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Une des premisses essentielles des modeles d'intervention et de l'education d'un enfant est que le comportement du nourrisson fait partie d'un systeme de communication avec le milieu de mode de soin. Cependant, les nourrissons varient selon les messages qu'ils transmettent au milieu de mode de soin et les parents varient selon leur aptitude a interpreter les signaux de leurs nourrissons et a offrir une mode de soin approprie. Cet article examine la tension que peut exister entre la communication du nourrisson et le mode de soin approprie

Mothers (N = 160) participating in a longitudinal study were interviewed to determine if their infants had colic. Infants with colic had to meet the criteria for excessive crying (crying for more than 3 hours a day, 3 days a week, for 3 weeks) plus show the following during episodes of colic: paroxysmal onset of cry, distinctive, high-pitched pain cry, infant is inconsolable and hypertonic. Sixteen 1- to 4-month-old infants who met the criteria for colic were compared with matched controls (N = 16) on the acoustic analysis of the infant's cry, on parent's perception of cry using eight standard rating scales, and on the Infant Characteristics Questionnaire measure of temperament. The cries of colic infants had a higher and more variable pitch and showed more turbulence. Parents rated the cries of these infants as more urgent, grating, piercing, and felt more sad and aroused by the cries. On the Infant Characteristics Questionnaire, colic infants scored higher on the fussy-difficult temperament dimension. Infants with colic show distinctive acoustic cry characteristics that are perceived by parents; parents rate these infants as having a more difficult temperament. Colicky infants appear to be a subset of infants with excessive crying and can be identified using clinical criteria.

The behavioral capabilities of neonatal chimpanzees are not well known. A major goal of this study was to document their ability to orient to social and nonsocial objects and to compare their performance with that of human infants. The Brazelton Neonatal Behavioral Assessment Scale (NBAS) was administered to 13 nursery-reared chimpanzees, every other day during their first month of life, and to 42 humans, twice, on the third and thirtieth day of life. The orientation items included social stimuli (a human face and both human and chimpanzee sounds) and nonsocial stimuli (a red ball and a red rattle). Repeated-measures analysis of variance on the orientation cluster of the NBAS revealed that chimpanzee neonates have the capacity for sustained attention to all stimuli, both social and nonsocial, indistinguishable from that of human neonotes. Significant improvements in orientation performance from Day 2 to Day 30 were found for both species. These striking similarities in early orientation ability are viewed as a challenge to notions of unique human propensities.

To determine whether Neonatal Intensive Care Unit Network Neurobehavior Scales (NNNS) at 44 weeks predict motor outcome at 2 years in preterm infants from the Maternal Lifestyles Study (MLS).Data were collected on all preterm infants (36 weeks) in the MLS who underwent an NNNS at 44 weeks (n = 395) and neurologic examination at 12 to 36 months or Bayley Psychomotor Development Index (PDI) at 24 months (n = 270). Logistic regression analyzed NNNS summary scores associated with cerebral palsy (CP) or PDI70, while controlling for birth weight/=1250 g.Eighteen of 395 infants (5%) had CP; 24 of 270 infants (9%) had PDI70. CP was associated with low quality of movement (odds ratio [OR], 1.95; 95% CI, 1.24-3.06; P = .004) and high lethargy (OR, 1.67; 95% CI, 1.01-2.76; P = .045). The model contributed 19% of the variance in CP diagnosis at 12 to 36 months (R(2) = .19, P.001). Low PDI was associated with low handling (OR, 1.83; 95% CI, 1.12-2.99; P = .017), low quality of movement (OR, 2.16; 95% CI, 1.38-3.38; P = .001), and hypotonia (OR, 1.63; 95% CI, 1.14-2.32; P = .007). The model contributed 26% of the variance in PDI70 at 24 months (R(2) = 0.26, P.001).The neurobehavioral profile of under-arousal in 44-week-old preterm infants may predict poor motor outcome.

Objective To evaluate the impact of prenatal cocaine exposure and small-for-gestational-age (SGA) status on childhood growth. Study design Cocaine exposure was defined by history or meconium metabolites. Hierarchical linear modeling was used to examine cocaine exposure and SGA status on growth, while controlling for exposure to other drugs and alcohol use. Results At birth cocaine-exposed infants (n = 364) had significantly lower growth parameters compared to non-exposed children (n = 771). At 6 years, weight was similar between exposed and unexposed children. SGA infants continued to be growth impaired. There was a significant interaction between prenatal cocaine exposure and SGA status at 6 years. The negative effects of cocaine on weight and height were greater among non-SGA than SGA children (432 vs. 280 gm, and 0.7 and 0.5 cm, respectively) while negative effects of SGA status on weight and height were larger in non-cocaine exposed compared to the exposed children (2.3 kg vs.1.6 kg and 2.2 and 1.0 cm). Conclusions Children exposed to prenatal cocaine were similar in weight to non-exposed children at 6 years of age. Cocaine had an unexplained greater detrimental effect on non-SGA than SGA children. SGA status at birth has an independent detrimental effect on childhood growth.

