Brain MRI segmentation of Zika-Exposed normocephalic infants shows smaller amygdala volumes

BACKGROUND

Infants with congenital Zika syndrome (CZS) are known to exhibit characteristic brain abnormalities. However, the brain anatomy of Zika virus (ZIKV)-exposed infants, born to ZIKV-positive pregnant mothers, who have normal-appearing head characteristics at birth, has not been evaluated in detail. The aim of this prospective study is, therefore, to compare the cortical and subcortical brain structural volume measures of ZIKV-exposed normocephalic infants to age-matched healthy controls.

METHODS AND FINDINGS

We acquired T2-MRI of the whole brain of 18 ZIKV-exposed infants and 8 normal controls on a 3T MRI scanner. The MR images were auto-segmented into eight tissue types and anatomical regions including the white matter, cortical grey matter, deep nuclear grey matter, corticospinal fluid, amygdala, hippocampus, cerebellum, and brainstem. We determined the volumes of these regions and calculated the total intracranial volume (TICV) and head circumference (HC). We compared these measurements between the two groups, controlling for infant age at scan, by first comparing results for all subjects in each group and secondly performing a subgroup analysis for subjects below 8 weeks of postnatal age at scan. ZIKV-exposed infants demonstrated a significant decrease in amygdala volume compared to the control group in both the group and subgroup comparisons (p<0.05, corrected for multiple comparisons using FDR). No significant volume differences were observed in TICV, HC, or any specific brain tissue structures or regions. Study limitations include small sample size, which was due to abrupt cessation of extramural funding as the ZIKV epidemic waned.

CONCLUSION

ZIKV-exposed infants exhibited smaller volumes in the amygdala, a brain region primarily involved in emotional and behavioral processing. This brain MRI finding may lead to poorer behavioral outcomes and warrants long-term monitoring of pediatric cases of infants with gestational exposure to Zika virus as well as other neurotropic viruses.

Case report: Fatal lung hyperinflammation in a preterm newborn with SARS-CoV-2 infection

Vertical transmission of SARS-CoV-2 from mother to fetus is widely accepted. Whereas most infected neonates present with mild symptoms or are asymptomatic, respiratory distress syndrome (RDS) and abnormal lung images are significantly more frequent in COVID-19 positive neonates than in non-infected newborns. Fatality is rare and discordant meta-analyses of case reports and series relating perinatal maternal COVID-19 status to neonatal disease severity complicate their extrapolation as prognostic indicators. A larger database of detailed case reports from more extreme cases will be required to establish therapeutic guidelines and allow informed decision making. Here we report an unusual case of a 28 weeks' gestation infant with perinatally acquired SARS-CoV-2, who developed severe protracted respiratory failure. Despite intensive care from birth with first line anti-viral and anti-inflammatory therapy, respiratory failure persisted, and death ensued at 5 months. Lung histopathology showed severe diffuse bronchopneumonia, and heart and lung immunohistochemistry confirmed macrophage infiltration, platelet activation and neutrophil extracellular trap formation consistent with late multisystem inflammation. To our knowledge, this is the first report of SARS CoV-2 pulmonary hyperinflammation in a preterm newborn with fatal outcome.

Maternal SARS-CoV-2, Placental Changes and Brain Injury in 2 Neonates

Long-term neurodevelopmental sequelae are a potential concern in neonates following in utero exposure to severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2). We report 2 neonates born to SARS-CoV-2 positive mothers, who displayed early-onset (day 1) seizures, acquired microcephaly, and significant developmental delay over time. Sequential MRI showed severe parenchymal atrophy and cystic encephalomalacia. At birth, neither infant was SARS-CoV-2 positive (nasopharyngeal swab, reverse transcription polymerase chain reaction), but both had detectable SARS-CoV-2 antibodies and increased blood inflammatory markers. Placentas from both mothers showed SARS-CoV-2-nucleocapsid protein and spike glycoprotein 1 in the syncytiotrophoblast, fetal vascular malperfusion, and significantly increased inflammatory and oxidative stress markers pyrin domain containing 1 protein, macrophage inflammatory protein 1 βη, stromal cell-derived factor 1, interleukin 13, and interleukin 10, whereas human chorionic gonadotropin was markedly decreased. One infant (case 1) experienced sudden unexpected infant death at 13 months of age. The deceased infant's brain showed evidence of SARS-CoV-2 by immunofluorescence, with colocalization of the nucleocapsid protein and spike glycoprotein around the nucleus as well as within the cytoplasm. The constellation of clinical findings, placental pathology, and immunohistochemical changes strongly suggests that second-trimester maternal SARS-CoV-2 infection with placentitis triggered an inflammatory response and oxidative stress injury to the fetoplacental unit that affected the fetal brain. The demonstration of SARS-CoV-2 in the deceased infant's brain also raises the possibility that SARS-CoV-2 infection of the fetal brain directly contributed to ongoing brain injury. In both infants, the neurologic findings at birth mimicked the presentation of hypoxic-ischemic encephalopathy of newborn and neurologic sequelae progressed well beyond the neonatal period.

First Locally Acquired Congenital Zika Syndrome Case in the United States: Neonatal Clinical Manifestations

In the spring of 2017, a full-term infant with microcephaly was delivered in South Florida. During first trimester, the mother presented with fever, nausea, and vomiting. She reported no foreign travel for herself or her partner. The infant's neurologic, ophthalmologic, neuroradiologic, and audiologic findings were highly suggestive of congenital Zika syndrome (CZS), confirmed by IgM antibodies and plaque reduction neutralization test. New observations, including peripheral temporal retinal avascularity and peripapillary retinal nerve fiber layer thinning, are presented from this first known case of non-travel-associated CZS in the United States. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e93-e98.].

