Abnormal auditory brainstem response among infants with prenatal cocaine exposure

Newborn Hearing Screening Results for Infants With Prenatal Opioid Exposure in Southern Appalachia

PURPOSE

Infants prenatally exposed to opioids exhibit withdrawal symptomology that introduce physiological noise and can impact newborn hearing screening results. This study compared the referral rate and physiological noise interpreted by number of trials rejected due to artifact on initial newborn hearing screenings of infants with prenatal opioid exposure (POE) and infants with no opioid exposure (NOE). Furthermore, within the POE group, it examined the relationship of referral rates with severity of withdrawal symptomology, and with maternal and infant risk factors.

METHOD

This study used a retrospective cohort design of electronic medical records from six delivery hospitals in South-Central Appalachia. Newborn hearing screenings were conducted using automated auditory brainstem response (ABR) for 334 infants with POE and 226 infants with NOE. Severity of withdrawal symptomology was measured using the Modified Finnegan Neonatal Abstinence Scoring Tool, which includes observation of behaviors that introduce physiological noise.

RESULTS

There was no significant difference in newborn hearing screening referral rate between infants with POE and infants with NOE. Referral rate was not affected by maternal or infant risk factors. Infants with POE had statistically significant higher artifact (defined as rejected ABR sweeps) than infants with NOE. There was a strong positive correlation between Finnegan scores and artifact but not referral rates. Sensitivity and specificity analysis indicated artifact decreased substantially after Day 4 of life.

CONCLUSIONS

Referral rates of infants with POE were similar to those of infants with NOE. Nevertheless, the withdrawal symptomology of infants with POE introduces physiological noise reflected as artifact on ABR, which can affect efficiency of newborn hearing screenings.

One-Year Neurodevelopmental Outcomes After Neonatal Opioid Withdrawal Syndrome: A Prospective Cohort Study

Purpose

The aims of this study were, in a cohort of children with neonatal opioid withdrawal syndrome (NOWS), (a) to report 1-year neurodevelopmental outcomes and specifically characterize speech, language, and hearing outcomes and (b) to report the prevalence of cleft lip and/or cleft palate.

Method

This prospective observational cohort study includes newborns with confirmed in utero opioid exposure who received pharmacological treatment for NOWS. During 1-year-old developmental visits, we administered standardized assessments (Bayley Scales of Infant and Toddler Development-Third Edition [Bayley-III] or Developmental Assessment of Young Children-Second Edition [DAYC-2]-due to COVID-19 restrictions). We compared Bayley-III scores to standardized population means using one-sample z tests. We report estimates, 95% confidence intervals, and two-sided p values.

Results

We enrolled 202 infants (October 2018 to March 2020). Follow-up at 1-year was 80%. Infants with NOWS had lower Bayley-III scores at 1 year compared to published norms for cognitive, language, and motor domains. One infant with NOWS was diagnosed with isolated cleft palate and Pierre Robin sequence. All infants passed the newborn hearing screen, and 7.5% had a formal hearing evaluation after neonatal intensive care unit discharge, with 40% having abnormal or inconclusive results; middle ear effusion was the leading cause of abnormal hearing (66.7%). Ten percent of children received a speech-language pathology referral prior to 2 years of age. Infants born to mothers with mental health conditions were more likely to have Bayley-III or DAYC-2 scores below 95 in language or motor domains.

Conclusions

Infants with pharmacologically treated NOWS have significantly lower cognitive, language, and motor scores on standardized developmental testing compared to population means at 1 year of age. Early speech-language pathology referral is frequently necessary to promote optimal development in this population.

Supplemental Material

https://doi.org/10.23641/asha.20044403.

