Prenatal cigarette smoke exposure: Are we sleeping through the alarm?
1999; Elsevier BV; Volume: 135; Issue: 1 Linguagem: Inglês
10.1016/s0022-3476(99)70318-5
ISSN1097-6833
Autores Tópico(s)Smoking Behavior and Cessation
ResumoSee related article, p. 34 .The purpose of this title is to convey two messages. First, infants exposed to cigarette smoke will quite likely sleep through an auditory alarm according to Franco et al1Franco P Groswasser J Hassid S Lanquart JP Scaillet S Kahn A. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants.J Pediatr. 1999; 135: 34-38Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar in the study appearing in this issue of The Journal, which demonstrates a lack of ability to be aroused by an “everyday” stimulus. Second, physicians and law makers are not responding to the repeated and resounding message that cigarette smoke damages infants. How can we in good conscience continue to tolerate this inertia? Why are we not modifying parental behavior and holding parents accountable for the damage to their infants?Although the effects of cigarette smoke exposure on fetal growth2Nordentoft M Lou HC Hansen D Nim J Pryds O Rubin P et al.Intrauterine growth retardation and premature delivery: the influence of maternal smoking and psychosocial factors.Am J Public Health. 1996; 86: 347-354Crossref PubMed Scopus (208) Google Scholar, 3Cooke RW. Smoking, intra-uterine growth retardation and sudden infant death syndrome.Int J Epidemiol. 1998; 27: 238-241Crossref PubMed Scopus (35) Google Scholar and sudden infant death syndrome4Hoffman HJ Damus K Hillman LS Krongrad E. Risk factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study.Ann N Y Acad Sci. 1988; 533: 13-30Crossref PubMed Scopus (305) Google Scholar, 5Taylor JA Sanderson M. A reexamination of the risk factors for the sudden infant death syndrome.J Pediatr. 1995; 126: 887-891Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 6Schoendorf KC Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy.Pediatrics. 1992; 90: 905-908PubMed Google Scholar are well documented, the effect on arousal from stimuli that an infant might experience in the course of a typical day is a more recent observation. Because arousal is essential to survival, such an insult may result in life-threatening sequelae. Saxton7Saxton DW. The behaviour of infants whose mothers smoke in pregnancy.Early Hum Dev. 1978; 2: 363-369Abstract Full Text PDF PubMed Scopus (96) Google Scholar demonstrated that the infant of a smoking mother had less auditory habituation and orientation to noise than the control infant when studied awake. This effect could potentially blunt the infant’s overall perception and response to an auditory stimulus. Lewis and Bosque8Lewis KW Bosque EM. Deficient hypoxia awakening response in infants of smoking mothers: possible relationship to sudden infant death syndrome.J Pediatr. 1995; 127: 691-699Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar reported that infants of smoking mothers had deficient awakening responses to hypoxic challenges at 2 to 3 months of age when evaluated during sleep. Such challenges (with associated hypercarbia) may occur when the infant rolls from the supine to the prone face-down position during sleep, burrows into bedding material,9Waters KA Gonzalez A Jean C Morielli A Brouillette RT. Face-straight-down and face-near-straight-down positions in healthy, prone-sleeping infants.J Pediatr. 1996; 128: 616-625Abstract Full Text PDF PubMed Scopus (109) Google Scholar or is accidentally placed in the prone position by an uninformed caretaker.10Gershon NB Moon RY. Infant sleep position in licensed child care centers.Pediatrics. 1997; 100: 75-78Crossref PubMed Scopus (27) Google Scholar In these everyday situations, the infant whose ability to be aroused is altered by prenatal exposure to cigarette smoke may experience physiologic compromise or die. And now, Franco et al1Franco P Groswasser J Hassid S Lanquart JP Scaillet S Kahn A. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants.J Pediatr. 