As details of the melamine contamination scandal continue to emerge, many of our pre- and post-adoptive parents are wondering how potential exposure to this chemical may affect their child. I wish we knew more. But I'd like to start by offering some general information about melamine, and some tentative guidelines about how to manage this issue.

Melamine is a chemical with a number of industrial uses, and an already scandalous history as one of the major contaminants in the 2007 Chinese pet food debacle. It is suspected that it was added to milk at milk collecting stations in China to disguise the fact that milk was being watered down, since melamine artificially increases the testable protein content. We don't yet know how long this has been a problem. According to Sanlu, a popular budget formula manufacturer implicated in this event, contaminated milk was used in the manufacture of infant formula processed before 8/6/08, as well as in other dairy products like liquid milk, frozen yogurt, and coffee creamer.

There is essentially no reliable toxicology information about melamine and human consumption. The animal data suggests that it is not metabolized in the body, and is excreted in urine. At high doses in animals, it can cause bladder stones, and inflammation of the bladder. Over time, this may be carcinogenic, but we have no human studies to evaluate this risk. 

The high number of serious kidney complications and deaths in pets exposed to contaminated food has been linked to the particularly toxic combination of melamine and cyanuric acid. We have not seen reports of cyanuric acid in human-consumed milk products, but it can be a contaminant in melamine products.

What is additionally confusing is that in animals, melamine alone can cause bladder stones (a mixture of melamine, protein, uric acid and phosphate), but has not caused kidney stones or kidney failure. The preliminary reports from China, however, do indicate that a small fraction of children who received contaminated formula have been diagnosed with kidney stones, reportedly containing uric acid. We are told that 4 infants have died, perhaps from obstruction of their kidneys from such stones, and 150 children have had renal failure. I don't know what to make of the high number of reported hospitalizations (over 14,000), and suspect that some of those may have been for workup and not because of illness.

Symptoms to Watch For

Please keep in mind that recently adopted children have plenty of more common and benign reasons for crying. That said, here are some things to watch for that would deserve prompt evaluation:

• Unexplained crying episodes or abdominal pain, especially with urination
• Passing blood, crystals, or particles in urine
• Dramatic decrease in urine output
• Swelling of the hands, feet, or around the eyes (edema)
• Pain when tapped over the kidneys
• Unexplained lethargy or vomiting

Our Evolving Approach

What remains unclear is which children deserve what workup. I'll cover our clinic's current approach here (which may be updated as consensus evolves and new information becomes available):

• So far, we are checking a urinalysis with microscopy (to look for blood or crystals), and an electrolytes/BUN/creatinine panel (to look for signs of impaired kidney function) on all new Chinese adoptees. We may also add more routine ultrasound of kidneys, ureters, and bladder to look for stones themselves (see below).
• Many of our previously adopted children have had some of these tests, but we are asking any symptomatic children (see above) to come in for urine & blood testing, and for an ultrasound, or perhaps CT scan if our suspicion is very high.
• Children who came home from China in the past 3 or so years (vague because we don't know how long melamine has been a contaminant) who are asymptomatic should probably have at least a non-urgent urinalysis, if they have not previously had one. If they've been growing well and are asymptomatic, and have no other reason to need a blood draw, I'm not convinced that bloodwork is necessary. But we may start ultrasounding more routinely for this group as well.
• A reasonable diagnostic code to use would be V87.39: contact with and (suspected) exposure to other potentially hazardous substances (for asymptomatic children), or codes based on a child's specific symptoms.
• As for specific testing for melamine itself in blood or urine, we are not doing that at this time. Such testing is investigational and hard to come by, and given the expected fairly rapid excretion of melamine, may not be of much clinical use. Plus, children may be exposed to insignificant amounts of melamine from other sources, which would complicate interpretation of results.
• Treatment of children with stones may involve close observation, IV fluids and urine alkalinization, medical management of acute renal failure if present, and various procedures to break up and remove recalcitrant or obstructing stones.

What is currently controversial is whether ultrasounds should be a routine screening test for asymptomatic Chinese adoptees with normal urinalysis. Thus far, we're not sure, and we have a low threshold to order ultrasounds if we're not sure about the "symptomatic" part, and are happy to order them for concerned parents. There have been several reports of renal stones diagnosed by ultrasound in otherwise asymptomatic children with normal urinalysis and bloodwork. If more of these are confirmed, we probably will start routinely ultrasounding. What remains unanswered is how common are these cases, and what needs to be done if asymptomatic stones are discovered.