Characteristics of the Frequency-Following Response to Speech in Neonates and Potential Applicability in Clinical Practice: A Systematic Review

Purpose We sought to critically analyze and evaluate published evidence regarding feasibility and clinical potential for predicting neurodevelopmental outcomes of the frequency-following responses (FFRs) to speech recordings in neonates (birth to 28 days). Method A systematic search of MeSH terms in the Cumulative Index to Nursing and Allied HealthLiterature, Embase, Google Scholar, Ovid Medline (R) and E-Pub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Web of Science, SCOPUS, COCHRANE Library, and ClinicalTrials.gov was performed. Manual review of all items identified in the search was performed by two independent reviewers. Articles were evaluated based on the level of methodological quality and evidence according to the RTI item bank. Results Seven articles met inclusion criteria. None of the included studies reported neurodevelopmental outcomes past 3 months of age. Quality of the evidence ranged from moderate to high. Protocol variations were frequent. Conclusions Based on this systematic review, the FFR to speech can capture both temporal and spectral acoustic features in neonates. It can accurately be recorded in a fast and easy manner at the infant's bedside. However, at this time, further studies are needed to identify and validate which FFR features could be incorporated as an addition to standard evaluation of infant sound processing evaluation in subcortico-cortical networks. This review identifies the need for further research focused on identifying specific features of the neonatal FFRs, those with predictive value for early childhood outcomes to help guide targeted early speech and hearing interventions.

Newborn hearing screening failure and maternal factors during pregnancy

OBJECTIVE

Temporary conductive hearing loss due to amniotic fluid accumulation in the middle ear cavity may lead to failure (false positive) in newborn hearing screening tests. The aim of this study was to identify whether amniotic fluid index has association with failure of the initial newborn otoacoustic emission (OAE) screening test.

METHODS

A cohort study in a tertiary hospital center (Royal Victoria Hospital, Montréal) was constructed from 70 newborns that failed the OAE test, but passed a subsequent auditory brainstem response (ABR) test, and 75 randomly selected newborns that passed initial otoacoustic emission testing. Maternal (including the amniotic fluid index in the third trimester) and newborn clinical data were extracted from medical records. Statistical association models were built to determine variables that influenced hearing screen passage or failure.

RESULTS

The two arms of the cohort had no significant differences in maternal or child clinical indices, including in amniotic fluid index. Calculated as individual odds ratios, maternal tobacco [95% CI of odds ratio: 0.04, 0.59, p = 0.0078], and drug use [95% CI of odds ratio: 0.0065, 0.72, p = 0.058] [borderline significance] were associated with failing the otoacoustic emission testing.

CONCLUSIONS

Amniotic fluid index was not found to be associated with failure of otoacoustic emission screening in newborns. However, our study unveiled an interesting unexpected association of OAE failure with maternal smoking and/or drug use. This finding can help alleviate some of the time, cost and parental anxiety related to failed OAE screening. In selected cases of maternal smoking or drug use we might want to replace or add OAE to the ABR test in newborn hearing screening protocols, that don't perform both tests before discharge.

Prenatal Cocaine Exposure Impacts Language and Reading Into Late Adolescence: Behavioral and ERP Evidence

Extant research documents impaired language among children with prenatal cocaine exposure (PCE) relative to nondrug exposed (NDE) children, suggesting that cocaine alters development of neurobiological systems that support language. The current study examines behavioral and neural (electrophysiological) indices of language function in older adolescents. Specifically, we compare performance of PCE (N = 59) and NDE (N = 51) adolescents on a battery of cognitive and linguistic assessments that tap word reading, reading comprehension, semantic and grammatical processing, and IQ. In addition, we examine event related potential (ERP) responses in in a subset of these children across three experimental tasks that examine word level phonological processing (rhyme priming), word level semantic processing (semantic priming), and sentence level semantic processing (semantic anomaly). Findings reveal deficits across a number of reading and language assessments, after controlling for socioeconomic status and exposure to other substances. Additionally, ERP data reveal atypical orthography to phonology mapping (reduced N1/P2 response) and atypical rhyme and semantic processing (N400 response). These findings suggest that PCE continues to impact language and reading skills into the late teenage years.