1999; 135: 34-38Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar have demonstrated that prenatal exposure to cigarette smoke results in higher arousal thresholds to auditory challenges in newborns and infants approximately 3 months old. Although the mechanisms for such effects are not immediately obvious, it is known that nicotine exposure during pregnancy may alter central nervous system development through complex interactions of the neurochemical and vascular systems.11Slotkin TA Lappi SE McCook EC Lorber BA Seidler FJ. Loss of neonatal hypoxia tolerance after prenatal nicotine exposure: implications for sudden infant death syndrome.Brain Res Bull. 1995; 38: 69-75Crossref PubMed Scopus (151) Google Scholar, 12Kinney HC O’Donnell TJ Kriger P Frost White W. Early developmental changes in [3H]nicotine binding in the human brainstem.Neuroscience. 1993; 55: 1127-1138Crossref PubMed Scopus (123) Google Scholar Because maternal cigarette smoke influences the development of the fetal brainstem regions associated with the regulation of arousal and cardiorespiratory integration, areas rich in cholinergic nicotinic binding sites,12Kinney HC O’Donnell TJ Kriger P Frost White W. Early developmental changes in [3H]nicotine binding in the human brainstem.Neuroscience. 1993; 55: 1127-1138Crossref PubMed Scopus (123) Google Scholar the fetal effects could include either maturational or permanent dysfunction of the infant’s repertoire to respond to a natural or noxious stimulus.Take a moment to reflect on the two statements that follow. Under the current judicial system, a parent who knowingly exposes his or her fetus or infant to an illicit drug known to inhibit fetal growth, alter neonatal and infant arousal, and be a prominent risk factor for SIDS would likely be subject to penalty in a court of law and be enrolled in a medical program to modify the substance abuse behavior. Ironically, the parent who similarly exposes the infant to a legalized drug with the above-described features (inhibits fetal growth, alters neonatal and infant arousal, and is a prominent risk factor for SIDS) would not be considered culpable in a court of law and would at best be advised that cigarette smoking is harmful to the infant. Nevertheless, the fetus or infant remains the victim, with effects that may potentially last a lifetime, whereas the parent remains free of responsibility. As pediatricians, how can we continue to tolerate a situation that is neither just nor improving? Surely, it is time to heed the alarm. See related article, p. 34 . The purpose of this title is to convey two messages. First, infants exposed to cigarette smoke will quite likely sleep through an auditory alarm according to Franco et al1Franco P Groswasser J Hassid S Lanquart JP Scaillet S Kahn A. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants.J Pediatr. 1999; 135: 34-38Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar in the study appearing in this issue of The Journal, which demonstrates a lack of ability to be aroused by an “everyday” stimulus. Second, physicians and law makers are not responding to the repeated and resounding message that cigarette smoke damages infants. How can we in good conscience continue to tolerate this inertia? Why are we not modifying parental behavior and holding parents accountable for the damage to their infants? Although the effects of cigarette smoke exposure on fetal growth2Nordentoft M Lou HC Hansen D Nim J Pryds O Rubin P et al.Intrauterine growth retardation and premature delivery: the influence of maternal smoking and psychosocial factors.Am J Public Health. 1996; 86: 347-354Crossref PubMed Scopus (208) Google Scholar, 3Cooke RW. Smoking, intra-uterine growth retardation and sudden infant death syndrome.Int J Epidemiol. 1998; 27: 238-241Crossref PubMed Scopus (35) Google Scholar and sudden infant death syndrome4Hoffman HJ Damus K Hillman LS Krongrad E. Risk factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study.Ann N Y Acad Sci. 1988; 533: 13-30Crossref PubMed Scopus (305) Google Scholar, 5Taylor JA Sanderson M. A reexamination of the risk factors for the sudden infant death syndrome.J Pediatr. 1995; 126: 887-891Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 6Schoendorf KC Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy.Pediatrics. 