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Children of Neverland
Gideon Koren, MD, FRCPC
Epidemiologic studies show that between 5% and 30% of sexually active women are using cocaine. What is the nature and extent of potential fetal risk to such exposure?
Cocaine exposure during pregnancy is associated with serious health hazards for babies, such as intrauterine growth restriction, prematurity, stillbirth, perinatal complications, and abruption of the placenta. In a study conducted in Toronto, cocaine-exposed babies achieved lower scores on language development and intelligence tests.
Neverland is the place where many children will reside permanently, not being able to reach their full potential. Unlike Peter Pan's legendary hidden land, there is neither legend not hiding here. The damage inflicted on these children in the womb or soon after birth will remind them throughout their long journey that they have been locked out. The following is an excerpt from the chapter, "And the babies crack," in my book, The Children of Neverland.1
Janine started experimenting with drugs when she was 14. It looked cool at that time, because both boys and girls in her class admired her for her guts. She did some grass and bennys, and of course she drank, but that was not something special because, except for a few nerds, all the other kids drank. That's the way things are in the senior year of junior high in any school at the east end of this city.
But it all changed when Jerome challenged her to try coke. He was 2 years older an he had dropped out of school the year before. Janine's mother warned her not to stick around Jerome, but that made it even sweeter because Janine could not stand the way her mother talked to her, as if she were a baby. Jerome thought she was cool when she started coke and in no time he made her his preferred girlfriend. At first she did not enjoy it so much, but soon she was sniffing and then shooting several times a day. Jerome got hold of the best coke in town, and he gave it to her free before having sex. Sex with him was not great, but she liked to see him enjoying being with her.
Then she dropped out of school and her mother was very upset. She even called her father who lived on the other coast, but he really did not care (he never did before). Her mother was so upset with her that Janine decided to move in with Jerome, who shared a small apartment with two other gang members. As months went by she was doing more and more coke. That's why when she began to feel sick she was sure it was the coke, but she could not and would not stop it. When the nausea became really bad, she could not eat or drink, as it all came out.
Then one day her former teacher saw her on the street very sick and took her by the hand to the doctor. It took the doctor a regular checkup and a urine test to tell her that she was pregnant. Janine did not know whether to laugh or to cry. Jerome told her to get rid of the baby, but she was already 4 months pregnant and Roman Catholic, and she thought it was cool to have a baby. Jerome told her to go back to her mom, and when she begged him to let her stay, he began to bring home other girls at night. When she was 71/2 months pregnant, she got fed up with the pregnancy. She thought she was fat and ugly and she wanted Jerome to want her again. Her girlfriend Sue Ellen told her that a big dose of coke can start labour, and that's why she took the overdose that brought her to the hospital. She lost consciousness and had very strong contractions.
Then the bleeding started and they had to rescue the baby by cesarean section because of abruption of the placenta.
Roni was born very tiny. He weighed only 2 pounds, which was very small even for his 7 months. He was premature and needed a ventilating machine to help him breathe. He also had bleeding in his brain, which is something that happens to many very tiny babies. They also said that, because of the extra oxygen he gets in the respiratory machine, he might have problems with his vision.
Janine left the hospital after 7 days and went back to her mother. Roni stayed in hospital for 6 months and then started his long journey through foster homes. He developed slowly, and by 3 years of age the tests said he was moderately delayed. Some of his muscles were not functioning well and his vision was not great because his retina was damaged by the oxygen. By 5 years of age the child-protection agency was lucky to find him adopting parents who were ready to take him despite his moderate retardation. Roni was lucky, because his good temper and sociability did not scare people.
This is the story of two children, a 14 year-old girl and her baby. There are many thousands of similar stories every year, and many damaged children join millions of other children in Neverland. For thousands of years, Indian tribes were aware of the potent pharmacologic effects of the coca leaves they were chewing. The active compound cocaine has potent effects inducing mood elevation, lack of fatigue, optimism, and initially, better sex performance.
One of the issues in detecting cocaine use by mothers is the short half-life of the drug, ie, the time it stays in the body. If a mother has not used cocaine during the last few days or weeks of pregnancy, her and her baby's urine and blood likely will test negative for the drug. Studies show that most women who use cocaine during pregnancy are reluctant to disclose their habit for fear of litigation, for fear of having the child taken from them by child-protection authorities, and because of guilt, shame, and embarrassment.
