The Adaptationist View: Ambiguity in Infant Withdrawal After Prenatal Cocaine Exposure

Locus: The Seton Hall Journal of Undergraduate Research

Volume 3 Article 2

October 2020

The Adaptationist View: Ambiguity in Infant Withdrawal after Prenatal Cocaine Exposure

Angelo Cadiente

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Recommended Citation Cadiente, Angelo (2020) "The Adaptationist View: Ambiguity in Infant Withdrawal after Prenatal Cocaine Exposure," Locus: The Seton Hall Journal of Undergraduate Research: Vol. 3 , Article 2. Available at: https://scholarship.shu.edu/locus/vol3/iss1/2 Cadiente: Adaptationist View

The Adaptationist View: Ambiguity in Infant Withdrawal After Prenatal Cocaine Exposure

Angelo Cadiente Seton Hall University

Abstract trointestinal (GI) system, and respiratory system. Speciﬁcally what symptoms arise and their sever- Neonatal Abstinence Syndrome is a set of ity are dependent on the drugs used and when the symptoms that result from prenatal exposure to ad- pregnant mother uses them. Historically, NAS has dictive drugs. This syndrome is often attributed been diagnosed in the context of opiates, yet it to opiate withdrawal; yet, there is a controversy is controversial as to whether infants experience within the literature as to whether cocaine, an ad- withdrawal when they have been exposed to co- dictive stimulant, leads to a variant, which I term caine prenatally (Jones & Fielder 2015). In pursu- “cocaine-based Neonatal Abstinence Syndrome.” ing the possible existence of infant cocaine with- In this paper, I contrast the evidence that supports drawal, I will refer to cocaine-based neonatal ab- the presence of cocaine withdrawal in neonates stinence syndrome as “cNAS.” with the opposing evidence that supports its absence. I offer an intermediary explanation through While the focus of this paper is to discuss the the “Adaptationist View,”which attributes the sup- relationship between neonates and cocaine with- posed symptoms of cocaine infant withdrawal to drawal, it is important to describe the effect of co- the neonate adapting to extreme changes in its en- caine on neurotransmitters and the placenta; un- vironment. Moreover, I introduce the Addictive- derstanding the physiological effects of cocaine ness of Cocaine Conclusion to serve as a logical will provide context for symptoms. Cocaine means to bridge the addiction cycle with the Adap- is a CNS stimulant that inhibits norepinephrine tationist view. transporters, serotonin transporters and dopamine transporters, preventing the reuptake of synaptic norepinephrine, serotonin, and dopamine re- 1. Introduction spectively (Cain, Bornick, and Whiteman 2013). As these neurotransmitters are not removed in a Neonatal Abstinence Syndrome (NAS), his- timely manner, they remain in excess in the synap- torically known as “infant addiction” and “con- tic cleft and elicit a signal upon binding to their genital addiction,” describes a body of symptoms corresponding receptors on post-synaptic neurons. experienced by an infant as a result of maternal This signal, known as an action potential, ulti- drug abuse over the course of a pregnancy (Jones mately leads to effects that are dependent on the & Fielder 2015). The symptoms that arise are neurotransmitter. The high concentration of neu- the result of defects in the central nervous system rotransmitters lead to the overstimulation of post- (CNS), autonomic nervous system (ANS), gas- synaptic neurons; hence cocaine’s classiﬁcation as

