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Brik M, Sandonis M, Cabeza Oliver C, Temprado J, Hernández Fleury A, Sánchez Echevarria E, Carreras E. Predictors for cannabis cessation during pregnancy: a 10-year cohort study. J Psychosom Obstet Gynaecol 2024; 45:2319290. [PMID: 38401055 DOI: 10.1080/0167482x.2024.2319290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/11/2024] [Indexed: 02/26/2024] Open
Abstract
The aim of this study is to determine factors associated with cannabis discontinuation, to assess the impact of mental health and addiction interventions on cannabis discontinuation during pregnancy and to investigate the neonatal impact of cannabis discontinuation. This is a 10-year cohort study in a tertiary hospital in Barcelona, Spain, including women with self-reported cannabis use during pregnancy. Main outcome was cannabis discontinuation based on biological sample testing. Secondary outcomes were neonatal intensive care unit (NICU) admission, preterm birth, birth weight and bottle-feeding. When cannabis use was detected during pregnancy, 32 out of 81 (38.3%) discontinued cannabis during pregnancy vs. four out of 61 (6.6%) when detected at birth (p < .001). Multivariate binary logistic regression showed that null parity (OR: 6.95, p = .011), detection of cannabis use during pregnancy (OR: 5.35, p = .018) and early detection and referral to mental health care for counseling on cannabis cessation and interventions on the first trimester (OR: 25.46, p < .001) increased cannabis discontinuation. Risk for preterm birth <37 weeks (11.4% vs. 30.8%) and NICU admission (25.7% vs. 54.2%) were lower when discontinuation. Early detection of cannabis use during pregnancy, cessation counseling with mental health interventions, and null parity are predictors for cannabis discontinuation during pregnancy.
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Affiliation(s)
- Maia Brik
- Obstetrics Department, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Obstetrics and Gynaecology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Sandonis
- Mental Health Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carmen Cabeza Oliver
- Obstetrics Department, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Joaquín Temprado
- Obstetrics Department, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Alina Hernández Fleury
- Obstetrics Department, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elena Sánchez Echevarria
- Department of Social Work Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain
| | - Elena Carreras
- Obstetrics Department, Maternal-Fetal Medicine Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department of Obstetrics and Gynaecology, Universitat Autònoma de Barcelona, Barcelona, Spain
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Young-Wolff KC, Adams SR, Alexeeff SE, Zhu Y, Chojolan E, Slama NE, Does MB, Silver LD, Ansley D, Castellanos CL, Avalos LA. Prenatal Cannabis Use and Maternal Pregnancy Outcomes. JAMA Intern Med 2024:2821358. [PMID: 39037795 PMCID: PMC11264060 DOI: 10.1001/jamainternmed.2024.3270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 05/18/2024] [Indexed: 07/24/2024]
Abstract
Importance Many studies have evaluated whether in utero cannabis exposure is associated with fetal and neonatal outcomes, yet little is known about whether prenatal cannabis use is associated with maternal health outcomes during pregnancy. Objective To evaluate whether prenatal cannabis use is associated with maternal health outcomes during pregnancy. Design, Setting, and Participants This population-based retrospective cohort study included pregnancies in Northern California from January 2011 to December 2019 that lasted 20 weeks or longer and were screened for prenatal cannabis use. Exposures Prenatal cannabis use was defined as any self-reported use during early pregnancy or a positive toxicology test result based on universal screening at entrance to prenatal care (approximately 8-10 weeks' gestation). Self-reported frequency of use (daily, weekly, monthly or less, never, unknown), use defined only by self-report, and use defined only by toxicology test results were examined. Main Outcomes and Measures Electronic health record data were used to define the following outcomes: gestational hypertension, preeclampsia, eclampsia, gestational diabetes, gestational weight gain greater and less than guidelines, placenta previa, placental abruption, placenta accreta, and severe maternal morbidity. Adjusted risk ratios (aRRs) were calculated using a modified Poisson regression. Results The sample (n = 316 722 pregnancies; 250 221 unique individuals) included 84 039 (26.5%) Asian/Pacific Islander, 20 053 (6.3%) Black, 83 145 (26.3%) Hispanic, and 118 333 (37.4%) White individuals; the mean (SD) age was 30.6 (5.4) years. Overall, 20 053 (6.3%) screened positive for prenatal cannabis use; 2.9% were positive by self-report, 5.3% by toxicology testing, and 1.8% by both. The frequency of cannabis use was 1930 (0.6%) daily, 2345 (0.7%) weekly, 4892 (1.5%) monthly or less, and 10 886 (3.4%) unknown. Prenatal cannabis use was associated with greater risk of gestational hypertension (aRR, 1.17; 95% CI, 1.13-1.21), preeclampsia (aRR, 1.08; 95% CI, 1.01-1.15), weight gain less than (aRR, 1.05; 95% CI, 1.01-1.08) and greater than (aRR, 1.09; 95% CI, 1.08-1.10) guidelines, and placental abruption (aRR, 1.19; 95% CI, 1.05-1.36). The pattern of results was similar when defining prenatal cannabis use only by self-report or only by toxicology testing, and associations between the frequency of prenatal cannabis use and outcomes varied with outcome. Conclusions and Relevance The results of this cohort study suggest that prenatal cannabis use was associated with several adverse maternal health outcomes during pregnancy. Continued research is needed to understand whether characteristics of prenatal cannabis use (eg, dose, mode, and timing) moderate these associations.
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Affiliation(s)
- Kelly C. Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Sara R. Adams
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Yeyi Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Natalie E. Slama
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Monique B. Does
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Deborah Ansley
- Regional Offices, Kaiser Permanente Northern California, Oakland
| | | | - Lyndsay A. Avalos
- Division of Research, Kaiser Permanente Northern California, Oakland
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Avalos LA, Adams SR, Alexeeff SE, Oberman NR, Does MB, Ansley D, Goler N, Padon AA, Silver LD, Young-Wolff KC. Neonatal outcomes associated with in utero cannabis exposure: a population-based retrospective cohort study. Am J Obstet Gynecol 2024; 231:132.e1-132.e13. [PMID: 38029850 PMCID: PMC11128475 DOI: 10.1016/j.ajog.2023.11.1232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The full spectrum of associations between in utero cannabis exposure and adverse neonatal outcomes is still unclear. OBJECTIVE This study aimed to evaluate the associations between in utero cannabis exposure and neonatal outcomes. STUDY DESIGN This population-based retrospective cohort study of singleton births among Kaiser Permanente Northern California members (January 1, 2011-July 31, 2020) included parent-infant dyads in which the pregnant parent was screened for cannabis use as part of standard prenatal care, generally upon entrance into care. Data were ascertained from electronic health records. Generalized estimating equation models were adjusted for sociodemographic characteristics, other non-cannabis prenatal substance use, medical and mental health comorbidities, and adequacy of prenatal care. In utero cannabis exposure was defined as self-reported use since becoming pregnant and/or a positive urine toxicology test for cannabis at any time during pregnancy (yes/no; primary exposure). Frequency of use was self-reported and categorized as daily, weekly, monthly or less, never, or unknown (secondary exposure). Neonatal outcomes included low birthweight, small for gestational age, preterm birth, neonatal intensive care unit admission, and infant respiratory support. RESULTS Of 364,924 infants, 22,624 (6.2%) were exposed to cannabis in utero. After adjustment for potential confounders, including in utero exposure to other substances, in utero exposure to cannabis was associated with greater odds of low birthweight (adjusted odds ratio, 1.20; 95% confidence interval, 1.12-1.28), small for gestational age (adjusted odds ratio, 1.24; 95% confidence interval, 1.18-1.30), preterm birth (<37 weeks; adjusted odds ratio, 1.06; 95% confidence interval, 1.00-1.13), and neonatal intensive care unit admission (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.11). There was a suggestive association with early preterm birth (<34 weeks; adjusted odds ratio, 1.11; 95% confidence interval, 1.00-1.23; P=.055), but no significant association with respiratory support (adjusted odds ratio, 1.07; 95% confidence interval, 0.97-1.18). Dose-response analysis found an increasing likelihood of low birthweight and small for gestational age with increasing frequency of prenatal cannabis use by the pregnant individual. Sensitivity analyses further supported an increased likelihood of low birthweight and small for gestational age, although associations with other outcomes did not reach statistical significance. CONCLUSION In utero cannabis exposure was associated with increased likelihood of low birthweight, small for gestational age, preterm birth, and neonatal intensive care unit admission. Clinicians should counsel individuals who are pregnant or considering pregnancy about the potential adverse neonatal health outcomes associated with prenatal cannabis use.
