Autism, ADHD, and Medicated Births
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, 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. 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.
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.
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. 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. 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.
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. 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.” Evidence at the molecular level helps support Hollander’s hypothesis. 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.
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. 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.