Longterm Outcome Of Children Who Have Undergone In Utero Exposure To Opioids

Despite the fact that a drug-exposed newborn may seem free of physical, behavioral, or neurolog ical deficits at the time of birth, the effects of pharmacological agents (used or abused) may not become apparent for many months or years. Although heroin abuse during pregnancy has been recognized for more than forty years, and methadone treatment has been employed for more than twenty years, follow-up of opioid-exposed infants is still fragmentary. The difficulties encountered in long-term follow-up of this population include an inability to fully document a mother's drug intake, separation of the drug effects from high-risk obstetric variables, problems in maintaining a cohesive group of infants for study, and the need to separate drug effects from those of parenting and the home environment.

The easiest part of caring for the neonate is actually over when drug therapy has been discontinued and the infant is physically well. The most difficult parts then begin—the care involved in discharge planning and assuring optimal growth and development throughout infancy and childhood. Because there is no standard for the disposition of these infants, some may be released to their mothers, some to relatives, and others placed in the custody of a state agency. Still others may be voluntarily released by the mother to private agencies for temporary or permanent placement.

In the United States, pressure recommending separation of infants from their addicted mothers has been growing. This solution may not be practical in cities where social services and courts are already understaffed and overworked. Decent foster care is expensive and hard to find. Pediatricians basically feel that the mother-infant association should not be dissolved except in extreme situations. Aside from intensive drug rehabilitation and medical treatment, these women need extensive educational and job training—to become the productive citizens and loving mothers who will positively socialize their children. Supportive therapies such as outpatient care or residential treatment may help eliminate some of the medical and social problems experienced by drug-dependent women and their children.

Most of the children evaluated for long-term development have been exposed to methadone. Evaluations have occurred at various intervals—at six, twelve, eighteen, and twenty-four months; then at three, four, and five years of age. Testing procedures utilized have been the Gesell Developmental Schedule, the Bayley Scales of Infant Development, the McCarthy Scales of Infant Abilities, and the Stanford-Binet and the Wechsler Preschool and Primary Scale of Intelligence. Infants have shown overall developmental scores in the normal range but a decrease in scores at about two years of age— which suggests that environment may confound long-term infant outcome: low socioeconomic groups suffer from this factor particularly, because of poor language stimulation and development.

The developmental scores in these early years, although useful in identifying areas of strength and weakness, may not predict subsequent intellectual achievement. More and more studies have proposed multiple-factor models to assess infant outcome following intrauterine drug exposure. One such postnatal influence involves maternal-infant interaction. Drug-exposed infants are often irritable, have decreased rhythmic movements, and may display increased muscle tone (tensing) when handled. Such behaviors may be interpreted by the mother as ''rejecting'' behavior, leading to inappropriate maternal caretaking and possible neglect of the infant. Studies of mother—infant interactions show that: (1) infants born to narcotic-addicted women show deficient social responsiveness after birth; (2) this deficient mother—infant interaction persists until the infants' treatment for withdrawal is completed; and (3) maternal drug dosage may affect that interaction.

Based on available data, at five years of age, children born to women maintained on methadone, in contrast to heroin-exposed babies, appear to function within the normal range of their mental development. In addition, no differences in language and perceptual skills were observed between them and children of mothers not involved with drugs and of comparable backgrounds. Difficulty in following large cohorts of drug-exposed infants has led to the study of very limited samples, however.

Positive and reinforcing environmental influences can significantly improve drug-exposed infant development. Women who show a caring concern for their infants are most likely to pursue follow-up pediatric care and cooperate in neurobehavioral follow-up studies. Lacking a large data base, there is an obvious need for comprehensive studies assessing the development of large populations of drug-exposed infants.

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