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Affiliation(s)
- Lyndsay A Avalos
- Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Sara R Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Stacey E Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Nina R Oberman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Monique B Does
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Deborah Ansley
- Regional Offices, Kaiser Permanente Northern California, Oakland, CA
| | - Nancy Goler
- Regional Offices, Kaiser Permanente Northern California, Oakland, CA
| | | | | | - Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA
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Crosland BA, Garg B, Bandoli GE, Mandelbaum AD, Hayer S, Ryan KS, Shorey-Kendrick LE, McEvoy CT, Spindel ER, Caughey AB, Lo JO. Risk of Adverse Neonatal Outcomes After Combined Prenatal Cannabis and Nicotine Exposure. JAMA Netw Open 2024; 7:e2410151. [PMID: 38713462 PMCID: PMC11077393 DOI: 10.1001/jamanetworkopen.2024.10151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 05/08/2024] Open
Abstract
Importance The prevalence of cannabis use in pregnancy is rising and is associated with adverse perinatal outcomes. In parallel, combined prenatal use of cannabis and nicotine is also increasing, but little is known about the combined impact of both substances on pregnancy and offspring outcomes compared with each substance alone. Objective To assess the perinatal outcomes associated with combined cannabis and nicotine exposure compared with each substance alone during pregnancy. Design, Setting, and Participants This retrospective population-based cohort study included linked hospital discharge data (obtained from the California Department of Health Care Access and Information) and vital statistics (obtained from the California Department of Public Health) from January 1, 2012, through December 31, 2019. Pregnant individuals with singleton gestations and gestational ages of 23 to 42 weeks were included. Data were analyzed from October 14, 2023, to March 4, 2024. Exposures Cannabis-related diagnosis and prenatal nicotine product use were captured using codes from International Classification of Diseases, Ninth Revision, Clinical Modification, and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification. Main Outcome and Measures The main outcomes were infant and neonatal death, infants small for gestational age, and preterm delivery. Results were analyzed by multivariable Poisson regression models. Results A total of 3 129 259 pregnant individuals were included (mean [SD] maternal age 29.3 [6.0] years), of whom 23 007 (0.7%) had a cannabis-related diagnosis, 56 811 (1.8%) had a nicotine-use diagnosis, and 10 312 (0.3%) had both in pregnancy. Compared with nonusers, those with cannabis or nicotine use diagnoses alone had increased rates of infant (0.7% for both) and neonatal (0.3% for both) death, small for gestational age (14.3% and 13.7%, respectively), and preterm delivery (<37 weeks) (12.2% and 12.0%, respectively). Moreover, risks in those with both cannabis and nicotine use were higher for infant death (1.2%; adjusted risk ratio [ARR], 2.18 [95% CI, 1.82-2.62]), neonatal death (0.6%; ARR, 1.76 [95% CI, 1.36-2.28]), small for gestational age (18.0%; ARR, 1.94 [95% CI, 1.86-2.02]), and preterm delivery (17.5%; ARR, 1.83 [95% CI, 1.75-1.91]). Conclusions and Relevance These findings suggest that co-occurring maternal use of cannabis and nicotine products in pregnancy is associated with an increased risk of infant and neonatal death and maternal and neonatal morbidity compared with use of either substance alone. Given the increasing prevalence of combined cannabis and nicotine use in pregnancy, these findings can help guide health care practitioners with preconception and prenatal counseling, especially regarding the benefits of cessation.
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Affiliation(s)
- B. Adam Crosland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | | | - Ava D. Mandelbaum
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Sarena Hayer
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Kimberly S. Ryan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | | | - Cindy T. McEvoy
- Division of Neonatology, Department of Pediatrics, Papé Family Pediatric Research Institute, Oregon Health & Science University, Portland
| | - Eliot R. Spindel
- Division of Neuroscience, Oregon National Primate Research Center, Beaverton
| | - Aaron B. Caughey
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Jamie O. Lo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
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Carlson E, Teboul E, Canale C, Coleman H, Angeliu C, Garbarini K, Markowski VP. Perinatal Tetrahydrocannabinol Compromises Maternal Care and Increases Litter Attrition in the Long-Evans Rat. TOXICS 2024; 12:311. [PMID: 38787090 PMCID: PMC11126083 DOI: 10.3390/toxics12050311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
The marijuana legalization trend in the U.S. will likely lead to increased use by younger adults during gestation and postpartum. The current study examined the hypothesis that delta-9-tetrahydrocannabinol (THC) would disrupt voluntary maternal care behaviors and negatively impact offspring development. Rat dams were gavaged with 0, 2, 5, or 10 mg/kg THC from the 1st day of gestation through the 21st postnatal day. Somatic growth and developmental milestones were measured in the offspring, and maternal pup retrieval tests were conducted on postnatal days 1, 3, and 5. THC did not affect body growth but produced transient delays in the righting reflex and eye opening in offspring. However, there was significant pup mortality due to impaired maternal care. Dams in all THC groups took significantly longer to retrieve their pups to the nest and often failed to retrieve any pups. Serum levels of THC and metabolites measured at this time were comparable to those in breastfeeding women who are chronic users. Benchmark doses associated with a 10% reduction of pup retrieval or increased pup mortality were 0.383 (BMDL 0.228) and 0.794 (BMDL 0.442) mg/kg THC, respectively. The current findings indicate that maternal care is an important and heretofore overlooked index of THC behavioral toxicity and should be included in future assessments of THC's health risks.
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Affiliation(s)
- Emma Carlson
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
| | - Eric Teboul
- Departments of Neurosurgery and Neuroscience, Brown University & Rhode Island Hospital, Providence, RI 02912, USA;
| | - Charlene Canale
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
| | - Harper Coleman
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
| | - Christina Angeliu
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
| | - Karissa Garbarini
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
| | - Vincent P. Markowski
- Department of Psychology, State University of New York at Geneseo, One College Circle, Geneseo, NY 14454, USA; (E.C.); (C.C.); (H.C.); (C.A.); (K.G.)