Associations Between TGFA/TGFB3/MSX1 Gene Polymorphisms and Congenital Non-Syndromic Hearing Impairment in a Chinese Population

BACKGROUND The aim of this study was to investigate whether the TGFA/TGFB3/MSX1 gene polymorphisms and haplotypes lead to individual differences between congenital non-syndromic hearing impairment (NSHI) patients and normal people in a Chinese population and to analyze the risk factors for NSHI. MATERIAL AND METHODS Between December 2010 and September 2014, 343 congenital NSHI patients were recruited as cases, and 272 healthy subjects were recruited as controls. Denaturing high-performance liquid chromatography (DHPLC) was used to identify genotypes, SHEsis software was used to conduct gene linkage disequilibrium and haplotype analyses, and regression analysis was performed to identify risk factors for congenital NSHI. RESULTS The distribution of genotype frequencies and allele frequencies of TGFA rs3771494, TGFB3 rs3917201 and rs2268626, and MSX1 rs3821949 and rs62636562 were significantly different between the case and the control groups (all P<0.05). TGFA/TGFB3/MSX1 gene rs3771494, rs1058213, rs3917201, rs2268626, rs3821949, and rs62636562 haplotype analysis showed that haplotype CCGTAC and TTACGT might be protective factors (both P<0.001), while TTGCGC might be a risk factor for the normal population (P<0.001). The other risk factors include paternal smoking, advanced maternal age, maternal sickness history, maternal contact with pesticides or similar drugs, maternal abortion history, maternal medication history, maternal passive smoking history during pregnancy, rs3771494 CT, rs2268626 CC and TC, and rs3821949 GG and AG genotypes were risk factors (all P<0.05), while maternal vitamin supplements during pregnancy, rs3917201 GA, rs62636562 TT and CT genotypes were protective factors for congenital NSHI (all P<0.05). CONCLUSIONS rs3771494, rs3917201, rs2268626, rs3821949 and rs62636562 might be associated with congenital NSHI.

Newborn hearing screening programme in Belgium: a consensus recommendation on risk factors

Background

Understanding the risk factors for hearing loss is essential for designing the Belgian newborn hearing screening programme. Accordingly, they needed to be updated in accordance with current scientific knowledge. This study aimed to update the recommendations for the clinical management and follow-up of newborns with neonatal risk factors of hearing loss for the newborn screening programme in Belgium.

Methods

A literature review was performed, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system assessment method was used to determine the level of evidence quality and strength of the recommendation for each risk factor. The state of scientific knowledge, levels of evidence quality, and graded recommendations were subsequently assessed using a three-round Delphi consensus process (two online questionnaires and one face-to-face meeting).

Results

Congenital infections (i.e., cytomegalovirus, toxoplasmosis, and syphilis), a family history of hearing loss, consanguinity in (grand)parents, malformation syndromes, and foetal alcohol syndrome presented a ‘high’ level of evidence quality as neonatal risk factors for hearing loss. Because of the sensitivity of auditory function to bilirubin toxicity, hyperbilirubinaemia was assessed at a ‘moderate’ level of evidence quality. In contrast, a very low birth weight, low Apgar score, and hospitalisation in the neonatal intensive care unit ranged from ‘very low’ to ‘low’ levels, and ototoxic drugs were evidenced as ‘very low’. Possible explanations for these ‘very low’ and ‘low’ levels include the improved management of these health conditions or treatments, and methodological weaknesses such as confounding effects, which make it difficult to conclude on individual risk factors. In the recommendation statements, the experts emphasised avoiding unidentified neonatal hearing loss and opted to include risk factors for hearing loss even in cases with weak evidence. The panel also highlighted the cumulative effect of risk factors for hearing loss.

Conclusions

We revised the recommendations for the clinical management and follow-up of newborns exhibiting neonatal risk factors for hearing loss on the basis of the aforementioned evidence-based approach and clinical experience from experts. The next step is the implementation of these findings in the Belgian screening programme.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0479-4) contains supplementary material, which is available to authorized users.