Zika Virus: An Emerging Global Health Threat

Zika virus (ZIKV) is an emerging healthcare threat. The presence of the mosquito Aedes species across South and Central America in combination with complementary climates have incited an epidemic of locally transmitted cases of ZIKV infection in Brazil. As one of the most significant current public health concerns in the Americas, ZIKV epidemic has been a cause of alarm due to its known and unknown complications. At this point, there has been a clear association between ZIKV infection and severe clinical manifestations in both adults and neonates, including but not limited to neurological deficits such as Guillain-Barré syndrome (GBS) and microcephaly, respectively. The gravity of the fetal anomalies linked to ZIKV vertical transmission from the mother has prompted a discussion on whether to include ZIKV as a formal member of the TORCH [Toxoplasma gondii, other, rubella virus, cytomegalovirus (CMV), and herpes] family of pathogens known to breach placental barriers and cause congenital disease in the fetus. The mechanisms of these complex phenotypes have yet to be fully described. As such, diagnostic tools are limited and no effective modalities are available to treat ZIKV. This article will review the recent advancements in understanding the pathogenesis of ZIKV infection as well as diagnostic tests available to detect the infection. Due to the increase in incidence of ZIKV infections, there is an immediate need to develop new diagnostic tools and novel preventive as well as therapeutic modalities based on understanding the molecular mechanisms underlying the disease.

Scalp congenital hemangioma with associated high-output cardiac failure in a premature infant: Case report and review of literature

Introduction Scalp congenital hemangiomas (CHs) are rare vascular malformations among infants; they can be associated with an array of complications, including cardiac and cosmetic issues. Here, we report the endovascular treatment of a premature infant with a suspected large right parietal scalp hemangioma and associated high-output cardiac failure. Case description A two-day-old female premature infant (29 weeks gestational age; 1330 g birth weight) was referred by the neonatologists to our department for consultation and potential treatment of a large right parietal CH causing abrupt hypotension and high-output cardiac failure. Doppler ultrasound imaging at bedside revealed areas of arterial-venous shunting from the scalp and the presence of a superior sagittal sinus waveform, consistent with intracranial venous drainage. To alleviate cardiac dysfunction secondary to this lesion, trans-arterial embolization via n-butyl cyanoacrylate (nBCA) glue and deployment of detachable coils was performed via umbilical artery to occlude the right superficial temporal and occipital artery branches supplying the CH. Following treatment, the infant continued to require ventilator management, vasopressor support, and correction of coagulopathy, but by post-operative day two, her condition improved remarkably and the mass size began decreasing. The patient was discharged after a relatively uncomplicated subsequent 2½-month course in the neonatal intensive care unit. Conclusion Endovascular therapy proved effective and safe in treating cardiac failure associated with scalp CH, despite potential complications associated with neuro-interventional surgery in premature infants. Appropriate consideration in this patient population should be given to factors including blood loss, contrast use, radiation exposure, operative time, and possible intra-/post-operative complications.

Prenatal Cocaine Exposure and Cardiometabolic Disease Risk Factors in 18- to 20-Year-Old African Americans

OBJECTIVE

The long-term effects of prenatal cocaine exposure (PCE) on physical health are largely unknown. No human studies support or refute a relationship between PCE and the long-term risk for cardiovascular and/or metabolic disease. We investigated the association of PCE on primary cardiometabolic disease risk factors in African Americans (AA) aged 18 to 20 years.

DESIGN

Cohort, longitudinal, prospective.

SETTING

Miami-Dade County, Florida, and the University of Miami Miller School of Medicine/Jackson Memorial Medical Center.

PARTICIPANTS

Healthy full-term inner-city AA adolescents (aged 18 to 20 years, n=350) previously enrolled at birth from 1990-1993.

MAIN OUTCOME MEASURES

Fasting serum insulin, glucose, lipids, and high-sensitivity C-reactive protein; systolic and diastolic blood pressures; and the components and prevalence of the metabolic syndrome.

RESULTS

There were no PCE-associated differences in cardiometabolic disease risk factors including the metabolic syndrome and its individual components in AAs aged 18 to 20 years.

CONCLUSIONS

The results of our study do not support an association between PCE and increased cardiometabolic disease risk in AAs aged 18 to 20 years. Whether PCE is associated with cardiovascular or metabolic disease in adulthood would require further investigation.

Illicit drug use and cardiometabolic disease risk: an analysis of 2005-2008 National Health and Nutrition Examination Survey data

PURPOSE

To explore the association between illicit drug use (IDU) and cardiometabolic disease risk factors (CDRF) in a nationally representative sample of adults.

METHODS

The 2005-2008 National Health and Nutrition Examination Surveys data from 20- to 45-year-old adults (n = 8738) were utilised to analyze the relationship between IDU (ever used, repeated use and current use) and CDRF (hyperlipidemia, hyperinsulinemia, hypertension, elevated C-reactive protein, body mass index, waist circumference and cigarette use) via chi square and logistic regression analyses. Age, gender, race/ethnicity, education level, poverty to income ratio (PIR), and alcohol use were included as confounders in the models.

RESULTS

Individuals who reported drug use (DU) at least once in lifetime were more likely to have CDRF than non-DU (NDU) (OR = 1.3, p = 0.004). Females with DU, IDU at least once in lifetime, and with repeated IDU were about 1.5 times more likely than their NDU counterparts to have CDRF (p < 0.0001, p = 0.02, p = 0.02, respectively).

