Exposed…

1. Exposed… The Impact of Maternal Drug and Alcohol Use on Infants and Children

2. Disclosure In the last 2 years, neither I nor any member of my immediate family have had a financial interest/arrangement of affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Objectives Discuss the impact of prenatal drug/alcohol exposure on infants and children Outline a clinician’s approach to evaluation and treatment of drug/alcohol exposed infants and children Discuss the current DHS stance on prenatal drug/alcohol exposure

4. Epidemiology • Tobacco, alcohol, and illicit drug use during pregnancy are common • Tobacco – 16% • Alcohol – 11% • 4% binge drinking • 1% heavy drinking • Illicit drug use – 4% • 2010 Nat’l Survey on Drug Use and Health

5. Epidemiology • Substance use during pregnancy are common • Urine from 30,000 California women • 8.8% nicotine • 6.7% alcohol • 3.5% illicit drugs • Increased risk in younger women, unmarried women, lower SES • Perinatal Substance Exposure Study Group

6. Epidemiology • Substance use during pregnancy is common • Many mothers use more than one • Half of mothers who used illicit drugs also used alcohol or tobacco • Neonates with heavy alcohol exposure 3 times as likely to be exposed to amphetamines • Estimated 800,000 U.S. infants exposed to nicotine, alcohol, or illicit drugs annually

7. Diagnosis • History • ID of a drug or its metabolites in either a maternal or neonatal specimen • Urine • Low sensitivity because only recent exposure will be positive • Meconium • More sensitive – “collects” metabolites over time • Hair, cord blood are also possibilities but less common • Presence of withdrawal symptoms

8. Diagnosis The presentation is variable and depends on the drug(s), timing, and quantity of last maternal use. Some drugs tend to cause withdrawal, while other drugs may not cause withdrawal but can have direct impact on the neonate.

9. General Approach • Identify the drug(s) • Anticipate withdrawal • Factors include timing of last use and drug ½ life • Neonatal abstinence syndrome (opioids) is decreased if last use > 1 week before delivery • Alcohol w/d occurs in 3-12 hours (short ½ life) vs. barbiturate w/d 7 days after delivery

10. General Approach • Assess gestational age and size of infant • Moms with substance abuse less likely to have prenatal care • Look for concomitant conditions • IUGR • Maternal infections (hepatitis, syphilis, HIV) • Think about breastfeeding • Many drugs excreted in breast milk and can affect infant

11. Nicotine • Associated with adverse pregnancy effects • Placental abruption • PROM • Placenta previa • Preterm labor/delivery • Low birth weight (avg. 205 g reduction) • Increased neonatal mortality • Unclear if it impacts birth defects

12. Nicotine • Associated with adverse neonatal effects • Hypertonicity • Irritability/excitability • Poorer self-regulation • ?smaller brain volumes (esp. frontal lobe and cerebellum • Increased SIDS, diabetes, behavioral problems, asthma

13. Alcohol • Spectrum of effects from normal to FASD • FASD more likely with certain maternal factors • Older maternal age • High parity • Race (AA or NA) • Binge drinking worse • Use in 1st trimester worse

14. Alcohol • Withdrawal from alcohol begins during the first 3-12 hours after delivery • Hyperactivity • Irritability • Poor sleeping • Tremors/seizures • Hypoglycemia • Abdominal distention

15. Alcohol • Withdrawal • lasts about 72 hours • Followed by 48 hours of lethargy • Finally return to normal activity – 5-7 days

16. Alcohol • Fetal Alcohol Spectrum Disorder • FAS – the most severe • Poor growth • Abnormal brain growth • Dysmorphic facial features • Partial FAS • Dysmorphic facial features • Abnormalities in only one other area

17. Alcohol • FASD • Alcohol related birth defects (ARBD) • FAS face • Normal growth and brain function • Other congenital anomalies • Alcohol related neurodevelopmental disorder (ARND) • No FAS face and normal growth • Behavioral or cognitive abnormalities typical of FAS

18. Opioids • Substances with morphine-like activity • Heroin and methadone are most common • Others include codeine/hydrocodone/oxycodone • Withdrawal usually starts in 2-3 days but can be delayed up to 4 weeks • Supportive care • Decreased sensory stimulation, consider pharmacologic therapy for infants with weight loss, seizures, severe sleep issues

19. Cocaine • Adverse pregnancy effects • Spontaneous abortion • Fetal demise • Placental abruption • Prematurity • IUGR

20. Cocaine • Neonatal effects • Symptoms start 48-72 hours after birth • Tremors • High pitched cry • Irritability • Excess suck • Hyperalertness • Apnea or tachypnea

21. Cocaine No or minimal long-term effects No evidence of increased birth defects No persistence of growth issues No decrease in cognitive function

22. Marijuana Studies are mixed May have a negative impact on intellectual development May have no impact

23. Amphetamines • Prematurity/IUGR (maybe) • Risk for birth defects • Poorer neurodevelopmental outcomes • Anxiety and depression • poor school performance • Increased behavior problems • ADHD

24. Other Drugs • Phencyclidine • May cause prematurity/IUGR • Hypertonicity, irritability, sleep and temperature instability • Barbiturates • Can have withdrawal or birth defects • Withdrawal 2-14 days after birth thru 2-4 months • Irritability, sleeplessness, tremors, increased appetite, reflux, gagging, sweating, hypersensitivity to sound

25. References “Infants of Mothers with Substance Abuse” – Up To Date Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis – CDC 2010 National Survey on Drug Use and Health Prevalence and magnitude of perinatal substance exposures in California – NEJM 1993; 329:850