Susan S. Martier

Detecting risk drinking during pregnancy: a comparison of four screening questionnaires.

OBJECTIVES This study investigated the efficacy of screening for risk drinking during pregnancy with two brief questionnaires, TWEAK and T-ACE. Both include an assessment of tolerance based on the number of drinks women report they can hold. METHODS Subjects were disadvantaged African-American obstetric patients in Detroit, Mich. Traditional alcoholism screens (Michigan Alcohol Screening Test [MAST], CAGE) and the tolerance question were administered (n = 2717); TWEAK and T-ACE were constructed from tolerance and embedded MAST and CAGE items. In a separate sample (n = 1420), only the T-ACE was administered. Periconceptional risk drinking was the gold standard. Screen evaluations were based on receiver-operating characteristic analyses. RESULTS At the cutpoint of 2, sensitivity/specificity for embedded screens were 91/77 for TWEAK and 88/79 for T-ACE; comparable values for T-ACE alone were 67/86. TWEAK and T-ACE screened more effectively than CAGE or MAST. CONCLUSIONS Embedded versions of TWEAK and T-ACE were both highly sensitive to periconceptional risk drinking in this population. Administering T-ACE alone reduced its sensitivity; this suggests that MAST and CAGE administration improves its performance.

New evidence for neurobehavioral effects of in utero cocaine exposure

Most studies of prenatal cocaine exposure have found gestational age or intrauterine growth deficits but few, if any, cognitive effects. In a large, well-controlled study we detected cognitive deficits in relation to heavy cocaine exposure. These findings demonstrate that prenatal exposure to cocaine at sufficiently high doses early in pregnancy has the potential to produce cognitive changes in infants and that more focused, narrow-band tests may be necessary to detect these subtle neurobehavioral effects. A total of 464 inner-city, black infants whose mothers were recruited prenatally on the basis of pregnancy alcohol and cocaine use were tested at 6.5, 12, and 13 months of age. Standard analyses, based on presence or absence of cocaine use during pregnancy, confirmed effects on gestational age but failed to detect cognitive effects. A new approach to identifying heavy users found that heavy exposure early in pregnancy was related to faster responsiveness on an infant visual expectancy test but to poorer recognition memory and information processing, deficits consistent with prior human and animal findings. These persistent neurobehavioral effects of heavy prenatal cocaine exposure appear to be direct effects of exposure and independent of effects on gestational age.

Alcohol teratogenicity in the human: A detailed assessment of specificity, critical period, and threshold

Though the occurrence of alcohol-related birth defects is well documented in the human and in animal models, definition of specificity, critical period, and dose-response threshold with a precision adequate for clinical risk assessment and management has been lacking. Data from a cohort of 359 neonates, from a large prospective observational study in which chronic alcohol problems and maternal drinking were assessed during pregnancy and standardized neonatal examinations were blinded for prenatal information, were analyzed with the use of multivariate techniques, with uniform control for confounding by eight factors. Craniofacial abnormalities were found to be definitively related to prenatal alcohol exposure in a dose-response manner (p less than 0.001); a significant, but less striking, relationship was observed for other anomalies (p less than 0.01). The critical period for alcohol teratogenicity was confirmed to be around the time of conception. Risk for anatomic abnormalities in the offspring was clearly defined among the 5.6% of infants whose mothers drank more than three ounces of absolute alcohol, that is, more than six drinks, per day. Because of a trend toward an increase in craniofacial abnormalities with increasing embryonic alcohol exposure at lower levels, a clear threshold could not be defined. These are not experimental data and the results should not be overinterpreted. Nevertheless, pending further studies with larger samples, the findings suggest that to completely avoid alcohol-related anatomic abnormalities, advice to discontinue drinking or at least to reduce it to a minimal level before conception is clinically appropriate.

