Substance-Exposed Infants

1. Substance-Exposed Infants Karen Farst, MD UAMS, College of Medicine, Department of Pediatrics Arkansas Children’s Hospital, Team for Children at Risk

2. Objectives • Definition of a “substance-exposed” infant • Identification of being exposed • Overview of substances • Adverse effects of pre-natal exposure • Recognition of drug-endangered child • Resources

3. Substance-Exposed Infants • Use of an illegal or potentially harmful substance by mother during pregnancy • Mother and fetus share a common circulation • Fetus depends on mom’s health and nutrition • Each state has different regulations • Tobacco, alcohol, illicit drugs, prescription….

4. “Garrett’s Law” • Garrett was Betty Stahl’s grandson • Born premature and died after 2 months from “ill-effects” of methamphetamine • Ms. Stahl lobbied AR legislature for law requiring intervention by child protection system of mother’s identified as using substances of abuse during pregnancy • Senate Bill 114 signed into law 3-28-2005 • Not intended to “criminalize” mother’s, but to identify those in need of services

5. ARKANSAS SENATE • 85th General Assembly - Regular Session, 2005 • * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Subtitle of Senate Bill No. 114 • "GARRETT'S LAW” • TO PROVIDE SERVICES TO • A NEWBORN CHILD BORN WITH AN ILLEGAL • SUBSTANCE PRESENT IN THE CHILD’S BLOOD.” • * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * • “AN ACT TO INCLUDE IN THE DEFINITION OF NEGLECT ITHE ARKANSAS CHILD MALTREATMENT ACT AND THE ARKANSAS JUVENILE CODE THE CAUSING OF A NEWBORN CHILD TO BE BORN WITH AN ILLEGAL SUBSTANCE IN HIS OR HER BLOOD OR BORN WITH A HEALTH PROBLEM AS A RESULT OF THE PREGNANT MOTHER’S USE BEFORE BIRTH OF AN ILLEGAL SUBSTANCE; AND FOR OTHER PURPOSES.”

6. Substance-Exposed Infant • “Exposed” infant • Confirmed test in infant • Positive test in mom with ill-effect in baby • Hard to get mom’s tests confirmed • Some ill-effects happen without drug exposure • Positive test in mom and no ill-effect in baby • Still concern for “Threat of Harm” • Concern for other children in the home

7. Fox 16 News Article • Mother of two born with meth in system faces no charge • AR Democrat Gazette, 6/9/2005 • “A new law requires doctors and hospital personnel to notify authorities when a baby is born with an illegal drug in its system, but a prosecutor says there's no law that the mother can be charged with violating.”

8. News article (cont’d) “But the prosecutor says that law doesn't apply in the case of a mother who takes drugs while pregnant. He said the law does not apply to unborn children. ‘That statute was never intended for this type of charge,’ the prosecutor said. The prosecutor said that, except in cases of homicide, Arkansas law does not define an unborn child as a person for the purpose of criminal prosecution.”

9. Substance identification • Toxicologic testing • Urine and blood negative in 1-2 days • Meconium reflects about last 6 weeks of gestation • Confirmation should be done on screening tests • Potential for false positive results • Inappropriate usage of prescription drugs included • Difficult for providers of OB and Peds care to deem what is “inappropriate” • Only healthcare providers can call this to hotline in AR

10. Who gets tested?

11. Maternal indicators Known drug abuse by mom Limited or no pre-natal care STD Placental abruption Unexpected pre-term labor Newborn indicators CNS complications Bleeding Seizures Drug withdrawal symptoms IUGR Who gets tested? Wegner et al. OB and Gynecol Clinics of North America, Vol 25(1)

12. 5 Drug Opiates Cocaine Marijuana Amphetamines PCP 7 Drug Above plus… Benzodiazepenes Barbiturates Can assay for other substances as well with most reference labs including… Alcohol Nicotine Typical tox screen panels

