Running Head: NAS AFFECTS THROUGHOUT LIFE

NAS Lifespan Affects Compared to Healthy Neonates

Paige Bandera, Melissa Bruss, Mary Jo Wardle, Shyniah Watson, and Jessica Welsh

Youngstown State University

Abstract

There has been a steady increase in the number of overdoses reported each year, this is especially

true in Northeast Ohio. With the drug epidemic on the rise research into how this affects the fetus

of mothers abusing these drugs becomes even more imperative. Research on the long-term adverse

effects of cocaine, marijuana, tobacco, alcohol, methamphetamines, and prescription drugs on the

neonate compared with unaffected neonates is lacking in conclusive concrete evidence. However,

there is some conclusive evidence regarding the effects on physical health, mental health, and

future drug use which is discussed in this paper as well as some of the probable conclusions and

gaps in the current research. It examines physical health from fetus to age ten, as well as mental

health and future drug use in adulthood. All information was obtained from journal articles that

either conducted their own study or were a peer review of several studies.

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The surgeon general has proclaimed that drug and alcohol use during pregnancy is not

recommended. Not only do these substances cause harm to the person using them, but they also

cause the same or more harm to the fetus. It is not just illegal drugs that are harmful to the fetus,

but also common prescription and over the counter medications that are just as harmful. “About 2

to 3% of all birth defects result from drugs that are taken to treat a disorder or symptom”

(Gunatilake & Avinash, 2017). In other words, a pregnant woman should not partake in drug

consumption.

Drugs and alcohol can affect the fetus in several ways. One way drugs can directly act on

the fetus is through the formation of birth defects or cause death of the fetus. Another way it can

affect the fetus is by transforming the placenta and altering its functions. For example, it causes

the blood vessels to constrict and reduces the supply of oxygen and blood, causing the fetus to be

under developed and underweight at the time of its birth. Drugs can also cause the uterus to

contract harder than usual which causes a reduction of blood supply to the fetus which may induce

pre-term labor.

Drug use can also affect the fetus in different ways determined by the various stages of the

pregnancy in which the drugs were used. For example, for the first 20 days after fertilization, a

baby can either be completely resistant to the drugs or alcohol, or the substances can cause

termination, or miscarriage, of the pregnancy. There is no in between in that time frame. In the 3

to 8-week period after fertilization the fetus may not have any effects, the woman could have a

miscarriage, or the fetus may be vulnerable to a birth defect because this is the time of organ

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development. In the second and third trimester, drugs could possibly alter the functions of newly

grown organs and tissues.

Although the timing of substance use can cause different effects on the fetus, the type of

substance used can also cause different effects. In the article, Gunatilake & Avinash (2017)

discussed the ways in which cigarettes can cause harm, stating:

The most consistent effect of smoking on the fetus during pregnancy is a reduction

in birth weight: The more a woman smokes during pregnancy, the less the baby is

likely to weigh. The average birth weight of babies born to women who smoke

during pregnancy is six ounces less than that of babies born to women who do not

smoke. Birth defects of the heart, brain, and face are more common among babies

of smokers than among those of nonsmokers. Also, the risk of sudden infant death

syndrome (SIDS) may be increased

Another substance that can cause harm is alcohol. Alcohol can cause low birth weight as

well, but the side effect most concerning is fetal alcohol syndrome. This syndrome causes facial

defects, intellectual disability, and abnormal growth of the fetus. It has been stated that there is no

safe amount of alcohol for a woman to consume while pregnant. The only way to prevent fetal

alcohol syndrome is to avoid all alcohol throughout the entire pregnancy.

One more class of drugs that can cause harm is opioids. Opioids can cause the baby to be

born addicted, a side effect of the mother’s drug use known as neonatal abstinence syndrome.

Because the drugs go directly through placenta, they therefore also act directly on the fetus. They

also can cause the fetus to develop birth defects, low birth weights, neonatal abstinence syndrome,

as well as pre-term labor.

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The only way for a mother to ensure her infant will be born without preventable birth

defects, low birth weights, neonatal abstinence syndrome, or fetal alcohol syndrome is to

completely avoid abusing drugs, alcohol, or cigarettes. If the mother is unable or unwilling to avoid

these teratogens, then these infants may face a multitude of complications throughout their

lifespan.

There are many drugs that can cause an infant to be diagnosed with neonatal abstinence

syndrome or NAS. However, Deborah Frank et. al conducted a study on the effects of cocaine in

5 domains: physical growth; cognition; language skills; motor skills; and behavior (2001). This

study reviewed thirty-six articles on the subject of the effects of cocaine exposure in early

childhood. The studies overall results showed that there is not a consistent negative association

between prenatal cocaine exposure and physical growth. It also showed no association with

developmental scores, or receptive or expressive language (Frank, 2001). However; it was proven

that in children diagnosed with NAS up to 7 months old will have lower motor scores. It was also

found that decreased attentiveness and emotional issues were connected to prenatal cocaine

exposure.

