Substance-Exposed Substance-Exposed InfantsInfants

Karen Farst, MDKaren Farst, MDUAMS, College of Medicine,UAMS, College of Medicine,Department of PediatricsDepartment of Pediatrics

Arkansas Children’s Hospital, Arkansas Children’s Hospital, Team for Children at RiskTeam for Children at Risk

ObjectivesObjectives

Definition of a “substance-exposed” Definition of a “substance-exposed” infantinfant

Identification of being exposedIdentification of being exposed Overview of substancesOverview of substances Adverse effects of pre-natal exposureAdverse effects of pre-natal exposure Recognition of drug-endangered childRecognition of drug-endangered child ResourcesResources

Substance-Exposed InfantsSubstance-Exposed Infants Use of an illegal or potentially harmful Use of an illegal or potentially harmful

substance by mother during pregnancysubstance by mother during pregnancy Mother and fetus share a common Mother and fetus share a common

circulationcirculation Fetus depends on mom’s health and Fetus depends on mom’s health and

nutritionnutrition Each state has different regulationsEach state has different regulations

Tobacco, alcohol, illicit drugs, Tobacco, alcohol, illicit drugs, prescription….prescription….

““Garrett’s Law”Garrett’s Law” Garrett was Betty Stahl’s grandsonGarrett was Betty Stahl’s grandson

Born premature and died after 2 months from Born premature and died after 2 months from “ill-effects” of methamphetamine“ill-effects” of methamphetamine

Ms. Stahl lobbied AR legislature for law Ms. Stahl lobbied AR legislature for law requiring intervention by child protection requiring intervention by child protection system of mother’s identified as using system of mother’s identified as using substances of abuse during pregnancysubstances of abuse during pregnancy

Senate Bill 114 signed into law 3-28-2005Senate Bill 114 signed into law 3-28-2005 Not intended to “criminalize” mother’s, Not intended to “criminalize” mother’s,

but to identify those in need of servicesbut to identify those in need of services

ARKANSAS SENATE85th General Assembly - Regular Session, 2005

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Subtitle of Senate Bill No. 114

"GARRETT'S LAW”TO PROVIDE SERVICES TO

A NEWBORN CHILD BORN WITH AN ILLEGALSUBSTANCE 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.”

Substance-Exposed InfantSubstance-Exposed Infant

““Exposed” infantExposed” infant Confirmed test in infantConfirmed test in infant Positive test in mom with ill-effect in babyPositive test in mom with ill-effect in baby

Hard to get mom’s tests confirmedHard to get mom’s tests confirmed Some ill-effects happen without drug exposureSome ill-effects happen without drug exposure

Positive test in mom and no ill-effect in Positive test in mom and no ill-effect in babybaby

Still concern for “Threat of Harm”Still concern for “Threat of Harm” Concern for other children in the homeConcern for other children in the home

Fox 16 News ArticleFox 16 News Article

Mother of two born with meth in Mother of two born with meth in system faces no chargesystem faces no charge

AR Democrat Gazette, 6/9/2005AR Democrat Gazette, 6/9/2005

““A new law requires doctors and hospital A new law requires doctors and hospital personnel to notify authorities when a baby personnel to notify authorities when a baby is born with an illegal drug in its system, is born with an illegal drug in its system, but a prosecutor says there's no law that but a prosecutor says there's no law that the mother can be charged with violating.”the mother can be charged with violating.”

News article (cont’d)News article (cont’d)

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

Substance identificationSubstance identification Toxicologic testingToxicologic testing

Urine and blood negative in 1-2 daysUrine and blood negative in 1-2 days Meconium reflects about last 6 weeks of gestationMeconium reflects about last 6 weeks of gestation

Confirmation should be done on screening Confirmation should be done on screening teststests Potential for false positive resultsPotential for false positive results

Inappropriate usage of prescription drugs Inappropriate usage of prescription drugs includedincluded Difficult for providers of OB and Peds care to deem Difficult for providers of OB and Peds care to deem

what is “inappropriate”what is “inappropriate” Only healthcare providers can call this to Only healthcare providers can call this to

hotline in ARhotline in AR

Who gets tested?Who gets tested?

Who gets tested?Who gets tested?