CONCLUSION

Results from this study suggest that healthcare professionals should be aware that patients with a history of DU may be at heightened risk for cardiometabolic disease. Females in particular have a heightened cluster of CDRF across drug-use categories.

Perinatal Factors Associated with Cardiovascular Disease Risk among Preschool-Age Children in the United States: An Analysis of 1999-2008 NHANES Data

We examined the relationships between selected perinatal and early infancy factors (maternal smoking during pregnancy, infant low birthweight, breastfeeding, and early introduction of solid foods [<6 months of age] and increased BMI [≥85th, ≥95th percentiles for age, sex]), waist circumference (WC), C-reactive protein (CRP), triglycerides, total cholesterol, low-density lipoprotein (LDL) cholesterol, non-high-density lipoprotein (HDL) cholesterol, and decreased HDL cholesterol during early childhood. The population-based sample included 3,644 3-to-6-year-old Non-Hispanic White (NHW), Hispanic, and Non-Hispanic Black (NHB) children who participated in the 1999-2008 National Health and Nutrition Examination Surveys. Analysis showed that breastfeeding was significantly protective against early childhood obesity (OR 0.43, 95% CI, 0.27-0.69) and the highest quintile for WC (OR 0.58, 95% CI, 0.37-0.32) among NHW, and against the highest quintile of non-HDL cholesterol among NHB (OR 0.56, 95% CI, 0.32-0.98). Additionally, NHW children were significantly more likely to be obese (OR 2.22, 95% CI 1.30-3.78) and have higher CRP levels (OR 1.63, 95% CI, 1.05-2.51) if their mothers smoked during pregnancy. These results support the observation that breastfeeding may be protective against early childhood obesity while maternal smoking during pregnancy is a risk factor for obesity and increased CRP levels among NHW young children.

Estimated effect of prenatal cocaine exposure on examiner-rated behavior at age 7 years

Prenatal cocaine exposure has been linked to increased child behavior difficulties in some studies but not others.

OBJECTIVE

The primary aim was to estimate the relationship between in utero cocaine exposure and child behavioral functioning at age 7 years with ratings made by blinded examiners during a structured testing session. A second aim was to examine whether caregiver drug use and psychological problems might mediate suspected relationships between prenatal cocaine exposure and aspects of examiner-rated behavior.

METHODS

407 children (212 cocaine-exposed, 195 non-exposed) participating in the longitudinal Miami Prenatal Cocaine Study (MPCS) were rated with regard to their behavior during a neuropsychological assessment conducted at age 7 years. Raters were trained research psychometricians blinded to drug exposure status. Individual behavioral items were summarized and the cocaine-behavior relationship was estimated within the context of latent variable modeling, using Mplus software.

RESULTS

Two latent variables, Behavioral Regulation and Sociability, were derived via exploratory latent structure analysis with promax rotation. Prenatal cocaine exposure, statistically controlling for child sex, test age, and prenatal exposure to alcohol, tobacco, and marijuana, was associated with Behavioral Regulation (estimated slope ß=-0.25; 95% CI=-0.48, -0.02; p=0.04) but not Sociability (estimated slope ß=-0.03; 95% CI=-0.26, 0.20; p=0.79). Neither postnatal drug use by caregivers nor the severity of their psychological problems at age 5 follow-up predicted levels of child Behavioral Regulation or Sociability at age 7 years (p>0.10).

CONCLUSIONS

Examiner ratings of child behavior at age 7 revealed less optimal behavioral regulation for prenatally cocaine-exposed compared to non-exposed children, in contrast with what had been previously found from parent-report data. This evidence highlights the potential value of trained observers in assessing behavioral outcomes of children exposed in utero to drugs and other toxicants.

Potential latent effects of prenatal cocaine exposure on growth and the risk of cardiovascular and metabolic disease in childhood

The literature strongly suggests that prenatal exposure to certain medications and substances does not cause major malformations in early childhood. However, these exposures may have far-reaching latent health effects, such as restricted growth, hypertension, and cardiovascular events in adulthood. We reviewed the literature to identify the effects of prenatal cocaine exposure on growth and the risk of cardiovascular and metabolic disease in late adolescence and early adulthood by examining studies that were published in peer-reviewed English-language journals from 1990 through 2009 and indexed in MEDLINE. We found that animal and clinical studies of the influence of prenatal cocaine exposure on child and adolescent growth and the subsequent development of myocardial and cardiometabolic disease risk factors are few and inconclusive. Studies support the hypothesis that vascular and hemodynamic functions are partially programmed in early life and thus substantially influence vascular aging and arterial stiffening in later life. Sub-optimal fetal nutrition and growth may increase blood pressure and the development of cardiovascular and metabolic disease in late life. How prenatal cocaine and other drug exposure effects this relationship is currently unknown. Despite high rates of cocaine and other drug use during pregnancy (up to 18% in some studies), little is known about the health effects of prenatal cocaine exposure in adolescence and early adulthood. The few studies of early growth deficits persisting into adolescence are inconclusive. The literature provides little information on how exposed children grow into adulthood and about their subsequent risk of cardiometabolic and vascular disease.

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.