13. Cocaine Methamphetamine Amphetamines Weight loss drugs Binge and crash cycle from high to low Increased heart rate, dizziness, elevated blood pressure, GI upset Increased aggression and paranoia Irritable, confused, depressed on withdrawal Stimulants Crack

14. Stimulants Methamphetamine Amphetamines http://www.methamphetamineaddiction.com/drug_photos.html

15. Methamphetamine • Highly addictive stimulant • Ice, crank, poor man’s crack, zip…. • Snorted, smoked, injected or taken orally • Can be manufactured in home or “clandestine” labs by reacting household agents from pseudoephedrine or ephedrine

16. Short-term Binge/crash Appetite loss Increase in blood pressure and heart rate Physical/sexual aggression Agitation Long-term Poor nutrition Self-neglect Pre-term labor Placental abruption Paranoia Delusions Violent relationships Meth use during pregnancy

17. Narcotics • Opiates • Heroin • Prescription pain meds • Morphine, codeine, demerol, dilaudid, hydrocodone, oxycodone • Methadone • Long lasting effects so can help with withdrawal and treatment of chronic pain Opium

18. Usage Sense of well-being, reduce tension and aggression, pain relief Overdosage Coma and respiratory suppression Withdrawal Watery eyes, runny nose, irritability, chills, vomiting and diarrhea Narcotics Oxycontin www.dea.gov

19. Cannabis • Marijuana • #1 illicit drug worldwide • Usage • Well-being, intoxication, hallucinations • Similar health effects of nicotine • Long-term usage • “Amotivational Syndrome” • Apathy and impaired judgement

20. Benzodiazepines Xanax, valium, klonopin Rohypnol “date rape” amnesia Gamma-hydroxybutyric acid (GHB) “date rape” drug Affects memory Difficult to detect on testing Barbiturates Depressants (Sedatives) GHB Liquid www.dea.gov

21. Sedatives • Usage • Intoxication and sense of well-being and calm (similar to alcohol) • Anti-anxiety • Overdosage • Coma and respiratory depression • Withdrawal • Anxiety, weakness, seizures

22. Hallucinogens • MDMA (Ecstasy) • PCP (distortions) • LSD (visual hallucinations) • Ketamine • Anesthetic • Usage • Sensory enhancement, distortion of thought (pleasure or fright) • RAVE parties • Accidents and poor judgement • Withdrawal • Flashbacks http://www.teenchallenge.com/images/drugs/pcp.jpg

23. False positive possibilities • Amphetamines • Pseudoephedrine, ADD medications, OTC stimulants, weight loss meds…. • Opiates • Dextromethorphan, poppy seeds, cough meds… • Marijuana • Phenergan, NSAID’s, second hand smoke (?) • Cocaine • ? • Barbiturates • Anesthetics, phenobarb, phenytoin, donnatol… • LSD • Tricyclic antidepressants, promethazine, migraine meds… ** Does not represent a complete list

24. How many women “use” in pregnancy? • Self-report surveys indicate 3-5 % • Anonymous screening test results are 3-6 times higher than self-report results • Prescription drug use and mis-use is more difficult to monitor

25. What are the short-term effects? • Cocaine and methamphetamine (stimulants) • Prematurity • Intra-uterine growth restriction (IUGR) • Placental abruption • Intra-cranial hemorrhages (ICH) • Withdrawal (not addiction) • Poor feeding, hypertonia, irritable, altered sleep/wake cycles, seizures

26. Prenatal use of methamphetamine • Increased risk of acute problems • Withdrawal, prematurity, IUGR, ICH • Dixon and Bejar, Western J of Medicine, 1989 • Stewart and Meeker, J of Analytical Tox, 1997 • Smith, et al. Devel and Behav Peds, 2003 • Ongoing problems • Growth and feeding • Oro and Dixon, Journal of Peds, 1987 • Growth and school performance • Cernerud, et al. Acta Paediatrica, 1996 • Same or different than cocaine? • NIDA research review, 2001