Follow-up studies relating prenatal cocaine and other substance exposures to behavioral problems during childhood typically use a behavioral teratology model.1–4 The goal here is to isolate the effects of a teratogen by controlling for effects of potential confounding variables through study design such as matching and/or statistics in which confounding variables are covaried. The variance in outcome explained by the confounding variables is essentially removed from the analysis, and the left over unexplained variance is attributed to the teratogen. For example, we found effects of prenatal cocaine exposure on trajectories of behavior problems from 3 to 7 years independent of the effects of prenatal exposure to alcohol and tobacco, as well as other potentially confounding variables.5 The behavioral teratology model is critically important because it enables us to determine, not only if there is a unique drug effect (i.e., drugs affect outcome when confounding factors are controlled), but also the magnitude of the drug effect (i.e., variability in the outcome measure explained by the drug alone). A limitation of the behavioral teratology approach, however, is that it does not lend itself to study the developmental processes that lead from exposure to developmental outcome. In addition to direct drug effects there may be indirect effects that suggest how factors mediate the relationship between teratogenic effects and developmental outcome. In a developmental model, effects that are removed as confounding variables can be studied as factors that explain more of the variability in developmental outcome in the presence of teratogenic effects. In other words, these factors are included rather than controlled or removed. In addition, other factors that are hypothesized to be involved in these developmental models can also be included. Statistical techniques such as path analysis or structural equation modeling (SEM) are often used to study these pathways. In previous work, path models have shown that growth deficits associated with prenatal cocaine exposure are mediated, in part, by gestational age.6 In addition to direct effects of prenatal cocaine exposure on IQ, there are indirect effects mediated by head circumference, child behavior, and the home environment.7 In our work, the relationship between prenatal cocaine exposure and hypertension was mediated by body mass index.8 In the present study, we used SEM to test a developmental model relating prenatal cocaine and other substance exposure to behavior problems at age 7. The primary hypothesis was that prenatal exposure to cocaine and other substances would result in neurobehavioral dysregulation in infancy (i.e., problems with arousal and reactivity), which would predict externalizing and internalizing behavior problems in childhood. Externalizing and internalizing behavior problems are part of the neurobehavioral disinhibition profile that includes cognitive, emotional, and behavioral disturbances.9 This profile reflects diminished inhibitory control and is related to early onset of substance use.9–11 In the present study, we were interested in the behavioral antecedents of neurobehavioral disinhibition. Therefore, we predicted children who showed signs of neurobehavioral dysregulation at one month would have a difficult temperament at 4 months, leading to behavior problems at 3 and 7 years of age. Our long-term goal is to delineate developmental pathways in which children with prenatal cocaine exposure are at increased risk for adolescent substance use.

Sleep data were collected by maternal report in a prospective longitudinal follow-up of cocaine exposed and unexposed children. There were 139 subjects: 23 with no prenatal drug exposure, 55 exposed to cocaine alone or in combination with other drugs, and 61 exposed to drugs other than cocaine. Characteristics differed between exposure groups, including birth size, caretaker changes, and maternal SES and postnatal drug use. Compared to those with no drug exposure, children with prenatal drug exposure other than cocaine experienced greater sleep problems (mean [SD], 5 [4.93] vs 7.7 [4.85], p = .026). Prenatal nicotine exposure was a unique predictor of sleep problems (R2 = .028, p = .048). Early sleep problems predicted later sleep problems (all p’s

Psychoactive drug use by pregnant women has the potential to effect fetal development; the effects are often thought to be drug-specific and gestational age dependent. This article describes the effects of three drugs with similar molecular targets that involve monoaminergic transmitter systems: cocaine, methamphetamine, and selective serotonin re-uptake inhibitors (SSRIs) used to treat maternal depression during pregnancy. We propose a possible common epigenetic mechanism for their potential effects on the developing child. We suggest that exposure to these substances acts as a stressor that affects fetal programming, disrupts fetal placental monoamine transporter expression and alters neuroendocrine and neurotransmitter system development. We also discuss neurobehavioral techniques that may be useful in the early detection of the effects of in utero drug exposure.

Previous studies suggest that prenatal methamphetamine exposure inhibits fetal growth. We examined neonatal growth effects of prenatal methamphetamine exposure in a prospective cohort study. After adjusting for covariates, exposed neonates had a higher incidence of being small for gestational age than unexposed neonates.

It has been reported that 83%–87% of full-term infants regularly sleep through the night (from midnight to 5 a.m.) by 6 months of age, but there is little information about the sleep patterns of premature infants. The purpose of the current study was to identify maternal perceptions of the sleep patterns of premature infants. Parents of 32 premature infants with birth weight below 1,750 gm and of 13 full-term infants completed a 24-hour sleep record in 30-minute epochs for 1 week at 7 months of chronological (term) or corrected age (premature). Mean birth weight of premature infants was 1,278 ± 340 gm, with a gestational age of 30.4 ± 2.7 weeks. The daily total sleep time, longest sleep segment, frequency of sleep-wake transitions, and percentage of night sleep (8 p.m.–8 a.m.), averaged from the 1-week sleep record and number of night wakenings per week, were used as indicators of sleep patterns. The longest reported sleep segments of premature infants were significantly shorter than those of full-term infants (8.2 ± 2 hours versus 9.6 ± 1 hour, p < 0.01) and the number of night wakenings per week was significantly greater (3.13 ± 3 versus 0.54 ± 7, p < 0.005). Total reported sleep time, percentage of night sleep, and sleep-wake transitions did not differ significantly between premature and full-term infants. However, analysis of feeding events revealed that premature infants received significantly more feedings between midnight and 5 a.m. (M = 0.31 + 3 versus M = 0.06 + 1, p < 0.001). We conclude that sleep pattern diaries kept by parents indicate that premature infants have developed a diurnal sleep rhythm by 7 months corrected age, but they still have shorter sleep segments and they awaken more during the night than term infants. Il a ete etabli que 83-87% des nourrissons nes a terme font regulierement leur nuit (de minuit a cinq heures du matin) a l'ǎge de six mois, mais il n'existe guere d'information sur les patterns de sommeil des nourrissons prematures. Le but de cette etude etait d'identifier les perceptions maternelles des patterns de sommeil des nourrissons prematures. Les parents de 32 nourrissons prematures dont le poids a la naissance etait de moins de 1750 gm et de 13 nourrissons Venus a terme ont complete un journal de sommeil etabli sur 24 heures et divise en periodes de 30 minutes pendant une semaine, ceci a 7 mois, ǎge chronologique (bebes a terme) ou ǎge corrige (prematures). La moyenne du poids a la naissance des nourrissons prematurts etait de 1278 ± 340 gm, avec un ǎge gestationnel de 30,4 ± 2,7 semaines. Le temps de sommeil total journalier, le segment de sommeil le plus long, la frequence des transitions sommeil-reveil et le pourcentage de nuit de sommeil (de huit heures du soir a huit heures du matin), dont la moyenne fut effectuee a partir du rapport de sommeil d'une semaine et du; nombre de reveils dans la nuit par semaine, ont ete utilises comme indicateurs de patterns de sommeil. Les segments de sommeil les plus longs qui furent rapportes chez les nourrissons prematures etaient bien plus courts que ceux des nourrissons nes a terme (8.2 ± 2 heures) par rapport a (9,6 ± 1 heure (p < 0.01) et le nombre de reveils durant la nuit par semaine etait beaucoup plus grand (3,13 ± 3 par rapport a 34 ± 7 (p < 0.005). Le temps de sommeil total rapporte, le pourcentage de sommeil pendant la nuit, et les transitions sommeil-reveil ne differaient pas de maniere significative entre les nourrissons prematures et ceux Venus a terme. Cependant, l'analyse des prises de nourriture a revele que les nourrissons prematures etaient plus souvent nourris entre minuit et cinq heures du matin. (M = 0.31 = 3 par rapport a M = 0.06 = 1; p < 0.001). Nous concluons que les journaux sur le sommeil que tiennent les parents indiquent que les nourrissons prematures ont developpe un rythme de sommeil diurne des l'ǎge de 7 mois en ǎge corrige, mais qu'ils continuent a avoir des segments de sommeil plus courts et qu'ils se reveillent plus souvent durant la nuit que les nourrissons a terme.