We are in discussion with our local kidney and urology specialists, as well as other adoption docs, about the advantages and drawbacks of more universal ultrasound screening for Chinese adoptees. There are other radiographic approaches, such as a CT KUB (non-contrast) or CT urogram (with contrast), which can give better resolution for children in whom we highly suspect stones based on symptoms or labs, but the substantial amount of radiation exposure (and cost) with CT scans makes them unattractive for routine screening.

We've not yet seen any children in our practice with diagnosed kidney stones or other complications. According to informal data from Half the Sky, less than 5% of exposed children in the orphanages they work with have been diagnosed with kidney problems. And without stones and renal complications, we think it unlikely that melamine-exposed children will have significant long-term impacts. But we will keep you posted here as we learn more. And as always, please do involve your child's medical provider. Their opinion on this as-yet-fuzzy issue may not be the same as ours, and they know your child better than the internet does.

Useful Melamine Resources

• The World Health Organization (WHO) has an excellent overview of melamine contamination in China
• The Hong Kong Journal of Pediatrics has published an excellent melamine overview and editorial (pdf), with new details and thoughtful analysis (link courtesy of Dr Gordina)
• The New England Journal of Medicine has a good overview of the global implications of the melamine contamination scandal
• JCICS has posted a helpful FAQ, including some reports from Half the Sky about affected children in their orphanages
• The Canadian Public Health Agency has a helpful set of melamine resources
• Our Centers for Disease Control (CDC) has a good FAQ as well
• "China Milk Issue" YahooGroup, an active listserv of concerned parents (and a few docs), with database of their test results
• Parent-organized survey collecting preliminary data regarding results of tests on children adopted from China who may have been exposed to melamine. Please consider adding your information here, to better understand the scope of the problem.

Recommendations from the Chinese Ministry of Health:

(via the WHO, as of 10/08 - check here for updates):

The World Health Organization has agreed to circulate the information contained herein regarding the treatment plan that is being implemented in China by the Ministry of Health. The information below does not reflect the rules, regulations, policies and guidelines of the World Health Organization.

The following regimen has been issued by the Ministry of Health, China.

Clinical manifestations

• Unexplained crying, especially when urinating, possible vomiting
• Macroscopic or microscopic haematuria
• Acute obstructive renal failure: oliguria or anuria
• Stones discharged while passing urine. For example, a baby boy with urethral obstruction with stones normally has dysuria
• High blood pressure, edema, painful when knocked on kidney area

Key diagnostic criteria

• Been fed with melamine-contaminated infant milk formula
• Having one or more of the above clinical manifestations
• Laboratory test results: routine urine tests with macroscopic or microscopic haematuria; blood biochemistry; liver and kidney function tests; urine calcium/creatinine ratio (usually normal); urinary red blood cell morphology shows normal morphology of red blood cells (not glomerular haematuria); parathyroid hormone test (usually normal).
• Imaging examination: preferably ultrasound B exam of urinary system. If necessary, abdominal CT scan and intravenous urography (not to be used in case of anuria or renal failure). Kidney radionuclide scans can be used where available to evaluate renal function.
• Ultrasound examination features:
  • General features: bilateral renal enlargement; increased echo on solid tissue; normal parenchyma thickness; slight pyelectasia and calicectasis; blunt renal calyx. If the obstruction locates in the ureter, then the ureter above the obstruction point dilates. Some cases have edema with perinephric fat and soft tissue around the ureter. As the disease develops, the renal pelvis and ureter wall may have secondary edema. A few cases have ascites.
  • Stone features: most stones affect the collecting system and ureters on both sides. Ureteral stones are mostly at pelviureteral junction, the part where the ureter passes across iliac artery, and ureter-bladder junction. Stones stay collectively, covering massive areas. Lighter echo in the background. Most stones are different from the calcium oxalate stones. Urinary tract is mostly completely obstructed by the stones.

Differential diagnosis

• Haematuria differentiation: need to rule out glomerular haematuria.
• Stone differentiation: the stones are normally radiolucent and have a negative image on urinary tract x-ray. This feature differentiates the stones from those of radiopaque stones of calcium oxalate and calcium phosphate.
• Differentiation of acute renal failure: need to rule out pre-renal and renal failure.