Level of intrauterine cocaine exposure and neuropsychological test scores in preadolescence: subtle effects on auditory attention and narrative memory

Neuropsychological processes such as attention and memory contribute to children's higher-level cognitive and language functioning and predict academic achievement. The goal of this analysis was to evaluate whether level of intrauterine cocaine exposure (IUCE) alters multiple aspects of preadolescents' neuropsychological functioning assessed using a single age-referenced instrument, the NEPSY: A Developmental Neuropsychological Assessment (NEPSY) (Korkman et al., 1998), after controlling for relevant covariates. Participants included 137 term 9.5-year-old children from low-income urban backgrounds (51% male, 90% African American/Caribbean) from an ongoing prospective longitudinal study. Level of IUCE was assessed in the newborn period using infant meconium and maternal report. 52% of the children had IUCE (65% with lighter IUCE, and 35% with heavier IUCE), and 48% were unexposed. Infants with Fetal Alcohol Syndrome, HIV seropositivity, or intrauterine exposure to illicit substances other than cocaine and marijuana were excluded. At the 9.5-year follow-up visit, trained examiners masked to IUCE and background variables evaluated children's neuropsychological functioning using the NEPSY. The association between level of IUCE and NEPSY outcomes was evaluated in a series of linear regressions controlling for intrauterine exposure to other substances and relevant child, caregiver, and demographic variables. Results indicated that level of IUCE was associated with lower scores on the Auditory Attention and Narrative Memory tasks, both of which require auditory information processing and sustained attention for successful performance. However, results did not follow the expected ordinal, dose-dependent pattern. Children's neuropsychological test scores were also altered by a variety of other biological and psychosocial factors.

Language outcomes at 12 years for children exposed prenatally to cocaine

PURPOSE

In this study, the authors aimed to examine the long-term effects of prenatal cocaine exposure (PCE) on the language development of 12-year-old children using a prospective design, controlling for confounding prenatal drug exposure and environmental factors.

METHOD

Children who were exposed to cocaine in utero (PCE; n = 183) and children who were not exposed to cocaine (i.e., no cocaine exposure [NCE]; n = 181) were followed prospectively from birth to 12 years of age and were compared on language subtests of the Test of Language Development-Intermediate, Third Edition ( Hammill & Newcomer, 1997b), and phonological processing as measured by the Comprehensive Test of Phonological Processing ( Wagner & Torgesen, 1999). The authors evaluated the relationship of PCE to language development through a multivariate analysis of covariance and regression analyses while controlling for confounders.

RESULTS

Results show that PCE has small effects on specific aspects of language, including syntax and phonological processing. The caregiver variables of lower maternal vocabulary, more psychological symptoms, and a poorer home environment also had consistent effects on language and phonological processing scores.

CONCLUSIONS

These findings suggest that PCE continues to have small, subtle effects on specific aspects of language at age 12 years. Phonological processing skills were significantly related to the reading outcomes of letter-word identification, reading fluency, and reading comprehension, indicating that PCE also has small but lasting effects on the language skills that are related to later literacy skills.

Neonatal drug withdrawal

Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.

Prenatal IV Cocaine: Alterations in Auditory Information Processing

One clue regarding the basis of cocaine-induced deficits in attentional processing is provided by the clinical findings of changes in the infants' startle response; observations buttressed by neurophysiological evidence of alterations in brainstem transmission time. Using the IV route of administration and doses that mimic the peak arterial levels of cocaine use in humans, the present study examined the effects of prenatal cocaine on auditory information processing via tests of the auditory startle response (ASR), habituation, and prepulse inhibition (PPI) in the offspring. Nulliparous Long-Evans female rats, implanted with an IV access port prior to breeding, were administered saline, 0.5, 1.0, or 3.0 mg/kg/injection of cocaine HCL (COC) from gestation day (GD) 8-20 (1×/day-GD8-14, 2×/day-GD15-20). COC had no significant effects on maternal/litter parameters or growth of the offspring. At 18-20 days of age, one male and one female, randomly selected from each litter displayed an increased ASR (>30% for males at 1.0 mg/kg and >30% for females at 3.0 mg/kg). When reassessed in adulthood (D90-100), a linear dose-response increase was noted on response amplitude. At both test ages, within-session habituation was retarded by prenatal cocaine treatment. Testing the females in diestrus vs. estrus did not alter the results. Prenatal cocaine altered the PPI response function across interstimulus interval and induced significant sex-dependent changes in response latency. Idazoxan, an α(2)-adrenergic receptor antagonist, significantly enhanced the ASR, but less enhancement was noted with increasing doses of prenatal cocaine. Thus, in utero exposure to cocaine, when delivered via a protocol designed to capture prominent features of recreational usage, causes persistent, if not permanent, alterations in auditory information processing, and suggests dysfunction of the central noradrenergic circuitry modulating, if not mediating, these responses.