Maternal indicatorsMaternal indicators Known drug abuse Known drug abuse

by momby mom Limited or no pre-Limited or no pre-

natal carenatal care STDSTD Placental abruptionPlacental abruption Unexpected pre-Unexpected pre-

term laborterm labor

Newborn indicatorsNewborn indicators CNS complicationsCNS complications

BleedingBleeding SeizuresSeizures

Drug withdrawal Drug withdrawal symptomssymptoms

IUGRIUGR

Wegner et al. OB and Gynecol Clinics of North America, Vol 25(1)

Typical tox screen panelsTypical tox screen panels

5 Drug5 Drug OpiatesOpiates CocaineCocaine MarijuanaMarijuana AmphetaminesAmphetamines PCPPCP

7 Drug7 Drug Above plus…Above plus… BenzodiazepenesBenzodiazepenes BarbituratesBarbiturates

Can assay for other Can assay for other substances as well substances as well with most with most reference labs reference labs including…including… AlcoholAlcohol NicotineNicotine

StimulantsStimulants

CocaineCocaine MethamphetamineMethamphetamine AmphetaminesAmphetamines Weight loss drugsWeight loss drugs

Binge and crash Binge and crash cycle from high to cycle from high to lowlow

Increased heart rate, Increased heart rate, dizziness, elevated dizziness, elevated blood pressure, GI blood pressure, GI upsetupset

Increased Increased aggression and aggression and paranoiaparanoia

Irritable, confused, Irritable, confused, depressed on depressed on withdrawalwithdrawalCrack

StimulantsStimulants

Amphetamines

http://www.methamphetamineaddiction.com/drug_photos.html

Methamphetamine

MethamphetamineMethamphetamine

Highly addictive stimulant Highly addictive stimulant Ice, crank, poor man’s crack, zip….Ice, crank, poor man’s crack, zip….

Snorted, smoked, injected or taken Snorted, smoked, injected or taken orallyorally

Can be manufactured in home or Can be manufactured in home or “clandestine” labs by reacting “clandestine” labs by reacting household agents from household agents from pseudoephedrine or ephedrinepseudoephedrine or ephedrine

Meth use during pregnancyMeth use during pregnancy

Short-termShort-term Binge/crashBinge/crash Appetite lossAppetite loss Increase in blood Increase in blood

pressure and heart pressure and heart raterate

Physical/sexual Physical/sexual aggressionaggression

AgitationAgitation

Long-termLong-term Poor nutritionPoor nutrition Self-neglectSelf-neglect Pre-term laborPre-term labor Placental abruptionPlacental abruption ParanoiaParanoia DelusionsDelusions Violent Violent

relationshipsrelationships

NarcoticsNarcotics OpiatesOpiates HeroinHeroin Prescription pain medsPrescription pain meds

Morphine, codeine, Morphine, codeine, demerol, dilaudid, demerol, dilaudid, hydrocodone, hydrocodone, oxycodoneoxycodone

MethadoneMethadone Long lasting effects so Long lasting effects so

can help with can help with withdrawal and withdrawal and treatment of chronic treatment of chronic painpain

Opium

NarcoticsNarcotics UsageUsage

Sense of well-being, Sense of well-being, reduce tension and reduce tension and aggression, pain reliefaggression, pain relief

OverdosageOverdosage Coma and respiratory Coma and respiratory

suppressionsuppression WithdrawalWithdrawal

Watery eyes, runny Watery eyes, runny nose, irritability, chills, nose, irritability, chills, vomiting and diarrheavomiting and diarrhea

Oxycontinwww.dea.gov

CannabisCannabis MarijuanaMarijuana

#1 illicit drug worldwide#1 illicit drug worldwide UsageUsage

Well-being, intoxication, Well-being, intoxication, hallucinationshallucinations

Similar health effects of Similar health effects of nicotinenicotine

Long-term usageLong-term usage ““Amotivational Syndrome”Amotivational Syndrome”

Apathy and impaired Apathy and impaired judgementjudgement

Depressants (Sedatives)Depressants (Sedatives) BenzodiazepinesBenzodiazepines

Xanax, valium, klonopinXanax, valium, klonopin RohypnolRohypnol

““date rape”date rape” amnesiaamnesia

Gamma-hydroxybutyric Gamma-hydroxybutyric acid (GHB)acid (GHB) ““date rape” drugdate rape” drug Affects memoryAffects memory Difficult to detect on Difficult to detect on

testingtesting BarbituratesBarbiturates

GHB Liquidwww.dea.gov

SedativesSedatives

UsageUsage Intoxication and sense of well-being and Intoxication and sense of well-being and

calm (similar to alcohol)calm (similar to alcohol) Anti-anxietyAnti-anxiety

OverdosageOverdosage Coma and respiratory depressionComa and respiratory depression