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a stimulant. fetal equivalent to the kidneys, the liver, and the Every neurotransmitter has a correspond- lungs (De Giovanni & Marchetti 2012). Consid- ing effect. Due to the inhibition of mecha- ering its wide-ranging utility, the placenta is the nisms that reuptake norepinephrine, serotonin, medium through which the mother prenatally pro- and dopamine, cocaine creates an imbalance in vides the neonate with the necessary nutrients to these neurotransmitters. This dysregulation leads support its growth and development (Coyle, et al. to the symptoms of cocaine-use. Norepinephrine 2018). is responsible for activating the sympathetic ner- Cocaine acts on the placenta due to the pres- vous system. The activation of the sympathetic ence of surface norepinephrine and serotonin re- nervous system increases blood ﬂow that is di- ceptors. The surface norepinephrine receptors act rected from the GI tract and reproductive system in tandem with the mother’s sympathetic nervous to the heart, brain, and skeletal muscles (Buckley system. This connection is one of the reasons that 2015). Serotonin is the prominent neurotransmit- cocaine-use during pregnancy has an increased ter that affects mood. Like cocaine, selective sero- risk for preterm rupturing of the membranes— tonin reuptake inhibitors (SSRIs) keep serotonin colloquially known as “the water breaking early.” in the synaptic cleft. Due to its function in main- This risk is due to the overstimulation of nore- taining high serotonin levels within the synaptic pinephrine receptors that line the face of the pla- cleft, there are similar arguments as to whether centa. As cocaine activates the sympathetic ner- SSRIs lead to neonate withdrawal when used over vous system and there is an increase in nore- the course of a pregnancy (Jones & Fielder 2015). pinephrine, uterine contractions occur as the preg- Dopamine is attributed to the feeling of euphoria, nant mother enters preterm labor (De Giovanni colloquially known as a “high” (Cain, Bornick & & Marchetti 2012). The constant stimulation of Whiteman 2013; Kuczkowski 2003, 2004, 2005). the sympathetic nervous system effectively pushes Excess dopamine in the nucleus accumbens is the the neonate into delivery. The increase in nore- biologically evident site of addiction. Cocaine in- pinephrine is characteristic of a “catecholamine 1 creases the production of enzymes that decrease surge” that occurs during birth and is speculated dopamine levels. This increase in enzymes is a to be the mechanism in which the infant adapts response to the abnormally high concentration of to hypoxia during delivery (Buckley 2015). Addi- dopamine in the synaptic cleft. The body adapts tionally, there are higher levels of catecholamines and synthesizes more enzymes in order to coun- in umbilical arterial blood during vaginal deliv- teract future imbalances. Thus, the body becomes ery than in caesarean sections, indicative of its less sensitive to dopamine; more precisely, it now use during stressful environments (Faxelius, et al. takes more dopamine to experience euphoria. In 1983). Regarding the use of serotonin, this neu- the context of cocaine addiction, the user now rotransmitter is transported to the fetus to reg- requires more cocaine in order to attain a high ulate brain development, namely thalamocortical enough dopamine concentration to experience eu- wiring in the forebrain, cortical development, and phoria. long-term behavior (Velasquez, et al. 2013). As an extension to neurotransmitters, cocaine Considering the potent effects of cocaine in directly affects the placenta. The placenta is both the placenta and the fetus, the presence of the site of maternal-fetal exchange. Within this withdrawal from prenatal maternal cocaine use, exchange, the placenta transfers nutrients from 1The term catecholamine describes a class of structurally mother to fetus, eliminates fetal metabolic waste, similar monoamine neurotransmitters. Among these neuro- mediates fetal gas exchange, and produces steroid transmitters, norepinephrine and dopamine are a part of this hormones. Effectively, the placenta serves as the class. Serotonin is not.