Maternal recall of alcohol, cocaine, and marijuana use during pregnancy

Alcohol, cocaine, and marijuana use during pregnancy was reported antenatally and at 13 months postpartum by 361 black inner city mothers. The two reports were moderately related for all three substances, but levels reported retrospectively were substantially higher. MAST scores did not differ for the two interviews. Most of the correlations of the antenatal and retrospective reports with maternal and infant characteristics were similar in magnitude; those that differed were somewhat stronger for the antenatal measures. Although the retrospective reports may provide a better indication of mean levels of fetal exposure, they may be less precise in rank ordering among individuals for purposes of correlational analysis. Women with higher MAST scores were particularly prone to report higher levels of both alcohol and cocaine when interviewed retrospectively, and more severely depressed mothers were more likely to report higher levels retrospectively for all three substances. These data suggest that women reporting more than 1.3 drinks/week antenatally (AA/day greater than 0.1) may actually be drinking at levels at risk for alcohol-related birth defects.

Effects of alcohol use, smoking, and illicit drug use on fetal growth in black infants.

STUDY OBJECTIVES To compare the effects of prenatal exposure to alcohol, smoking, and illicit drugs on birth size. DESIGN Prospective, longitudinal correlational study, with statistical control for confounding. PARTICIPANTS Four hundred seventeen black infants. Mothers recruited at first prenatal clinic visit on the basis of moderate-to-heavy use of alcohol or cocaine or both, plus a 5% random sample of lower-level drinkers and abstainers. MAIN RESULTS Alcohol, smoking, opiates, and cocaine were each correlated with smaller birth weight, length, and head circumference (median r = -0.21; p < 0.001). However, when all four substances, gestational age, and six covariates were controlled statistically, birth weight related only to alcohol and smoking (p < 0.05), length only to alcohol (p < 0.05), and head circumference only to opiates (p < 0.01). Although smoking affected birth weight at all levels of exposure, a larger deficit was seen in relation to heavy drinking (509 gm) than to heavy smoking (269 gm). Alcohol and smoking did not affect birth size synergistically, and their effects were seen primarily in infants of women more than 30 years of age. CONCLUSIONS The association of reduced birth weight and length with illicit drug use may be a consequence of simultaneous exposure of the fetus to alcohol and smoking. Opiate exposure is specifically related to reduced head circumference, and the effect of cocaine on birth size is primarily an indirect consequence of shorter gestation and poorer maternal nutrition.

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 Teachers Report Form (TRF). Drug use since the childs 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, childs 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 childs report of violence exposure, had an independent effect on teacher-assessed child behavioral problems. Furthermore, among the children prenatally exposed to cocaine, change in the childs custody status was a significant predictor of TRF scores. It remains possible that other unmeasured postnatal characteristics of the cocaine-using household may play important roles in teacher-assessed child behavior.

Significant Determinants of Susceptibility to Alcohol Teratogenicity

Typically, the rate of abusive drinking during pregnancy considerably exceeds the rates of fetal alcohol syndrome (FAS) and alcohol-related birth defects, suggesting that other factors may modify the impact of alcohol on the developing organism. Data in the literature supporting this susceptibility hypothesis are sparse. In this paper, two studies in different samples, using different analytic strategies to examine susceptibility to different adverse outcomes are presented. Among 176 pregnancies in which lowered birth weight for gestational age was detected as an effect attributable to frequent beer drinking, 27 infants weighted less than 2,700 grams and 149 weighed more. Using discriminant analysis to contrast these groups, lowered birth weight for gestational age was associated with black race and lower maternal weight and weight gain. The effects of these factors were additive with that of persistent alcohol exposure; no interactions were detected, but pregnancies with risks in addition to alcohol were more likely to yield growth-retarded infants. In a second study, pregnancies resulting in 25 FAS cases were contrasted with 50 controls. A four-factor model accounted for nearly two-thirds of the explainable variance in the occurrence of FAS. Adjusted for frequency of maternal drinking, chronic alcohol problems and parity, there was a sevenfold increase in risk for FAS among black infants. The findings from both studies are consistent with the susceptibility hypothesis and have potentially important implications for public health and clinical approaches to prevention, as well as for future research.