WithdrawalWithdrawal Anxiety, weakness, seizuresAnxiety, weakness, seizures

HallucinogensHallucinogens MDMA (Ecstasy)MDMA (Ecstasy) PCP (distortions)PCP (distortions) LSD (visual hallucinations)LSD (visual hallucinations) KetamineKetamine

AnestheticAnesthetic UsageUsage

Sensory enhancement, distortion Sensory enhancement, distortion of thought (pleasure or fright)of thought (pleasure or fright)

RAVE partiesRAVE parties Accidents and poor judgementAccidents and poor judgement

WithdrawalWithdrawal FlashbacksFlashbacks

http://www.teenchallenge.com/images/drugs/pcp.jpg

False positive possibilitiesFalse positive possibilities AmphetaminesAmphetamines

Pseudoephedrine, ADD medications, OTC stimulants, Pseudoephedrine, ADD medications, OTC stimulants, weight loss meds….weight loss meds….

OpiatesOpiates Dextromethorphan, poppy seeds, cough meds…Dextromethorphan, poppy seeds, cough meds…

MarijuanaMarijuana Phenergan, NSAID’s, second hand smoke (?)Phenergan, NSAID’s, second hand smoke (?)

CocaineCocaine ??

BarbituratesBarbiturates Anesthetics, phenobarb, phenytoin, donnatol…Anesthetics, phenobarb, phenytoin, donnatol…

LSDLSD Tricyclic antidepressants, promethazine, migraine Tricyclic antidepressants, promethazine, migraine

meds…meds…** Does not represent a complete list

How many women “use” in How many women “use” in pregnancy?pregnancy?

Self-report surveys indicate 3-5 % Self-report surveys indicate 3-5 % Anonymous screening test results Anonymous screening test results

are 3-6 times higher than self-report are 3-6 times higher than self-report resultsresults

Prescription drug use and mis-use is Prescription drug use and mis-use is more difficult to monitormore difficult to monitor

What are the short-term What are the short-term effects?effects?

Cocaine and methamphetamine Cocaine and methamphetamine (stimulants)(stimulants)

PrematurityPrematurity Intra-uterine growth restriction (IUGR)Intra-uterine growth restriction (IUGR) Placental abruptionPlacental abruption Intra-cranial hemorrhages (ICH)Intra-cranial hemorrhages (ICH) Withdrawal (not addiction)Withdrawal (not addiction)

Poor feeding, hypertonia, irritable, altered Poor feeding, hypertonia, irritable, altered sleep/wake cycles, seizuressleep/wake cycles, seizures

Prenatal use of Prenatal use of methamphetaminemethamphetamine

Increased risk of acute problemsIncreased risk of acute problems Withdrawal, prematurity, IUGR, ICHWithdrawal, prematurity, IUGR, ICH

Dixon and Bejar, Western J of Medicine, 1989Dixon and Bejar, Western J of Medicine, 1989 Stewart and Meeker, J of Analytical Tox, 1997Stewart and Meeker, J of Analytical Tox, 1997 Smith, et al. Devel and Behav Peds, 2003Smith, et al. Devel and Behav Peds, 2003

Ongoing problemsOngoing problems Growth and feeding Growth and feeding

Oro and Dixon, Journal of Peds, 1987Oro and Dixon, Journal of Peds, 1987 Growth and school performanceGrowth and school performance

Cernerud, et al. Acta Paediatrica, 1996Cernerud, et al. Acta Paediatrica, 1996 Same or different than cocaine?Same or different than cocaine?