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Rouzer SK, Sreeram A, Miranda RC. Reduced fetal cerebral blood flow predicts perinatal mortality in a mouse model of prenatal alcohol and cannabinoid exposure. BMC Pregnancy Childbirth 2024; 24:263. [PMID: 38605299 PMCID: PMC11007973 DOI: 10.1186/s12884-024-06436-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Children exposed prenatally to alcohol or cannabinoids individually can exhibit growth deficits and increased risk for adverse birth outcomes. However, these drugs are often co-consumed and their combined effects on early brain development are virtually unknown. The blood vessels of the fetal brain emerge and mature during the neurogenic period to support nutritional needs of the rapidly growing brain, and teratogenic exposure during this gestational window may therefore impair fetal cerebrovascular development. STUDY DESIGN To determine whether prenatal polysubstance exposure confers additional risk for impaired fetal-directed blood flow, we performed high resolution in vivo ultrasound imaging in C57Bl/6J pregnant mice. After pregnancy confirmation, dams were randomly assigned to one of four groups: drug-free control, alcohol-exposed, cannabinoid-exposed or alcohol-and-cannabinoid-exposed. Drug exposure occurred daily between Gestational Days 12-15, equivalent to the transition between the first and second trimesters in humans. Dams first received an intraperitoneal injection of either cannabinoid agonist CP-55,940 (750 µg/kg) or volume-equivalent vehicle. Then, dams were placed in vapor chambers for 30 min of inhalation of either ethanol or room air. Dams underwent ultrasound imaging on three days of pregnancy: Gestational Day 11 (pre-exposure), Gestational Day 13.5 (peri-exposure) and Gestational Day 16 (post-exposure). RESULTS All drug exposures decreased fetal cranial blood flow 24-hours after the final exposure episode, though combined alcohol and cannabinoid co-exposure reduced internal carotid artery blood flow relative to all other exposures. Umbilical artery metrics were not affected by drug exposure, indicating a specific vulnerability of fetal cranial circulation. Cannabinoid exposure significantly reduced cerebroplacental ratios, mirroring prior findings in cannabis-exposed human fetuses. Post-exposure cerebroplacental ratios significantly predicted subsequent perinatal mortality (p = 0.019, area under the curve, 0.772; sensitivity, 81%; specificity, 85.70%) and retroactively diagnosed prior drug exposure (p = 0.005; AUC, 0.861; sensitivity, 86.40%; specificity, 66.7%). CONCLUSIONS Fetal cerebrovasculature is significantly impaired by exposure to alcohol or cannabinoids, and co-exposure confers additional risk for adverse birth outcomes. Considering the rising potency and global availability of cannabis products, there is an imperative for research to explore translational models of prenatal drug exposure, including polysubstance models, to inform appropriate strategies for treatment and care in pregnancies affected by drug exposure.
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Affiliation(s)
- Siara Kate Rouzer
- Department of Neuroscience and Experimental Therapeutics, Texas A&M School of Medicine, 8447 Riverside Parkway, Bryan, TX, 77807, USA
| | - Anirudh Sreeram
- Department of Neuroscience and Experimental Therapeutics, Texas A&M School of Medicine, 8447 Riverside Parkway, Bryan, TX, 77807, USA
| | - Rajesh C Miranda
- Department of Neuroscience and Experimental Therapeutics, Texas A&M School of Medicine, 8447 Riverside Parkway, Bryan, TX, 77807, USA.
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Lo JO, Shaw B, Robalino S, Ayers CK, Durbin S, Rushkin MC, Olyaei A, Kansagara D, Harrod CS. Cannabis Use in Pregnancy and Neonatal Outcomes: A Systematic Review and Meta-Analysis. Cannabis Cannabinoid Res 2024; 9:470-485. [PMID: 36730710 PMCID: PMC11262585 DOI: 10.1089/can.2022.0262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective: To determine whether prenatal cannabis use alone increases the likelihood of fetal and neonatal morbidity and mortality. Study Design: We searched bibliographic databases, such as PubMed, Embase, Scopus, Cochrane reviews, PsycInfo, MEDLINE, Clinicaltrials.gov, and Google Scholar from inception through February 14, 2022. Cohort or case-control studies with prespecified fetal or neonatal outcomes in pregnancies with prenatal cannabis use. Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small-for-gestational-age (SGA), birthweight (grams), and perinatal mortality. Two independent reviewers screened studies. Studies were extracted by one reviewer and confirmed by a second using a predefined template. Risk of bias assessment of studies, using the Newcastle-Ottawa Quality Assessment Scale, and Grading of Recommendations Assessment, Development, and Evaluation for evaluating the certainty of evidence for select outcomes were performed by two independent reviewers with disagreements resolved by a third. Random effects meta-analyses were conducted, using adjusted and unadjusted effect estimates, to compare groups according to prenatal exposure to cannabis use status. Results: Fifty-three studies were included. Except for birthweight, unadjusted and adjusted meta-analyses had similar results. We found very-low- to low-certainty evidence that cannabis use during pregnancy was significantly associated with greater odds of PTB (adjusted odds ratio [aOR], 1.42; 95% confidence interval [CI], 1.19 to 1.69; I2, 93%; p=0.0001), SGA (aOR, 1.76; 95% CI, 1.52 to 2.05; I2, 86%; p<0.0001), and perinatal mortality (aOR, 1.5; 95% CI, 1.39 to 1.62; I2, 0%; p<0.0001), but not significantly different for birthweight (mean difference, -40.69 g; 95% CI, -124.22 to 42.83; I2, 85%; p=0.29). Because of substantial heterogeneity, we also conducted a narrative synthesis and found comparable results to meta-analyses. Conclusion: Prenatal cannabis use was associated with greater odds of PTB, SGA, and perinatal mortality even after accounting for prenatal tobacco use. However, our confidence in these findings is limited. Limitations of most existing studies was the failure to not include timing or quantity of cannabis use. This review can help guide health care providers with counseling, management, and addressing the limited existing safety data. Protocol Registration: PROSPERO CRD42020172343.
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Affiliation(s)
- Jamie O. Lo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Beth Shaw
- Department of Obstetrics and Gynecology, Center for Evidence-Based Policy, Oregon Health and Science University, Portland, Oregon, USA
| | - Shannon Robalino
- Department of Obstetrics and Gynecology, Center for Evidence-Based Policy, Oregon Health and Science University, Portland, Oregon, USA
| | - Chelsea K. Ayers
- Center for the Involvement of Veterans in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Shauna Durbin
- Department of Obstetrics and Gynecology, Center for Evidence-Based Policy, Oregon Health and Science University, Portland, Oregon, USA
| | - Megan C. Rushkin
- Department of Obstetrics and Gynecology, Center for Evidence-Based Policy, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy Olyaei
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Devan Kansagara
- Center for the Involvement of Veterans in their Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Curtis S. Harrod
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Tadesse AW, Ayano G, Dachew BA, Tusa BS, Damtie Y, Betts K, Alati R. The association between prenatal cannabis use and congenital birth defects in offspring: A cumulative meta-analysis. Neurotoxicol Teratol 2024; 102:107340. [PMID: 38460861 DOI: 10.1016/j.ntt.2024.107340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To examine the association between prenatal cannabis use and structural birth defects in exposed offspring. METHODS In line with the preregistered protocol (PROSPERO: CRD42022368623), we systematically searched PubMed/Medline, CINHAL, EMBASE, Web of Science, ProQuest, Psych-Info, and Google Scholar for published articles until 25 January 2024. The methodological quality of the included studies was appraised by the Newcastle-Ottawa Quality Assessment Scale (NOS). A meta-analysis was carried out to report the pooled effect estimates from the included studies. We further performed subgroup, leave-one-out sensitivity, and meta-regression analyses, which increased the robustness of our findings. RESULTS In this cumulative meta-analysis, thirty-six observational studies, consisting of 18 case-control and 18 cohort studies, with 230, 816 cases of birth defects and 18,049,013 controls (healthy babies) were included in the final analysis. We found that offspring exposed to maternal prenatal cannabis are at greater risks of a wide range of structural birth defects: cardiovascular/heart [OR = 2.35: 95 % CI 1.63 - 3.39], gastrointestinal [OR = 2.42: 95 % CI 1.61 - 3.64], central nervous system [OR = 2.87: 95 % CI 1.51 - 5.46], genitourinary [OR = 2.39: 95 % CI 1.11 - 5.17], and any (unclassified) birth defects [OR = 1.25: 95 % CI 1.12 - 1.41]. CONCLUSION The findings from the current study suggest that maternal prenatal cannabis exposure is associated with a higher risk of different forms of structural birth defects in offspring. The findings underscore the significance of implementing preventive strategies, including enhanced preconception counselling, to address cannabis use during pregnancy and mitigate the risk of birth defects in offspring.