Recently, two new methods have been developed that can detect exposure to cocaine in the uterus. Cocaine, like many other compounds, is incorporated into the fetus's hair as it grows during the last 3 or 4 months of pregnancy. In a recent study in Toronto, using the hair test, we detected many cases of cocaine use during pregnancy that were missed by both urine tests and mothers' reports. In fact, had we used only urine test or mothers' report, we would have missed more than 80% of these cases.2 In Detroit, Ostrea and colleagues1 have developed a test using neonatal meconium. This first fecal excretion of newborn infants appears to trap drugs such as cocaine as they circulate in the amniotic fluid and are swallowed by the fetus.
While medically very important, the issue of testing babies for cocaine is difficult from an ethical standpoint. On one hand, many opponents to such testing claim that it infringes on the basic human rights and privacy of mothers. However, many health professionals and other members of society believe that cocaine use is no different from other forms of child abuse.
Since the introduction of epidemiologic studies showing that between 5% and 30% of sexuality active women are using cocaine, scores of research groups have tried to elucidate the nature and extent of risk to unborn babies. Most studies compared cocaine users' pregnancy outcome and child health with that of non-users. These studies have overwhelmingly shown that cocaine exposure during pregnancy is associated with serious health hazards for babies, such as intrauterine growth restriction, prematurity, stillbirth, perinatal complications, and abruption of the placenta, probably due to increased blood pressure caused by cocaine.
Resulting bleeding can cause acute decrease in blood supply to a fetus leading to severe morbidity or even death of the unborn baby.4
In Toronto, we tried to separate the effects of cocaine use during pregnancy from factors associated with a poor environment and home. We tested the cognitive and language development of children exposed to cocaine in the womb but given up for adoption very young to middle- or upper-class families.5 For comparison, we matched these toddlers to offspring of mothers similar to the exposed children's birth mothers in socioeconomic class and intelligence who did not use drugs during pregnancy. As expected, the cocaine-exposed children were smaller and tended to be more often premature than the control group. By follow-up at a mean age of 33 months, the cocaine-exposed babies caught up with the control group on height and weight but were far behind on head circumference. In fact, one third were in the range of microcephaly (ie, two standard deviations lower than the mean for their age).
The cocaine-exposed babies achieved significantly lower scores on language development tests and tended to get lower scores in intelligence tests. These effects cannot be explained by concomitant use of alcohol; we excluded from the study mothers who drank heavily, and none of the children had features of fetal alcohol syndrome. Moreover, heavy smoking, a common habit among cocaine users, is not known to affect child development in a similar way. It is possible, however, that there is a synergistic effect between cocaine on the one hand and cigarettes and alcohol on the other that might affect brain development. Recent research has shown that cocaine and alcohol react in the human liver to create a new toxin, cocaethylene, which appears to be more toxic to the central nervous system than cocaine itself.
Our preliminary results, if confirmed by more studies,
substantiate the worst fears of scientists, educators, and other
members of society as they think of the many thousands of Neverland
children born every year who will not achieve their full potential.
Even if these initial estimates are exaggerated , there remain
devastating, irrefutable facts : if the risk of prematurity doubles
among children exposed in utero to cocaine, twice as many of these
children will need respirators and will suffer from long-term
complications to their lungs, eyes, and brains.
- Koren G. The Children of Neverland. Toronto : The Kid in us publications, 1997.
- Forman R, Klein J, Meta D, Barks J, Greenwald M, Koren G. Prevalence of fetal exposure to cocaine in Toronto 1990-1991. Clin Invest Med 1994;17: 206-11.
- Ostrea EM, Parks O, Brady M. The detection of heroin, cocaine and cannabis metabolites in meconium of infants of drug dependent mothers. Pediatr Res 1989;25:225-225A.
- Lutiger B, Graham K, Einarson T, Koren G. Relationship between gestational cocaine use and pregnancy outcome : a meta-analysis. Teratology 1994;44:405-14.
- Nulman I, Rovet J, Altman D, Bradley C, Einarson T, Koren G. Neurodevelopment of adopted children exposed in utero to cocaine. Can Med Assoc J 1994;151: 1591-7.