NIDA research review, 2001NIDA research review, 2001

Placental abruptionPlacental abruption

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

Neonatal Abstinence SyndromeNeonatal Abstinence SyndromeOpiates/NarcoticsOpiates/Narcotics

SweatySweaty FeverFever Sneezing/Runny Sneezing/Runny

nosenose Watery stoolsWatery stools Poor feedingPoor feeding

Increased Increased respiratory raterespiratory rate

Muscle twitchesMuscle twitches Increased muscle Increased muscle

tone (hypertonia)tone (hypertonia)

Short term effectsShort term effects

Marijuana (similar to nicotine)Marijuana (similar to nicotine) Growth restrictionGrowth restriction PrematurityPrematurity Often other drugs involvedOften other drugs involved

Narcotics (pain meds, opiates…)Narcotics (pain meds, opiates…) Respiratory difficultiesRespiratory difficulties ““Neonatal Narcotic Abstinence”Neonatal Narcotic Abstinence”

Sedatives (benzo’s…ativan, xanax, Sedatives (benzo’s…ativan, xanax, valium)valium) Respiratory difficultiesRespiratory difficulties withdrawalwithdrawal

Long-term effectsLong-term effects Majority of research is on cocaine-exposedMajority of research is on cocaine-exposed

Long-term studies don’t look as bad as people Long-term studies don’t look as bad as people feared during the height of the crack epidemicfeared during the height of the crack epidemic

Lester, et al. JAMA 2001, Vol 285(12) Lester, et al. JAMA 2001, Vol 285(12) Only one long-term study on amphetamine Only one long-term study on amphetamine

exposed (out to age 14 years)exposed (out to age 14 years) Showed difference in academic and athletic Showed difference in academic and athletic

achievementachievement Take care in assuming meth results will be Take care in assuming meth results will be

the same as cocainethe same as cocaine NIDA/NIH studies in adults and kidsNIDA/NIH studies in adults and kids

MessingerMessinger

Peds 2004, 113(6)Peds 2004, 113(6)CocainCocainee

OpiateOpiatess

Bayley Scale of Bayley Scale of Infant Devel IIInfant Devel II

(out to 3 years)(out to 3 years)

No diff with No diff with controls when controls when env’t factors env’t factors controlledcontrolled

SingerSinger

JAMA 2004, 291 JAMA 2004, 291 (20)(20)

CocainCocainee

Bayley Mental and Bayley Mental and Motor Scale of Motor Scale of Infant DevelInfant Devel

Sig Sig cognitive/devel cognitive/devel deficits at 2 yearsdeficits at 2 years

SingerSinger

JAMA 2002, 287(15)JAMA 2002, 287(15)CocainCocainee

Wischler Preschool Wischler Preschool Scale of Scale of IntelligenceIntelligence

No diff in overall No diff in overall IQ, but specific IQ, but specific cog deficitscog deficits

Delaney-BlackDelaney-Black

Peds 1998, 102(4, Peds 1998, 102(4, 1)1)

CocainCocainee

Conner’s Teacher Conner’s Teacher Rating Scale Rating Scale (blinded)(blinded)

Exposed rated Exposed rated with more with more behavior probsbehavior probs

LesterLester

Science 1998, 282Science 1998, 282CocainCocainee

Meta-analysisMeta-analysis Subtle, but signif Subtle, but signif effects in behavior effects in behavior and neurodeveland neurodevel

CernerudCernerud

Acta Paediatr 1996, Acta Paediatr 1996, 8585

AmpheAmphett

Growth, cognition, Growth, cognition, language, athleticslanguage, athletics

1, 4 y growth 1, 4 y growth behindbehind

8y aggressive 8y aggressive behavbehav

14 y math, lang, 14 y math, lang, athath

Author Drug Measure Outcome

Pre-natal studiesPre-natal studies Study found an abnormality in energy Study found an abnormality in energy

metabolism in the brains of children metabolism in the brains of children exposed to methamphetamine in utero.exposed to methamphetamine in utero. Smith, et al. Smith, et al. NeurologyNeurology, 2001; 57, 2001; 57 (12 exposed, 13 controls) (12 exposed, 13 controls)

Children exposed to Meth prenatally Children exposed to Meth prenatally exhibit smaller subcortical volumes and exhibit smaller subcortical volumes and associated neurocognitive deficits. These associated neurocognitive deficits. These preliminary findings suggest prenatal Meth preliminary findings suggest prenatal Meth exposure may be neurotoxic to the exposure may be neurotoxic to the developing brain.developing brain. Chang, et al. Chang, et al. Psychiatry ResearchPsychiatry Research, 2004; 132(2), 2004; 132(2) (13 exposed, 15 controls)(13 exposed, 15 controls)

Associated problemsAssociated problems

Domestic violenceDomestic violence Abuse and neglectAbuse and neglect Related stressorsRelated stressors