Treatment programs for women who use drugs during pregnancy have developed out of a backdrop of punitive policies and the psychosocial complexities of this population, which include psychological comorbidities and consideration of the needs of their children. In this literature review, we examine evidence-based approaches to treatment for these women and some promising newer initiatives. We also discuss limitations of this research and issues that need to be addressed. The increasing understanding and acceptance of substance abuse as a treatable mental health disorder brings renewed optimism to this field.

Increased use of cocaine in the United States in the 1980s turned the scientific community toward studying the children of mothers who used cocaine during pregnancy. Initial legal and social stigma attached to mothers who abused cocaine during pregnancy and their “crack kids” who were feared to be “brain damaged”1,2 has been tempered by evidence that the risk for serious congenital malformations or medical complications in newborns with prenatal cocaine exposure (PCE) is minimal3; however, little is known about the potential long-term neurodevelopmental effects of PCE. Previous studies revealed varying effects of PCE on behavior4–6 and cognitive outcomes.7–13 Longitudinal follow-up studies of the intelligence of these children suggested that cocaine effects are apparent but more subtle than originally feared.14 Inconsistencies in the cocaine literature have been described and may be attributable to methodologic issues such as small sample size; confounding of cocaine exposure with exposure to other drugs; lack of biochemical verification for exposure status and levels; and lack of adequate control for demographic variables such as prenatal care, socioeconomic status (SES), and out-of-home placement.14,15 There are few studies of school function in children with PCE. Teacher rating of school behavior suggested increased behavior problems in children with PCE in some5,6,16 but not all studies.17 Studies have reported adverse effects of PCE on language in children aged 2.5 to 9.5 years,14,18–24 whereas others have not25,26; however, there are no studies of use of school-based speech and language services in this group. One study of school performance showed no effects of PCE on grade progression, grade point average, or standardized test.27 We provide the first report of enrollment in special education of children with PCE. These services require significant school funding and teacher resources. On the basis of these findings, we hypothesized that PCE is associated with higher rates of enrollment in special education and the need for support services at 7 years, especially speech and language services.

The pathophysiology of the effects of cocaine on fetal development has been described along 2 major pathways: neurochemical effects and vasoconstrictive effects. Following a summary of these effects, we suggest a ‘third pathophysiology’ in which altered fetal programming affects the acute and long-term adverse effects of in utero cocaine exposure. We describe how cocaine as a stressor alters the expression of key candidate genes, increasing exposure to catecholamines and fetal cortisol-altering neuroendocrine (hypothalamic-pituitary-adrenal axis) activity, leading to infant behavioral dysregulation, poor behavioral control and emotion regulation during childhood and phenotypes that confer vulnerability to substance use in adolescence. This model is discussed in relation to follow-up studies of the effects of in utero cocaine exposure and maturational changes in brain development.

Prenatal nicotine exposure via maternal smoking during pregnancy has been described as “the most widespread prenatal drug insult in the world”.1 Despite pervasive medical and societal sanctions against maternal smoking, between 11 and 30% of women continue to smoke during pregnancy.2–4 Rates are as high as 50% in high-risk samples, including young, poor, and urban populations.3, 4 Compared with other pregnant substance users, pregnant smokers are less likely to quit during pregnancy,5 and use cigarettes more frequently.3 Maternal smoking during pregnancy has been linked to low birthweight, admission to neonatal intensive care units, increased risk for sudden infant death syndrome,2, 3, 6 and long-term adverse neurobehavioral outcomes in offspring including attention deficits, hyperactivity, conduct disorder, and substance/nicotine use.7–10. Relatively less attention has been focused on neurobehavioral outcomes of maternal smoking during the newborn period. Documenting early effects of maternal smoking is critical for identifying vulnerability markers for intervention and prevention efforts, examining unfolding developmental pathways, and educating parents of exposed infants. Our group published the first study specifically designed to examine effects of maternal smoking on newborn neurobehavior controlling for likely confounds and involving biochemical verification of smoking.11 We utilized a neurobehavioral examination designed for examining effects of prenatal drug exposure in infants: the NICU Network Neurobehavioral Scale; NNNS.12 After adjustment for significant covariates, tobacco-exposed infants were more excitable, hypertonic, and required more handling compared with unexposed infants. Exposed infants also showed higher scores on the NNNS stress-scale—a scale demonstrated to reveal signs of neonatal abstinence following exposure to other drugs of abuse. Effects of maternal smoking/nicotine exposure on offspring neurobehavior and signs of abstinence in the immediate newborn period (up to postnatal day 5) have been corroborated by two additional studies. Both examined specific effects of maternal tobacco exposure and involved biochemical verification of exposure.13, 14 What remains unknown, however, is whether behavioral effects in the newborn period signify acute effects of nicotine, a withdrawal process, or more persistent dysregulation representing early vulnerability for later neurobehavioral deficits. This pilot study represents the first examination of specific effects of maternal smoking during on infant neurobehavior at 10–27 days. The half-life of nicotine is approximately 2.5 hours in adults15 and 9–11 hours in newborns,16--one of the shortest half-lives of drugs used during pregnancy17. Most nicotine withdrawal symptoms in adults peak at one week.18 Further, neonatal withdrawal from drugs with longer half-lives (e.g., caffeine) typically last less than 10 days17. Thus, examining infants at 10–27 days is less likely to indicate acute effects of nicotine or nicotine withdrawal and may represent a neurobehavioral profile more consistent with early vulnerability to long-term behavioral deficits. As in our prior study, 11 we utilized the NNNS to measure infant neurobehavior and cotinine as a bioassay for nicotine exposure. By design, smokers and non-smokers were matched for common confounders as in prior studies: socioeconomic status, alcohol use, and age. Exposed and unexposed infants were selected to be healthy, full-term, and normal birthweight.

