Prenatal cocaine exposure and child outcomes: a conference report based on a prospective study from Cleveland

Neonatal Abstinence Syndrome: An Insight Over Impact of Maternal Substance Use

Neonatal abstinence syndrome (NAS) highlights the intricate interplay between maternal substance use during pregnancy and the challenges neonates face from the distressing global opioid crisis. This comprehensive review captures the multilayered landscape of NAS, encircling its underlying mechanisms, epidemiology, diagnostic intricacies, clinical manifestations, continuing developmental impacts, treatment paradigms, and the crucial role of multidisciplinary care. The core pathophysiology of NAS involves the transplacental passage of addictive substances, activating chemical dependence in the maturing fetus, which is characterized by neurotransmitter dysregulation, neuroadaptations, and receptor sensitization. A diverse clinical presentation ranges from central nervous system hyperactivity and autonomic dysregulation to gastrointestinal manifestations, necessitating homogenous assessment tools such as the Finnegan Neonatal Abstinence Scoring System. The demand for a multilayered approach is essential for comprehensive management, involving pharmacological interventions like morphine or methadone and non-pharmacological strategies such as swaddling. The complications of NAS are not only limited to but are also well beyond infancy, leading to behavioral, longstanding cognitive, and socioemotional consequences. Addressing these developmental arcs demands decisive longitudinal monitoring and early interventions. NAS management is fundamentally multidisciplinary, requiring the teamwork of nurses, social workers, psychologists, pediatricians, and neonatologists. Apart from the clinical realm, managing the psychosocial needs of families traversing NAS requires resources and empathy. A crucial comprehensive approach is essential to confront the challenges and limitations of NAS. From early identification and prevention to longstanding support through pharmacological, non-pharmacological, and psychological channels, it creates a holistic structure that emerges as the basis for understanding the complicated relationship between maternal substance use and its impact on neonates. An amalgamation of community engagement, society, policy initiatives, and medical expertise is essential to mitigate the repercussions of NAS and adopt healthier outcomes for affected infants.

Prenatal cocaine exposure and substance use disorder in emerging adulthood at age 21

BACKGROUND

Prenatal cocaine exposure (PCE) has been associated with child and adolescent externalizing behaviors and early substance use, yet few studies investigated its association with substance use disorder (SUD) in emerging adults. The present study examined the association of PCE with SUD in emerging adulthood, and whether childhood externalizing behaviors and adolescent substance use mediated the relationship.

METHODS

Participants were 367 (187 PCE; 53% female) adults at age 21, primarily urban African American who were recruited at birth. PCE and exposure to alcohol, tobacco, and marijuana were determined using biologic assays for drug metabolites and/or maternal self-report at birth. Offspring externalizing problems were assessed using the Youth Self-Report at age 12, substance use and substance use-related problems via biologic assays and/or self-report at age 15, and SUD determined using DSM-5 diagnostic criteria at age 21.

RESULTS

About 32.3% of the emerging adults were determined to have marijuana use disorder, 30.3% tobacco use disorder, and 15.5% alcohol use disorder. PCE was related to greater externalizing behaviors at age 12 (β = 0.12, p = .042), which in turn was related to SUD (β = 0.22, p = .008). PCE was also related to substance use, mainly marijuana, at age 15 (β = 0.22, p = .011), which was related to SUD (β = 0.51, p < .001). Total indirect effects including these two pathways were significant (β = 0.19, p = .002).

CONCLUSIONS

PCE may increase risk for SUD in emerging adulthood through childhood externalizing behaviors and adolescent substance use.