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Affiliation(s)
- Abay Woday Tadesse
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia; Samara University, College of Medicine and Health Sciences, Department of Public Health, 132, Semera, Ethiopia; Dream Science and Technology College, 1466 Dessie, Ethiopia.
| | - Getinet Ayano
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Berihun Assefa Dachew
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Biruk Shalmeno Tusa
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Yitayish Damtie
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Kim Betts
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Rosa Alati
- School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA 6102, Australia; Institute for Social Sciences Research, The University of Queensland, 80 Meier's Rd, Indooroopilly, QLD 4068, Australia
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9
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Sorkhou M, Singla DR, Castle DJ, George TP. Birth, cognitive and behavioral effects of intrauterine cannabis exposure in infants and children: A systematic review and meta-analysis. Addiction 2024; 119:411-437. [PMID: 37968824 PMCID: PMC10872597 DOI: 10.1111/add.16370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 09/18/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND AND AIMS Δ9-tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, has been implicated in affecting fetal neurodevelopment by readily crossing the placenta. However, little is known regarding the long-term effects of intrauterine cannabis exposure. This systematic review and meta-analysis synthesized prospective and cross-sectional human studies to measure the effects of intrauterine cannabis exposure on birth, behavioral, psychological and cognitive outcomes in infancy until early childhood. METHODS Reporting according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, cross-sectional and prospective studies published from database inception until June 2023, investigating developmental outcomes of infants, toddlers and young children with intrauterine cannabis exposure were considered. All articles were obtained from PubMed or PsycINFO databases. RESULTS The literature search resulted in 932 studies, in which 57 articles met eligibility criteria. The meta-analysis revealed that intrauterine cannabis exposure increases the risk of preterm delivery [odds ratio (OR) = 1.68, 95% confidence interval (CI) = 1.05-2.71, P = 0.03], low birth weight (OR = 2.60, CI = 1.71-3.94, P < 0.001) and requirement for neonatal intensive care unit (NICU) admission (OR = 2.51, CI = 1.46-4.31; P < 0.001). Our qualitative synthesis suggests that intrauterine cannabis exposure may be associated with poorer attention and externalizing problems in infancy and early childhood. We found no evidence for impairments in other cognitive domains or internalizing behaviors. CONCLUSIONS Prenatal cannabis use appears to be associated with lower birth weight, preterm birth and neonatal intensive care unit admission in newborns, but there is little evidence that prenatal cannabis exposure adversely impacts behavioral or cognitive outcomes in early childhood, with the exception of attention and externalizing problems.
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Affiliation(s)
- Maryam Sorkhou
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Medical Sciences, Department of Psychiatry, University of Toronto, ON, Canada
| | - Daisy R Singla
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Medical Sciences, Department of Psychiatry, University of Toronto, ON, Canada
| | - David J Castle
- Tasmania Centre for Mental Health Service Innovation, University of Tasmania, Hobart, Australia
| | - Tony P George
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Medical Sciences, Department of Psychiatry, University of Toronto, ON, Canada
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Baía I, Domingues RMSM. The Effects of Cannabis Use during Pregnancy on Low Birth Weight and Preterm Birth: A Systematic Review and Meta-analysis. Am J Perinatol 2024; 41:17-30. [PMID: 35901851 DOI: 10.1055/a-1911-3326] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Our objective was to summarize the literature regarding the effects of cannabis use during pregnancy on low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). STUDY DESIGN This is a systematic review and meta-analysis. A literature search was conducted in PubMed, Scopus, EBSCO, and Web of Science in May 2021 and updated in November 2021. Only studies that assessed the isolated use of cannabis during pregnancy, controlling for cigarette smoking, and other illicit drug use were included. Data were synthesized using a narrative summary and pooled adjusted estimates, and 95% confidence intervals (CIs) were calculated for each outcome. Data were analyzed using Stata 13.0 with METAN software package, using random effects. Statistical heterogeneity was assessed using Cochran's Q and Higgins I2 tests. RESULTS In total, 32 studies were included with data from approximately 5.5 million women with the LBW outcome and 23 million with the PTB and SGA outcomes. Pregnant women using cannabis are at increased risk for LBW (adjusted odds ratio [aOR] = 1.52; 95% CI = [1.18; 1.96]), PTB (aOR = 1.39; 95% CI = [1.28; 1.51]), and SGA (aOR = 1.47; 95% CI = [1.38; 1.58]). Studies that assessed the type of PTB and gestational age at birth indicate higher risks of spontaneous PTB and of early or very-early PTBs associated with cannabis use during pregnancy. The few studies that assessed the timing and frequency of consumption suggest a dose-response effect, with higher odds of negative outcomes among women who reported heavy use and with continued use during the second and third trimesters of gestation. CONCLUSION There is an effect of cannabis irrespective of other illicit drugs and tobacco despite high heterogeneity and low quality of evidence. There is a need to discuss public policies regarding cannabis' regulation and how it influences its consumption. Future studies should focus on the effects of cannabis's type (medicinal or recreational), timing, and dosage during pregnancy on perinatal outcomes. KEY POINTS · Cannabis use during pregnancy is increasing.. · Cannabis has an independent effect on PTB, LBW, and SGA.. · Future studies should focus on the timing of exposure during pregnancy, mode of use, and dosage..