Objective To examine the relationship between early parenting stress and later child behavior in a high-risk sample and measure the effect of drug exposure on the relationship between parenting stress and child behavior. Methods A subset of child-caregiver dyads (n = 607) were selected from the Maternal Lifestyle Study (MLS), which is a large sample of children (n = 1,388) with prenatal cocaine exposure and a comparison sample unexposed to cocaine. Of the 607 dyads, 221 were prenatally exposed to cocaine and 386 were unexposed to cocaine. Selection was based on the presence of a stable caregiver at 4 and 36 months with no evidence of change in caregiver between those time points. Results Parenting stress at 4 months significantly predicted child externalizing behavior at 36 months. These relations were unaffected by cocaine exposure suggesting the relationship between parenting stress and behavioral outcome exists for high-risk children regardless of drug exposure history. Conclusions These results extend the findings of the relationship between parenting stress and child behavior to a sample of high-risk children with prenatal drug exposure. Implications for outcome and treatment are discussed.

Introduction Birth weight often is used to predict how preterm infants will grow, but scant attention has been paid to the effect of neonatal morbidities on growth trajectories. We investigated birth weight and neonatal morbidity in preterm infants’ growth to age 12 years. Method A five-group, prospective, longitudinal study was conducted with 194 infants: 46 full term; 29 healthy preterm without morbidity; 56 preterm with medical illness (MPT); 34 preterm with neurologic illness; and 29 preterm small for gestational age (SGA). Height, weight, and body mass index were measured at six ages. Results The full-term group had greater height than the preterm groups to age 8 years, when healthy preterm and MPT groups caught up. Only the SGA group had smaller height at age 12 years. The MPT, preterm with neurologic illness, and SGA groups had lower weight through age 12 years. Body mass index was appropriate for preterm groups by age 4 years. Across time, neonatal morbidity had a significant effect on height and weight trajectories. Birth weight was significant for weight trajectories only. Discussion With variation in growth trajectories, details of neonatal morbidity in health history interviews will inform child health assessments.

Our understanding of the etiology, pathophysiology, sequelae, incidence, and management of colic is hampered by the absence of a standard definition and accepted clinical criteria for colic. In this paper we distinguish colic from excessive crying and offer a set of criteria that can be used in clinical practice to determine if an infant has colic or excessive crying. We also discuss differences between colic and excessive crying from a developmental perspective, including biological and transactional components. We conclude that many components have long-term consequences for the parent-infant relationship, and we briefly consider some directions for colic management.

Robert was small and slightly underweight at birth. He had been exposed to drugs while his mother was pregnant. His cries sometimes sounded high-pitched, and he was often tense and rigid. Robert's mother moved twice before he was two years old. First she moved in with her mother; then she moved out again. Robert was not quite as quick as other children at learning new words. He was not good at sorting blocks and learning to pick up beads. Robert had a new sister, a half-sister, when he was three. There were not many books or magazines at home. When Robert began kindergarten, he had trouble learning the letters. Sometimes, he seemed a little tuned out and apathetic. Neighborhood poverty and family disorganization contributed to Robert's delayed developmental course – as did the prenatal insult of Robert's mother's substance abuse. In our society, prenatal drug exposure is a major public health problem. Many drugs used during pregnancy travel freely through the umbilical cord and cross the fetal blood–brain barrier. What kind of effect would such drugs have on Robert's development? A developmental systems model suggests that the interplay of many factors influenced Robert's development. The impact of drugs on the fetus during the pregnancy depends on the timing of use, dosage, level of prenatal nutrition, and individual differences among mothers, some of which may be heritable. The impact of maternal drug abuse on subsequent child development is even more complex and multidetermined.

In this first study of violence and resilience in 517 youth exposed to cocaine and other drugs during pregnancy, we identified specific links between four types of violence and delinquency, drug use, and psychopathology in early adolescence. Further, positive and interpersonal attributes promoted resilience in the face of exposure to violence and other risks. This study provides new evidence for the impact of violence as well as resilience against disruptive forms of psychopathology and behavior.

The impact of maternal substance abuse is reflected in the 2002–2003 National Survey on Drug Use and Health. Among pregnant women in the 15–44 age group, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. Maternal pregnancy complications following substance use include increases in sexually transmitted disorders, placental abruption and HIV-positive status. Effects on the neonate include a decrease in growth parameters and increases in central nervous system and autonomic nervous system signs and in referrals to child protective agencies. In childhood, behavioral and cognitive effects are seen after prenatal cocaine exposure; tobacco and alcohol have separate and specific effects. The ongoing use of alcohol and tobacco by the caretaker affects childhood behavior. Therefore, efforts should be made to prevent and treat behavioral problems as well as to limit the onset of drug use by adolescent children born to women who use drugs during pregnancy.

