is still not known about what factors may exist to aid children who were exposed to cocaine in utero. whether the effects of pce are increased once children reach adolescence is unknown, as is whether the neural rewiring that occurs during this developmental period attenuates the effects. a review of 27 studies performed between 2006 and 2012 found that cognitive development was mildly to moderately affected in pce adolescents, but how important these effects were in practical terms was unclear. unlike fetal alcohol syndrome, no set of characteristics has been discovered that results uniquely from cocaine exposure in utero. cocaine exposure in utero may affect the structure and function of the brain, predisposing children to developmental problems later, or these effects may be explained by children of crack-using mothers being at higher risk for domestic violence, deadbeat parenting, and maternal depression. when researchers are able to identify effects of pce, they are typically small. pregnancy and birth premature baby studies have found after controlling for other factors that some effects are present in pregnancies involving cocaine: abruptio placenta, prematurity, low birth weight, and small size compared to babies of the same gestational time. pce newborns have smaller heads and shorter bodies. pce effects are more severe when the amounts of cocaine are greater. as many as 17–27% of cocaine-using pregnant women deliver prematurely. in association with prematurity, growth in the womb is reduced, and low birth weight is connected to pce. also, some data associate spontaneous abortion with cocaine use. cocaine reduces the appetite and has been linked with reduced maternal weight gain during pregnancy; in addition, constriction of the blood vessels may further limit supply of nutrients to the fetus. using cocaine while pregnant also heightens the chances of maternal and fetal vitamin deficiencies, respiratory distress syndrome for the baby, and infarction of the bowels. early reports found that cocaine-exposed babies were at high risk for sudden infant death syndrome; however, by itself, cocaine exposure during fetal development has not subsequently been identified as a risk factor for the syndrome. some pce children experience hypertonia (excessive muscle tone), and reduced reflexes and motor function have been found in babies four to six weeks old. while newborns who were exposed prenatally to drugs such as barbiturates or heroin frequently have symptoms of drug withdrawal (neonatal abstinence syndrome), this does not happen with babies exposed to crack in utero; at least, such symptoms are difficult to separate in the context of other factors such as prematurity or prenatal exposure to other drugs. mental, emotional, and behavioral outcomes studies have shown small deficits in behavioral, cognitive, attention, emotional, and language function in pce infants, children, and adolescents, but other studies attribute findings of negative effects on cognitive development to confounding factors. studies suggest that the environment in which a child grows up makes a more important contribution to outcome in cognitive, behavioral, and other outcomes than does the cocaine exposure itself. school performance is mildly affected in older children. in iq studies, cocaine-exposed children do not appear to score lower than others. although pce is correlated with low iq scores, scientists generally believe that pce alone does not cause this effect; rather, it is more likely due to associated factors. in school-aged and younger children, pce does not appear in studies to predispose children to poorer intellectual performance. poor performance on iq tests could actually be due to trouble with sustaining attention if the tests fail to account for this factor separately. cocaine causes impaired growth of the fetus's brain, an effect that is most pronounced with high levels of cocaine and prolonged duration of exposure throughout all three trimesters of pregnancy. prenatal cocaine exposure has been found to affect the cognitive performance of individuals and affect speech and language development, behavior, physical and cognitive growth, and function. the more of the substance the fetus is exposed to the more of an effect it can have on the overall development as well as running the risk of being fatal to the fetus during the prenatal stage(s) of pregnancy. the effects of cocaine uses can cause for there to be an increased chance of the baby being born premature, affecting the body weight, height and the growth of the organs and brain due to the premature state of the baby as well as the impact of the harmful substances the baby was exposed to. this can have effects on other areas such as brain development, being exposed to a stimulant such as cocaine can cause damage and issues in development over time. in behavior, cognition, memory, grasping of information, and attention are areas that are common struggles for children that were exposed to cocaine in the womb. these effects are seen in individuals reaching the age of 10 and older. long-term studies have shown that there are alterations made in the structure and function of the brain occur when exposed to these drugs with cause change in the behaviors of the individual over time and they develop and grow. all of the effects physically and cognitively all vary for each individual based on their level of exposure to the drug, the gestational timing of the infant as it develops, determine some physical effect that might have occurred and the care they receive after being born. studies that use neuroimaging such as magnetic resonance imaging (mri) and fmri have shown differences in brain structure of pce children, for example in the cerebral cortex and limbic system. those pce children who had slowed brain growth as fetuses are at higher risk for impaired brain growth and motor, language and attention problems after they are born. studies have found that children exposed to cocaine during fetal development experience problems with language, behavior, development, and attention. however these effects are small, especially when studies control for other factors like exposure to other drugs. cognitive and attention skills can be impacted by pce, possibly due to effects on brain areas such as the prefrontal cortex. brain areas in the frontal lobe involved in dealing with