Selective Serotonin Reuptake Inhibitors or SSRIs are commonly prescribed

antidepressants often used by pregnant women. Use of SSRI's during pregnancy can cause the

baby to be diagnosed with Neonatal Abstinence Syndrome, therefore recognizing SSRI related

symptoms is important.

Short-term effects include disruptions in a wide range of neurobehavioral

outcomes. Neonatal neurological symptoms include signs of both central nervous

system excitation and depression, autonomic symptoms (decreased heart rate

variability, temperature instability, mottling, sweating), decreased changes in

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behavioral states and abnormal sleep organization (Klinger, 2011).

There are multiple things to look for in the development of a child affected by SSRI's and some of

these side effects can lead to long-term issues for the child diagnosed with NAS due to SSRI’s.

Neurodevelopment is one of the key factors affected long-term in infants diagnosed with

NAS. There are many ways to assess a child's neurodevelopment, but in Klinger's research study

the Denver Developmental Screening Test II was used along with the Wechsler Preschool and

Primary Scale of Intelligence-II, the Stanford-Binet Intelligence Scales or the Bayley Scale of

Infant Development-II as was age appropriate. “Two groups of children were compared: Group 1

included children who exhibited NAS after birth and Group 2 included children who did not exhibit

symptoms compatible with NAS” (Klinger 2011). This study included a total of eighty-two

children aged two to six years old; thirty with NAS and fifty-two without NAS.

Per Klinger there was a trend towards a smaller head circumference among former NAS

babies and the only neurological abnormality detected was hypotonia. Children who had NAS

were also more likely to have a threefold risk for abnormal results on the social component of the

DDST-II. The results also showed that intelligence is not affected by drug exposure. Per Klinger's

study the areas where children affected with NAS showed abnormalities were; behavior and social

adaptability which includes activities of daily living, social imitative play and the ability to clearly

communicate personal needs and desires.

[T]he Bayley psychomotor development indices and the motor quality factor of the

Bayley Behavioral Rating Scale were lower in exposed vs unexposed children,

indicating that SSRI exposure may have subtle effects on motor development

(Klinger, 2011)

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While there is quite a bit of research on the effects of illicit drugs on the fetus and newborns,

there is far less research into the long-term effects on the exposed neonate. However, in the article

by Ardendt 2004, studying the effects of cocaine exposed neonates and their developmental

outcomes at the age of seven show deficits in several areas. This was measured using the

Bruininiks-Oseretsky Test of Motor Proficiency or BOTMP which consist of eight subtests. Three

fine motor, four gross motor, and one combination test. As well as the Wechsler Intelligence Scale

for Children-Third Edition or WISC-III which is a standardized measure of cognitive functioning

in children.

The results concluded from these two-test given to a total sample of two hundred thirty-

one children, one hundred and one cocaine exposed and one hundred and thirty unexposed, display

deficits on several skills. Including verbal, visual motor integration, and fine motor skills.

However, it must be noted that the results may overlap with other cognitive risk factors

experienced by many low-income families. It should also be noted that both groups did not do well

in comparison to the normative standards, particularly on the WISC-III. While the results indicated

a correlation between cocaine exposed infants and developmental issues there is a need for further

research for a confirmation of these findings.

In the journal of American Academy of Pediatrics Behnke et. Al states that while there is

no clear research with a direct correlation between methamphetamine, cocaine, or opiates in

regards to growth or achievement there have been some studies with direct correlation. The

conclusions that could be drawn were that opiates have a direct effect on long-term behavior, but

no effect on growth. This article also shows that cocaine influences future behavior, cognition, and

language, however, there is no consensus on the long-term effects on growth and achievement.

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Finally, it should be noted that there is limited or no data regarding methamphetamine in the short

or long term regarding use during pregnancy.

Research has indicated that prenatal exposure to drugs puts the neonate at risk for mental

health deficits as well physical deficits throughout their lifespan. Like the physical deficits that

may occur, the degree of mental impairment depends on the quantity and type of drug used. Drugs

that have been commonly studied, with regards to short term and long term adverse effects, to the

prenatally exposed fetus include: nicotine, alcohol, marijuana, opiates, cocaine and

methamphetamine.

Per Behnke and Smith (2013), prenatal exposure to nicotine has an adverse effect on

behavior that begins in early childhood and continues into adulthood. They found that the affected

individual may struggle with hyperactivity as well as negative and externalizing behaviors in

childhood. Such adverse behavioral effects in childhood are carried throughout adolescence and

into adulthood. Which is demonstrated by higher rates of criminal behavior in adults who were

prenatally exposed to nicotine.

Ross, Graham, Money and Stanwood (2015) found that “Of all the substances of abuse

(including cocaine, heroin and marijuana), alcohol produces by far the most serious

neurobehavioral effects in the fetus” (as cited in Institute of Medicine, 1996). The effects of fetal

exposure to alcohol may lead to maladaptive behaviors that last from early childhood to adulthood;

per Behnke and Smith (2013). Like those prenatally exposed to nicotine, the result of prenatal

exposure to alcohol is higher rates of criminal activity.