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i.e. cNAS, is a point of controversy within the lit- cocaine; their conclusion is derived through a erature (Jones & Fielder 2015). It is logical to de- symptom-based definition of withdrawal (Ogun- duce that infants that were prenatally exposed to yemi & Hernandez-Loera´ 2004). In Study B, I cocaine experience withdrawal. A deductive argu- discuss evidence derived from a cross-sectional ment that aptly represents this view can structured case-control study that concludes that withdrawal such that: does not occur in infants prenatally exposed to cocaine; their conclusion is derived through a stan- 1. Some drugs are addictive. dardized scale (Eyler, et al 2001). The purpose 2. Users of addictive drugs become addicted af- of defining each view as “Study A” and “Study ter repeated use. B” is to utilize a representative argument in favor of each perspective. Among the different articles 3. Removal of addictive drugs from an addicted supporting either side of the argument, the arti- user leads to withdrawal. cle by Ogunyemi & Hernandez-Loera´ in 2004 and 4. Cocaine is an addictive drug. Eyler, et al in 2001 were used as exemplars to support the presence and absence of cocaine neonate 5. Therefore, the removal of cocaine from an withdrawal respectively. Figure 2 under Conclu- addicted user leads to withdrawal. sion and Discussion provides explicit differences I will label this argument the Addictiveness of between the two representative studies. Addition- Cocaine Conclusion (ACC). This argument is ally, other supporting articles were considered in commonsensical; if an addictive substance is re- order to supplement both arguments provided in moved from its timely abuser, then withdrawal Studies A and B. In light of these opposing views, follows. The ACC is described in part from the I conclude with the “Adaptationist View” to unite addiction cycle, which considers three intercon- both views while responding to the ACC. nected phases: intoxication, withdrawal, and pre- 2. Comparison of Methods between Parent occupation (Herman & Roberto 2015). In in- Studies toxication, the addictive substance is consumed, prompting psychological and physiological ef- Study A: Source of Data, Definition of With- fects, e.g. pleasure that stimulates the reward cir- drawal, and Methodology cuit in the brain. In withdrawal, an unpleasurable state is sustained after the addictive substance is removed for a period of time. Preoccupation is the Study A utilizes a retrospective case-control state in which an addicted user craves the addictive study. In this study, cNAS was defined as substance after a period of abstinence. While ad- “neurobehavioral abnormalities, including greater diction has been heavily researched in both human irritability, hypertonicity, tremulousness, mood and non-human subjects (Koob & Le Moal 1997), alterations and inconsolability” (Ogunyemi & there still remains a discrepancy as to whether Hernandez-Loera´ 2004). Thus, the presence of co- cocaine-exposed neonates experience withdrawal. caine neonate withdrawal is determined on the ba- I will consider the ACC in response to whether sis of observed symptoms. withdrawal exists in cocaine-exposed infants. Study A’s cases included 253 pregnant women In this paper, I will present two viewpoints, with neonates that were diagnosed with prenatal labeled “Study A” and Study “B”. In Study cocaine exposure and selected from the study’s A, I discuss evidence derived from a retrospec- Division of Obstetrics database. The control tive case-control study that concludes that with- group was determined through a random selection drawal occurs in infants prenatally exposed to of 237 pregnancies with neonates that have no his-

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tory of prenatal cocaine exposure from the same database. Of the selected, 53 cocaine-exposed and 37 non-exposed maternal-neonatal charts were excluded from the analysis as a result of incomplete records. Each chart of the selected maternal- neonate pair was then reviewed for the following pieces of information: maternal age, gravid- ity, parity, race, onset of prenatal care, medical history, obstetric and gynecological history, ed- ucational level, employment, marital status, le- gal problems, living conditions, urine toxicology Table 1. Study B’s selection of controls and co- results, routine prenatal laboratory data, obstet- caine exposed infants. ric complications, delivery records and neonatal complications. If the maternal-neonatal chart did Urine toxicology was used to differentiate co- not possess these variables, they were excluded caine exposed neonates at birth. Infants testing from the analysis and were considered incomplete “cocaine–” for cocaine metabolites was indicative (Ogunyemi & Hernandez-Loera´ 2004). of the fact that cocaine was not found in the in- Data analysis was undertaken through an fant’s system. Infants testing “cocaine+” for co- SPSS statistical program with categorical variable caine metabolites was indicative of the fact that relationships being tested for significance through cocaine was found in the infant’s system. The chi squared analysis. T-tests, variance, and reason why urine toxicology is nominally used linear regression were used as needed. Multiple is because cocaine, after consumption, is even- logistic regression was also used for multivariable tually broken down in the body and removed analysis. A p-value less than 0.05 and a 95% through the infant’s excretory system. Of the co- confidence interval was considered statistically caine exposed neonates, 47 tested cocaine– and 27 significant (Ogunyemi & Hernandez-Loera´ 2004). tested cocaine+ at birth. Neonates that were born preterm or by cesarean section were disqualified Study B: Source of Data, Definition of With- to avoid confounding factors (Table from Eyler, et drawal, and Methodology al 2001). Data analysis was undertaken to compare cat- Study B was a cross sectional case-control egorical variable relationships for significance study. In this study, cNAS was defined as the through chi squared analysis and t-tests. In par- lack of improvement or the worsening of cocaine ticular, these variables were graded using the metabolite-positive infants following the removal Brazelton Neonate Behavior Assessment Scale of cocaine (Eyler, et al 2001). Thus, the pres- (NBAS). Significant differences in correlative ence of cocaine neonate withdrawal is determined studies among mean levels by group or by time from significantly lower scores for varying quali- were determined through ANOVA (Eyler, et al tative data of cocaine metabolite-positive neonates 2001). contrasted with the data from an exposed cocaine metabolite-negative group and non-exposed con- 3. Results trol group. Study B selected 74 cocaine-exposed neonates Study A indicated that cocaine-users, on aver- and 81 nonexposed neonates. The selectivity of age, delivered their infants earlier than the con- the study is described in Table 1. trols, i.e. at 36 weeks versus 39 weeks, with