Clinical treatment

• Immediately stop using melamine-contaminated infant formula milk powder.
• Medical treatment: use infusion and urine alkalinization to dispel the stones. Correct the water, electrolyte and acid-base imbalance. Closely monitor routine urine tests, blood biochemistry, renal functions, ultrasound findings (with particular attention to the renal pelvis, ureter expansion, and the change of the stones in shape and location). If the stones are loose and sand-like, they are very likely to be passed out with urine.
• Treatment of complicated acute renal failure: priority should be given to the treatment of life-threatening complications such as hyperkalemia. Measures include the administration of sodium bicarbonate and insulin. If possible, blood dialysis and peritoneal dialysis can be used early. Surgical measures can be taken to remove the obstruction if necessary.
• Surgical treatment: if medical treatment is not effective, and hydrocele and kidney damage present, or blood dialysis and peritoneal dialysis are not available in case of renal failure, surgical methods can be considered to remove the obstruction. Stones can be removed by different methods including cystoscope retrograde intubation into the ureter, percutaneous kidney drainage, surgical removal and percutaneous kidney stone removal. Extracorporeal shock wave lithotripter (ESWL) is greatly limited in its application, because the stones are loose and mainly composed of urate, and the patients are infants.

Follow-up

Once the urinary obstruction is relieved, and the general condition and renal function and urination are back to normal, the children can be discharged.

Key issues to follow-up

Urine routine tests; ultrasound of urinary system; renal function tests; IVP (intravenous pyelogram) if necessary.

We had an hour-long discussion about rough estimates of alcohol risk for various countries, the fetal alcohol spectrum, things to look for in a referral, how to address alcohol concerns post-adoption, and the long-term outlook. There's lots more we could have covered, but we ran out of time, so we hope to do this again in several months, focusing on post-adoption FASD issues. In general, I hope to get more audio and video presentations up on the site in coming months, including some highlights from our Raising Resilient Rascals conferences.

• Stream this interview on their site (ads and window resizing alert)
  
• Download as an mp3 "podcast"
• Or play it using this Flash embedded player:

Integrative, Brain-Based and Practical Ways
to Nurture Adopted and Fostered Children

 
Save the date! On Feb 2nd we'll be hosting an all-day conference with Deborah Gray and colleagues.  We're aiming to be interesting and informative for both parents and professionals interested in adoption. Check out the topics below, and sign up at the Cascadia Training website.

Topics include:

The "Decade of the Brain" Came and Went - What Have We Learned?

The past 10 years brought many advances in neuro-imaging, and better understanding of the effects of prenatal drug and alcohol exposures, malnutrition, maltreatment, lack of attuned care giving, and stress on the developing brain.  What can the latest research tell us about how these all-too-frequent influences affect the neurodevelopment of adopted and foster children?  We will explore different regions of the brain, and aspects of learning and behavior, with an emphasis on avenues for intervention at home and school.

Loving the Child Who Bites You - Disciplining Scared/Aggressive Kids. 

Children who have been maltreated or lost attachment figures desperately need to form secure attachments with their parents.  Often the children are aggressive and/or immature and impulsive.  What strategies are useful when children show limited empathy?  We will look at approaches designed to bring out the best in children whose histories of maltreatment have resulted in dysregulation and behavior problems.

From Snake Oil to Fish Oil - Integrative Medicine and Adoption. 

A lively romp through the wilderness of complementary/alternative therapies commonly used by adoptive families, from an "alterna-friendly" pediatrician.  We'll review the evidence or lack thereof, safety, and cost of interventions ranging from vitamins, minerals, essential fatty acids, and other "nutriceuticals", herbs and homeopathy, elimination diets, chelation therapy, bodywork and chiropractic, developmental movement therapy, sensory and auditory integration, and bio/neurofeedback.  We'll also cover ways to evaluate therapies and practitioners, and the cardinal signs of quackery.

Adderall and Risperdal et al. - Meds and Adoption.  

In this part of our talk, we'll address the use of psychiatric medications with adopted and fostered children.  Stimulants, antidepressants, mood stabilizers, blood-pressure medications, and atypical anti-psychotics are being used more and more with younger and younger children.  Unfortunately, the evidence for safety and efficacy in children for many of these drugs is lacking (as are the child psychiatrists!)  What do we know about these meds and children?  What goes into the decision to medicate a child for specific psychiatric conditions like ADHD, depression, anxiety, and bipolar disorders, as well as less defined emotional and behavioral problems?  What sort of monitoring is important?

