Substance Abuse and the Perinatal Period

1. Kathryn Wells, MD, FAAP Medical Director, Denver Family Crisis Center Child Abuse Pediatrician, Denver Health & Children’s Hospital Colorado Assistant Professor of Pediatrics, University of Colorado (720) 944-3747 Kathryn.wells@dhha.org Substance Abuse and the Perinatal Period Colorado Perinatal Care Council August 3, 2012 Sharon Langendoerfer, MD, FAAP Associate Director of Newborn Services, Denver Health Associate Professor of Pediatrics, University of Colorado School of Medicine (303) 602-9270 Sharon.Langendoerfer@dhha.org

2. Objectives • Discuss the relationship between substance abuse and child welfare • List the harmful effects of drugs of abuse on the fetus • Describe five points of intervention for the issue of perinatal substance abuse

3. Children in Substance-Abusing Homes 8.3 million (12%of U.S. children) live with at least one parent who is alcoholic or in need of substance abuse treatment [National Survey on Drug Use and Health Report, April 16, 2009 – combined data from 2002-2007]

4. Have poorer developmental outcomes (physical, intellectual, social and emotional) than other children Are at (a three- to eight-fold) increased risk of substance abuse themselves Children of Parents with Substance Abuse Problems

5. Substance Abuse Affects Parenting • Impaired judgment and priorities • Inability to provide the consistent care, supervision and guidance children need • Substance abuse is a critical factor in child welfare [Blending Perspectives and Building Common Ground, A Report to Congress on Substance Abuse and Child Protection, April 1999]

6. How Prevalent? • Survey of 36 hospitals found an estimated 375,000 infants exposed in utero to illegal drugs each year in the U.S., or 11% of all births (Chasnoff, 1989) • The American Academy of Pediatrics estimates that 1 in 10 newborns in the US have been exposed to an illicit drug (AAP, 1990)

7. How Prevalent? Nat’l Survey on Drug Use & Health 2008-09 (US Births ’09: 4,131,000) Substance 1st tri 2nd tri 3rd tri (past mo) (National Prevalence) Any Illicit 8.5% 3.2% 2.3% Alcohol 20.4% 6.5% 3.5% Binge Alc 11.9% 0.9% 0.8% Cigarettes 22.4% 12.6% 11.6% SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2007-2008, http://oas.samhsa.gov/NSDUH/2K8NSDUH/tabs/Sect7peTabs71to78.pdf

8. Obtaining Data Difficulties • The unreliabilityof mother’s self-reports • Thelimitationsof urine/mec toxicology techniques • The nature of observableclinical conditions • Lack of uniformity in hospital policies and procedures • Drug-affectedvs. drug-exposed

9. What are the Effects? • Effects may be fetal, maternal or both • Great variability in harm • Problems with attention, self-regulation, and cognition • Risk of maltreatment and impaired attachment • Significant financial cost

10. What Drugs? • Legal: tobacco, alcohol, marijuana (?) • Illegal: LSD, (marijuana), etc, etc! • Substances with recognized medical uses: narcotics, barbiturates, cocaine and amphetamines

11. Indirect Maternal Effects • Infections: HIV, tuberculosis, hepatitis, syphilis, endocarditis, pulmonary infections • Toxin-Induced: nutritional deficiency (alcohol), cardiotoxins (cocaine, alcohol, amphetaminies), direct pulmonary effects (marijuana, tobacco), hepatotoxic (cirrhosis, solvent), nephropathy (heroin)

12. Abortion Abruptio placenta Breech presentation Previous cesarean-section Chorioamnionitis Pre-eclampsia Eclampsia Gestational diabetes Placental insufficiency Intrauterine growth restriction Intrauterine death Post-partum hemorrhage Premature labor Premature rupture of membranes Septic thrombophlebitis Obstetrical Complications

13. Fetal Effects altered by: • Route of intake (dose) and dosage interval • Route of administration (IV, PO,SQ, inhaled) • Rate of absorption • Rate of elimination • Lipid solubility • Protein binding • Concomitant maternal dz- renal, hepatic,etc • Placental well-being • Gestational age