Prenatal marijuana exposure can lead to attention deficits, elevated impulsivity,

hyperactivity and neuropsychiatric disorders in children (Ross et al., 2015). Ross et al. (2015) have

identified that the behavioral problems of those prenatally exposed to marijuana may lead to

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delinquency and externalizing behaviors as the individual grows. Additionally, they found that the

impulsiveness, of the prenatally exposed fetus, may last into the individual’s twenties.

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More research is needed on the long term mental health deficits associated with prenatal

opiate exposure. However, Behnke and Smith (2013) have found that neonates prenatally exposed

to opiates exhibit inattention and hyperactivity at ten years of age. Ross et al. (2015) have

determined that doctors need to study children prenatally exposed to opiates based on studies

previously performed on animals. These animal studies have suggested that prenatal exposure to

opiates has a long-lasting effect on the exposed individual.

The affect that prenatal cocaine exposure has on the mental health of the exposed individual

is inconclusive at present (Behnke & Smith, 2013). Ross et al. (2015) references studies that imply

that prenatal cocaine exposure leads to differing adverse behavioral effects depending on the time

of exposure. For instance, first trimester exposure has been connected to depression in children;

subsequent psychiatric problems may occur later in life.

As with opiates and cocaine there are few studies that have been published to demonstrate

the long-term effects of methamphetamine (Behnke & Smith, 2013). Ross et al. (2015) reviewed

one study “found that prenatal meth exposure was associated with children externalizing

behavioral problems at 5 years of age” (as cited in LaGasse et al., 2012; Towmey et al., 2013).

They conclude that the conduction of more animal studies will enable researchers to understand

the long-term effects of meth on those prenatally exposed to it.

Behnke and Smith (2013), as well as Ross et al. (2015), have demonstrated that nicotine,

alcohol and marijuana have adverse effects on the mental health of the prenatally exposed

individual; effects that may last their entire lives. “Better animal models will allow us to predict

and treat later-in-life disorders in [those prenatally exposed to drugs]” (Ross et al. 2015); clearly,

indicates the need for further study. More research is especially needed for those who were exposed

to opiates, cocaine and methamphetamine in utero. Mental health issues are often seen in persons

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who abuse drugs. Since these two issues are so entwined it is necessary to not only look at studies

regarding the mental health of the affected infants, it is also necessary to look at the studies

regarding drug abuse in their later years.

It is strongly believed that people who are born to drug addicted parents, especially those

born with neonatal abstinence syndrome and other complications resulting from maternal drug use,

will more than likely become drug addicts themselves later in life. Although it is quoted quite

often, not much research has been done to back up this popular assumption. As Herranz, Vilchez,

Ledo, and Sierra showed in their study of 30 participants that were born to heroin addicted mothers,

this may certainly be true (2014). However, just like the research of Solis, Shadur, and Hussong

found in 2012, the results are very inconsistent.

Herranz et al. found out of their sample of thirty subjects that were born to heroin addicted

mothers between 1985 and 1990, only one of them had ever been treated for drug-related problems

while nearly all of them had consumed some sort of drug over the span of their life. Out of the

thirty participants, twenty-six had consumed cannabis, fourteen had consumed cocaine, two had

consumed benzodiazepines that were not prescribed to them, two had consumed GHB, six had

consumed ecstasy, nine had consumed amphetamines, seven had consumed hallucinogens, while

only two had consumed heroin like their mothers were addicted to when they were born. According

to their study, with the exception of cannabis and cocaine none of them habitually used drugs and

had only consumed each substance on less than four days over the previous year.

It was discovered by Solis et al. that children whose parents had issues with drug and

alcohol abuse had a fifty-three percent chance of developing a drug and alcohol abuse issue

themselves in young adulthood, while only approximately twenty five percent of young adults

without a substance abusing parent would (2012). The double in occurrence of substance abuse

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disorders in young adults from those who grew up without parents with substance abuse disorders

to those who did is a clear indicator that children with parents with substance abuse disorders are

significantly more likely to develop an addiction themselves. However, that still leaves forty-seven

percent that didn't develop a substance abuse problem, even though one or both of their parents

had one (Solis et al., 2012).

Even though Herranz et al. were only able to use thirty surveys for their research when they

sent out one hundred and fifty, a few other key points were highlighted (2014). Despite only being

between the ages of twenty-four and twenty-nine, five of their one hundred and fifty subjects had

passed away, four of them due to the complications they suffered from AIDS due to their mother

contracting HIV from the use of contaminated needles while the other was of an unknown cause.

Many selected people who chose not to participate in the survey may have been substance abusers,

the people who weren't heavy substance abusers more than likely would have been more inclined

to answer the questions and return it. This may have skewed the results slightly, since a higher

ratio of substance abuse was expected among the one hundred and fifty than was seen in the group

of thirty.

From the research conducted by Solis et al. in 2012 and Herranz et al. in 2014, it can be

concluded that people that were born to or lived with parents who have substance abuse issues,

especially those who were exposed to drugs prenatally, have a much higher risk of developing

substance issues themselves later in life. Although some people never developed any substance

abuse disorders per the surveys conducted, they were twice as likely to develop them than other

people in their demographic that did not have a substance abusing parent(s).

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