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birth weights significantly lower than their control counterparts, i.e. 2660 grams versus 3305 grams. Fetal death had only occurred in the cocaine-using sample. 131 cocaine-exposed infants tested cocaine+ in the womb with 75 of these infants fitting the criteria to be diagnosed with neonatal abstinence syndrome after birth. The average time that cocaine metabolites remained in the urine toxicology tests was 3.16 days after birth (Ogunyemi & Hernandez-Loera´ 2004). Study B revealed that only autonomic regulation scores differed significantly between the groups at birth. The data that was not controlled for the effects of other drugs—i.e. marijuana, alcohol, and tobacco—indicated that there were significant differences in alert responsiveness, reg- ulatory capacity, state regulation, and reinforce- ment value as shown in Table 2.

Table 3. Chart depicting the mean regulation state scores for each of the three groups over time. State regulation score is also given as a function of time in a graphical representation. (Figures from Eyler, et al. 2001)

nificant difference among the three groups. From Days 2 to 4, the cocaine+ group had a significantly higher regulation state score than both the control group and cocaine– group. For the data between Table 2. The results of Study B that did not control for the effects of other drugs. In controlling their Days 5 to 7, the cocaine+ group was significantly effects, the data reveals that autonomic regulation lower than the control group but not significantly was the only source of significant difference from different than the cocaine– group. one another. (Table from Eyler, et al. 2001) 4. Conclusion and Discussion Of the 27 cocaine+ infants, 79% remained positive between Days 2–4 with none testing posi- Study A concluded that 75 of the 131 tive between Days 5–7. In analyzing NBAS scores cocaine-exposed infants were afflicted with cNAS. over time, the regulation state was the only statisti- Namely, this diagnosis of cNAS was undertaken cally significant change over time when contrasted through the observation of specific symptoms. between the cocaine-exposed groups and the con- These symptoms focused on neurobehavioral ab- trol group. Figure 1 depicts the actual NBAS normalities such as hyperirritability, hypertonic- scores and a pictorial representation of tested reg- ity, tremulousness, mood alterations and incon- ulation state scores of the groups over time. solability (Ogunyemi & Hernandez-Loera´ 2004). Within the data depicted in Figure 1, it is im- Concurrent with these observations, Ogunyemi & portant to note that on Day 1, there was no sig- Hernandez-Loera´ found that cocaine– infants of-