27. Placental abruption http://health.allrefer.com/health/placenta-abruptio-placenta-1.html

28. Sweaty Fever Sneezing/Runny nose Watery stools Poor feeding Increased respiratory rate Muscle twitches Increased muscle tone (hypertonia) Neonatal Abstinence SyndromeOpiates/Narcotics

29. Short term effects • Marijuana (similar to nicotine) • Growth restriction • Prematurity • Often other drugs involved • Narcotics (pain meds, opiates…) • Respiratory difficulties • “Neonatal Narcotic Abstinence” • Sedatives (benzo’s…ativan, xanax, valium) • Respiratory difficulties • withdrawal

30. Long-term effects • Majority of research is on cocaine-exposed • Long-term studies don’t look as bad as people feared during the height of the crack epidemic • Lester, et al. JAMA 2001, Vol 285(12) • Only one long-term study on amphetamine exposed (out to age 14 years) • Showed difference in academic and athletic achievement • Take care in assuming meth results will be the same as cocaine • NIDA/NIH studies in adults and kids

31. Author Drug Measure Outcome

32. Pre-natal studies • Study found an abnormality in energy metabolism in the brains of children exposed to methamphetamine in utero. • Smith, et al. Neurology, 2001; 57 • (12 exposed, 13 controls) • Children exposed to Meth prenatally exhibit smaller subcortical volumes and associated neurocognitive deficits. These preliminary findings suggest prenatal Meth exposure may be neurotoxic to the developing brain. • Chang, et al. Psychiatry Research, 2004; 132(2) • (13 exposed, 15 controls)

33. Associated problems • Domestic violence • Abuse and neglect • Related stressors • Poverty, single-parent homes, …. • Inter-generational usage • Access to treatment (effectiveness) • Stressed child protection system

34. Effects on the caregiver • Meth users are more likely than other substance abusers to be involved with DHS • Hohman, et al. Social Work, 2004 • 53 % of children with abusive head trauma had parental substance abuse • Ricci, et al. Child Abuse and Neglect, 2003 • 80 % of women in treatment for meth addiction report IPV • Cohen, et al. Am Journal of Addiction, 2003

35. The big picture • Drug use and drug treatment status are not independent predictors of potential for mom’s to perpetrate child abuse. • Hogan & Elswick, Child Abuse Neglect, 2006 (30) • There may be a higher risk of maltreatment and out-of-home placements in cocaine-exposed infants, but that was not the sole risk factor. • Leventhal, et al. Pediatrics, 1997, 100(2) • Most studies support that the quality of the environment is the most important factor

36. Stress on the system • DCFS caseloads • Foster care availability • Healthcare/Medicaid expenses • Substance abuse treatment • Funding/Access • Monitoring compliance Law enforcement time and money • School readiness/failure • Judicial costs • Law enforcement resources

37. Costs • New York City, 1991-1992 • “Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed.” • Joyce, et al. Health Serv Res. 1995 Jun;30(2):341-58.

38. Follow-up of substance-exposed infant • Breast milk testing • Home evaluation • Feeding issues • Follow growth parameters • Support attachment/bonding • Early intervention programs U.S. Dept of Health and Human Services-TIPS

39. Resources Plessinger. Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstet Gynecol Clin North Am. 1998 Mar;25(1):119-38. Review. Wegner, et al. The impact of prenatal drug exposure on the neonate. Obstet Gynecol Clin North Am, 1998 Mar;25(1):169-94. U.S. Department of Health and Human Services-TIPS (1993) http://www.health.org/govpubs/BKD110/default.aspx Meth Awareness and Prevention Project http://www.mappsd.org/DEC%20Meth%20Preg.htm Future of Children-Brookings Institute (1991-cocaine) http://www.futureofchildren.org/usr_doc/vol1no1entire_journal.pdf