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Affiliation(s)
- Inês Baía
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Universidade do Porto, Rua das Taipas, Porto, Portugal
| | - Rosa M S M Domingues
- Epidemiologist, Instituto Nacional de Infectologia Evandro Chagas/Fundação Oswaldo Cruz. Rio de Janeiro, Brazil
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Potnuru PP, Jonna S, Williams GW. Cannabis Use Disorder and Perioperative Complications. JAMA Surg 2023; 158:935-944. [PMID: 37405729 PMCID: PMC10323761 DOI: 10.1001/jamasurg.2023.2403] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/19/2023] [Indexed: 07/06/2023]
Abstract
Importance Cannabis use is growing in the US and is increasingly perceived as harmless. However, the perioperative impact of cannabis use remains uncertain. Objective To assess whether cannabis use disorder is associated with increased morbidity and mortality after major elective, inpatient, noncardiac surgery. Design, Setting, and Participants This retrospective, population-based, matched cohort study used data from the National Inpatient Sample for adult patients aged 18 to 65 years who underwent major elective inpatient surgery (including cholecystectomy, colectomy, inguinal hernia repair, femoral hernia repair, mastectomy, lumpectomy, hip arthroplasty, knee arthroplasty, hysterectomy, spinal fusion, and vertebral discectomy) from January 2016 to December 2019. Data were analyzed from February to August 2022. Exposure Cannabis use disorder, as defined by the presence of specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes. Main Outcome and Measures The primary composite outcome was in-hospital mortality and 7 major perioperative complications (myocardial ischemia, acute kidney injury, stroke, respiratory failure, venous thromboembolism, hospital-acquired infection, and surgical procedure-related complications) based on ICD-10 discharge diagnosis codes. Propensity score matching was performed to create a 1:1 matched cohort that was well balanced with respect to covariates, which included patient comorbidities, sociodemographic factors, and procedure type. Results Among 12 422 hospitalizations, a cohort of 6211 patients with cannabis use disorder (median age, 53 years [IQR, 44-59 years]; 3498 [56.32%] male) were matched with 6211 patients without cannabis use disorder for analysis. Cannabis use disorder was associated with an increased risk of perioperative morbidity and mortality compared with hospitalizations without cannabis use disorder in adjusted analysis (adjusted odds ratio, 1.19; 95% CI, 1.04-1.37; P = .01). The outcome occurred more frequently in the group with cannabis use disorder (480 [7.73%]) compared with the unexposed group (408 [6.57%]). Conclusions and Relevance In this cohort study, cannabis use disorder was associated with a modest increased risk of perioperative morbidity and mortality after major elective, inpatient, noncardiac surgery. In the context of increasing cannabis use rates, our findings support preoperative screening for cannabis use disorder as a component of perioperative risk stratification. However, further research is needed to quantify the perioperative impact of cannabis use by route and dosage and to inform recommendations for preoperative cannabis cessation.
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Affiliation(s)
- Paul P. Potnuru
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Srikar Jonna
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - George W. Williams
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
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12
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Bouquet E, Blouin P, Pérault-Pochat MC, Carlier-Guérin C, Millot F, Ricco JB, De Keizer J, Pain S, Guétarni F. Maternal, Fetal and Neonatal Outcomes Related to Recreational Cannabis Use during Pregnancy: Analysis of a Real-World Clinical Data Warehouse between 2010 and 2019. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6686. [PMID: 37681826 PMCID: PMC10487904 DOI: 10.3390/ijerph20176686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Cannabis is the main illicit psychoactive substance used in French childbearing women and very few data are available about adverse events (AEs) related to its use during pregnancy. The aim of this study was to evaluate the association between recreational cannabis use during pregnancy and adverse outcomes from a real-world clinical data warehouse. METHODS Data from the Poitiers University Hospital warehouse were analyzed between 1 January 2010 and 31 December 2019. Logistic regression models were used to evaluate associations between outcomes in three prenatal user groups: cannabis alone ± tobacco (C ± T) (n = 123), tobacco alone (T) (n = 191) and controls (CTRL) (n = 355). RESULTS Pregnant women in the C ± T group were younger (mean age: 25.5 ± 5.7 years), had lower pre-pregnancy body mass index (22.8 ± 5.5 kg/m2), more psychiatric history (17.5%) and were more likely to benefit from universal free health-care coverage (18.2%) than those in the T and CTRL groups. Cannabis use increases the occurrence of voluntary interruption of pregnancy, at least one AE during pregnancy, at least one neonatal AE, the composite adverse pregnancy outcome over 28, prematurity and small for gestational age. CONCLUSION Given the trivialization of recreational cannabis use during pregnancy, there is an urgent need to communicate on AEs of cannabis use during pregnancy.
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Affiliation(s)
- Emilie Bouquet
- Addictovigilance Center, Department of Clinical Pharmacology, Poitiers University Hospital, 86000 Poitiers, France
- French National Institute of Health and Medical Research (INSERM) U1084, Experimental and Clinical Neurosciences Laboratory, University of Poitiers, CEDEX 9, 86073 Poitiers, France
- Clinical Investigation Center CIC1402, INSERM, Poitiers University Hospital, University of Poitiers, 86000 Poitiers, France
| | - Pascal Blouin
- Department of Clinical Research and Innovation, Poitiers University Hospital, 86000 Poitiers, France
| | - Marie-Christine Pérault-Pochat
- Addictovigilance Center, Department of Clinical Pharmacology, Poitiers University Hospital, 86000 Poitiers, France
- French National Institute of Health and Medical Research (INSERM) U1084, Experimental and Clinical Neurosciences Laboratory, University of Poitiers, CEDEX 9, 86073 Poitiers, France
- Clinical Investigation Center CIC1402, INSERM, Poitiers University Hospital, University of Poitiers, 86000 Poitiers, France
| | - Caroline Carlier-Guérin
- Department of Obstetrics and Gynecology, Poitiers University Hospital, 86000 Poitiers, France
| | - Frédéric Millot
- Department of Pediatrics, Poitiers University Hospital, 86000 Poitiers, France
| | - Jean-Baptiste Ricco
- Department of Clinical Research and Innovation, Poitiers University Hospital, 86000 Poitiers, France
| | - Joe De Keizer
- Clinical Investigation Center CIC1402, INSERM, Poitiers University Hospital, University of Poitiers, 86000 Poitiers, France
| | - Stéphanie Pain
- Addictovigilance Center, Department of Clinical Pharmacology, Poitiers University Hospital, 86000 Poitiers, France
- French National Institute of Health and Medical Research (INSERM) U1084, Experimental and Clinical Neurosciences Laboratory, University of Poitiers, CEDEX 9, 86073 Poitiers, France
| | - Farid Guétarni
- Department of Clinical Research and Innovation, Poitiers University Hospital, 86000 Poitiers, France
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13
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Delker E, Hayes S, Kelly AE, Jones KL, Chambers C, Bandoli G. Prenatal Exposure to Cannabis and Risk of Major Structural Birth Defects: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:269-283. [PMID: 37473409 DOI: 10.1097/aog.0000000000005252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/13/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To review and perform a meta-analysis of observational studies that examined associations between prenatal cannabis exposure and major structural birth defects. DATA SOURCES Information sources included Google Scholar, BIOSIS, PubMed/MEDLINE, EMBASE CINAHL, and ClinicalTrials.gov. METHODS OF STUDY SELECTION Study titles and abstracts were reviewed with Abstrackr software. We included observational studies that examined the risk of major structural birth defects in people who used cannabis during pregnancy compared with those who had not used cannabis. We excluded case reports, ecologic studies, conference abstracts, manuscript preprints, studies designed to examine effects of cannabis used concurrently with other drugs, and studies that included synthetic cannabinoids. This process yielded 23 studies that analyzed data from birth years 1968-2021. TABULATION, INTEGRATION, AND RESULTS We clustered and meta-analyzed measures of association for birth defects by anatomic group. Eleven articles reported an association between cannabis use and the risk of a nonspecific outcome (eg, congenital anomaly). We estimated a pooled odds ratio of 1.33 (95% CI 1.14-1.56) and a pooled adjusted odds ratio (aOR) of 1.22 (95% CI 1.00-1.50). Anatomic groups examined were cardiac (nine studies), oral cleft (three studies), digestive (four studies), genitourinary (three studies), musculoskeletal (seven studies), and nervous system (five studies). Across most outcomes, we reported positive pooled unadjusted associations that were usually attenuated after the inclusion of only adjusted estimates. Two specific anomalies, with limited data, had pooled effect estimates that did not attenuate to the null after adjustment: Ebstein anomaly (two studies, aOR 2.19, 95% CI 1.25-3.82) and gastroschisis (five studies, aOR 2.50, 95% CI 1.09-5.740). CONCLUSION Studies examining associations between prenatal exposure to cannabis and major structural birth defects were heterogeneous. Most published effect estimates were unadjusted and scored low on our risk-of-bias assessment. Overall, we found inconsistent evidence to suggest that prenatal cannabis exposure is associated with birth defects. However, findings related to specific anomalies should be considered in further research. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022319041.