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ten did not meet the criteria to be diagnosed with recognize, however, that this system is nominally cNAS. Instead, they proposed the idea of an “in used to diagnose opioid NAS, which bears differ- utero withdrawal,” i.e. the concept that cocaine– ent symptoms than cocaine addiction and cocaine infants at birth did not display withdrawal symp- withdrawal (Eyler, et al. 2001). Thus, the reliabil- toms because they had already experienced with- ity of these results are questionable as to whether drawal in the womb. The authors came to this the scores were the result of cNAS or simply an suggestion by analyzing both maternal urine tox- overall effect of cocaine. icology and neonatal urine toxicology. In finding Study B suggests otherwise. While Study trends within neonatal toxicology, they found that A concludes with the presence of neonate with- if the urine sample had resulted in a positive test drawal in utero and postnatally, Study B statis- for only one day or outright negative for cocaine tically concludes that cocaine– and cocaine+ in- metabolites postnatally, withdrawal was unlikely fants are not significantly different from one an- to be observed. In contrast, if the urine sample had other as denoted by their NBAS score; thus, the resulted in a positive test for two days or longer evidence supports the idea that the generally lower postnatally, neonatal withdrawal was more likely scores of cocaine-exposed infants relative to the to be observed. The authors attribute this discrep- nonexposed infants is an overall effect of co- ancy to the time taken between the last adminis- caine. This approach is convincing because NBAS tration of cocaine and delivery. If the infant was is a standardized evaluation that has the capac- cocaine+ for one day or cocaine– at birth, it is sug- ity to measure behaviors that are commonly at- gested that the mother’s last dose was one week tributed to cocaine exposure. Thus, the usage of or earlier prior to delivery. In this instance, with- this evaluation provides a standardized means for drawal would have occurred in utero. If the in- diagnosing cNAS. In analyzing the results, the fant was cocaine+ for greater than two days post- lack of a statistical significance between cocaine+ natally, it is suggested that the mother’s last dose and cocaine– symptoms leads to the conclusion was two to seven days prior to delivery. Thus, that withdrawal does not occur within neonates the infant would exhibit symptoms that resemble exposed to cocaine. Instead, the results indi- withdrawal postnatally (Ogunyemi & Hernandez-´ cate that, when contrasted with the behavior of Loera 2004). the control group, cocaine-exposed groups expe- Study A is particularly convincing in that it rience intransient defects due to the influence of provides an explanation as to why some cocaine- cocaine on an infant’s neurobehavioral pattern. exposed neonates do not display withdrawal This view is supported through observational stud- symptoms. The study draws a distinction between ies (Chiriboga 1993; Hadeed & Siegel 1989) and cocaine+ and cocaine– infants, where the former through Finnegan’s Neonatal Abstinence Scor- group is proposed to experience withdrawal in ing system (Ryan, Ehrlich, and Finnegan 1987). utero and the latter experiences withdrawal post- Again, it is important to note that Finnegan’s sys- natally. The results of Study A are also sup- tem was primarily used to diagnose opiate NAS ported by other studies that have diagnosed mild rather than cNAS. Moreover, it is also noteworthy to moderate withdrawal based on observed behav- that the creator-namesake of this system, Loretta ior (Cherukuri, et al. 1988; va de Bor, et al. 1990; Finnegan, also concluded the lack of cocaine with- Mastrogianis, et al. 1990). Studies have also drawal in infants (Ryan, Ehrlich, and Finnegan supported Study A’s conclusion through a stan- 1987). Both views are outlined and contrasted in dardized scale, i.e. Finnegan’s Neonatal Absti- Figure 2. nence Scoring System (Fulroth, Phillips & Du- Considering both studies aptly describe differ- rand 1989; Terri, et al. 1995). It is important to ent perspectives regarding the existence of cNAS,

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Table 4. A Comparison of Study A (Ogunyemi & Hernandez-Loera´ 2004) and Study B (Eyler, et al. 2001). Notice the conclusion column for a summary of both studies’ main point.