Estimated Risk of Developing Selected DSM-IV Disorders Among 5-Year-Old Children with Prenatal Cocaine Exposure

This study estimated childhood risk of developing selected DSM-IV Disorders, including Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Separation Anxiety Disorder (SAD), in children with prenatal cocaine exposure (PCE). Children were enrolled prospectively at birth (n=476) with prenatal drug exposures documented by maternal interview, urine and meconium assays. Study participants included 400 African-American children from the birth cohort, 208 cocaine-exposed (CE) and 192 non-cocaine-exposed (NCE) who attended a 5-year follow-up assessment and whose caregiver completed the Computerized Diagnostic Interview Schedule for Children. Under a generalized linear model (logistic link), Fisher's exact methods were used to estimate the CE-associated relative risk (RR) of these disorders. Results indicated a modest but statistically robust elevation of ADHD risk associated with increasing levels of PCE (p<0.05). Binary comparison of CE versus NCE children indicated no CE-associated RR. Estimated cumulative incidence proportions among CE children were 2.9% for ADHD (vs 3.1% NCE); 1.4% for SAD (vs 1.6% NCE); and 4.3% for ODD (vs 6.8% NCE). Findings offer suggestive evidence of increased risk of ADHD (but not ODD or SAD) in relation to an increasing gradient of PCE during gestation.

Impact of prenatal cocaine exposure on attention and response inhibition as assessed by continuous performance tests

OBJECTIVE

This study examined the influence of prenatal cocaine exposure on attention and response inhibition measured by continuous performance tests (CPTs) at ages 5 and 7 years.

METHODS

The baseline sample consisted of 253 cocaine-exposed and 223 non-cocaine-exposed children enrolled prospectively at birth and assessed comprehensively through age 7 years in the longitudinal Miami Prenatal Cocaine Study. This report includes a subsample of 415 children (219 cocaine-exposed, 196 non-cocaine-exposed) who completed at least one CPT assessment at ages 5 and/or 7 years. Prenatal cocaine exposure was measured by maternal self-report and maternal and infant bioassays. Deficits in attention and response inhibition are estimated in relation to prenatal cocaine exposure using generalized estimating equations within the general linear model.

RESULTS

Results indicate cocaine-associated increases in omission errors at ages 5 and 7 as well as increases in response times for target tasks (i.e., slower reaction times) and decreased consistency in performance at age 7. There were no demonstrable cocaine-associated deficits in commission errors. Estimates did not change markedly with statistical adjustment for selected prenatal and postnatal covariates.

CONCLUSION

Evidence supports cocaine-associated deficits in attention processing through age 7 years.

Learning disabilities and intellectual functioning in school-aged children with prenatal cocaine exposure

Risk for developing a learning disability (LD) or impaired intellectual functioning by age 7 was assessed in full-term children with prenatal cocaine exposure drawn from a cohort of 476 children born full term and enrolled prospectively at birth. Intellectual functioning was assessed using the Wechsler Intelligence Scale for Children-Third Edition (Wechsler, 1991) short form, and academic functioning was assessed using the Wechsler Individual Achievement Test (WIAT; Wechsler, 1993) Screener by examiners blind to exposure status. LDs were categorized based on ability-achievement discrepancy scores, using the regression-based predicted achievement method described in the WIAT manual. The sample in this report included 409 children (212 cocaine-exposed, 197 non-cocaine-exposed) from the birth cohort with available data. Cumulative incidence proportions and relative risk values were estimated using STATA software (Statacorp, 2003). No differences were found in the estimate of relative risk for impaired intellectual functioning (IQ below 70) between children with and without prenatal cocaine exposure (estimated relative risk = .95; 95% confidence interval [CI] = 0.65, 1.39; p = .79). The cocaine-exposed children had 2.8 times greater risk of developing a LD by age 7 than non-cocaine-exposed children (95% CI = 1.05, 7.67; p = .038; IQ >/= 70 cutoff). Results remained stable with adjustment for multiple child and caregiver covariates, suggesting that children with prenatal cocaine exposure are at increased risk for developing a learning disability by age 7 when compared to their non-cocaine-exposed peers.

Prenatal cocaine exposure: an examination of childhood externalizing and internalizing behavior problems at age 7 years

AIM

This study examines the relationship between prenatal cocaine exposure and parent-reported child behavior problems at age 7 years.

METHODS

Data are from 407 African-American children (210 cocaine-exposed, 197 non-cocaine-exposed) enrolled prospectively at birth in a longitudinal study on the neurodevelopmental consequences of in utero exposure to cocaine. Prenatal cocaine exposure was assessed at delivery through maternal self-report and bioassays (maternal and infant urine and infant meconium). The Achenbach Child Behavior Checklist (CBCL), a measure of childhood externalizing and internalizing behavior problems, was completed by the child's current primary caregiver during an assessment visit scheduled when the child was seven years old.

RESULTS

Structural equation and GLM/GEE models disclosed no association linking prenatal cocaine exposure status or level of cocaine exposure to child behavior (CBCL Externalizing and Internalizing scores or the eight CBCL subscale scores).

CONCLUSIONS

This evidence, based on standardized ratings by the current primary caregiver, fails to support hypothesized cocaine-associated behavioral problems in school-aged children with in utero cocaine exposure. A next step in this line of research is to secure standardized ratings from other informants (e.g., teachers, youth self-report).

Expressive and receptive language functioning in preschool children with prenatal cocaine exposure

OBJECTIVE

To estimate the relationship between severity of prenatal cocaine exposure and expressive and receptive language skills in full-term, African American children at age 3 years.

METHODS

Language was assessed at age 3 using the Clinical Evaluation of Language Fundamentals-Preschool (CELF-P). The sample included 424 children (226 cocaine exposed, 198 non-cocaine exposed) who received preschool language assessments at age 3, drawn from a cohort of 476 children enrolled prospectively at birth.