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Affiliation(s)
- Erin Delker
- Department of Pediatrics, University of California, San Diego, San Diego, California
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14
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Hayer S, Mandelbaum AD, Watch L, Ryan KS, Hedges MA, Manuzak JA, Easley CA, Schust DJ, Lo JO. Cannabis and Pregnancy: A Review. Obstet Gynecol Surv 2023; 78:411-428. [PMID: 37480292 PMCID: PMC10372687 DOI: 10.1097/ogx.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Importance Prenatal cannabis use is rising and is a major public health issue. Cannabis use in pregnancy and during lactation has been associated with increased maternal and offspring morbidity and mortality. Objective This review aims to summarize the existing literature and current recommendations for cannabis use during pregnancy or lactation. Evidence Acquisition A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoid," "delta-9-tetrahydrocannabinol," "THC," "cannabidiol," "fetal outcomes," "perinatal outcomes," "pregnancy," and "lactation." Results Available studies on cannabis use in pregnancy and during lactation were reviewed and support an association with increased risk of preterm birth, neonatal intensive care unit admission, low birth weight, and small-for-gestational-age infants. Conclusion and Relevance There is a critical need for research on the effects of cannabis use in pregnancy and during lactation. This is a necessary first step before furthering patient education, developing interventions, and targeting antenatal surveillance to ameliorate the adverse impacts on maternal and fetal health.
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Affiliation(s)
- Sarena Hayer
- Postgraduate Year 2, Obstetrics-Gynecology Resident, Department of Obstetrics and Gynecology
| | - Ava D Mandelbaum
- MS2 Medical Student, Oregon Health & Science University, Portland, OR
| | - Lester Watch
- Postgraduate Year 1, Obstetrics-Gynecology Resident, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | | | - Madeline A Hedges
- Research Assistant, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Jennifer A Manuzak
- Assistant Professor, Division of Immunology, Tulane National Primate Research Center, Covington, LA
| | - Charles A Easley
- Associate Professor, Department of Environmental Health Science, University of Georgia, Athens, GA
| | - Danny J Schust
- Professor, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Jamie O Lo
- Associate Professor, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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15
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Sujan AC, Pal A, Avalos LA, Young-Wolff KC. A systematic review of in utero cannabis exposure and risk for structural birth defects. Front Pediatr 2023; 11:1149401. [PMID: 37303758 PMCID: PMC10248236 DOI: 10.3389/fped.2023.1149401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Cannabis use among pregnant women has increased over time. Therefore, there is a great public health need to understand the consequences of in utero cannabis exposure. While several meta-analyses and reviews have summarized the evidence of in utero cannabis exposure on adverse obstetric outcomes (e.g., low birth weight and preterm birth) and long-term offspring development, there has not been a focus on in utero cannabis exposure and risk for structural birth defects. Methods We conducted a systematic review using PRISMA guidelines to evaluate the association between in utero cannabis exposure and structural birth defects. Results We identified 20 articles to include in our review and focused on interpreting findings from the 12 that adjusted for potential confounders. We report findings by seven organ systems. Within the 12 articles, four reported on cardiac malformations, three reported on central nervous system malformations, one reported on eye malformations, three reported on gastrointestinal malformations, one reported on genitourinary malformations, one reported on musculoskeletal malformations, and two reported on orofacial malformations. Discussion Findings on associations between in utero cannabis exposure and birth defects reported in more than two articles were mixed (i.e., findings for cardiac, gastrointestinal, central nervous system malformations). Findings for associations between in utero cannabis exposure and birth defects reported in two articles (i.e., orofacial malformations) or in a single article (eye, genitourinary, and musculoskeletal) suggested that cannabis exposure was not associated with these types of malformations, but strong conclusions cannot be drawn from such sparce research. We review the limitations and gaps in the existing literature and call for more research to rigorously evaluate associations between in utero cannabis exposure and structural birth defects. Systematic Review Registration identifier CRD42022308130.
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Affiliation(s)
- Ayesha C. Sujan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Anish Pal
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
| | - Lyndsay A. Avalos
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Kelly C. Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, United States
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16
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Duko B, Dachew BA, Pereira G, Alati R. The effect of prenatal cannabis exposure on offspring preterm birth: a cumulative meta-analysis. Addiction 2023; 118:607-619. [PMID: 36305657 DOI: 10.1111/add.16072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/02/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Mixed results have been reported on the association between prenatal cannabis exposure and preterm birth. This study aimed to examine the magnitude and consistency of associations reported between prenatal cannabis exposure and preterm birth. METHODS This review was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We performed a comprehensive search of the literature on the following electronic databases: PubMed, EMBASE, SCOPUS, Psych-INFO and Web of Science. The revised version of the Newcastle-Ottawa Scale (NOS) was used to appraise the methodological quality of the studies included in this review. Inverse variance weighted random-effects cumulative meta-analysis was undertaken to pool adjusted odds ratios (aOR) after sequential inclusion of each newly published study over time. The OR and 95% confidence interval (CI) limits required (stability threshold) for a new study to move the cumulative odds ratio to the null were also computed. RESULTS A total of 27 observational studies published between 1986 and 2022 were included in the final cumulative meta-analysis. The sample size of the studies ranged from 304 to 4.83 million births. Prenatal cannabis exposure was associated with an increased risk of preterm birth (pooled aOR = 1.35, 95% CI = 1.24-1.48). The stability threshold was 0.74 (95% CI limit = 0.81) by the end of 2022. CONCLUSIONS Offspring exposed to maternal prenatal cannabis use was associated with higher risk of preterm birth, which warrants public health messages to avoid such exposure, particularly during pregnancy.