Creating Resilience in Children: What areas promote competencies in children?  What are we doing well?  What are we missing?   How should we be doing it? 

The remarkable increase in the number of adoptions of children adopted after trauma and neglect has pushed the need for support.  But, professionals and parents alike need to know when to obtain support.  This talk describes symptom clusters in childhood trauma, neglect's impact on children's functioning,  and best practices in providing help.  We will also discuss what to look for in acquiring help and what to avoid.

Resilience Panel

The day will end with a panel to include all the speakers and a few invited guests.  The panel will discuss resilience factors, resilience gene, adult influences, orphanage interventions, goodness of fit, what can parents do to prepare/promote resilience?  There will be plenty of time to take attendee questions.

About the presenters:

Julia Bledsoe, MD, is a Clinical Associate Professor of Pediatrics at the University of Washington, and a staff pediatrician at the UW Fetal Alcohol Syndrome Diagnostic and Prevention Network in Seattle.  She founded the Center for Adoption Medicine, and has worked in the field of international adoption for ten years, with travels to Russia, Romania, China, and Guatemala.  She has two children adopted from Korea, one of whom has Tourette's Syndrome and ADHD.

Julian Davies, MD, is a Clinical Assistant Professor of Pediatrics at the University of Washington, and the other pediatrician at the UW FAS Clinic.  He is also the Co-Director of the Center for Adoption Medicine, where he provides pre-adoption consultations, post-placement evaluations, and ongoing general pediatric care for adopted children.  He is the primary author for www.adoptmed.org, an online resource for medical and developmental issues in adoption and pediatrics.  He has traveled, clowned, and volunteered extensively in Russia, with an arts rehabilitation program and summer arts camp for Russian orphans.

Deborah Gray, MSW, MPA, is a national trainer, a psychotherapist in private practice, and the author of the well-received book, Attaching in Adoption: Practical Tools for Today’s Parents, Perspectives Press, 2002. Deborah has spent 20 years helping children develop attachments and work through trauma and grief. She teaches in the Trauma Certificate Program at the Univ. of WA School of Social Work and both graduate adoption therapy programs at Portland State University and Northwest Adoption Exchange. Her second book on best practices with children after neglect and trauma is in preparation.

About the particulars:

Location: Tukwila Community Center
When: February 2nd, 2007
Hours: 8:30am-5:00pm
Fee: $65.00 US
CEU info: 7 CEU's 
Cascadia Training is approved by the NASW, Washington State Chapter, to provide continuing education units to Licensed Social Workers, Mental Health Counselors and Marriage and Family Therapists.  Certificates of Completion are awarded to attendees at the end of each workshop.  Provider number #1975-118; Cascadia is an OSPI approved provider of in-service education.  This is a "Washington State Approved Clock Hour Offering Workshop."

• Parent Guide: Toilet Training Basics (start here)
• Parent Guide: Toilet Training Resistance (if you're having trouble)
• Parent Guide: Stool holding - When your child holds back bowel movements and is not toilet trained (uhoh)
• Parent Guide: Using Incentives to Motivate Your Child (you might need this)

Dr Parker, a developmental pediatrician with a mighty fine blog, has a this post on the Poop Wars:

• Poop Culture: Potty Training Your Child
  

Elizabeth Pantley, author of several "No-Cry" and other excellent parenting books, has several articles on this topic as well, which she permitted us to excerpt here:

• Quick Facts About Potty Training
• Potty Training Readiness Quiz
• Potty Training - Get Ready, Get Set, Go!

• The perfect age to begin potty training is different for every child. Your child's best starting age could be anywhere from eighteen to thirty-two months. Pre-potty training preparation can begin when a child is as young as ten months.
• You can begin training at any age, but your child's biology, skills, and readiness will determine when he can take over his own toileting.
• Teaching your child how to use the toilet can, and should, be as natural as teaching him to build a block tower or use a spoon.
• No matter the age that toilet training begins, most children become physically capable of independent toileting between ages two and a half and four.
• It takes three to twelve months from the start of training to daytime toilet independence. The more readiness skills that a child possesses, the quicker the process will be.
• The age that a child masters toileting has absolutely no correlation to future abilities or intelligence.
• There isn’t only one right way to potty train – any approach you use can work - if you are pleasant, positive and patient.
• Nighttime dryness is achieved only when a child's physiology supports this - you can't rush it.
• A parent's readiness to train is just as important as a child's readiness to learn.
• Potty training need not be expensive. A potty chair, a dozen pairs of training pants and a relaxed and pleasant attitude are all that you really need. Anything else is truly optional.
• Most toddlers urinate four to eight times each day, usually about every two hours or so.
• Most toddlers have one or two bowel movements each day, some have three, and others skip a day or two in between movements. In general, each child has a regular pattern.
• More than 80 percent of children experience setbacks in toilet training. This means that what we call “setbacks” are really just the usual path to mastery of toileting.
• Ninety-eight percent of children are completely daytime independent by age four.
  

