for 30 seconds after (BSt2). Sleep states decreased for both groups. BSts considered more optimal for feeding increased more during NNS (86 vs. 46). Restless states were three times less frequent after NNS (23 vs. 68). Differences between groups were nonsignificant at BSt1, but were significant at BSt2, p < .001. In the absence of self-regulatory feeding policies based on early hunger cues, NNS for 5 minutes prefeeding is simple, brief, and suitable for implementation in busy neonatal intensive care units. Nonnutritive sucking was an effective modulator of behavioral state for this sample.

Policy statement - Tobacco use: A pediatric disease

Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobacco-use prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobacco-control measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in tobacco control to promote the health of children, adolescents, and young adults.

The consequences of prenatal substance use for the developing fetus, newborn, and young child

Although substance use has been a worldwide problem at all levels of society since ancient times, recent attention has been focused on the use of legal and illegal substances by the pregnant woman. Almost all drugs taken by the pregnant woman are known to cross the placenta and have some effect on the fetus. This article reviews the effects of the drugs most frequently used by pregnant women in the United States--nicotine, alcohol, marijuana, opiates, and cocaine--on the fetus and neonate; when possible, information regarding long-term medical problems is included.

Diffusion Tensor Imaging of Frontal White Matter and Executive Functioning in Cocaine-Exposed Children

BACKGROUND. Although animal studies have demonstrated frontal white matter and behavioral changes resulting from prenatal cocaine exposure, no human studies have associated neuropsychological deficits in attention and inhibition with brain structure. We used diffusion tensor imaging to investigate frontal white matter integrity and executive functioning in cocaine-exposed children. METHODS. Six direction diffusion tensor images were acquired using a Siemens 3T scanner with a spin-echo echo-planar imaging pulse sequence on right-handed cocaine-exposed (n = 28) and sociodemographically similar non-exposed children (n = 25; mean age: 10.6 years) drawn from a prospective, longitudinal study. Average diffusion and fractional anisotropy were measured in the left and right frontal callosal and frontal projection fibers. Executive functioning was assessed using two well-validated neuropsychological tests (Stroop color-word test and Trail Making Test). RESULTS. Cocaine-exposed children showed significantly higher average diffusion in the left frontal callosal and right frontal projection fibers. Cocaine-exposed children were also significantly slower on a visual-motor set-shifting task with a trend toward lower scores on a verbal inhibition task. Controlling for gender and intelligence, average diffusion in the left frontal callosal fibers was related to prenatal exposure to alcohol and marijuana and an interaction between cocaine and marijuana exposure. Performance on the visual-motor set-shifting task was related to prenatal cocaine exposure and an interaction between cocaine and tobacco exposure. Significant correlations were found between test performance and fractional anisotropy in areas of the frontal white matter. CONCLUSIONS. Prenatal cocaine exposure, alone and in combination with exposure to other drugs, is associated with slightly poorer executive functioning and subtle microstructural changes suggesting less mature development of frontal white matter pathways. The relative contribution of postnatal environmental factors, including characteristics of the caregiving environment and stressors associated with poverty and out-of-home placement, on brain development and behavioral functioning in polydrug-exposed children awaits further research.

Policy statement - Alcohol use by youth and adolescents: A pediatric concern

Alcohol use continues to be a major problem from preadolescence through young adulthood in the United States. Results of recent neuroscience research have substantiated the deleterious effects of alcohol on adolescent brain development and added even more evidence to support the call to prevent and reduce underaged drinking. Pediatricians should be knowledgeable about substance abuse to be able to recognize risk factors for alcohol and other substance abuse among youth, screen for use, provide appropriate brief interventions, and refer to treatment. The integration of alcohol use prevention programs in the community and our educational system from elementary school through college should be promoted by pediatricians and the health care community. Promotion of media responsibility to connect alcohol consumption with realistic consequences should be supported by pediatricians. Additional research into the prevention, screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents continues to be needed to improve evidence-based practices.

Cocaine use during pregnancy: Maternal depressive symptoms and infant neurobehavior over the first month

Research on the effects of prenatal cocaine exposure has produced an inconsistent pattern of results. The goals of this project were (a) to improve upon the methodology of previous research by matching subjects one-to-one on important confounding maternal and infant variables, (b) to investigate a population of rural women not enrolled in an intensive prenatal intervention program, (c) to assess the impact of cocaine use on maternal depressive symptoms both immediately and 1-month postpartum, and (d) to provide longitudinal data regarding the effect of cocaine exposure and maternal affect on neurobehavioral development of neonates by assessing the infants in the hospital and at 1 month of age. Cocaine-using mothers had significantly fewer prenatal visits and reported more depressive symptoms following delivery thon did control mothers. Cocaine-exposed infants had significantly lower birthweights and shorter gestations. There were no significant differences in neonatal performance on the Brazelton scale at birth or 1 month of age. These findings demonstrate that not all cocaine-exposed infants exhibit neurobehavioral deficits in the neonatal period. Longitudinal research is needed to determine if problems will manifest themselves at later ages when greater developmental demands are placed upon these children.

Policy statement - Alcohol use by youth and adolescents

Alcohol use continues to be a major problem from preadolescence through young adulthood in the United States. Results of recent neuroscience research have substantiated the deleterious effects of alcohol on adolescent brain development and added even more evidence to support the call to prevent and reduce underaged drinking. Pediatricians should be knowledgeable about substance abuse to be able to recognize risk factors for alcohol and other substance abuse among youth, screen for use, provide appropriate brief interventions, and refer to treatment. The integration of alcohol use prevention programs in the community and our educational system from elementary school through college should be promoted by pediatricians and the health care community. Promotion of media responsibility to connect alcohol consumption with realistic consequences should be supported by pediatricians. Additional research into the prevention, screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents continues to be needed to improve evidence-based practices.

Prenatal cocaine use: A comparison of neonates matched on maternal risk factors

This study was designed to overcome some of the methodological limitations of previous work and investigate the impact of prenatal cocaine use in an understudied population: women using rural county public health units who had minimal access to drug rehabilitation. Through maternal history, interviews, and urine screens, 172 cocaine users were identified. Using an independently collected perinatal data base, 168 nonusers were matched for six variables known to affect pregnancy outcome and chosen a priori: race, age, parity, prenatal care, alcohol, and nicotine use. To avoid chance findings, 10 adverse perinatal outcome variables were identified prospectively. Cocaine-exposed neonates experienced significantly more of the adverse events than the matched controls and were more likely to be preterm, low birthweight, resuscitated at birth, and to remain in the hospital after their mothers were discharged. We conclude that prenatal cocaine use can be a contributor to adverse perinatal outcome in this population. An understanding of the effects of prenatal cocaine use and the needs of these women and infants is important for designing appropriate prenatal care, treatment, and follow-up programs.

Women and Children in Residential Treatment: Outcomes for Mothers and Their Infants

This paper examines the relationship between the living arrangement of mother and baby in a residential treatment center and measures of self-esteem, depression and parenting sense of competence and a womans length of stay and completion or non-completion of treatment. Scores on the Bayley Scales of Infant Development (Bayley 1969) are also examined by the amount of time the baby spent with mother, an arrangement that affords the opportunity for the child to participate in the facilitys therapeutic child care center. Findings suggest that the earlier a mothers infant resides with her in the treatment setting, the longer her length of stay will be, with an increased opportunity for program completion. In addition, measures of depression were lower and measures of self-esteem were higher for women with their babies than for clients who did not have their infant in the treatment facility. Scores on the Bayley Scales of Infant Development were within normal limits for all infants living with their mothers in treatment.