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Affiliation(s)
- Bereket Duko
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.,enAble Institute, Curtin University, Bentley, Western Australia, Australia
| | - Berihun Assefa Dachew
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Gavin Pereira
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.,enAble Institute, Curtin University, Bentley, Western Australia, Australia
| | - Rosa Alati
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.,Institute for Social Sciences Research, The University of Queensland, Indooroopilly, Queensland, Australia
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17
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Mulligan MK, Hamre KM. Influence of prenatal cannabinoid exposure on early development and beyond. ADVANCES IN DRUG AND ALCOHOL RESEARCH 2023; 3:10981. [PMID: 38389825 PMCID: PMC10880766 DOI: 10.3389/adar.2023.10981] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2024]
Abstract
Public perception surrounding whether cannabis use is harmful during pregnancy often diverges greatly from the recommendations of doctors and healthcare providers. In contrast to the medical guidance of abstinence before, during, and after pregnancy, many women of reproductive age believe cannabis use during pregnancy is associated with little potential harm. Legalization and social cues support public perceptions that cannabis use during pregnancy is safe. Moreover, pregnant women may consider cannabis to be a safe alternative for treating pregnancy related ailments, including morning sickness. Compounding the problem is a lack of medical and federal guidance on safe, low, or high-risk levels of cannabis use. These issues mirror the continuing debate surrounding alcohol use and health, in particular, whether there are safe or lower risk levels of alcohol consumption during pregnancy. Clinical studies to date suffer from several limitations. First, most human studies are correlative in nature, meaning that causal associations cannot be made between in utero cannabis exposure and health and behavioral outcomes later in life. Due to obvious ethical constraints, it is not possible to randomly assign pregnant mothers to cannabis or other drug exposure conditions-a requirement needed to establish causality. In addition, clinical studies often lack quantitative information on maternal exposure (i.e., dose, frequency, and duration), include a small number of individuals, lack replication of outcome measures across cohorts, rely on self-report to establish maternal drug use, and suffer from unmeasured or residual confounding factors. Causal associations between maternal cannabis exposure and offspring outcomes are possible in preclinical cohorts but there is a large amount of heterogeneity across study designs and developmental differences between rodents and humans may limit translatability. In this review, we summarize research from human and preclinical models to provide insight into potential risks associated with prenatal cannabinoid exposure (PCE). Finally, we highlight gaps in knowledge likely to contribute to the growing divide between medical guidance and public attitudes regarding cannabis use during pregnancy.
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Affiliation(s)
- Megan K Mulligan
- Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center (UTHSC), Memphis, TN, United States
| | - Kristin M Hamre
- Department of Anatomy and Neurobiology, University of Tennessee Health Science Center (UTHSC), Memphis, TN, United States
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18
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Teyton A, Baer RJ, Benmarhnia T, Bandoli G. Exposure to Air Pollution and Emergency Department Visits During the First Year of Life Among Preterm and Full-term Infants. JAMA Netw Open 2023; 6:e230262. [PMID: 36811862 PMCID: PMC9947725 DOI: 10.1001/jamanetworkopen.2023.0262] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
IMPORTANCE Previous studies have focused on exposure to fine particulate matter 2.5 μm or less in diameter (PM2.5) and on birth outcome risks; however, few studies have evaluated the health consequences of PM2.5 exposure on infants during their first year of life and whether prematurity could exacerbate such risks. OBJECTIVE To assess the association of PM2.5 exposure with emergency department (ED) visits during the first year of life and determine whether preterm birth status modifies the association. DESIGN, SETTING, AND PARTICIPANTS This individual-level cohort study used data from the Study of Outcomes in Mothers and Infants cohort, which includes all live-born, singleton deliveries in California. Data from infants' health records through their first birthday were included. Participants included 2 175 180 infants born between 2014 and 2018, and complete data were included for an analytic sample of 1 983 700 (91.2%). Analysis was conducted from October 2021 to September 2022. EXPOSURES Weekly PM2.5 exposure at the residential ZIP code at birth was estimated from an ensemble model combining multiple machine learning algorithms and several potentially associated variables. MAIN OUTCOMES AND MEASURES Main outcomes included the first all-cause ED visit and the first infection- and respiratory-related visits separately. Hypotheses were generated after data collection and prior to analysis. Pooled logistic regression models with a discrete time approach assessed PM2.5 exposure and time to ED visits during each week of the first year of life and across the entire year. Preterm birth status, sex, and payment type for delivery were assessed as effect modifiers. RESULTS Of the 1 983 700 infants, 979 038 (49.4%) were female, 966 349 (48.7%) were Hispanic, and 142 081 (7.2%) were preterm. Across the first year of life, the odds of an ED visit for any cause were greater among both preterm (AOR, 1.056; 95% CI, 1.048-1.064) and full-term (AOR, 1.051; 95% CI, 1.049-1.053) infants for each 5-μg/m3 increase in exposure to PM2.5. Elevated odds were also observed for infection-related ED visit (preterm: AOR, 1.035; 95% CI, 1.001-1.069; full-term: AOR, 1.053; 95% CI, 1.044-1.062) and first respiratory-related ED visit (preterm: AOR, 1.080; 95% CI, 1.067-1.093; full-term: AOR,1.065; 95% CI, 1.061-1.069). For both preterm and full-term infants, ages 18 to 23 weeks were associated with the greatest odds of all-cause ED visits (AORs ranged from 1.034; 95% CI, 0.976-1.094 to 1.077; 95% CI, 1.022-1.135). CONCLUSIONS AND RELEVANCE Increasing PM2.5 exposure was associated with an increased ED visit risk for both preterm and full-term infants during the first year of life, which may have implications for interventions aimed at minimizing air pollution.
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Affiliation(s)
- Anaïs Teyton
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
- School of Public Health, San Diego State University, San Diego
- Scripps Institution of Oceanography, University of California, San Diego, La Jolla
| | - Rebecca J. Baer
- California Preterm Birth Initiative, University of California, San Francisco, San Francisco
- Department of Pediatrics, University of California, San Diego, La Jolla
| | - Tarik Benmarhnia
- Scripps Institution of Oceanography, University of California, San Diego, La Jolla
| | - Gretchen Bandoli
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla
- Department of Pediatrics, University of California, San Diego, La Jolla
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19
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Cáceres D, Ochoa M, González-Ortiz M, Bravo K, Eugenín J. Effects of Prenatal Cannabinoids Exposure upon Placenta and Development of Respiratory Neural Circuits. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1428:199-232. [PMID: 37466775 DOI: 10.1007/978-3-031-32554-0_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Cannabis use has risen dangerously during pregnancy in the face of incipient therapeutic use and a growing perception of safety. The main psychoactive compound of the Cannabis sativa plant is the phytocannabinoid delta-9-tetrahydrocannabinol (A-9 THC), and its status as a teratogen is controversial. THC and its endogenous analogues, anandamide (AEA) and 2-AG, exert their actions through specific receptors (eCBr) that activate intracellular signaling pathways. CB1r and CB2r, also called classic cannabinoid receptors, together with their endogenous ligands and the enzymes that synthesize and degrade them, constitute the endocannabinoid system. This system is distributed ubiquitously in various central and peripheral tissues. Although the endocannabinoid system's most studied role is controlling the release of neurotransmitters in the central nervous system, the study of long-term exposure to cannabinoids on fetal development is not well known and is vital for understanding environmental or pathological embryo-fetal or postnatal conditions. Prenatal exposure to cannabinoids in animal models has induced changes in placental and embryo-fetal organs. Particularly, cannabinoids could influence both neural and nonneural tissues and induce embryo-fetal pathological conditions in critical processes such as neural respiratory control. This review aims at the acute and chronic effects of prenatal exposure to cannabinoids on placental function and the embryo-fetal neurodevelopment of the respiratory pattern. The information provided here will serve as a theoretical framework to critically evaluate the teratogen effects of the consumption of cannabis during pregnancy.
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Affiliation(s)
- Daniela Cáceres
- Laboratorio de Sistemas Neurales, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile, Santiago, Chile
| | - Martín Ochoa
- Laboratorio de Sistemas Neurales, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile, Santiago, Chile
| | - Marcelo González-Ortiz
- Laboratorio de Investigación Materno-Fetal (LIMaF), Departamento de Obstetricia y Ginecología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Karina Bravo
- Laboratorio de Sistemas Neurales, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile, Santiago, Chile
- Facultad de Ingeniería, Universidad Autónoma de Chile, Providencia, Chile
| | - Jaime Eugenín
- Laboratorio de Sistemas Neurales, Departamento de Biología, Facultad de Química y Biología, Universidad de Santiago de Chile, Santiago, Chile.