OBJECTIVE. Methamphetamine use among pregnant women is an increasing problem in the United States. Effects of methamphetamine use during pregnancy on fetal growth have not been reported in large, prospective studies. We examined the neonatal growth effects of prenatal methamphetamine exposure in the multicenter, longitudinal Infant Development, Environment and Lifestyle study.DESIGN/METHOD. The Infant Development, Environment and Lifestyle study screened 13808 subjects at 4 clinical centers: 1618 were eligible and consented, among which 84 were methamphetamine exposed, and 1534 were unexposed. Those who were methamphetamine exposed were identified by self-report and/or gas chromatography-mass spectrometry confirmation of amphetamine and metabolites in infant meconium. Those who were unexposed denied amphetamine use and had a negative meconium screen. Both groups included prenatal alcohol, tobacco, or marijuana use, but excluded use of opiates, LSD, PCP or cocaine only. Neonatal parameters included birth weight and gestational age in weeks. One-way analysis of variance and linear-regression analyses were conducted on birth weight by exposure. The relationship of methamphetamine exposure and the incidence of small for gestational age was analyzed using multivariate logistic-regression analyses.RESULTS. The methamphetamine exposed group was 3.5 times more likely to be small for gestational age than the unexposed group. Mothers who used tobacco during pregnancy were nearly 2 times more likely to have small-for-gestational-age infants. In addition, less maternal weight gain during pregnancy was more likely to result in a small-for-gestational-age infant. Birthweight in the methamphetamine exposed group was lower than the unexposed group.CONCLUSIONS. These findings suggest that prenatal methamphetamine use is associated with fetal growth restriction after adjusting for covariates. Continued follow-up will determine if these infants are at increased risk for growth abnormalities in the future.

Objective: To examine the association between intrauterine growth restriction (IUGR) status at birth among full-term infants, exposure to substance use during pregnancy, and risk of hypertension at 6 years of age. Design: Prospective evaluation of high-risk children. Setting: Four centers of the National Institute of Child Health and Human Development Neonatal Research Network. Participants: One thousand three hundred eighty-eight infants (600 cocaine exposed, 781 nonexposed, and 7 indeterminate, matched by gestational age, race, and sex), were enrolled at these sites. Nine hundred fifty children (415 exposed, 535 nonexposed) were followed up for 6 years. Intervention: Right arm blood pressure was measured using the Dinamap portable adult/pediatric monitor with appropriate cuff size. Main Outcome Measure: Blood pressure levels. Hypertension was defined as either systolic or diastolic blood pressure higher than the 95th percentile for sex, age, and height. Results: Eight hundred ninety-one children had blood pressure data at 6 years of age: 516 were born at full term; 144 (28%) of the 516 children had a diagnosis of IUGR at birth. At 6 years of age, 93 (19%) of 516 children had hypertension. Of 144 children with IUGR, 35 (24%) had hypertension as compared with 58 (16%) of 372 children without IUGR (P

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

To identify associations between cocaine exposure during pregnancy and medical conditions in newborn infants from birth through hospital discharge.Multisite, prospective, randomized study.Brown University, University of Miami, University of Tennessee (Memphis), and Wayne State University. Subjects A total of 717 cocaine-exposed infants and 7442 nonexposed infants.Results of physical examination and conditions observed during hospitalization.Cocaine-exposed infants were about 1.2 weeks younger, weighed 536 g less, measured 2.6 cm shorter, and had head circumference 1.5 cm smaller than nonexposed infants (all P.001). Results did not confirm previously reported abnormalities. Central and autonomic nervous system symptoms were more frequent in the exposed group: jittery/tremors (adjusted odds ratio, 2.17; 99% confidence interval, 1.44-3.29), high-pitched cry (2.44; 1.06-5.66), irritability (1.81; 1.18-2.80), excessive suck (3.58; 1.63-7.88), hyperalertness (7.78; 1.72-35.06), and autonomic instability (2.64; 1.17-5.95). No differences were detected in organ systems by ultrasound examination. Exposed infants had more infections (3.09; 1.76-5.45), including hepatitis (13.46; 7.46-24.29), syphilis (8.84; 3.74-20.88), and human immunodeficiency virus exposure (12.37; 2.20-69.51); were less often breastfed (0.26; 0.15-0.44); had more child protective services referrals (48.92; 28.77-83.20); and were more often not living with their biological mother (18.70; 10.53-33.20).Central and autonomic nervous system symptoms were more frequent in the exposed cohort and persisted in an adjusted analysis. They were usually transient and may be a true cocaine effect. Abnormal anatomic outcomes previously reported were not confirmed. Increased infections, particularly sexually transmitted diseases, pose a serious public health challenge. Exposure increased involvement of child protective services and out-of-home placement.

To determine the factors that would increase the likelihood of outcomes: low birth weight (LBW), preterm births and intrauterine growth restriction (IUGR). Secondary data analysis from a multi-center study. Risk factors for each outcome were derived from logistic regression models. Odds ratios (OR), 95% confidence intervals, and population-attributable risk proportions (PAR%) were estimated. Prenatal cocaine exposure increased the likelihood of LBW (OR: 3.59), prematurity (OR: 1.25), and IUGR (OR: 2.24). Tobacco, but not marijuana, significantly influenced these outcomes. Alcohol had an effect on LBW and IUGR. Etiologic fractions (PAR%) attributable to tobacco for LBW, prematurity, and IUGR were 5.57, 3.66, and 13.79%, respectively. With additional drug exposure including cocaine, estimated summary PAR% increased to 7.20% (LBW), 5.68% (prematurity), and 17.96% (IUGR). Disease burden for each outcome increases with each added drug exposure; however, etiologic fraction attributable to tobacco is greater than for cocaine.