Get Ready

• During diaper changes, narrate the process to teach your toddler the words and meanings for bathroom-related functions, such as pee-pee and poo-poo. Include descriptive words that you'll use during the process, such as wet, dry, wipe, and wash.
• If you're comfortable with it, bring your child with you when you use the toilet. Explain what you're doing. Tell him that when he gets bigger, he'll put his pee-pee and poo-poo in the toilet instead of in his diaper. Let him flush the toilet if he wants to.
• Help your toddler identify what's happening when she wets or fills her diaper. Tell her, "You're going poo-poo in your diaper." Have her watch you dump and flush.
• Start giving your child simple directions and help him to follow them. For example, ask him to get a toy from another room or to put the spoon in the dishwasher.
• Encourage your child to do things on her own: put on her socks, pull up her pants, carry a cup to the sink, or fetch a book.
• Have a daily sit-and-read time together.
• Take the readiness quiz again every month or two to see if you're ready to move on to active potty learning.
  

Get Set

• Buy a potty chair, a dozen pairs of training pants, four or more elastic-waist pants or shorts, and a supply of pull-up diapers or disposables with a feel-the-wetness sensation liner.
• Put the potty in the bathroom, and tell your child what it's for.
• Read books about going potty to your child.
• Let your child practice just sitting on the potty without expecting a deposit.
  

Go

• Begin dressing your child in training pants or pull-up diapers.
• Create a potty routine - have your child sit on the potty when she first wakes up, after meals, before getting in the car, and before bed.
• If your child looks like she needs to go - tell, don't ask! Say, "Let's go to the potty."
• Boys and girls both can learn sitting down. Teach your son to hold his penis down. He can learn to stand when he's tall enough to reach.
• Your child must relax to go: read a book, tell a story, sing, or talk about the day.
• Make hand washing a fun part of the routine. Keep a step stool by the sink, and have colorful, child-friendly soap available.
• Praise her when she goes!
• Expect accidents, and clean them up calmly.
• Matter-of-factly use diapers or pull-ups for naps and bedtime.
• Either cover the car seat or use pull-ups or diapers for car trips.
• Visit new bathrooms frequently when away from home.
• Be patient! It will take three to twelve months for your child to be an independent toileter.
  

Stop

• If your child has temper tantrums or sheds tears over potty training, or if you find yourself getting angry, then stop training. Review your training plan and then try again, using a slightly different approach if necessary, in a month or two.
  

Overview

Methamphetamine abuse has increased dramatically in the United States in the past decade, especially in the western and midwestern states [105]. In Russia, cheap imported heroin still prevails, but abuse of home-produced ephedrine-based “vint” and other injectable amphetamines is on the rise and already predominates in certain cities, including Vladivostok and Pskov [106]. Methamphetamine abuse is a significant problem in Southeast Asia as well, with 19% of Thai female students using methamphetamine in one school-based study [107]. The UNODC reports large increases in methamphetamine production and abuse in China, Singapore, and Thailand [35]. Because methamphetamine is relatively cheap to manufacture from readily available products, “home labs” are becoming increasingly common in many parts of the world. Unfortunately, the chemicals and byproducts involved are highly toxic and flammable.

Methamphetamine is a CNS stimulant that releases large amounts of dopamine, resulting in a sense of euphoria, alertness, and confidence [108]. It can be injected, smoked, snorted, or ingested orally. Prolonged use at high levels results in dependence and erratic behavior [105]. Evidence on the effects of prenatal methamphetamine use is still emerging, but effects on prenatal growth, behavior, and cognition have been described.