stress, attention, and impulsiveness seem to be particularly impacted by pce, as evidenced by neuroimaging studies that show abnormalities in these areas of the brain. pce infants have been shown to be more jittery and excitable and have lower arousal and self-regulation; such behavioral effects may persist or worsen after 12 months of age. children whose mothers used cocaine during pregnancy may develop symptoms akin to those of attention deficit disorder, and a link has been found between the disorder itself and pce. mild deficits in language have been found in older pce children. language development is impaired, possibly into late adolescence, but adolescents up to age 17 may improve their receptive language skills. evidence suggests that in utero cocaine exposure leads to problems with behavior and sustained attention, possibly by affecting parts of the brain that are vulnerable to toxins during fetal development. school-age pce children have been found to have trouble regulating their behavior and sustaining their attention. children who had been exposed to high levels of cocaine in utero show poorer behavioral inhibition than those with lower levels of exposure or unexposed children. the changes in behavior and attention caused by pce are measurable by standardized scales; however these behavioral effects seem to be mild. children exposed to cocaine in the first trimester are less sociable, more withdrawn, and show more anxious and depressed behaviors. those exposed to higher doses of cocaine have been reported to show aggressive and disruptive behaviors. pce girls are seven times more likely to have delinquent behavioral problems, but pce boys are no more likely than other boys. studies from the 2000s and 2010s are conflicted on whether pce adolescents are at greater risk for use of drugs such as cocaine, alcohol, and marijuana. a 2010 study found that pce adolescent girls were have anxiety than their non-exposed peers. physical outcomes slowed growth is well documented in fetuses, but it is not as clear whether older children remain smaller or catch up to their peers. some studies show that growth remains slowed for as many as ten years. pce may also interfere with the way the motor system matures. motor effects that have been documented include poorer reflexes and quality of movement in infants. pce may have an effect on the neuroendocrine system, but more study is needed to determine whether it does and what the effects are. a review of the literature reported that cocaine use causes congenital defects between 15 and 20% of the time; however another large-scale study found no difference in rates of birth anomalies in pce and non-pce infants. it has been suggested that some birth defects could be due to cocaine's disruption of blood vessel growth. most pce-related congenital defects are found in the brain, heart, genitourinary tract, arms and legs. cocaine use by pregnant mothers may directly or indirectly contribute to defects in the formation of the circulatory system and is associated with abnormalities in development of the aorta. heart malformations can include a missing ventricle and defects with the septum of the heart, and can result in potentially deadly congestive heart failure. genital malformations occur at a higher-than-normal rate with pce. the liver and lungs are also at higher risk for abnormalities. cloverleaf skull, a congenital malformation in which the skull has three lobes, the brain is deformed, and hydrocephalus occurs, is also associated with pce. like birth defects, small head size, and stroke are risks in pce. epidemiology of all cocaine users, women of childbearing age comprise 15–17%. an estimated 0.6 to 3% of pregnant women in the developed world use cocaine. a 1995 survey in the us found that between 30,000 and 160,000 cases of prenatal exposure to cocaine occur each year. by one estimate, in the us 100,000 babies are born each year after having been exposed to crack cocaine in utero. an estimated 7.5 million pce children are living in the us. pregnant women in urban parts of the us and who are of a low socioeconomic status use cocaine more often. however, the real prevalence of cocaine use by pregnant women is unknown. legal and ethical issues women have been prosecuted for using crack while pregnant. the harm to a child from pce has implications for public policy and law. some us states have pressed charges against pregnant women who use drugs, including assault with a deadly weapon, corruption of a minor, manslaughter, child abuse, and distribution of drugs to a minor. however these approaches have generally been rejected in the courts on the basis that a fetus is not legally a child. between 1985 and 2001, more than 200 women in over 30 us states faced prosecution for drug use during pregnancy. in south carolina, a woman who used crack in her third trimester of pregnancy was sentenced to prison for eight years when her child was born with cocaine metabolites in its system. the supreme court of south carolina upheld this conviction. as of 2013, all but one of the women prosecuted in the us for drug use while pregnant have won their cases on appeal. from 1989 to 1994, in the midst of public outcry about cocaine babies, the medical university of south carolina tested pregnant women for cocaine, reporting those who tested positive to the police. the us supreme court found the policy to be unacceptable on constitutional grounds in 2001. some advocates argue that punishment for crack-using pregnant women as a means to treat their addiction is a violation of their right to privacy. according to studies, fear of prosecution and having children taken away is associated with a refusal to seek prenatal care or medical treatment. some nonprofit organizations aim to prevent pce with birth control. one such initiative, project prevention, offers women addicted to cocaine money as an incentive to undergo long-term birth control or, frequently, sterilization—an approach which has led to public outcry from those who consider this practice to be eugenics. social stigma children who were exposed to crack prenatally faced social stigma as babies and school-aged children; some experts say that the "crack baby" stigma was more harmful than the pce. teachers were affected by these cultural stereotypes; such biases may have negatively affected the educational experiences of children thus