Co-occurrence of Psychopathology Problems in At-Risk Adolescents

No known studies have investigated co-occurrence of psychopathology problems in adolescents with biologic and/or environmental susceptibility, including prenatal drug exposure. This study identified comorbidity patterns of psychopathology problems by utilizing data from urban, primarily African American, youth, majority of whom were at heightened risk for exposure to drugs in utero. The roles of Research Domain Criteria (RDoC)-informed behavioral constructs of the Negative Valence (irritability) and Social Process Systems (social disinhibition) as antecedents of the comorbidity patterns were further examined. Lastly, the predictive validity of the identified patterns was evaluated in relation to emerging adulthood outcomes. Participants were 358 urban adolescents, primarily African Americans, drawn from a 21-year prospective birth-cohort study of the effects of prenatal drug exposure. Psychopathology problems were assessed at age 15. Irritability and social disinhibition were self-reported at age 12. Emerging adulthood outcomes were measured at age 21. Latent class modeling indicated four patterns: Normative (57%), substance-use (SU; 24%), mental-health-problems-without-substance-use (MH; 11%), and substance-use-and-other-mental-health-problems (SUMH; 7%). Higher irritability increased the odds of developing the MH pattern, whereas higher social disinhibition increased the odds of developing the SU pattern. The odds of manifesting the SUMH pattern were higher for children with higher irritability. For children with higher social disinhibition, the odds of manifesting the SUMH pattern were higher at a trend level. Adolescent comorbidity patterns were differentially associated with problematic tobacco and marijuana use and clinically relevant mental health problems in emerging adulthood, and completion of high school education. Peri-pubertal identification of individual differences in irritability and social disinhibition may mitigate the emergence of adolescent psychopathology, which could influence emerging adulthood adjustment in this at-risk population.

Substance use and individual assets in urban adolescents: Subgroups and correlates in emerging adulthood

INTRODUCTION

To investigate patterns of divergence in adolescent adjustment, this study examined the co-occurring patterns of adolescents' individual assets (e.g., school engagement, values) and substance use, and whether the co-occurring patterns were associated with later functioning in emerging adulthood.

METHODS

Participants were 358 (54% females), predominantly African American, urban adolescents, recruited at birth for a prospective study on the effects of prenatal substance exposure in the Midwest United States. Individual assets, using the Developmental Assets Profile, substance use (alcohol, tobacco, marijuana), via biologic assays and self-report, and substance use-related problems were assessed at age 15 years. High-school completion, substance use disorder, mental health symptoms, and legal problems were assessed at age 21 years.

RESULTS

Latent class analysis identified five classes as follows: high assets with low substance use (C1, 10.2%); moderate assets with low substance use (C2, 28.7%); low assets with low substance use (C3, 32%); moderate assets with high substance use (C4, 9.4%); and low assets with high substance use (C5, 19.2%). Despite similar levels of assets, adolescents in C5 reported more life adversities (suboptimal caregiving environment, daily hassles, non-birth parents' care) than those in C3. C4 and C5 reported more substance use disorder at age 21 years than the three low substance use classes; adolescents in C5 were less likely to complete high school than those in C2. More females in C5 reported greater mental health symptoms than those in C1 and C3, and criminal justice involvement than those in C1.

CONCLUSIONS

The current findings underscore the significance of substance use in adolescence in disrupting healthy transition to adulthood, especially among females in the context of low individual assets.

Fatty acid ethyl esters in meconium and substance use in adolescence

Prenatal alcohol exposure (PAE) continues to be a serious public health problem, yet no reliable clinical tools are available for assessing levels of drinking during pregnancy. Fatty acid ethyl esters (FAEEs), the nonoxidative metabolites of ethanol measured in meconium, are potential biomarkers to quantify the level of PAE. The association between the concentrations of FAEEs from meconium and adolescent substance use and related problems was examined in a prospective birth-cohort of adolescents exposed to alcohol and drugs in utero. FAEEs were quantified with gas chromatography via a flame ionization detector. Meconium was analyzed for FAEEs in 216 newborns; 183 of them (81 boys, 102 girls) were assessed at age 15 for alcohol, tobacco, and marijuana use using biologic assays and self-report. Substance use problems were assessed using the Problem Oriented Screening Instrument for Teenagers. Findings from multivariable logistic regression analyses indicated that, after controlling for other prenatal drug exposure and covariates, higher concentrations of FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, ethyl linoleate, ethyl linolenate, and ethyl arachidonate) were related to a greater likelihood of marijuana use and experiencing substance use problems, but not tobacco or alcohol use, at age 15. Elevated levels of FAEEs in meconium may be promising markers for PAE, identifying newborns at risk for early substance use and developing substance use problems.