the question arises as to whether both views can be vous system. As a result of the active sympathetic united. Study A is reasonable when a symptom- nervous system, less blood flows to the placenta. centric perspective is considered, where specific Thus, less oxygen, hormones, and nutrients arrive defects are a result of cNAS. The downfall from at the fetus (Messiah, et al. 2011; Nathanielsz this study, however, is the inability to distinguish & Hanson 2003). Due to this low supply, the the symptoms of withdrawal from the direct ef- exposed neonate does not possess comparative fects of cocaine. Likewise, Study B is reasonable amounts of nutrients or oxygen in order to grow at when a scale-centric perspective relative to a con- a similar rate to unexposed neonates; this concept trol is considered, where lower NBAS scores com- is evident in that cocaine exposed neonates, on pared to controls are the result of cocaine’s direct average, weigh less than nonexposed neonates as effects rather than withdrawal. The concern for birth (Ogunyemi & Hernandez-Loera´ 2004; Chiri- Study B, however, is that this conclusion is coun- boga et al., 1999; Bandstra et al., 2001; Bada et terintuitive. Recall the logic behind the ACC: the al.,2002; Nordstrom-Klee et al., 2002). Thus, the removal of an addictive drug from a user leads fetus adapts to this state by growing accustomed to withdrawal. Neonates are exposed to cocaine to its low-resource environment. It is of inter- with the substance flowing in and out of their sys- est to note that as hypoxia occurs during labor, tem; how can the exposed infant seemingly be im- norepinephrine is in high concentration as part of mune to withdrawal from cocaine, an addictive the catecholamine surge in order to adapt to this substance? The answer is that they are not im- state (Buckley 2015). Though I am not claiming mune to withdrawal and this question can be ap- that cocaine-exposed infants become hypoxic per proached by uniting both perspectives through the se, they do utilize a comparatively lower supply “Adaptationist View”. of oxygen; thus, neonates are forced into making necessary adjustments, i.e. less expenditure of en- The Adaptationist View begins with the ergy and devoting less resources for growth. Nore- maternal-fetal connection of the placenta. The pinephrine is the principal hormone for long-term effects of cocaine stimulate the sympathetic ner-

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adaptation. Moreover, dopamine has recently be- tion was that cocaine– neonates tended to lack come a prominent treatment for neonate hypoten- withdrawal symptoms due to the withdrawal phase sion due to its capacity to increase blood pressure, occurring in utero (2004). When juxtaposing this circulating more oxygen (Bhayat, et al 2016). In view with the Adaptationist view, there does not this low-resource state, the neonate adapts to co- leave much room as to when the neonate would caine use at the expense of size and neurobehav- experience withdrawal prenatally. Though it can ioral development. be argued that in utero withdrawal occurs as the Upon birth, this adapted, maintained state is neonate is adapting to the low resource environ- disturbed. In particular, the neonate is not re- ment, this environment and subsequent adaptation liant on the mother’s blood supply and is thus is undertaken in the presence of cocaine; with- exposed to an excess of environmental oxygen. drawal, as considered in the addiction cycle, oc- With this significant amount of oxygen, the in- curs when cocaine is absent (Herman & Roberto fant is overstimulated and ill-informed as to what 2015; Eyler, et al. 2001). The unpleasurable he or she ought to do with this excess energy. state sustained is the result of cocaine affecting the Thus, the symptoms of hyperirritability, hyper- mother’s sympathetic system, hindering the opti- tonicity, and tremulousness arise. With an excess mal nutrients needed in neonate growth and devel- amount of oxygen, the body also must readjust opment. Thus, in utero withdrawal is not compat- to the higher concentrations of usable dopamine, ible with the Adaptationist view. readapting from its adapted cocaine-exposed state. When considering Study A, the argument in This excess dopamine leads to the observed mood favor of withdrawal is supported as a pathophys- alterations and inconsolability described in Study iological function, where each neurobehavioral A. symptom can be derived when observing this Upon the excretion of the cocaine metabolites, view. When considering Study B, the Adaptation- the Adaptationist View would posit that the body ist View can explain how cocaine leads to an over- attempts to recalibrate a set point, indicative of all effect on the infants, i.e. lower amounts of oxy- the stark increase in state regulation followed by gen and nutrients and rapid changes in environ- a stark decrease as shown in Eyler, et al.’s study ment, rather than withdrawal specifically. Thus, (2001). As the infant seeks a set point for homeo- in application, the Adaptationist View very aptly static function, the final result would, when com- connects the differences within Studies A and B pared to unexposed infants, be lower in NBAS and lines up with the conclusion made by Study B. scores. Due to the distressing environment in Yet, by rejecting the presence of in utero cocaine utero and the change of environment postnatally, withdrawal, there is no explanation as to why a decrease in the state of regulation is an expected withdrawal-like symptoms are present in some result of adaptation when contrasted with the un- cocaine-exposed neonates but not others. More- exposed controls. This result is in accordance with over, if the symptoms that were present postna- Eyler, et al.’s study (2001), indicative of an overall tally are the effects of neonate cocaine withdrawal, effect of cocaine rather than cocaine withdrawal. there must be an explanation as to why withdrawal The Adaptationist View connects the data pre- is selective to one cocaine-exposed population but sented between Study A and Study B and also not the latter. satisfies a logical basis through which symptoms Though I united the results of both studies to arise from both studies. Yet, it formulates an support the notion of an overall effect of cocaine, important objection to Study A: the presence of the following scenario must be addressed: When in utero withdrawal. According to Ogunyemi & neonates are exposed to cocaine repeatedly over Hernandez-Loera’s´ study, their primary explana- the course of a pregnancy if cocaine is suddenly

