Substance-Exposed
Infants
Karen Farst, MD
UAMS, College of Medicine,
Department of Pediatrics
Arkansas Children’s Hospital,
Team for Children at Risk
Objectives
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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
Substance-Exposed Infants
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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
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Tobacco, alcohol, illicit drugs, prescription….
“Garrett’s Law”
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Garrett was Betty Stahl’s grandson
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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
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.”
Substance-Exposed Infant
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“Exposed” infant
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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
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Positive test in mom and no ill-effect in baby
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Still concern for “Threat of Harm”
Concern for other children in the home
Fox 16 News Article
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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.”
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.”
Substance identification
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Toxicologic testing
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Confirmation should be done on screening tests
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Potential for false positive results
Inappropriate usage of prescription drugs
included
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Urine and blood negative in 1-2 days
Meconium reflects about last 6 weeks of gestation
Difficult for providers of OB and Peds care to deem
what is “inappropriate”
Only healthcare providers can call this to hotline
in AR
Who gets tested?
Who gets tested?
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Maternal indicators
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Known drug abuse by
mom
Limited or no pre-natal
care
STD
Placental abruption
Unexpected pre-term
labor
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Newborn indicators
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CNS complications
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Bleeding
Seizures
Drug withdrawal
symptoms
IUGR
Wegner et al. OB and Gynecol Clinics of
North America, Vol 25(1)
Typical tox screen panels
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5 Drug
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Opiates
Cocaine
Marijuana
Amphetamines
PCP
7 Drug
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Above plus…
Benzodiazepenes
Barbiturates
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Can assay for other
substances as well
with most reference
labs including…
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Alcohol
Nicotine
Stimulants
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Cocaine
Methamphetamine
Amphetamines
Weight loss drugs
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Crack
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
Methamphetamine
Amphetamines
http://www.methamphetamineaddiction.com/
drug_photos.html
Methamphetamine
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Highly addictive stimulant
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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
Meth use during pregnancy
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Short-term
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Binge/crash
Appetite loss
Increase in blood
pressure and heart
rate
Physical/sexual
aggression
Agitation
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Long-term
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Poor nutrition
Self-neglect
Pre-term labor
Placental abruption
Paranoia
Delusions
Violent relationships
Narcotics
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Opiates
Heroin
Prescription pain meds
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Morphine, codeine,
demerol, dilaudid,
hydrocodone, oxycodone
Methadone
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Long lasting effects so
can help with withdrawal
and treatment of chronic
pain
Opium
Narcotics
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Usage
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Overdosage
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Sense of well-being,
reduce tension and
aggression, pain relief
Coma and respiratory
suppression
Withdrawal
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Watery eyes, runny
nose, irritability, chills,
vomiting and diarrhea
Oxycontin
www.dea.gov
Cannabis
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Marijuana
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Usage
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#1 illicit drug worldwide
Well-being, intoxication,
hallucinations
Similar health effects of
nicotine
Long-term usage
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“Amotivational Syndrome”
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Apathy and impaired judgement
Depressants (Sedatives)
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Benzodiazepines
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Xanax, valium, klonopin
Rohypnol
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Gamma-hydroxybutyric
acid (GHB)
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“date rape”
amnesia
“date rape” drug
Affects memory
Difficult to detect on testing
Barbiturates
GHB Liquid
www.dea.gov
Sedatives
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Usage
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Overdosage
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Intoxication and sense of well-being and calm
(similar to alcohol)
Anti-anxiety
Coma and respiratory depression
Withdrawal
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Anxiety, weakness, seizures
Hallucinogens
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MDMA (Ecstasy)
PCP (distortions)
LSD (visual hallucinations)
Ketamine
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Anesthetic
Usage
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Sensory enhancement, distortion of
thought (pleasure or fright)
RAVE parties
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Accidents and poor judgement
Withdrawal
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Flashbacks
http://www.teenchallenge.c
om/images/drugs/pcp.jpg
False positive possibilities
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Amphetamines
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Opiates
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?
Barbiturates
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Phenergan, NSAID’s, second hand smoke (?)