Developmental Outcomes of Infants Adopted from Foster Care: Predictive Associations from Perinatal and Preplacement Risk Factors

Infants adopted domestically from foster care often present with prenatal substance exposure and risky birth outcomes such as prematurity and low birth weight. Because few longitudinal studies of foster-adoptive infants exist, it is unclear how these preplacement risk factors influence development over time. The present study examined associations between perinatal risk factors and developmental outcomes among an ethnically/racially-diverse sample of 97 infants in foster-care (56% boys) placed into adoptive homes at ages 0-19 months. Relative to population-norms, foster-adoptive infants showed comparable cognitive but lower language and motor functioning at baseline and one-year follow-up. Age-adjusted language scores significantly improved one year following placement, consistent with a developmental "catch-up" effect. Low birth weight uniquely predicted lower language scores at baseline, but this association was no longer significant at follow-up. Prenatal substance exposure was associated with lower baseline cognitive scores, but only for infants placed after six months of age. In contrast, infants with low birth weight and later placement age (>12 months) showed the most accelerated motor development. Sex differences emerged at follow-up when predicting motor and language outcomes, suggesting potential sex-specific pathways of risk. Overall, results support adoption as an early intervention that may buffer vulnerability to perinatal risk on development.

A comparison of common practices for identifying substance use during pregnancy in obstetric clinics

BACKGROUND

Substance use during pregnancy has been linked to adverse birth and other outcomes. Screening and intervention in the prenatal clinic are recommended, and reliance on patient reports or selective urine drug screening is inadequate. The aim of this prospective project was to determine substance use identification rates associated with common screening practices, compared to universal screening, among pregnant women seeking care at an urban, academic obstetric clinic.

METHODS

Women attending their first prenatal visit (N = 275) completed a self-report questionnaire on lifetime and current substance use. A urine drug screening was also conducted, the results of which were not reported to providers. Participants' charts were reviewed to obtain the results of provider-ordered screens.

RESULTS

The sample was primarily African-American and Latino, with Medicaid insurance. Ten women (4.6%) reported current marijuana use, while more than double that number (n = 27; 11.6%) screened positive for marijuana via universal screening. The majority of women who screened positive via universal screening did not have a provider-ordered urine drug screening, and less than one-third (29.3%) of clinician-ordered screens were positive for at least one substance. Finally, 90% of women who reported they were using marijuana were not selected by providers for a screen.

DISCUSSION

Data demonstrate the high proportion of women using marijuana and the limitations of patient self-report and selective, nonroutine screening to identify substance use during pregnancy. Effective, standardized, clinic-wide strategies are needed to support providers in identifying pregnant women who use substances in order to increase the frequency of education and intervention.

Effects of Fetal Substance Exposure on Offspring Substance Use

Prenatal exposure to alcohol and drugs is associated with physical, cognitive, and behavioral problems across the offspring's lifespan and an increased risk of alcohol and drug use in adolescent and young adult offspring. These prenatal effects continue to be evident after control for demographic background and parental alcohol and drug use. Behavior problems in childhood and adolescence associated with prenatal exposures may serve as a mediator of the prenatal exposure effects on offspring substance use.