1992; 90: 905-908PubMed Google Scholar are well documented, the effect on arousal from stimuli that an infant might experience in the course of a typical day is a more recent observation. Because arousal is essential to survival, such an insult may result in life-threatening sequelae. Saxton7Saxton DW. The behaviour of infants whose mothers smoke in pregnancy.Early Hum Dev. 1978; 2: 363-369Abstract Full Text PDF PubMed Scopus (96) Google Scholar demonstrated that the infant of a smoking mother had less auditory habituation and orientation to noise than the control infant when studied awake. This effect could potentially blunt the infant’s overall perception and response to an auditory stimulus. Lewis and Bosque8Lewis KW Bosque EM. Deficient hypoxia awakening response in infants of smoking mothers: possible relationship to sudden infant death syndrome.J Pediatr. 1995; 127: 691-699Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar reported that infants of smoking mothers had deficient awakening responses to hypoxic challenges at 2 to 3 months of age when evaluated during sleep. Such challenges (with associated hypercarbia) may occur when the infant rolls from the supine to the prone face-down position during sleep, burrows into bedding material,9Waters KA Gonzalez A Jean C Morielli A Brouillette RT. Face-straight-down and face-near-straight-down positions in healthy, prone-sleeping infants.J Pediatr. 1996; 128: 616-625Abstract Full Text PDF PubMed Scopus (109) Google Scholar or is accidentally placed in the prone position by an uninformed caretaker.10Gershon NB Moon RY. Infant sleep position in licensed child care centers.Pediatrics. 1997; 100: 75-78Crossref PubMed Scopus (27) Google Scholar In these everyday situations, the infant whose ability to be aroused is altered by prenatal exposure to cigarette smoke may experience physiologic compromise or die. And now, Franco et al1Franco P Groswasser J Hassid S Lanquart JP Scaillet S Kahn A. Prenatal exposure to cigarette smoking is associated with a decrease in arousal in infants.J Pediatr. 1999; 135: 34-38Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar have demonstrated that prenatal exposure to cigarette smoke results in higher arousal thresholds to auditory challenges in newborns and infants approximately 3 months old. Although the mechanisms for such effects are not immediately obvious, it is known that nicotine exposure during pregnancy may alter central nervous system development through complex interactions of the neurochemical and vascular systems.11Slotkin TA Lappi SE McCook EC Lorber BA Seidler FJ. Loss of neonatal hypoxia tolerance after prenatal nicotine exposure: implications for sudden infant death syndrome.Brain Res Bull. 1995; 38: 69-75Crossref PubMed Scopus (151) Google Scholar, 12Kinney HC O’Donnell TJ Kriger P Frost White W. Early developmental changes in [3H]nicotine binding in the human brainstem.Neuroscience. 1993; 55: 1127-1138Crossref PubMed Scopus (123) Google Scholar Because maternal cigarette smoke influences the development of the fetal brainstem regions associated with the regulation of arousal and cardiorespiratory integration, areas rich in cholinergic nicotinic binding sites,12Kinney HC O’Donnell TJ Kriger P Frost White W. Early developmental changes in [3H]nicotine binding in the human brainstem.Neuroscience. 1993; 55: 1127-1138Crossref PubMed Scopus (123) Google Scholar the fetal effects could include either maturational or permanent dysfunction of the infant’s repertoire to respond to a natural or noxious stimulus. Take a moment to reflect on the two statements that follow. Under the current judicial system, a parent who knowingly exposes his or her fetus or infant to an illicit drug known to inhibit fetal growth, alter neonatal and infant arousal, and be a prominent risk factor for SIDS would likely be subject to penalty in a court of law and be enrolled in a medical program to modify the substance abuse behavior. Ironically, the parent who similarly exposes the infant to a legalized drug with the above-described features (inhibits fetal growth, alters neonatal and infant arousal, and is a prominent risk factor for SIDS) would not be considered culpable in a court of law and would at best be advised that cigarette smoking is harmful to the infant. Nevertheless, the fetus or infant remains the victim, with effects that may potentially last a lifetime, whereas the parent remains free of responsibility. As pediatricians, how can we continue to tolerate a situation that is neither just nor improving? Surely, it is time to heed the alarm.
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