14. Relationship to Gestational Age • (Malformations ~ infrequent) • First 6 weeks: most severe malformations • Up to 12 weeks:malformations of the abdominal wall, gastrointestinal tract, reproductive system and urinary tract • Second and third trimesters: intrauterine growth restriction and vascular disruption syndromes

15. Hyperbilirubinemia Hypocalcemia Hypoglycemia Intracranial hemorrhage Intrauterine growth restriction Neonatal abstinence syndrome Meconium aspiration Pneumonia Respiratory distress syndrome Septicemia HIV Infection Sudden infant death syndrome Neonatal Medical Complications

16. Cocaine – The Drug

17. Cocaine – Effects on the Fetus • Use occurs in about 1% of women – rarely used alone • Constricts blood vessels reducing blood flow to the fetus and diminishing oxygen supply and nutrients • Fetal anomalies • CNS abnormalities • Intestinal abnormalities • Urogenital system abnormalities • Malformations of extremities • May have periods of extreme heart rate variability

18. Cocaine – Effects on Pregnancy and Delivery • High rate of spontaneous abortion and placental abruption • Increased rate of premature rupture of membranes, early onset of labor and preterm delivery • Common knowledge on the streets – may attempt self-induced abortions • Birth outcomes improve if mother stops drug in the last 3 months of pregnancy – damage to vessels is non-reversible

19. Cocaine – Effects on the Newborn • Increased risk for IUGR • Neurobehavioral symptoms - jittery, high-pitched cry, startle at mild stimulation • Abnormal sleep, poor feeding, tremors and increased muscle tone – attributed to direct effects • Deficits in ability to habituate or self-regulate, especially under stressful conditions • May have increased risk for SIDS

20. Cocaine – Effects on the Growing Child • Behavior problems • Small changes in IQ, language abilities, executive functioning, impulse control and attention

21. Cocaine – Brain Effects • Effects from direct effects on neurotransmitter systems, vasoconstrictive effects, and fetal programming (altered expression of genes and gene networks) • MRI studies contributed to understanding of brain effects • Longitudinal studies with careful control of other factors need to be done

22. Cocaine – Effects on Breastfeeding • May cause tremulousness, irritability, startle responses and other neurobehavioral abnormalities • May even cause seizures

23. Methamphetamine – The Drug

24. Overview – Pregnancy and Methamphetamine • Very little information • Studies ongoing • Similar to cocaine exposure • Many challenges

25. Methamphetamine Use in Pregnancy • Very similar to cocaine but not as studied • Increased heart rate in fetus and constriction of blood vessels causing elevated blood pressure • Increased maternal blood pressure resulting in premature delivery or spontaneous abortion • Restriction of fetal development due to decreased blood flow

26. Methamphetamine Use in Pregnancy • Considerable transfer of meth to fetal blood where it may remain in fetal circulation longer than in maternal blood • Newborns may be sleepy and lethargic for the first few weeks, to the point of not waking to feed • After the first few weeks, behave similar to cocaine-exposed infants • Later on may have aggressive behavior and poor school performance by 7-8 years of age

27. Methamphetamine Use During Pregnancy • Women who use methamphetamine and/or cocaine in the first trimester are more likely to use during the third trimester • Nicotine use is universal among drug using pregnant women • Marijuana and alcohol are secondary drugs, used in 60% of the group (Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)

28. Use During Pregnancy: IDEAL Study • Further evaluation of study revealed that methamphetamine use does diminish during pregnancy • However, a substantial proportion of users had consistently high or increasing use • Those that decreased use had a higher incidence of polydrug use

29. Symptoms of Meth Exposed Infants and Children Newborn to 4 Weeks (I) (Dopamine Depletion Syndrome) • Lethargic – Excessive sleep period • Poor suck and swallow coordination • Sleep apnea • Poor habituation (Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)

30. Symptoms of Meth Exposed Infants and Children 4 weeks to 4 months (II) • Symptoms of CNS immaturity – effects on motor development • Sensory integration problems – tactile, defensive, texture issues • Neurobehavioral symptoms – interaction social development (Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)

31. Symptoms of Meth Exposed Infants and Children 6 months to 18 months (III) • The Honeymoon Phase • Symptom-free period (Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)

32. Symptoms of Meth Exposed Infants and Children 18 months to 5 years (IV) • Sensory integration deficit (same as II) • Less focused attention • Easily distracted • Poor anger management • Aggressive outbursts (Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)