Prenatal drug exposure: infant and toddler outcomes

This manuscript provides an overview of the current scientific literature on the impact of maternal drug use, specifically opioids and cocaine, during pregnancy on the acute and long-term outcomes of infants and toddlers from birth through age 3 years. Emphasis with regard to opioids is placed on heroin and opioid substitutes used to treat opioid addiction, including methadone, which has long been regarded as the standard of care in pregnancy, and buprenorphine, which is increasingly being investigated and prescribed as an alternative to methadone. Controlled studies comparing methadone at high and low doses, as well as those comparing methadone with buprenorphine, are highlighted and the diagnosis and management of neonatal abstinence syndrome is discussed. Over the past two decades, attention of the scientific and lay communities has also been focused on the potential adverse effects of cocaine and crack cocaine, especially during the height of the cocaine epidemic in the United States. Herein, the findings are summarized from prospective studies comparing cocaine-exposed with non-cocaine-exposed infants and toddlers with respect to anthropometric growth, infant neurobehavior, visual and auditory function, and cognitive, motor, and language development. The potentially stigmatizing label of the so-called "crack baby" preceded the evidence now accumulating from well-designed prospective investigations that have revealed less severe sequelae in the majority of prenatally exposed infants than originally anticipated. In contrast to opioids, which may produce neonatal abstinence syndrome and infant neurobehavioral deficits, prenatal cocaine exposure appears to be associated with what has been described as statistically significant but subtle decrements in neurobehavioral, cognitive, and language function, especially when viewed in the context of other exposures and the caregiving environment which may mediate or moderate the effects. Whether these early findings may herald more significant learning and behavioral problems during school-age and adolescence when the child is inevitably confronted with increasing social and academic challenges is the subject of ongoing longitudinal research.

Systemic 5-fluorouracil treatment causes a syndrome of delayed myelin destruction in the central nervous system

BACKGROUND

Cancer treatment with a variety of chemotherapeutic agents often is associated with delayed adverse neurological consequences. Despite their clinical importance, almost nothing is known about the basis for such effects. It is not even known whether the occurrence of delayed adverse effects requires exposure to multiple chemotherapeutic agents, the presence of both chemotherapeutic agents and the body's own response to cancer, prolonged damage to the blood-brain barrier, inflammation or other such changes. Nor are there any animal models that could enable the study of this important problem.

RESULTS

We found that clinically relevant concentrations of 5-fluorouracil (5-FU; a widely used chemotherapeutic agent) were toxic for both central nervous system (CNS) progenitor cells and non-dividing oligodendrocytes in vitro and in vivo. Short-term systemic administration of 5-FU caused both acute CNS damage and a syndrome of progressively worsening delayed damage to myelinated tracts of the CNS associated with altered transcriptional regulation in oligodendrocytes and extensive myelin pathology. Functional analysis also provided the first demonstration of delayed effects of chemotherapy on the latency of impulse conduction in the auditory system, offering the possibility of non-invasive analysis of myelin damage associated with cancer treatment.

CONCLUSIONS

Our studies demonstrate that systemic treatment with a single chemotherapeutic agent, 5-FU, is sufficient to cause a syndrome of delayed CNS damage and provide the first animal model of delayed damage to white-matter tracts of individuals treated with systemic chemotherapy. Unlike that caused by local irradiation, the degeneration caused by 5-FU treatment did not correlate with either chronic inflammation or extensive vascular damage and appears to represent a new class of delayed degenerative damage in the CNS.