Mechanism

Studies of adult methamphetamine abusers have shown potential neurotoxic effects on subcortical brain structures, namely, decreased dopamine transporters, brain metabolism, and perfusion [108]. Although the impact of methamphetamine use during human pregnancy is currently unknown, animal studies have demonstrated neurotoxic effects of amphetamines and remodeling of synaptic morphology in response to prenatal methamphetamine exposure [109]. One study did describe a smaller putamen, globus pallidus, and hippocampus in methamphetamine-exposed children [108].

Pregnancy

Women using methamphetamine during pregnancy may have an increased rate of premature delivery and placental abruption [110]. Methamphetamine use during pregnancy is linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic intervention at birth [111]. Clefting, cardiac anomalies, and fetal growth reduction have been described in infants exposed to amphetamines during pregnancy. These findings have been reproduced in animal studies [112].

Child Health

Late effects on child health resulting from prenatal methamphetamine use are unknown. Children who live at or visit methamphetamine home labs face acute health and safety hazards from fires, explosions, and toxic chemical exposures, however. The caregiving environments of methamphetamine users are often characterized by chaos, neglect and abuse, and criminal behavior as well as the presence of firearms, contaminated sharps, and other risks [113].

Behavior and Cognition

The scant research describing the outcomes of methamphetamine-exposed children describes possible links with aggressive behavior, peer problems, and hyperactivity [114], [115]. A small recent study found that methamphetamine-exposed children scored lower on measures of visual motor integration, attention, verbal memory, and long-term spatial memory [108]. In rats, even low doses of prenatal methamphetamine exposure can alter learning and memory in adulthood [116].

Selected References

[105]   Anglin M.D.,  Burke C.,  Perrochet B.,  History of the methamphetamine problem. J Psychoactive Drugs (2000) 32 : pp 137-141.
[106]   Rhodes T.,  Bobrik A.,  Bobkov E.,  HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation. Int J Drug Policy (2004) 15 : pp 1-16.  
[107]   Sattah M.V.,  Supawitkul S.,  Dondero T.J.,  Prevalence of and risk factors for methamphetamine use in northern Thai youth: results of an audio-computer-assisted self-interviewing survey with urine testing. Addiction (2002) 97 : pp 801-808.
[108]   Chang L.,  Smith L.M.,  Lopresti C.,  Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Res (2004) 132 : pp 95-106.
[109]   Weissman A.D.,  Caldecott-Hazard S.,  Developmental neurotoxicity to methamphetamines. Clin Exp Pharmacol Physiol (1995) 22 : pp 372-374.
[110]   Eriksson M.,  Larsson G.,  Winbladh B.,  The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Paediatrica Scandinavica (1978) 67 : pp 95-99.  
[111]   Smith L.,  Yonekura M.L.,  Wallace T.,  Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr (2003) 24 : pp 17-23.
[112]   Plessinger M.A.,  Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 119-138.
[113]   Swetlow K.,  Children at clandestine methamphetamine labs: helping meth's youngest victims 2003. Washington, DC: US Department of Justice, Office of Justice Programs, Office for Victims of Crime.  
[114]   Billing L.,  Eriksson M.,  Jonsson B.,  The influence of environmental factors on behavioural problems in 8-year-old children exposed to amphetamine during fetal life. Child Abuse Negl (1994) 18 : pp 3-9.
[115]   Eriksson M.,  Billing L.,  Steneroth G.,  Health and development of 8-year-old children whose mothers abused amphetamine during pregnancy. Acta Paediatr Scand (1989) 78 : pp 944-949.
[116]   Williams M.T.,  Moran M.S.,  Vorhees C.V.,  Behavioral and growth effects induced by low dose methamphetamine administration during the neonatal period in rats. Int J Dev Neurosci (2004) 22 : pp 273-283.

Overview

Cocaine has received much attention since the 1980s, when crack cocaine began to plague urban America. Early alarmist predictions about an epidemic of neurologically damaged “crack babies” gave way to guarded optimism with early reports of neurodevelopmental functioning reporting no differences attributable to cocaine exposure. Follow-up studies with more specific measures, however, suggest effects of prenatal cocaine abuse on aspects of neurobehavior and language, as demonstrated with specific developmental tasks.