RESULTS

Structural equation modeling was used to regress expressive and receptive language as intercorrelated response variables on level of prenatal cocaine exposure, measured by a latent construct including maternal self-report of cocaine use and maternal/infant urine toxicology assays and infant meconium. Results indicated a.168 SD decrease in expressive language functioning for every unit increase in exposure level (95% CI = -.320, -.015; p =.031) after consideration for fetal growth and gestational age as correlated response variables. Receptive language was more modestly related to prenatal cocaine exposure and was not statistically significant. Results for expressive language remained stable with inclusion of the McCarthy general cognitive index as a response variable (expressive language beta = -.173, 95% CI = -.330, -.016; p =.031), and with adjustment for maternal age and prenatal exposures to alcohol, tobacco, and marijuana (expressive language beta = -.175, 95% CI = -.347, -.003; p =.046). Additional child and caregiver environmental variables assessed at age 3 were also evaluated in varying statistical models with similar results.

CONCLUSION

The evidence from this study supports a gradient relationship between increased level of prenatal cocaine exposure and decreased expressive language functioning in preschool-aged cocaine-exposed children.

Severity of prenatal cocaine exposure and child language functioning through age seven years: a longitudinal latent growth curve analysis

The current study estimates the longitudinal effects of severity of prenatal cocaine exposure on language functioning in an urban sample of full-term African-American children (200 cocaine-exposed, 176 noncocaine-exposed) through age 7 years. The Miami Prenatal Cocaine Study sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview and toxicology assays of maternal and infant urine and infant meconium. Language functioning was measured at ages 3 and 5 years using the Clinical Evaluation of Language Fundamentals--Preschool (CELF-P) and at age 7 years using the Core Language Domain of the NEPSY: A Developmental Neuropsychological Assessment. Longitudinal latent growth curve analyses were used to examine two components of language functioning, a more stable aptitude for language performance and a time-varying trajectory of language development, across the three time points and their relationship to varying levels of prenatal cocaine exposure. Severity of prenatal cocaine exposure was characterized using a latent construct combining maternal self-report of cocaine use during pregnancy by trimesters and maternal and infant bioassays, allowing all available information to be taken into account. The association between severity of exposure and language functioning was examined within a model including factors for fetal growth, gestational age, and IQ as intercorrelated response variables and child's age, gender, and prenatal alcohol, tobacco, and marijuana exposure as covariates. Results indicated that greater severity of prenatal cocaine exposure was associated with greater deficits within the more stable aptitude for language performance (D = -0.071, 95% CI = -0.133, -0.009; p = 0.026). There was no relationship between severity of prenatal cocaine exposure and the time-varying trajectory of language development. The observed cocaine-associated deficit was independent of multiple alternative suspected sources of variation in language performance, including other potential responses to prenatal cocaine exposure, such as child's intellectual functioning, and other birth and postnatal influences, including language stimulation in the home environment.

Influence of prenatal cocaine exposure on early language development: longitudinal findings from four months to three years of age

The influence of prenatal cocaine exposure on children's language functioning was evaluated longitudinally at six time points from 4 months to 3 years of age. The Miami Prenatal Cocaine Study prospectively enrolled 476 full-term African-American infants at birth, categorized as cocaine-exposed (n = 253) or non-cocaine-exposed (n = 223) by maternal self-report and bioassays (maternal/infant urine, meconium). The Bayley Scales of Infant Development, scored using the Kent Scoring Adaptation for language, was administered at 4, 8, 12, 18, and 24 months. The Clinical Evaluation of Language Fundamentals-Preschool was administered at 3 years. In longitudinal analyses using Generalized Estimating Equations, cocaine-exposed children had lower overall language skills than non-cocaine-exposed children (D = -0.151; 95% CI = -0.269, -0.033; p =.012). Longitudinal findings remained stable after evaluation of potential confounding influences including other prenatal substance exposures and sociodemographic factors. Preliminary evidence also indicated possible mediation through an intermediary effect involving cocaine-associated deficits in fetal growth.

Maternal cocaine use: estimated effects on mother-child play interactions in the preschool period

The study objective was to evaluate the quality of parent-child interactions in preschool-aged children exposed prenatally to cocaine. African-American mothers and their full-term newborns (n = 343) were enrolled prospectively at birth and classified as either prenatally cocaine-exposed (n = 157) or non-cocaine-exposed (n = 186) on the basis of maternal self-report and bioassays. Follow-up evaluations at 3 years of age (mean age, 40 mo) included a videotaped dyadic play session and maternal interviews to assess ongoing drug use and maternal psychological distress. Play interactions were coded using a modified version of Egeland et al's Teaching Task coding scheme. Regression analyses indicated cocaine-associated deficits in mother-child interaction, even with statistical adjustment for multiple suspected influences on interaction dynamics. Mother-child interactions were most impaired in cocaine-exposed dyads when the mother continued to report cocaine use at the 3-year follow-up. Multivariate profile analysis of the Egeland interaction subscales indicated greater maternal intrusiveness and hostility, poorer quality of instruction, lower maternal confidence, and diminished child persistence in the cocaine-exposed dyads.

Longitudinal influence of prenatal cocaine exposure on child language functioning

The present study estimates the longitudinal effects of in utero cocaine exposure on language functioning at 3, 5 and 7 years of age in an urban sample of 443 full-term children (236 cocaine-exposed and 207 noncocaine-exposed) participating in the Miami Prenatal Cocaine Study. The sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview and urine and meconium toxicology assays. Language functioning was measured at ages 3 and 5 years using the Clinical Evaluation of Language Fundamentals-Preschool (CELF-P) and at age 7 years using the Core Language Domain of the NEPSY: A Developmental Neuropsychological Assessment. Longitudinal Generalized Linear Model and Generalized Estimating Equations (GLM/GEE) analyses revealed an association between prenatal cocaine exposure and deficits in total language functioning after statistically controlling for child sex, visit age, prenatal exposure to alcohol, marijuana and tobacco and over 20 additional medical and sociodemographic covariates drawn from potentially confounding influences assessed at birth and follow-up visits (D=-0.17; 95% CI=-0.32, -0.03; P=.019). The link from prenatal cocaine exposure to later language deficits does not appear to be mediated by cocaine-associated deficits in birth weight, length or head circumference. Overall, the evidence tends to support an inference of a stable cocaine-specific effect on indicators of language functioning during early childhood through age 7 years.