Infant crying signals distress to potential caretakers who can alleviate the aversive conditions that gave rise to the cry. The cry signal results from coordination among several brain regions that control respiration and vocal cord vibration from which the cry sounds are produced. Previous work has shown a relationship between acoustic characteristics of the cry and diagnoses related to neurological damage, SIDS, prematurity, medical conditions, and substance exposure during pregnancy. Thus, assessment of infant cry provides a window into the neurological and medical status of the infant. Assessment of infant cry is brief and noninvasive and requires recording equipment and a standardized stimulus to elicit a pain cry. The typical protocol involves 30 seconds of crying from a single application of the stimulus. The recorded cry is submitted to an automated computer analysis system that digitizes the cry and either presents a digital spectrogram of the cry or calculates measures of cry characteristics. The most common interpretation of cry measures is based on deviations from typical cry characteristics. Another approach evaluates the pattern across cry characteristics suggesting arousal or under-arousal or difficult temperament. Infants with abnormal cries should be referred for a full neurological evaluation. The second function of crying--to elicit caretaking--involves parent perception of the infant's needs. Typically, parents are sensitive to deviations in cry characteristics, but their perception can be altered by factors in themselves (e.g., depression) or in the context (e.g., culture). The potential for cry assessment is largely untapped. Infant crying and parental response is the first language of the new dyadic relationship. Deviations in the signal and/or misunderstanding the message can compromise infant care, parental effectiveness, and undermine the budding relationship. (c) 2005 Wiley-Liss, Inc. MRDD Research Reviews 2005;11:83-93.

Background Prenatal cocaine exposure is a marker of developmental risk. Social environmental risk factors may include maternal stress and maternal perceptions of difficult infant temperament. Objectives To examine factors that may predict or moderate maternal ratings of parenting stress and difficult temperament in cocaine-exposed (CE) infants. Method Neonatal behavior, infant temperament, parenting stress, and maternal psychopathology were measured in a large sample of infant-mother dyads with prenatal CE and a nonexposed comparison sample. Participants were drawn from an existing longitudinal data set (Maternal Lifestyle Study). Result Relations between neonatal behavior and infant temperament ratings were moderated by mothers' ratings of parenting stress. Relations between neonatal cry and parenting stress were moderated by maternal psychopathology ratings. Results were unrelated to drug exposure history. Conclusions For mothers of at risk infants (with or without prenatal CE), psychological distress affects the degree to which infant behavioral characteristics are experienced as stressful or difficult. Implications for treatment and outcome are discussed.

A partially randomised, controlled trial was performed to test the hypothesis that opiate exposed infants treated with diluted tincture of opium (DTO) and phenobarbital would have better neurobehavioral scores than infants treated with DTO alone. Compared with those treated with DTO alone (n = 15), infants treated with DTO and phenobarbital (n = 17) were more interactive, had smoother movements, were easier to handle, and less stressed. Dual treatment results in improved neurobehavioral organisation during the first three weeks of life, which may indicate a more rapid recovery from opiate withdrawal.

Aims: To examine the relation between colic and feeding difficulties and their impact on parental functioning for a primarily clinic referred sample. Methods: Forty three infants (and their mothers) were enrolled between 6 and 8 weeks of age. Infants were divided into two groups, colic (n = 19) and comparison (n = 24), based on a modified Wessel rule of three criteria for colic. Families were assessed at two visits; one occurred in the laboratory and one occurred in a paediatric radiology office. Outcome measures included the clinical assessment of infant oral motor skills, behavioural observation of mother-infant feeding interactions, maternal questionnaires on infant crying, sleeping and feeding behaviours, and the occurrence of gastro-oesophageal reflux (GOR) in the infants using abdominal ultrasound. Results: Infants in the colic group displayed more difficulties with feeding; including disorganised feeding behaviours, less rhythmic nutritive and non-nutritive sucking, more discomfort following feedings, and lower responsiveness during feeding interactions. Infants in the colic group also had more evidence of GOR based on the number of reflux episodes on abdominal ultrasound as well as maternal report of reflux. Mothers in the colic group reported higher levels of parenting stress. Conclusions: Results provide the first systematic evidence of feeding problems in a subgroup of infants with colic. Data also illustrate the impact of these difficulties on parental and infant functioning. The association between feeding difficulties and colic suggests the potential for ongoing regulatory problems in infants presenting with clinically significant colic symptoms.

Objective. To determine the effects of patterns of drug use during term pregnancy on infant growth parameters at birth. Methods. Histories of cocaine, opiate, alcohol, tobacco, and marijuana use during the 3-month period before pregnancy and the 3 trimesters of pregnancy were recorded at the infants’ 1-month visit. Patterns of use were categorized as consistently high, moderate, or low/none or increasing/decreasing, and effects on growth parameters were analyzed in multivariate linear regression analyses, with adjustment for clinical site, maternal age, prepregnancy weight, multidrug use, and socioeconomic status. Results. A total of 241 cocaine-exposed women and 410 non–cocaine-exposed women participated in the study. In the cocaine-exposed group, 75% used alcohol, 90% used tobacco, and 53% used marijuana; in the non–cocaine-exposed group, 57% used alcohol, 34% used tobacco, and 19% used marijuana. Birth weight, birth length, and head circumference were significantly greater among infants born to women who used no drugs, compared with women with any cocaine, opiate, alcohol, tobacco, or marijuana use, and were greater among infants born to cocaine nonusers, compared with cocaine users. With adjustment for confounders, birth weight was significantly affected by cocaine (deficit of 250 g with consistently low pattern) and tobacco (deficits of 232 g with consistently high pattern, 173 g with consistently moderate pattern, 153 g with decreasing pattern, and 103 g with consistently low pattern). Head size was affected by cocaine (deficit of 0.98 cm with consistently moderate pattern) and tobacco (deficits of 0.72 cm with consistently high pattern and 0.89 cm with consistently moderate pattern). Birth length was affected by tobacco use only (deficits of 0.82 cm with consistently high pattern and 0.98 cm with decreasing use). Conclusion. Patterns of tobacco use during pregnancy affect birth weight, length, and head circumference, whereas cocaine affects birth weight and head size, when adjustments are made for confounders, including multidrug use.

