Autism, ADHD, and Medicated Births

May 31, 2009

From Medscape Ob/Gyn & Women's Health

Autism, ADHD, and Medicated BirthsKatharine M. Hikel, MDPublished: 05/28/2009

Introduction

Over

the past decade, concerns over traditional childhood diseases such as

measles and whooping cough have been supplanted by developmental

disorders such as autism and attention-deficit disorder and

attention-deficit/hyperactivity disorder (ADD/ADHD). Autism now affects

1 in 150 eight-year-olds in the United States,[1] while more than 4 million children nationwide qualify for a diagnosis of ADD/ADHD.[2,3]

As these changes have taken place, no one has satisfactorily answered

the question of the etiology of these problems, and why their

incidences have increased so dramatically over the past decade.

Theories

abound regarding the causes of these 2 conditions: low birth weight and

premature delivery, viral infections, vaccines, sugar, psychological

trauma, too much TV, older parents, genetic mutation. Another area that

might be explored is medicated birth and "actively managed" labor,

which has increased since the early 1980s.[4,5]

Prevalence of Medicated Birth

Medicated

birth is now quite common in the United States. The Centers for Disease

Control and Prevention (CDC) reported a 65% use of spinal or epidural

labor analgesia in 2005.[5] That report captured a 21% rate

of "augmented" births -- births speeded up, usually through the use of

Pitocin® (synthetic oxytocin). This figure may be an underestimate. In

a 2002 study in American Family Physician, 44% of laboring women who received epidural analgesia required synthetic oxytocin augmentation.[6]

Pituitary

oxytocin orchestrates contractions as well as the release of

pain-blocking endorphins in mother and baby. Nicknamed the "hormone of

love," it facilitates nursing and mother-child bonding and enhances

relationships among family members, friends, and intimate partners.

The

primary action of synthetic oxytocin is to cause all uterine fibers to

contract at once, instead of in fundally dominant peristaltic waves

from top to bottom. Synthetic oxytocin-augmented contractions are

associated with uterine hyperstimulation, fetal distress, and hypoxia.[7]

Relationship to Autism and Attention-Deficit/Hyperactivity Disorder?

A report in the January 2009 issue of the American Journal of Obstetrics and Gynecology

stated that "[synthetic] oxytocin is the drug most commonly associated

with preventable adverse perinatal outcomes." Adverse outcomes with

synthetic oxytocin administration include lowered fetal oxygen

saturation.[8] It "was recently added by the Institute for

Safe Medication Practices to a small list of medications 'bearing a

heightened risk for harm,' which may 'require special safeguards to

reduce the risk for error.'"

So is

there a connection between synthetic oxytocin and autism, ADHD/ADD, or

both? A 2007 review of studies on the etiology of autism cited neonatal

hypoxia among the risk factors for the condition.[9] Fetal

distress, cesarean delivery, and low Apgar scores, as well as maternal

hypotension and bleeding during pregnancy, were regarded as "obstetric

surrogates" for hypoxia: "Taken together, the studies suggest that

hypoxia-related obstetric complications and fetal hypoxia may possibly

increase the risk for autism." The reviewers noted the limitations of

the studies: few in number, variable diagnostic criteria, and the fact

that "several other neurodevelopmental diseases, as noted, may likewise

be associated with the identified risk factors." In other words,

intranatal hypoxia was associated with neurologic problems other than

autism. The authors called for future studies to investigate "obstetric

conditions such as newborn hypoxia and LBW (low birth weight)" -- and

by inference, the obstetric causes of these problems.[9]

An April 2001 study in Pediatrics

supported older findings suggesting that autism diagnoses are

associated with unfavorable perinatal events, including induction of

labor, prolonged or precipitous labor, and oxygen requirements.[10]

However, no single complication or cluster of complications was clearly

responsible for the disorder; and the findings may indirectly support

the hypothesis that autism is a genetic disorder that may itself create

complications in pregnancy and birth. That study called for more

investigation of pre-, peri-, and postnatal associations that could

generate a risk profile for autism spectrum disorders. Parental age and

genetic susceptibility have been recently associated with autism

spectrum disorders. However, if autism is a form of iatrogenic brain

damage, parental age could very well be an indicator, because high-risk

pregnancies, many of which include women over age 35, are often

aggressively managed at delivery.

Moreover,

recent discovery of genetic variations linked with autism may indicate

a genetic susceptibility to the environmental event.

Eric

Hollander, director of the Seaver and New York Autism Center of

Excellence at Mount Sinai School of Medicine, has been studying

potential benefits of oxytocin in the treatment of autism. However, in

a 2007 interview he said, "In some individuals whose oxytocin system

could be genetically vulnerable, a strong environmental early hit while

the brain is still developing could downregulate the oxytocin system,

leading to developmental problems. But this is only a hypothesis that

has been observed by association."[11] Evidence at the molecular level helps support Hollander's hypothesis.[11]

Nevertheless, a study published in 2003 that examined the rates of

labor induction using synthetic oxytocin in children with autism and

matched controls reported no differences in synthetic oxytocin-induced

rates as a function of either autism or IQ level vs control. The study

was small and more research is warranted.[12]

Two questions remain unanswered:

Are pediatric developmental disorders, such as autism spectrum and ADD/ADHD, actually forms of perinatal brain injury?Is

there a relationship between the increase in the active management of

labor and the increased incidence of these brain disorders in children?