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removed, as is the case after birth, shouldn’t the of withdrawal may be still be possible but sec- infant experience withdrawal symptoms, consid- ondary to the overall effects of cocaine, causing ering that cocaine is an addictive substance? This the lack of an identifiable physiological response scenario falls in line with the ACC presented in the for NAS. When considering NAS in the context of introduction. As commonsensical as the argument the Adaptationist View and ACC, the argument in may be, I will offer a solution that may circumvent favor of the direct effects of cocaine on the infant this discrepancy between cocaine addiction and is strengthened but the presence of withdrawal re- neonate withdrawal. The infant may experience mains logically possible. some variant of selective attention, where there is a stronger negative effect experienced directly References from cocaine than there is from withdrawal. In essence, the negative stimuli attributed to the over- Bada HS, Das A, Bauer CR, et al. (2002). all effects of cocaine are perceived stronger than Gestational cocaine exposure and intrauter- the negative distractor stimuli attributed to with- ine growth: maternal lifestyle study. Obstet. drawal (Johansen-Berg & Lloyd 2000). If there is Gynecol 100:916–924. withdrawal within a cocaine-exposed neonate, its Bandstra ES, Morrow CE, Anthony JC, et al. effects are secondary to the direct effects of co- (2001). Intrauterine growth of full-term in- caine and the body physiologically reacts to the fants: impact of prenatal cocaine exposure. stronger stimulant. Thus, the ACC may be ac- Pediatrics 108:1309–1319. cepted in this context. Note that this conclusion does not undermine the Adaptationist View but Bhayat, S. I., Gowda, H. M., & Eisenhut, M. rather provides an explanation as to why some (2016). Should dopamine be the first line in- cocaine-exposed infants did not experience with- otrope in the treatment of neonatal hypoten- drawal symptoms. The complication that arises is sion? Review of the evidence. World Journal that the scales used to diagnose cNAS are actually of Clinical Pediatrics, 5(2), 212–222. diagnosing the overall effects of cocaine. In ef- Buckley S. J. (2015). Executive Summary of fect, these scales are not sensitive enough to cap- Hormonal Physiology of Childbearing: Ev- ture less stimulating cNAS. Without any data on idence and Implications for Women, Babies, borderline cases of NAS, i.e. cases where their and Maternity Care. Journal of Perinatal Ed- score was minutely below the threshold for diag- ucation, 24(3), 145–153. nosis, this concern may hold. More studies, however, need to be done to verify that this complica- Cain, M. A., Bornick, P., & Whiteman, V.(2013). tion is present. The maternal, fetal, and neonatal effects of Both studies support the Adaptationist View cocaine exposure in pregnancy. Clinical Ob- by equating the symptoms commonly attributed stetrics and Gynecology, 56(1), 124–132. to cNAS to the adaption of an infant to a new, Cherukuri, R., Minkoff, H., Feldman, J., Parekh, higher oxygen environment. This view continues A., & Glass, L. (1988). A cohort study of al- by attributing the extreme increases and decreases kaloidal cocaine (“crack”) in pregnancy. Ob- in NBAS scores for autonomic regulation to be stetrics and Gynecology, 72(2), 147–151. the result of seeking a setpoint for homeostasis. Thus, withdrawal is not primarily evident and both Chiriboga, C. A., Bateman, D. A., Brust, J. C., & studies would support the presence of an adapta- Hauser, W. A. (1993). Neurologic findings in tion mechanism that points to the direct effects of neonates with intrauterine cocaine exposure. cocaine. In introducing the ACC, the presence Pediatric Neurology, 9(2), 115–119.

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