Objective. To evaluate the direct effects of prenatal cocaine exposure and prenatal opiate exposure on infant mental, motor, and behavioral outcomes longitudinally between 1 and 3 years old.Methods. As part of a prospective, longitudinal, multisite study, the Bayley Scales of Infant Development II were administered to 1227 infants who were exposed to cocaine (n = 474), opiates (n = 50), cocaine and opiates (n = 48), and neither substance (n = 655) at 1, 2, and 3 years of corrected age by certified, masked examiners. Hierarchic linear modeling of the 1-, 2-, and 3-year scores was conducted using cocaine and opiate exposure as predictors with and without controlling for covariates.Results. Overall retention was 88.4% and did not differ by cocaine or opiate exposure. Overall (at 1, 2, and 3 years), cocaine-exposed infants scored 1.6 Mental Development Index points below infants who were not exposed to cocaine. Opiate-exposed infants scored 3.8 Psychomotor Development Index points below infants who were not exposed to opiates. Neither the cocaine nor the opiate effect remained significant after controlling for covariates. Neither cocaine nor opiate exposure was associated with the Behavioral Record Score during the examination. Low birth weight and indices of nonoptimal caregiving were associated with lower Mental Development Index, Psychomotor Development Index, and Behavioral Record Score scores for all groups of infants.Conclusions. In the largest at-risk sample observed longitudinally to date, infant prenatal exposure to cocaine and to opiates was not associated with mental, motor, or behavioral deficits after controlling for birth weight and environmental risks.

The phenomenon of substance abuse during pregnancy has fostered much controversy, specifically regarding treatment vs. punishment. Should the pregnant mother who engages in substance abuse be viewed as a criminal or as someone suffering from an illness requiring appropriate treatment? As it happens, there is a noticeably wide range of responses to this matter in the various states of the United States, ranging from a strictly criminal perspective to one that does emphasize the importance of the mother's treatment. This diversity of dramatically different responses illustrates the failure to establish a uniform policy for the management of this phenomenon. Just as there is lack of consensus among those who favor punishment, the same lack of consensus characterizes those states espousing treatment. Several general policy recommendations are offered here addressing the critical issues. It is hoped that by focusing on these fundamental issues and ultimately detailing statistics, policymakers throughout the United States will consider the course of action that views both pregnant mother and fetus/child as humanely as possible.

Features of the Neonatal Intensive Care Unit Network Neurobehavioral Scale that make the examination useful for clinical application are described. Clinical applications in various settings and populations are described. This is followed by a summary of the clinical significance of the examination according to the packages of administration. We then explain how to use the summary scores clinically, writing a clinical summary and the clinical interpretation of the summary scores. Finally, we present a case study with a clinical summary and a work sheet that clinicians may find useful for clinical consultation with caregivers and parents.

Descriptive statistics for the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores are provided based on data from 1388 1-month-old infants in the Maternal Lifestyle Study (MLS) of prenatal drug exposure and child outcome. The multisite MLS is described, followed by tables with descriptive statistics and percentile for the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores. The tables include data for the entire MLS sample as well as tables by drug exposure status, gestational age, poverty status, sex, race and ethnicity, and MLS study site. These tables can be used as quasinorms for comparison with other infants of this age.

The procedures for the Neonatal Intensive Care Unit Network Neurobehavioral Scale includes a brief background, description of the examination, key concepts, a summary of the procedures, and order of administration of the items described in "packages," information about the testing kit, scoring issues, and summary scores. This is followed by presentation of the 115 items that are scored. Each item is described, including (where appropriate) specific procedures for how to manipulate or handle the infant. Rating scales with scoring criteria are provided for each item. With training and certification, users of the manual will be able to reliably administer and score the Neonatal Intensive Care Unit Network Neurobehavioral Scale.

Occupational therapists working with infants in neonatal intensive care units (NICUs) make positioning recommendations to optimize self-regulation, with little published data supporting this practice. In this retrospective descriptive study, 15 hospitalized preterm infants (Mgestational age = 32 weeks) were videotaped during noncaregiving periods in order to record the frequency of specific behaviors in relation to six infant positions (prone nested, prone un-nested, side-lying nested, side-lying un-nested, supine nested, and supine un-nested). Behaviors coded were those that suggest infant stress or motor efforts at self-regulation, as defined for the original study. Mixed effects regressions and post-hoc Tukey Honestly Significant Difference tests were used to analyze the data, after the calculation of a ratio of the number of behaviors in each position. Higher ratio values reflect a greater occurrence of behaviors. The number of motor self-regulatory and stress behaviors were related to infant position, with the highest ratios of behaviors observed in side-lying un-nested and the lowest in prone nested. Behavior ratios did not differ between prone un-nested and prone nested, nor between supine un-nested and supine nested. More self-regulatory and stress behaviors were related to longer periods of fussing and crying. Longer periods of light sleep were related to fewer stress behaviors. Infants performed the fewest stress behaviors in prone nested, prone un-nested, or side-lying nested. These positions may benefit infants in the NICU by reducing the need for motor-based self-regulatory behaviors and potentially conserving energy for growth.

Objective. This was a prospective study of the effects of maternal smoking during pregnancy on newborn neurobehavior, including dose-response relationships using self-report and a bioassay of nicotine exposure.Methods. The sample included 27 nicotine exposed and 29 unexposed full-term newborn infants with no medical problems from comparable social class backgrounds. Mothers were excluded for using illegal drugs during pregnancy, using antidepressant medication, or if they consumed >3 alcoholic drinks per month. Nicotine exposure was determined by maternal self-report and cotinine in maternal saliva. The NICU Network Neurobehavioral Scale (NNNS) was administered by masked examiners in hospital to measure neurobehavioral function. NNNS scores were compared between nicotine-exposed and -unexposed groups including adjustment for covariates. Dose-response relationships with NNNS scores were computed for maternal salivary cotinine and maternal report of number of cigarettes per day during pregnancy.Results. After adjustment for covariates, the tobacco-exposed infants were more excitable and hypertonic, required more handling and showed more stress/abstinence signs, specifically in the central nervous system (CNS), gastrointestinal, and visual areas. Dose-response relationships showed higher maternal salivary cotinine values related to more stress/abstinence signs (r = .530) including CNS (r = .532) and visual stress (r = .688) and higher excitability scores (r = .617). Cigarettes per day during pregnancy was related to more stress/abstinence signs (r = .582) including CNS (r = .561) and visual stress (r = .640).Conclusions. These findings suggest neurotoxic effects of prenatal tobacco exposure on newborn neurobehavior. Dose-response relationships could indicate neonatal withdrawal from nicotine. Research directed at understanding the effects of cigarette smoking during pregnancy on infants can lead to improved public health outcome.