One

2009 review recommended a precautionary approach to active management,

emphasizing more physiologic protocols and advocating lower synthetic

oxytocin doses and allowing more labor time -- rather than adding more

oxytocin.[13] The authors said, "There is no place in modern

obstetrics ... continuing to blindly increase the Pitocin® dose until

the 1-minute Apgar score is recorded." That seems a welcome approach

until questions about the role of labor drugs in childhood

developmental disorders are answered.

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References

Centers for Disease Control and Prevention

(CDC). Autism Information Center: Autism Spectrum Disorders Overview.

February 9, 2007. Available at:

http://www.cdc.gov/ncbddd/autism/overview.htm#who Accessed March 9,

2009.Centers for Disease Control and

Prevention (CDC). Mental health in the United States: prevalence of

diagnosis and medication treatment for attention-deficit/hyperactivity

disorder -- United States, 2003. MMWR Morb Mortal Wkly Rep.

2005;54:842-847. Available at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm Accessed March 9,

2009.Froehlich TE, Lanphear BP, Epstein JN,

Barbaresi WJ, Katusic SK, Kahn RS. Prevalence, recognition, and

treatment of attention-deficit/hyperactivity disorder in a national

sample of US children. Arch Pediatr Adolesc Med. 2007;161:857-864.

Available at: http://archpedi.ama-assn.org/cgi/content/full/161/9/857

Accessed March 9, 2009.O'Driscoll K, Foley

M, MacDonald D. Active management of labor as an alternative to

cesarean section for dystocia. Obstet Gynecol. 1984;63:485. Available

at: http://www.medscape.com/medline/abstract Accessed May 4, 2009.CDC,

Table R-3. Number and rate of live births by characteristics of labor

and delivery, by age and race and Hispanic origin of mother: total of

12 reporting states, 2005. Available at:

http://wonder.cdc.gov/wonder/sci_data/natal/detail/type_txt/natal05/RestofTables05.pdf

Accessed March 12, 2009.Walling AD. Epidural

analgesia prolongs the active phase of labor. American Family

Physician, Nov. 15, 2002. Available at:

http://www.aafp.org/afp/20021115/tips/18.html Accessed March 12, 2009.Verspyck

E, Sentilhes L. Abnormal fetal heart rate pattern associated with

different labour managements and intrauterine resuscitation techniques.

J Gynecol Obstet Biol Reprod (Paris). 2008;37 :S56-64. Epub 2008 Jan 9

(Abstract). Available at:

http://www.ncbi.nlm.nih.gov/pubmed/18187267?ordinalpos=1 & itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_

DiscoveryPanel.Pubmed_Discovery_RA & linkpos=4 & log$=relatedreviews & logdbfrom=pubmed Accessed May 1, 2009.Simpson

KR, James DC. Effects of oxytocin-induced uterine hyperstimulation

during labor on fetal oxygen status and fetal heart rate patterns. Am J

Obstet Gynecol. 2008;199:34.e1-5. Epub 2008 Mar 14. Available at:

http://www.ncbi.nlm.nih.gov/pubmed/18342288?dopt=AbstractPlus Accessed

May 1, 2009.Kolevzon A, Gross R, Reichenberg

A. Prenatal and perinatal risk factors for autism: a review and

integration of findings. Arch Pediatr Adolesc Med. 2007;161:326-333.

Available at: http://archpedi.ama-assn.org/cgi/content/full/161/4/326

Accessed April 30, 2009.Juul-Dam N, Townsend

J, Courchesne E. Prenatal, perinatal, and neonatal factors in autism,

pervasive developmental disorder-not otherwise specified, and the

general population. Pediatrics. 2001;107:e63. Available at:

http://pediatrics.aappublications.org/cgi/content/full/107/4/e63?maxtoshow= & HITS=10 & hits=10 & RESULTFORMAT= & fulltext=autism+spectrum+AND+birth &

andorexactfulltext=and & searchid=1 & FIRSTINDEX=10 & sortspec=relevance & resourcetype=HWCIT Accessed March 9, 2009.Partridge

M. Oxytocin, pitocin, and autism: researchers wrestle with links.

Psychiatric Times, July 1, 2007. Available at:

http://www.psychiatrictimes.com/autism/article/10168/57071 Accessed

March 12, 2009.Wahl RU. Could oxytocin

administration during labor contribute to autism and related behavioral

disorders? A look at the literature. Med Hypotheses. 2004;63:456-460. Abstract

Clark SL, Simpson KR, Knox GE, et al.

Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol.

2009;200:35.e1-35.e6. Available at:

http://www.ajog.org/article/S0002-9378(08)00620-0/abstract Accessed May

4, 2009.

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Authors and Disclosures

Author(s)

Katharine M. Hikel, MD

Independent Physician, Hinesberg, Vermont

Disclosure: Katharine M. Hikel, MD, has disclosed no relevant financial relationships.

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