Ototoxicity and noise trauma: electron transfer, reactive oxygen species, cell signaling, electrical effects, and protection by antioxidants: practical medical aspects

Ototoxins are substances of various structures and classes. This review provides extensive evidence for involvement of electron transfer (ET), reactive oxygen species (ROS) and oxidative stress (OS) as a unifying theme. Successful application is made to the large majority of ototoxins, as well as noise trauma. We believe it is not coincidental that these toxins generally incorporate ET functionalities (quinone, metal complex, ArNO(2), or conjugated iminium) either per se or in metabolites, potentially giving rise to ROS by redox cycling. Some categories, e.g., peroxides and noise, appear to operate via non-ET routes in generating OS. These highly reactive entities can then inflict injury via OS upon various constituents of the ear apparatus. The theoretical framework is supported by the extensive literature on beneficial effects of antioxidants, both for toxins and noise. Involvement of cell signaling and electrical effects are discussed. This review is the first comprehensive one based on a unified mechanistic approach. Various practical medical aspects are also addressed. There is extensive documentation for beneficial effects of antioxidants whose use might be recommended clinically for prevention of ototoxicity and noise trauma. Recent research indicates that catalytic antioxidants may be more effective. In addition to ototoxicity, a widespread problem consists of ear infections by bacteria which are demonstrating increasing resistance to conventional therapies. A recent, novel approach to improved drugs involves use of agents which inhibit quorum sensors that play important roles in bacterial functioning. Prevention of ear injury by noise trauma is also discussed, along with ear therapeutics.

Chemically diverse toxicants converge on Fyn and c-Cbl to disrupt precursor cell function

Identification of common mechanistic principles that shed light on the action of the many chemically diverse toxicants to which we are exposed is of central importance in understanding how toxicants disrupt normal cellular function and in developing more effective means of protecting against such effects. Of particular importance is identifying mechanisms operative at environmentally relevant toxicant exposure levels. Chemically diverse toxicants exhibit striking convergence, at environmentally relevant exposure levels, on pathway-specific disruption of receptor tyrosine kinase (RTK) signaling required for cell division in central nervous system (CNS) progenitor cells. Relatively small toxicant-induced increases in oxidative status are associated with Fyn kinase activation, leading to secondary activation of the c-Cbl ubiquitin ligase. Fyn/c-Cbl pathway activation by these pro-oxidative changes causes specific reductions, in vitro and in vivo, in levels of the c-Cbl target platelet-derived growth factor receptor-α and other c-Cbl targets, but not of the TrkC RTK (which is not a c-Cbl target). Sequential Fyn and c-Cbl activation, with consequent pathway-specific suppression of RTK signaling, is induced by levels of methylmercury and lead that affect large segments of the population, as well as by paraquat, an organic herbicide. Our results identify a novel regulatory pathway of oxidant-mediated Fyn/c-Cbl activation as a shared mechanism of action of chemically diverse toxicants at environmentally relevant levels, and as a means by which increased oxidative status may disrupt mitogenic signaling. These results provide one of a small number of general mechanistic principles in toxicology, and the only such principle integrating toxicology, precursor cell biology, redox biology, and signaling pathway analysis in a predictive framework of broad potential relevance to the understanding of pro-oxidant–mediated disruption of normal development.

Chemically different toxins (lead, methylmercury, and paraquat) each cause the intracellular environment to become more oxidized, and thereby activate a common pathway that suppresses signaling from growth factor receptors that may be associated with developmental impairments.

Discovering general principles underlying the effects of toxicant exposure on biological systems is one of the central challenges of toxicological research. We have discovered a previously unrecognized regulatory pathway on which chemically diverse toxicants converge, at environmentally relevant exposure levels, to disrupt the function of progenitor cells of the developing central nervous system. We found that the ability of low levels of methylmercury, lead, and paraquat to make progenitor cells more oxidized causes activation of an enzyme called Fyn kinase. Activated Fyn then activates another enzyme (c-Cbl) that modifies specific proteins—receptors that are required for cell division and survival—to initiate the proteins' degradation. By enhancing degradation of these receptors, their downstream signaling functions are repressed. Analysis of developmental exposure to methylmercury provided evidence that this same pathway is activated in vivo by environmentally relevant toxicant levels. The remarkable sensitivity of progenitor cells to low levels of toxicant exposure, and the discovery of the redox/Fyn/c-Cbl pathway as a mechanism by which small increases in oxidative status can markedly alter cell function, provide a novel and specific means by which exposure to chemically diverse toxicants might perturb normal development. In addition, the principles revealed in our studies appear likely to have broad applicability in understanding the regulation of cell function by alterations in redox balance, regardless of how they might be generated.