Behavioral outcome of preschoolers exposed prenatally to cocaine: role of maternal behavioral health

OBJECTIVE

To examine the impact of prenatal cocaine exposure and maternal behavioral health (recent drug use and psychological functioning) on child behavior at age 5 years.

METHOD

In this longitudinal investigation, maternal report of child behavior was assessed using the Achenbach Child Behavior Checklist (CBCL) in 140 cocaine-exposed and 181 noncocaine-exposed (61 alcohol, tobacco, and/or marijuana-exposed, and 120 nondrug-exposed) low-income, African American children. Structural equation modeling was used to estimate suspected causal relationships between indicators of maternal behavioral health at 5-year follow-up, according to self-report on a modified Addiction Severity Index (ASI) and CBCL scores.

RESULTS

Prenatal cocaine exposure was not related to child behavior at age 5. Recent maternal drug use and psychological functioning had relationships with CBCL Internalizing and Externalizing scores. However, when considered within a combined model, only maternal psychological functioning remained significant.

CONCLUSIONS

Findings highlight the importance of maternal functioning in the behavioral outcome of children exposed prenatally to cocaine.

Intrauterine growth of full-term infants: impact of prenatal cocaine exposure

OBJECTIVE

The objectives of this study were to estimate the effect of prenatal cocaine exposure on fetal growth and gestational age after controlling for exposure to alcohol, tobacco, and marijuana and other covariates; to evaluate whether prenatal cocaine exposure has a disproportionate adverse effect on head circumference compared with overall somatic growth; and to assess whether the effect of prenatal cocaine exposure on fetal growth is mediated by cocaine's suspected effect on gestational age.

METHODS

The study population includes 476 neonates participating in the Miami Prenatal Cocaine Study, a longitudinal follow-up of in utero cocaine exposure. The sample, restricted to full-term neonates born to African-American inner-city mothers, included 253 infants exposed prenatally to cocaine (with or without alcohol, tobacco, or marijuana exposure) and 223 non-cocaine-exposed infants, of whom 147 were drug-free and 76 were exposed to varying combinations of alcohol, tobacco, or marijuana.

RESULTS

Evidence based on structural equations and multiple regression models supports a hypothesis of cocaine-associated fetal growth deficits (0.63 standard deviation) and an independent mild effect on gestational age (0.33 standard deviation). There was no evidence of a disproportionate adverse effect on birth head circumference once the impact on overall growth was estimated. There was evidence that some but not all of the cocaine effect on fetal growth was direct and some was indirect, acting via an intermediate influence of cocaine on gestational age.

CONCLUSIONS

Cocaine-associated growth deficits, symmetrical and partially mediated by gestational age, were observed in this sample of inner-city African-American full-term infants prospectively enrolled at birth. Long-term implications will be the subject of future reports from this longitudinal investigation.

Longitudinal investigation of task persistence and sustained attention in children with prenatal cocaine exposure

The present study estimates the longitudinal effects of prenatal cocaine exposure on indicators of sustained attention processing at 3, 5 and 7 years of age in an urban sample of full-term African-American children (235 cocaine-exposed, 207 noncocaine-exposed). The sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview, urine and meconium toxicology assays. Sustained attention was measured at age 3 years using a standardized measure of task persistence during a challenging task [G.A. Morgan, N.A. Busch-Rossnagel, C.A. Maslin-Cole and R.J. Harmon, Individualized Assessment of Mastery Motivation: Manual for 15-36 Month Old Children, 1992.], and at ages 5 and 7 years using omission error scores from computerized continuous performance tasks (CPT) [L. Greenberg, R. Leark, T. Dupuy, C. Corman, C. Kindschi, M. Cenedela, Test of Variables of Attention (T.O.V.A. and T.O.V.A.-A.), 22, Universal Attention Disorders, Los Alamitos, CA, 1996; C.K. Conners, Conners' Continuous Performance Test (CPT), second ed., Multi-Health Systems, Canada, 1995.]. Findings from longitudinal GLM/GEE analyses of the three measured time points support a stable influence of prenatal cocaine exposure on indicators of sustained attention, after controlling for prenatal exposure to alcohol, marijuana, tobacco and over 20 additional medical and social-demographic covariates drawn from potentially confounding influences assessed at birth and later assessment visits (D=0.21; 95% CI=0.04, 0.38; P=.017). This effect was not mediated by fetal growth or gestational age and remained highly stable with increasing levels of covariate control. Separately, using the age 7 data, a structural equations model (SEM) was constructed combining all available self-report and bioassay data to measure magnitude of cocaine exposure in relationship to attention task performance. Results indicated a gradient of influence, with each standard deviation increase in the level of prenatal cocaine exposure relating to a 16% standard deviation increase in omission error scores at age 7. Overall findings support a stable cocaine-specific effect on indicators of sustained attention processing during the early childhood years. Results are discussed within the context of neurobiological and behavioral research linking prenatal cocaine exposure to long-lasting disruption of the brain systems subserving arousal and attention.