Aims: To determine risk for central nervous system/autonomic nervous system (CNS/ANS) signs following in utero cocaine and opiate exposure. Methods: A multisite study was designed to determine outcomes of in utero cocaine and opiate exposure. A total of 11 811 maternal/infant dyads were enrolled. Drug exposed (EXP) infants were identified by maternal self report of cocaine or opiate use or by meconium testing. Of 1185 EXP, meconium analysis confirmed exposure in 717 to cocaine (CO) only, 100 to opiates (OP), and 92 to opiates plus cocaine (OP+CO); 276 had insufficient or no meconium to confirm maternal self report. Negative exposure history was confirmed in 7442 by meconium analysis and unconfirmed in 3184. Examiners masked to exposure status, assessed each enrolled infant. Using generalised estimating equations, adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated for manifesting a constellation of CNS/ANS outcomes and for each sign associated with cocaine and opiate exposure. Results: Prevalence of CNS/ANS signs was low in CO, and highest in OP+CO. Signs were significantly related to one another. After controlling for confounders, CO was associated with increased risk of manifesting a constellation of CNS/ANS outcomes, OR (95% CI): 1.7 (1.2 to 2.2), independent of OP effect, OR (95% CI): 2.8 (2.1 to 3.7). OP+CO had additive effects, OR (95% CI): 4.8 (2.9 to 7.9). Smoking also increased the risk for the constellation of CNS/ANS signs, OR (95% CI) of 1.3 (1.04 to 1.55) and 1.4 (1.2 to 1.6), respectively, for use of less than half a pack per day and half a pack per day or more. Conclusion: Cocaine or opiate exposure increases the risk for manifesting a constellation of CNS/ANS outcomes.

The purpose of this study was to test the hypothesis that treatment of neonatal opiate withdrawal (NOW) in the term infant with diluted tincture of opium (DTO) and phenobarbital was superior to treatment with DTO alone.This was a partially randomized, controlled trial in which 20 term infants exposed to methadone and/or heroin in utero were studied. The severity of NOW was assessed by using the Finnegan scoring system. Infants were assigned to either DTO and placebo (n = 10) or DTO and phenobarbital (n = 10) when medication was required. The primary outcome variable was the duration of hospitalization. Severity of withdrawal and hospital cost were secondary outcome variables.There were no significant differences in the gestational age, growth variables, maternal methadone dose, or age at enrollment between the 2 groups. The duration of hospitalization was reduced by 48% (79-38 days) (P.001) and hospital cost per patient reduced by $35,856 (P.001) for the DTO and phenobarbital group. Furthermore, these infants spent less time with severe withdrawal (P.04), more time with mild withdrawal (P.03), and required a lower maximum daily DTO dose (P.009) when compared with the DTO-only group. The average duration of outpatient phenobarbital use was 3.5 months.The combined use of DTO and phenobarbital resulted in a shorter duration of hospitalization, less severe withdrawal, and reduced hospital cost. This combination may be a preferred regimen for the treatment of NOW.

Objective. The purpose of this prospective longitudinal study was to examine neurocognitive and school performance outcomes of low birth weight infants with reference to neonatal morbidity and socioeconomic status. We further evaluated the cognition and school performance based on their neurologic status at the time of assessment. Methods. One hundred eighty-eight children (39 healthy full-term and 149 preterm infants) were classified into 4 subgroups based on their neonatal medical status: healthy, sick (without neurologic complications), small for gestational age, and neurologically compromised infants. Neurologic status was classified as normal, suspect, or abnormal at hospital discharge, 18 months, 30 months, 4 years, and 8 years of age. Socioeconomic status, cognitive, and school performances were assessed. Results. Neurologically, both full-term and healthy preterm groups did well during the 8-year period. There were significant fluctuations between suspect and abnormal neurologic classifications among the 3 preterm groups with neonatal complications. Preterms with neurologic abnormality during the neonatal period did the poorest with 45% of the group remaining abnormal at 8 years of age. Children who were neurologically normal had higher cognitive scores at ages 4 and 8 than those categorized as suspect or abnormal. Preterm infants with neurologic abnormality required significantly more academic resources in the school. Reading and math achievement scores were the lowest for the preterm groups classified as neurologically suspect or abnormal. Conclusions. Neonatal morbidities exert a significant impact in neurologic outcomes among preterm children during the 8 years of assessment. Compromised neurologic status adversely affects cognitive and school performances. Neonatal medical status is an important variable indicating neurocognitive and school performance outcomes in low birth weight infants.

Objective To examine the autonomic nervous system and neurobehavioral response to a sustained visual attention challenge in 1-month-old infants with prenatal substance exposure. Study design We measured heart rate, respiratory sinus arrhythmia, and neurobehavior during sustained visual orientation tasks included in the Neonatal Intensive Care Unit Network Neurobehavioral Scale in 1129 1-month-old infants with prenatal substance exposure. Four groups were compared: infants with prenatal cocaine and opiate exposure, infants with cocaine exposure, infants with opiate exposure, and infants with exposure to other substances (ie, alcohol, marijuana, and tobacco). Results The infants with prenatal exposure to both cocaine and opiates had the highest heart rates and lowest levels of respiratory sinus arrhythmia during a sustained visual attention challenge compared with the other 3 groups. Infants with prenatal cocaine and opiate exposure had poorer quality of movement and more hypertonicity during the Neonatal Intensive Care Unit Network Neurobehavioral Scale examination. They also had more nonoptimal reflexes and stress/abstinence signs compared with infants with prenatal exposure to cocaine only and those with prenatal exposure to alcohol, tobacco, and marijuana. Conclusion Problems with arousal regulation were identified in infants with prenatal substance exposure. Autonomic dysregulation has been implicated as a mechanism by which these difficulties occur. Our results suggest that infants with prenatal exposure to both cocaine and opiates have the greatest autonomic response to the challenge of a sustained visual attention task, possibly putting these infants at risk for problems associated with physiologic and behavioral regulation, a necessary prerequisite for early learning.