The clinical utility of maternal body mass index in pregnancy

To describe maternal body mass index and to compare the use of maternal weight and body mass index for risk assessment at the initial prenatal visit, 6270 gravid women who were consecutively delivered of infants were studied. Body mass index increased with advancing maternal age, parity, and advancing gestational age and was significantly greater in black women than in nonblack women. Risks for the development of adverse outcome associated with maternal obesity, including development of gestational diabetes, preeclampsia, fetal macrosomia, and shoulder dystocia, were comparably predicted by either maternal weight or body mass index greater than 90th percentile. Maternal weight was as predictive of preeclampsia, macrosomia, and shoulder dystocia as was body mass index when these factors were analyzed as continuous variables, whereas increasing body mass index was more predictive of gestational diabetes. The prediction of factors associated with low maternal weights, small-for-gestational-age birth, prematurity, low birth weight, and perinatal death was equivalent for maternal weight and body mass index that was less than 10th percentile. This study indicates that in the initial risk assessment of outcomes related to maternal weight, the calculation of maternal body mass index offers no advantage over simply weighing the patient. This finding contrasts with results in nonpregnant women.

Expressive Language Development of Children Exposed to Cocaine Prenatally: Literature Review and Report of a Prospective Cohort Study.

It was hypothesized that prenatal exposure to cocaine and other substances would be related to delayed expressive language development. Speech and language data were available for 458 6-year olds (204 were exposed to cocaine). No significant univariate or multivariate differences by cocaine exposure group were observed. Classification and regression tree modeling was then used to identify language variable composites predictive of cocaine exposure status. Meaningful cut points for two language measures were identified and validated. Children with a type token ratio of less than 0.42 and with fewer than 97 word types were classified into a low language group. Low language children (n = 57) were more likely to be cocaine exposed (63.1%), with cocaine-exposed children 2.4 times more likely to be in the low language group compared with control children after adjustment for covariates. Prenatal cigarette, but not alcohol exposure, was also significantly related to expressive language delays.

Alcohol Consumption in Pregnant, Black Women Is Associated With Decreased Plasma and Erythrocyte Docosahexaenoic Acid

BACKGROUND Inner-city, black women are among those groups that are at higher risk for having infants with fetal alcohol spectrum disorders that can include life-long neurobehavioral and cognitive impairments. Chronic alcohol consumption can decrease amounts of docosahexaenoic acid (DHA), a fatty acid that is essential for optimal infant neural and retinal development in a variety of tissues. METHODS Black women who presented at an inner-city antenatal clinic for their first prenatal visit were recruited into a longitudinal, observational study. Alcohol intake was determined by a structured interview. Participants provided blood specimens and completed food frequency surveys at 24 weeks of gestation, infant delivery, and 3 months postpartum. Fatty acid composition analyses were completed on 307, 260, and 243 for plasma and 278, 261, and 242 erythrocyte specimens at 24 weeks of gestation, delivery, and 3 months postpartum, respectively. RESULTS Proportion of drinking days at the first prenatal visit was associated with decreased DHA in plasma and erythrocytes throughout the study. This association was the strongest at 24 weeks of gestation. In addition, an interaction between proportion of drinking days at the time of conception and ounces of absolute alcohol per drinking day at the time of conception was detected and demonstrated that, in daily drinkers, high intakes of alcohol are associated with decreased DHA and arachidonic acid (AA) concentrations in plasma. CONCLUSIONS Frequent and high intakes of alcohol that have been previously associated with fetal alcohol spectrum disorders are also associated with decreased maternal DHA and AA plasma concentrations. The present findings indicate that maternal DHA deficiency is associated with high-risk drinking and may contribute to the mechanism(s) of alcohol-related neurodevelopmental disorders.