Influence of prenatal cocaine exposure on full-term infant neurobehavioral functioning

This study investigated infant neurobehavioral functioning during the newborn period in 334 full-term, African American neonates (187 cocaine exposed, 147 non-cocaine exposed) enrolled prospectively at birth, with documentation of drug exposure status through maternal interview and urine and meconium toxicology assays. Infants were assessed using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) during the newborn period (0-6 postnatal days). Findings from multivariate profile analyses support a consistent, modest effect of prenatal cocaine exposure on neurobehavioral functioning in full-term neonates. All of the BNBAS cluster scores, with the exception of abnormal reflexes, were similarly affected, sharing a common slope (D=-0.14; 95% CI=-0.27, -0.003; P=.046) representing a -0.14 point difference between cocaine-exposed and non-cocaine-exposed infants after controlling for prenatal exposure to alcohol, tobacco, and marijuana (ATM); maternal age, education, employment, primigravida status, and prenatal care visits; and infant sex and postnatal age in days. Fetal growth was also related to neurobehavioral functioning and, in part, mediated the relationship between cocaine exposure and the BNBAS cluster scores. Cocaine exposure during each trimester similarly influenced infant neurobehavioral profiles, with cocaine-associated deficits most pronounced in infants with exposure in all three trimesters. Results from qualitative and quantitative urine and meconium bioassay indicators further substantiated these results. Findings, while significant, represent modest effect sizes in full-term infants.

Brief report: relationship between HIV infection and WPPSI-R performance in preschool-age children

OBJECTIVE

To determine the neurodevelopmental effects of perinatally acquired HIV infection on children of preschool age.

METHODS

Participants included 40 children infected with HIV between the ages of three and five and an equal number of noninfected controls individually matched according to ethnicity, age, sex, and prenatal drug exposure. Participants were administered the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), upon which an analysis of subtest distribution was conducted.

RESULTS

Whereas both groups evidenced mean IQ and subtest scores significantly below published norms, an effect for HIV group status was not found when a factor combining Performance IQ (PIQ) and Verbal IQ (VIQ) was analyzed. However, the group infected with HIV scored significantly lower than controls on the Block Design subtest.

CONCLUSIONS

Gross cognitive deficits are not evident among preschool children infected with HIV relative to matched controls. However, this study does provides some evidence for more focal deficits. Further investigation with older children should be conducted.

Neonatal fellowship. Neonatal pneumopericardium: successful treatment with nitrogen washout technique

Pneumopericardium in the neonate is a rare event but is associated with significant morbidity and mortality. We describe a neonate with mild respiratory distress and cardiovascular compromise after delivery and resuscitation. A large isolated pneumopericardium was diagnosed. Treatment with an oxygen hood (FiO2 1.00) resulted in a complete resolution of the pneumopericardium within 12 hours.

Cocaine-exposed preterm neonates show behavioral and hormonal differences

OBJECTIVE

Prematurity has been associated with prenatal cocaine exposure, but most studies on the behavioral effects of prenatal cocaine exposure have been restricted to full-term infant samples. The current study focused on behavioral and hormonal responses in preterm cocaine-exposed infants compared with a cohort of non-cocaine-exposed infants of similar gestational age.

METHODOLOGY

A comparison between 30 cocaine-exposed and 30 non-cocaine-exposed preterm neonates suggested that the cocaine-exposed neonates were born to mothers who had higher parity and more obstetric complications. In addition, mothers of cocaine-exposed preterm neonates visited, touched, held, and fed their infants less frequently than mothers of nonexposed infants.

RESULTS

The cocaine-exposed infants had smaller head circumferences at birth, spent more time in the neonatal intensive care unit, and had a greater incidence of periventricular-intraventricular hemorrhages. They also had inferior Brazelton cluster scores, including lower state regulation and range-of-state scores, and greater depression. During sleep-wake behavior observations, they showed difficulty maintaining alert states and self-regulating their behavior, and they spent more time in indeterminate sleep and had decreased periods of quiet sleep and increased levels of agitated behavior, including tremulousness, mouthing, multiple limb movements, and clenched fists. Finally, higher urinary norepinephrine, dopamine, and cortisol levels and lower plasma insulin levels were noted in the cocaine-exposed preterm neonates.

CONCLUSIONS

These findings highlight the need for follow-up assessments and early intervention.

Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions

Recent federal health financing and health care delivery programs have increased access to alcohol and other drug abuse treatment programs for low-income women, and have provided intervention and prevention services for their children and families. The Village South Families in Transition (FIT) in Miami, Florida, implemented a residential treatment program for women and their children that aims to decrease alcohol and other drug use, reduce reliance on social and health welfare systems, improve functioning in specific life-skill and vocational areas, improve parenting techniques and maternal/child relations, and provide intervention and prevention services for the clients' children in a safe and supportive environment. Program implementation required resolutions to numerous barriers, including securing a facility for women and children; recruiting, hiring and training of staff; establishing and maintaining community linkages; treatment considerations; balancing treatment versus evaluation/research; and critical decisions faced by treatment staff as they modify client-centered programs to incorporate gender-specific and family-centered programs.

m-Hydroxybenzoylecgonine: an important contributor to the immunoreactivity in assays for benzoylecgonine in meconium