The rate of prenatal cocaine exposure in the United States ranges from 0.3% to 31% depending on the population surveyed and method of ascertainment [77], [78] and was 10% in the ongoing Maternal Lifestyle Study [34]. In our clinic's experience, reports of cocaine exposure in the international adoptee population are quite rare. The UNODC estimates the lifetime prevalence of cocaine consumption to be approximately 2% to 5% in a study of Guatemalan teenagers; in Russia, China, Korea, and other frequent countries of international adoption, the prevalence seems to be much less [35].

Mechanism

Cocaine and its metabolites readily cross the placenta, concentrating in amniotic fluid, and may produce direct neurotoxic effects, disturb monoaminergic (eg, dopamine, norepinephrine, serotonin) pathways, and cause vascular-mediated damage [91].

Pregnancy

The use of cocaine in pregnancy has been associated with a number of obstetric complications, such as stillbirth, placental abruption, premature rupture of membranes, fetal distress, and preterm delivery [92]. Growth restriction is often reported but may require higher levels of exposure and does not seem to persist after birth [93]. There may be a dose-response effect of cocaine on newborn head circumference [94]. Other CNS lesions (eg, stroke, cystic changes, possible seizures), cardiac defects, and genitourinary (GU) anomalies have also been reported, but the few available large, controlled, population-based studies on cocaine exposure and malformations have reached contradictory conclusions [95].

Behavior and Cognition

Prenatal cocaine abuse may cause specific neurobehavioral and learning problems, although it is not associated with global cognitive deficits [96], [97]. The largest matched cohort study to date found no significant covariate-controlled associations between cocaine exposure and mental, psychomotor, or behavioral functioning through 3 years of age [98]. Infant neurobehavioral abnormalities like irritability or excitability, sleep difficulties, and state regulation difficulty as well as transient neurologic abnormalities like tremor, hypertonia, and extensor posturing have been reported [99], [100]. Heavy prenatal cocaine use has been linked to poor memory and information processing in infancy [101]. At 3 years of age, increased fussiness, difficult temperament, and behavior problems were described [102]. Language delay has also been described, with foster or adoptive caregiving described as a promising protective factor [103], [104].

Selected References

[91]   Chiriboga C.A.,  Fetal effects. Neurol Clin (1993) 11 : pp 707-728.
[92]   Kain Z.N.,  Mayes L.C.,  Ferris C.A.,  Cocaine-abusing parturients undergoing cesarean section. A cohort study. Anesthesiology (1996) 85 : pp 1028-1035.
[93]   Nordstrom-Klee B.,  Delaney-Black V.,  Covington C.,  Growth from birth onwards of children prenatally exposed to drugs: a literature review. Neurotoxicol Teratol (2002) 24 : pp 481-488.
[94]   Bateman D.A.,  Chiriboga C.A.,  Dose-response effect of cocaine on newborn head circumference. Pediatrics (2000) 106 : pp E33-.
[95]   Vidaeff A.C.,  Mastrobattista J.M.,  In utero cocaine exposure: a thorny mix of science and mythology. Am J Perinatol (2003) 20 : pp 165-172.
[96]   Wasserman G.A.,  Kline J.K.,  Bateman D.A.,  Prenatal cocaine exposure and school-age intelligence. Drug Alcohol Depend (1998) 50 : pp 203-210.
[97]   Singer L.T.,  Minnes S.,  Short E.,  Cognitive outcomes of preschool children with prenatal cocaine exposure. Obstet Gynecol Surv (2005) 60 : pp 23-24.  
[98]   Messinger D.S.,  Bauer C.R.,  Das A.,  The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics (2004) 113 : pp 1677-1685.
[99]   Tronick E.Z.,  Frank D.A.,  Cabral H.,  Late dose-response effects of prenatal cocaine exposure on newborn neurobehavioral performance. Pediatrics (1996) 98 : pp 76-83.
[100]   Chiriboga C.A.,  Brust J.C.,  Bateman D.,  Dose-response effect of fetal cocaine exposure on newborn neurologic function. Pediatrics (1999) 103 : pp 79-85.
[101]   Jacobson S.W.,  Jacobson J.L.,  Sokol R.J.,  New evidence for neurobehavioral effects of in utero cocaine exposure. J Pediatr (1996) 129 : pp 581-590.
[102]   Richardson G.A.,  Prenatal cocaine exposure. A longitudinal study of development. Ann NY Acad Sci (1998) 846 : pp 144-152.  
[103]   Delaney-Black V.,  Covington C.,  Templin T.,  Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study. J Commun Disord (2000) 33 : pp 463-480.
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