Poverty, single-parent homes, ….Poverty, single-parent homes, …. Inter-generational usageInter-generational usage Access to treatment (effectiveness)Access to treatment (effectiveness) Stressed child protection systemStressed child protection system

Effects on the caregiverEffects on the caregiver

Meth users are more likely than other Meth users are more likely than other substance abusers to be involved with substance abusers to be involved with DHSDHS

Hohman, et al. Social Work, 2004Hohman, et al. Social Work, 2004

53 % of children with abusive head 53 % of children with abusive head trauma had parental substance abusetrauma had parental substance abuse

Ricci, et al. Child Abuse and Neglect, 2003Ricci, et al. Child Abuse and Neglect, 2003

80 % of women in treatment for meth 80 % of women in treatment for meth addiction report IPVaddiction report IPV

Cohen, et al. Am Journal of Addiction, 2003Cohen, et al. Am Journal of Addiction, 2003

The big pictureThe big picture Drug use and drug treatment status are not Drug use and drug treatment status are not

independent predictors of potential for mom’s independent predictors of potential for mom’s to perpetrate child abuse.to perpetrate child abuse. Hogan & Elswick, Hogan & Elswick, Child Abuse NeglectChild Abuse Neglect, 2006 (30), 2006 (30)

There may be a higher risk of maltreatment There may be a higher risk of maltreatment and out-of-home placements in cocaine-and out-of-home placements in cocaine-exposed infants, but that was not the sole risk exposed infants, but that was not the sole risk factor.factor. Leventhal, et al. Leventhal, et al. PediatricsPediatrics, 1997, 100(2), 1997, 100(2)

Most studies support that the quality of the Most studies support that the quality of the environmentenvironment is the most important factor is the most important factor

Stress on the systemStress on the system DCFS caseloadsDCFS caseloads

Foster care availabilityFoster care availability Healthcare/Medicaid expensesHealthcare/Medicaid expenses Substance abuse treatmentSubstance abuse treatment

Funding/AccessFunding/Access Monitoring compliance Law enforcement Monitoring compliance Law enforcement

time and moneytime and money School readiness/failure School readiness/failure Judicial costsJudicial costs Law enforcement resourcesLaw enforcement resources

CostsCosts New York City, 1991-1992New York City, 1991-1992 ““Infants exposed to cocaine or some Infants exposed to cocaine or some

other illicit drug stay approximately other illicit drug stay approximately seven days longer at a cost of $7,731 seven days longer at a cost of $7,731 more than infants unexposed.”more than infants unexposed.” Joyce, et al. Joyce, et al. Health Serv ResHealth Serv Res. 1995 . 1995

Jun;30(2):341-58. Jun;30(2):341-58.

Follow-up of substance-Follow-up of substance-exposed infantexposed infant

Breast milk testing Breast milk testing Home evaluation Home evaluation Feeding issuesFeeding issues Follow growth parametersFollow growth parameters Support attachment/bondingSupport attachment/bonding Early intervention programsEarly intervention programs

U.S. Dept of Health and Human Services-TIPS

ResourcesResources

Plessinger. Plessinger. Prenatal exposure to amphetamines. Risks Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. and adverse outcomes in pregnancy. Obstet Gynecol Obstet Gynecol Clin North AmClin North Am. 1998 Mar;25(1):119-38. Review. . 1998 Mar;25(1):119-38. Review.

Wegner, et al. Wegner, et al. The impact of prenatal drug exposure on The impact of prenatal drug exposure on the neonate. the neonate. Obstet Gynecol Clin North AmObstet Gynecol Clin North Am, 1998 , 1998 Mar;25(1):169-94. Mar;25(1):169-94.

U.S. Department of Health and Human Services-TIPS (1993)U.S. Department of Health and Human Services-TIPS (1993)http://www.health.org/govpubs/BKD110/default.aspxhttp://www.health.org/govpubs/BKD110/default.aspx

Meth Awareness and Prevention ProjectMeth Awareness and Prevention Projecthttp://www.mappsd.org/DEC%20Meth%20Preg.htmhttp://www.mappsd.org/DEC%20Meth%20Preg.htm

Future of Children-Brookings Institute (1991-cocaine)Future of Children-Brookings Institute (1991-cocaine)http://www.futureofchildren.org/usr_doc/vol1no1entire_journal.pdhttp://www.futureofchildren.org/usr_doc/vol1no1entire_journal.pdff