33. Methamphetamine – Effects on the Growing Child • Too early to know • Behavior problems • Small changes in IQ and language abilities • Later on may have aggressive behavior and poor school performance by 7-8 years of age

34. Methamphetamine – Brain Effects • Only 3 MRI studies – small sample sizes • Studies suggest methamphetamine may have a neurotoxic effect on developing subcortical brain structures and prefrontal-striatal circuitry involved in attention and memory • Very recent study suggests that striatal and limbic structures may be more vulnerable to prenatal methamphetamine than alcohol exposure and that more severe striatal damage is associated with more severe cognitive deficit

35. Methamphetamine – Effects on Breastfeeding • May cause tremulousness, irritability, startle responses and other neurobehavioral abnormalities • May even cause seizures

36. Methamphetamine – Effects on Breastfeeding • Few cases reported in the media • Arizona 2002 – breastfeeding infant died from Methamphetamine overdose • California 2003 – breastfeeding infant • California 2011 - current case - ? Breastfeeding infant

37. Meth Labs

38. Marijuana – The Drug

39. Marijuana Use in Pregnancy • Frequently used as part of a poly-drug regimen • Studies are difficult to find on use of marijuana alone • Pharmacology is worrisome because it can be stored for long periods of time in organs with high amounts of lipids (e.g. the brain)

40. Marijuana – Effects on Pregnancy and Delivery • May cause spontaneous abortions and stillbirths • Readily crosses placenta – higher in early pregnancy

41. Marijuana – Effects on the Newborn • Increased tremulousness, altered visual response patterns to light stimulus, and withdrawal-like crying • Short-term effects are poor neurobehavioral organization poor state regulation • Usually disappears in 30 days (?) • Affects sleep and arousal patterns • May have synergistic effect with alcohol and other substances

42. Marijuana – Effects on the Growing Child • Studies limited and inconsistent • May be associated with deficits in short-term memory, verbal and abstract/visual reasoning, and executive functioning (complex tasks, sustained attention, hyperactivity, impulsivity and delinquency)

43. Marijuana – Brain Effects • Very little data • Studies suggest relationship between prenatal MJ exposure and adol/young adult neural functioning during tasks requiring response inhibition and visuo-spatial working memory • MRI studies suggest prenatal exposure may alter thelateralization and functional connectivity of multiple brain regions important in the performance of complex executive level functioning tasks

44. Marijuana – Effects on Breastfeeding • Rapidly transmitted into breast milk and remains there for longer time • Breastfeeding not recommended for mothers who smoke marijuana and are not willing to give it up

45. Opiates (Heroin, Methadone, Morphine…)

46. Opiate Use in Pregnancy • Heroin, other street narcotics: • Low birth weight due to symmetric IUGR or prematurity • Meconium aspiration – fetal distress due to placental insufficiency • Effects due to mother’s behavior • Lack of prenatal care • Poor nutrition • Medical problems • Abuse of other drugs

47. Opiate Use in Pregnancy Methadone in a Treatment Program Eliminates most adverse maternal factors Usually normally grown Significant Neonatal Abstinence Syndr.

48. Opiate Use in PregnancyNeonatal Abstinence Syndrome • Occurs in 60-80% of heroin-exposed infants • Onset within 70 hours of birth • Lasts 2-3 weeks to 4-6 months, even as long as a year • Involves central nervous system • Irritability, hyperreflexia, abnormal suck, and poor feeding • Seizures in 1 – 3% • GI symptoms include diarrhea and vomiting • Respiratory signs include tachypnea, hyperpnea, and respiratory alkalosis • Autonomic signs include sneezing, yawning, lacrimation, sweating and hyperpyrexia

49. Opiate Use in PregnancyDelayed Effects • Subacute withdrawal with symptoms such as restlessness, agitation, irritability, and poor socialization that may persist for 4 – 6 months • Association between SIDS and intrauterine exposure to opiates • Delayed physical growth, neurologic performance, and cognitive development

50. Opiate Use in Pregnancy Delayed Effects (cont.) • Poor weight gain during the first month of life • Later in life have difficulties with decreased attention span • Creates a vulnerability in infants that makes them more susceptible to poor environments, with subsequent poor developmental outcomes