Meconium has been reported to be a more suitable specimen than maternal or neonatal urine for detecting fetal exposure to cocaine. In a study comparing various immunoassays with gas chromatography/mass spectrometry (GC/MS), several unexplained discrepancies among the assays were noted. Using methanol extracts of meconium samples, an immunoreactive spot that was more polar than benzoylecgonine was detected by thin-layer chromatography (TLC). An extract of this spot analyzed by GC/MS yielded a fragmentation pattern indicative of an aryl hydroxylated benzoylecgonine. Standards of m-hydroxybenzoylecgonine, o-hydroxybenzoylecgonine, and p-hydroxybenzoylecgonine were synthesized; it was determined that m-hydroxybenzoylecgonine had the same retention time and ion ratios as the TLC immunoreactive spot. Furthermore, m-hydroxybenzoylecgonine proved to be immunoreactive. Ten meconium samples immunoreactive for benzoylecgonine were analyzed by GC/MS. Results before and after hydrolysis with beta-glucuronidase (type IX) showed free m-hydroxybenzoylecgonine comprising 59 to 94% of the total m-hydroxybenzoylecgonine and showed total m-hydroxybenzoylecgonine values ranging from 0.2 to 6.3 times as high as benzoylecgonine. Therefore, m-hydroxybenzoylecgonine appears to be a quantitatively important cocaine metabolite in meconium, which is responsible for a significant portion of the discrepancy between benzoylecgonine concentrations in meconium extracts as measured by immunoassay and GC/MS.

Rapid cocaine screening of urine in a newborn nursery

A rapid cocaine screening test, the Abuscreen OnTrak assay, was compared with the EMIT (enzyme-multiplied immunoassay technique) screening test to determine relative accuracy in 450 newborn infants sequentially tested for urinary cocaine during a 6-week period at a large urban hospital. The Abuscreen Ontrak screen had a sensitivity of 96% and a specificity of 100%.

Perinatal cocaine effects on neonatal stress behavior and performance on the Brazelton Scale

Fifty-two newborns were assessed for the effects of maternal cocaine use on their performance on the Brazelton Neonatal Behavior Assessment Scale and on their stress behaviors during the Brazelton as tapped by the Neonatal Stress Scale. The cocaine-exposed newborns experienced more obstetric complications, had smaller head circumferences, showed more limited habituation abilities on the Brazelton Scale, and exhibited more stress behaviors than control newborns.

Transcutaneous oxygen tension in preterm neonates during neonatal behavioral assessments and heelsticks

This study evaluates the effects of neonatal behavioral assessments and heelsticks on transcutaneous oxygen tension (TcPO2) in 37 preterm neonates from a neonatal intensive care unit. Two behavioral assessments were evaluated, the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) and the Neurobehavioral Assessment for Preterm Infants (NAPI). TcPO2 during heelsticks was used as a comparison because reliable decreases have typically been noted during heelsticks. Although the heelsticks resulted in significant declines in TcPO2, the behavioral assessments led to only negligible changes in TcPO2. Observed changes during the behavioral assessments occurred in a small number of infants, primarily during the few test procedures administered to the infants outside of their isolettes. Accordingly, it is suggested that time outside the isolette and associated temperature changes may be more critical variables than the assessments per se.

Cocaine-related maternal death

Hemodynamic overload, cardiac ischemia, and arrhythmia are postulated to originate from "sex-cocaine" syndrome resulting in maternal and fetal death. High concentrations of cocaine and metabolites in maternal blood, urine, and nasal secretions confirmed recent ingestion. Changes in the maternal life-style may have contributed to the poor pregnancy outcome.

Prophylactic indomethacin for prevention of intraventricular hemorrhage in premature infants

The impact of early prophylactic use of intravenous indomethacin on the incidence and severity of periventricular-intraventricular hemorrhage and patent ductus arteriosus in 199 oxygen-requiring premature infants (less than or equal to 1300 g birth weight) was prospectively investigated. The trial was controlled, the infants were randomized, and the investigators were unaware of the group assignments. Patients with minimal (grade I) or no periventricular-intraventricular hemorrhage determined by prestudy echoencephalography were randomized within two birth weight subgroups (500 to 899 and 900 to 1300 g) to receive either prophylactic indomethacin (n = 99) or an equal volume of saline-vehicle placebo (n = 100). The first dose (0.2 mg/kg) was given within 12 hours of delivery and two subsequent doses (0.1 mg/kg) were administered at 12 hourly intervals. Prophylactic indomethacin significantly reduced the incidence of grades II to IV periventricular-intraventricular hemorrhage. Intraventricular hemorrhage was half as common in infants given prophylactic indomethacin as in control infants (23% v 46%, P less than .002). The reduction was manifested in both birth weight subgroups. Results of this study also confirmed a lower incidence of clinically significant patent ductus arteriosus in infants who received prophylactic indomethacin in contrast to those who received placebo (11% v 42%, P less than .001). No significant differences were found between treatment and control groups in the duration of oxygen therapy, mechanical ventilation, or hospitalization or in the incidence of pneumothorax, chronic lung disease, sepsis, necrotizing enterocolitis, retinopathy of prematurity, or death. Early prophylactic indomethacin initiated within 12 hours of delivery is effective in reducing the incidence of intraventricular hemorrhage as well as clinically significant patent ductus arteriosus in very low birth weight premature infants.

Grief responses of pediatric house officers to a patient's death

Twenty-five pediatric house officers were surveyed (14 M; 11 F) to assess their behavioral and psychophysiologic responses to patient death. Vignettes about the deaths of two pediatric patients were included as part of a self-administered questionnaire. The vignettes were followed by 14 behavioral and 20 psychophysiologic responses to the deaths depicted, and physicians were asked to indicate the expected occurrence of these reactions for themselves and for an ideal physician. Reported reactions were found to be similar to grief responses experienced with the death of a loved one. Significant differences were found between the responses of female and male house officers to patient death. Additionally, differences were found between the manner in which the physicians personally responded to a patient's death in comparison to the way they considered an ideal physician would respond. Practical suggestions are given, based on these data, for inclusion of information in death education courses for physicians.