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20
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Bandoli G, Delker E, Schumacher BT, Baer RJ, Kelly AE, Chambers CD. Prenatal cannabis use disorder and infant hospitalization and death in the first year of life. Drug Alcohol Depend 2023; 242:109728. [PMID: 36516553 PMCID: PMC10363398 DOI: 10.1016/j.drugalcdep.2022.109728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/02/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether maternal cannabis use disorder is associated with infant hospitalization or death in the first year of life. METHODS We queried an administrative birth cohort derived from the hospital discharge database maintained by the California Office of Statewide Health Planning and Development and linked with vital statistics files. We included singleton, live-birth deliveries between 2011 and 2018. Pregnancies with cannabis use disorder were classified from International Classification of Disease codes. Outcomes included infant emergency department visits and hospital admissions identified from health records, and infant deaths identified from death records. Models were adjusted for sociodemographic variables, psychiatric comorbidities and other substance use disorders. RESULTS There were 34,544 births (1.0 %) with a cannabis use disorder diagnosis in pregnancy, with increasing prevalence over the study period. The incidence of infant death in the first year of life was greater among those with a maternal cannabis use disorder diagnosis than those without (1.0 % vs 0.4 %; adjusted risk ratio 1.4 95 % CI: 1.2-1.6). When examining specific causes of death, the increased risk estimates were attributable to perinatal conditions and sudden unexpected infant death. After adjustment, there was no increased risk of infant hospitalizations or emergency department visits. CONCLUSIONS These findings warrant further investigation into the underlying mechanisms of maternal prenatal CUD on infant outcomes, and add to a rapidly expanding body of literature supporting the need for effective treatment options for pregnant individuals with cannabis use disorders.
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Affiliation(s)
- Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, USA.
| | - Erin Delker
- Department of Pediatrics, University of California San Diego, USA
| | - Benjamin T Schumacher
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, USA; Department of Epidemiology, School of Public Health, University of Pittsburgh, USA
| | - Rebecca J Baer
- Department of Pediatrics, University of California San Diego, USA
| | - Ann E Kelly
- Department of Pediatrics, University of California San Diego, USA
| | - Christina D Chambers
- Department of Pediatrics, University of California San Diego, USA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, USA
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21
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De Genna NM, Willford JA, Richardson GA. Long-term effects of prenatal cannabis exposure: Pathways to adolescent and adult outcomes. Pharmacol Biochem Behav 2022; 214:173358. [PMID: 35216971 PMCID: PMC8911923 DOI: 10.1016/j.pbb.2022.173358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 12/09/2022]
Abstract
With the increased prevalence, potency, and acceptability of cannabis use during pregnancy, it is important to understand the developmental effects of prenatal cannabis exposure (PCE). This review discusses methodological considerations for studies of PCE, including the assessment of exposures, covariates, and outcomes, and reviews findings from prospective, longitudinal studies of PCE. There is some evidence for associations between PCE and restricted growth at birth, but not for long-term effects on growth. PCE appears to have subtle yet enduring effects on memory and achievement in children and adolescents. Despite differences in sample demographics and measurement, there are remarkably consistent effects of PCE on externalizing behaviors, such as delinquency and substance use, which persist into adulthood. Longitudinal analyses demonstrate the importance of early cannabis initiation for pathways between PCE and adult functioning, including substance use and abuse, memory deficits, and psychotic symptoms. Animal studies demonstrate direct effects on the development of the brain via activation of endogenous endocannabinoid systems. Cannabis-induced activation of the endocannabinoid system causes alterations in the release of neurotransmitters and the modulation of brain plasticity in neural pathways that underlie cognition, motivation, and behavior regulation. Future research should consider cannabis use before pregnancy, the timing and route of exposure, polysubstance exposures, and inter-generational effects.
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Affiliation(s)
- Natacha M. De Genna
- University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O’Hara Street, Pittsburgh, PA 15213,Corresponding author:
| | - Jennifer A. Willford
- Slippery Rock University, Department of Psychology, 1 Morrow Way, Slippery Rock, PA 16057
| | - Gale A. Richardson
- University of Pittsburgh School of Medicine, Department of Psychiatry, 3811 O’Hara Street, Pittsburgh, PA 15213
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22
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Harvey DC, Baer RJ, Bandoli G, Chambers CD, Jelliffe-Pawlowski LL, Kumar SR. Association of Alcohol Use Diagnostic Codes in Pregnancy and Offspring Conotruncal and Endocardial Cushion Heart Defects. J Am Heart Assoc 2022; 11:e022175. [PMID: 35014860 PMCID: PMC9238516 DOI: 10.1161/jaha.121.022175] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background The pathogenesis of congenital heart disease (CHD) remains largely unknown, with only a small percentage explained solely by genetic causes. Modifiable environmental risk factors, such as alcohol, are suggested to play an important role in CHD pathogenesis. We sought to evaluate the association between prenatal alcohol exposure and CHD to gain insight into which components of cardiac development may be most vulnerable to the teratogenic effects of alcohol. Methods and Results This was a retrospective analysis of hospital discharge records from the California Office of Statewide Health Planning and Development and linked birth certificate records restricted to singleton, live‐born infants from 2005 to 2017. Of the 5 820 961 births included, 16 953 had an alcohol‐related International Classification of Diseases, Ninth and Tenth Revisions (ICD‐9; ICD‐10) code during pregnancy. Log linear regression was used to calculate risk ratios (RR) for CHD among individuals with an alcohol‐related ICD‐9 and ICD10 code during pregnancy versus those without. Three models were created: (1) unadjusted, (2) adjusted for maternal demographic factors, and (3) adjusted for maternal demographic factors and comorbidities. Maternal alcohol‐related code was associated with an increased risk for CHD in all models (RR, 1.33 to 1.84); conotruncal (RR, 1.62 to 2.11) and endocardial cushion (RR, 2.71 to 3.59) defects were individually associated with elevated risk in all models. Conclusions Alcohol‐related diagnostic codes in pregnancy were associated with an increased risk of an offspring with a CHD, with a particular risk for endocardial cushion and conotruncal defects. The mechanistic basis for this phenotypic enrichment requires further investigation.
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Affiliation(s)
- Drayton C Harvey
- Department of Surgery Keck School of Medicine of University of Southern California Los Angeles CA
| | - Rebecca J Baer
- Department of Pediatrics and Herbert Wertheim School of Public Health and Longevity Science University of California San Diego La Jolla CA.,The California Preterm Birth Initiative University of California San Francisco San Francisco CA.,Department of Obstetrics, Gynecology and Reproductive Sciences University of California San Francisco San Francisco CA
| | - Gretchen Bandoli
- Department of Pediatrics and Herbert Wertheim School of Public Health and Longevity Science University of California San Diego La Jolla CA
| | - Christina D Chambers
- Department of Pediatrics and Herbert Wertheim School of Public Health and Longevity Science University of California San Diego La Jolla CA
| | - Laura L Jelliffe-Pawlowski
- The California Preterm Birth Initiative University of California San Francisco San Francisco CA.,Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
| | - S Ram Kumar
- Department of Surgery Keck School of Medicine of University of Southern California Los Angeles CA.,Department of Pediatrics Keck School of Medicine of University of Southern California Los Angeles CA.,Heart Institute, Children's Hospital Los Angeles Los Angeles CA
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