The cellular basis of fetal endoplasmic reticulum stress and oxidative stress in drug-induced neurodevelopmental deficits

Prenatal substance exposure is a growing public health concern worldwide. Although the opioid crisis remains one of the most prevalent addiction problems in our society, abuse of cocaine, methamphetamines, and other illicit drugs, particularly amongst pregnant women, are nonetheless significant and widespread. Evidence demonstrates prenatal drug exposure can affect fetal brain development and thus can have long-lasting impact on neurobehavioral and cognitive performance later in life. In this review, we highlight research examining the most prevalent drugs of abuse and their effects on brain development with a focus on endoplasmic reticulum stress and oxidative stress signaling pathways. A thorough exploration of drug-induced cellular stress mechanisms during prenatal brain development may provide insight into therapeutic interventions to combat effects of prenatal drug exposure.

Prenatal cocaine exposure and its impact on cognitive functions of offspring: a pathophysiological insight

It is estimated that approximately 0.5%-3% of fetuses are prenatally exposed to cocaine (COC). The neurodevelopmental implications of this exposure are numerous and include motor skill impairments, alterations of social function, predisposition to anxiety, and memory function and attention deficits; these implications are commonly observed in experimental studies and ultimately affect both learning and IQ. According to previous studies, the clinical manifestations of prenatal COC exposure seem to persist at least until adolescence. The pathophysiological cellular processes that underlie these impairments include dysfunctional myelination, disrupted dendritic architecture, and synaptic alterations. On a molecular level, various neurotransmitters such as serotonin, dopamine, catecholamines, and γ-aminobutyric acid seem to participate in this process. Finally, prenatal COC abuse has been also associated with functional changes in the hormones of the hypothalamic-pituitary-adrenal axis that mediate neuroendocrine responses. The purpose of this review is to summarize the neurodevelopmental consequences of prenatal COC abuse, to describe the pathophysiological pathways that underlie these consequences, and to provide implications for future research in the field.

Prenatal exposure: The effects of prenatal cocaine and methamphetamine exposure on the developing child

Prenatal substance use remains a significant issue in the United States. Initial reports regarding prenatal cocaine and methamphetamine exposure suggested profound adverse effects on child development. However, subsequent prospective, longitudinal investigations have found more subtle effects. What follows is a brief review of the health, growth, behavioral, and intellectual outcomes for children exposed to prenatal cocaine and prenatal methamphetamine. Factors that may mitigate or intensify subtle adverse effects manifested in exposed children will also be discussed. Birth Defects Research (Part C) 108:142-146, 2016. © 2016 Wiley Periodicals, Inc.

The association of prenatal cocaine exposure, externalizing behavior and adolescent substance use

Prenatal cocaine exposure (PCE) may increase adolescent substance use through alterations of neurotransmitter systems affecting fetal brain development. The relationship between PCE and substance use at 15 and 17 years was examined. Subjects (365: 186 PCE; 179 non-cocaine exposed (NCE)) supplied biologic and self-report data using the Youth Risk Behavior Surveillance System (YRBSS) and Computerized Diagnostic Interview Schedule for Children (C-DISC 4) at ages 15 and 17. The relationship between PCE and substance use was assessed using General Estimating Equation (GEE) analyses controlling for confounding factors including violence exposure and preschool lead level. Teens with PCE vs. NCE teens were 2 times more likely to use tobacco (OR=2.1; 95% CI 1.21-3.63; p<.001) and marijuana (OR=1.85; CI 1.18-2.91; p<.001) and have a substance use disorder at age 17 (OR=2.51; CI 1.00-6.28; p<.05). Evaluation of PCE status by gender revealed an association between PCE and marijuana use that was more pronounced for boys than girls at 17 years. Violence exposure was also a significant predictor of alcohol (p<.001), tobacco (p<.05), and marijuana (p<.0006) use and substance abuse/dependence (p<.01). Externalizing behavior at age 12 fully mediated the effects of PCE on substance use disorder at age 17 and partially mediated effects of PCE on tobacco use, but did not mediate effects on marijuana use. The percentage of substance use reported increased between 15 and 17 years, with no differences between the PCE and NCE groups. Data suggest specialized drug use prevention measures for children with PCE may benefit this high risk group.