Cocaine
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Dextromethorphan, poppy seeds, cough meds…
Marijuana
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Pseudoephedrine, ADD medications, OTC stimulants, weight loss
meds….
Anesthetics, phenobarb, phenytoin, donnatol…
LSD
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Tricyclic antidepressants, promethazine, migraine meds…
** Does not represent a complete list
How many women “use” in
pregnancy?
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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
What are the short-term effects?
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Cocaine and methamphetamine
(stimulants)
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Prematurity
Intra-uterine growth restriction (IUGR)
Placental abruption
Intra-cranial hemorrhages (ICH)
Withdrawal (not addiction)
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Poor feeding, hypertonia, irritable, altered
sleep/wake cycles, seizures
Prenatal use of methamphetamine
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Increased risk of acute problems
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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
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Ongoing problems
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Growth and feeding
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Growth and school performance
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Oro and Dixon, Journal of Peds, 1987
Cernerud, et al. Acta Paediatrica, 1996
Same or different than cocaine?
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NIDA research review, 2001
Placental abruption
http://health.allrefer.com/health/placenta-abruptio-placenta-1.html
Neonatal Abstinence Syndrome
Opiates/Narcotics
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Sweaty
Fever
Sneezing/Runny nose
Watery stools
Poor feeding
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Increased respiratory
rate
Muscle twitches
Increased muscle
tone (hypertonia)
Short term effects
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Marijuana (similar to nicotine)
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Narcotics (pain meds, opiates…)
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Growth restriction
Prematurity
Often other drugs involved
Respiratory difficulties
“Neonatal Narcotic Abstinence”
Sedatives (benzo’s…ativan, xanax, valium)
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Respiratory difficulties
withdrawal
Long-term effects
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Majority of research is on cocaine-exposed
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Only one long-term study on amphetamine
exposed (out to age 14 years)
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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)
Showed difference in academic and athletic achievement
Take care in assuming meth results will be the
same as cocaine
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NIDA/NIH studies in adults and kids
Author
Drug
Measure
Outcome
Messinger
Peds 2004, 113(6)
Cocaine
Opiates
Bayley Scale of Infant No diff with controls
Devel II
when env’t factors
controlled
(out to 3 years)
Singer
JAMA 2004, 291 (20)
Cocaine
Bayley Mental and
Motor Scale of Infant
Devel
Sig cognitive/devel
deficits at 2 years
Singer
JAMA 2002, 287(15)
Cocaine
Wischler Preschool
Scale of Intelligence
No diff in overall IQ,
but specific cog
deficits
Delaney-Black
Peds 1998, 102(4, 1)
Cocaine
Conner’s Teacher
Exposed rated with
Rating Scale (blinded) more behavior probs
Lester
Science 1998, 282
Cocaine
Meta-analysis
Subtle, but signif
effects in behavior
and neurodevel
Growth, cognition,
language, athletics
1, 4 y growth behind
8y aggressive behav
14 y math, lang, ath
Cernerud
Amphet
Acta Paediatr 1996, 85
Pre-natal studies
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Study found an abnormality in energy
metabolism in the brains of children exposed
to methamphetamine in utero.
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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.
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Chang, et al. Psychiatry Research, 2004; 132(2)
(13 exposed, 15 controls)
Associated problems
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Domestic violence
Abuse and neglect
Related stressors
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Poverty, single-parent homes, ….
Inter-generational usage
Access to treatment (effectiveness)
Stressed child protection system
Effects on the caregiver
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Meth users are more likely than other
substance abusers to be involved with DHS
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53 % of children with abusive head trauma
had parental substance abuse
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Hohman, et al. Social Work, 2004
Ricci, et al. Child Abuse and Neglect, 2003
80 % of women in treatment for meth
addiction report IPV
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Cohen, et al. Am Journal of Addiction, 2003
The big picture
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Drug use and drug treatment status are not
independent predictors of potential for
mom’s to perpetrate child abuse.
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There may be a higher risk of maltreatment
and out-of-home placements in cocaineexposed infants, but that was not the sole
risk factor.
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Hogan & Elswick, Child Abuse Neglect, 2006 (30)
Leventhal, et al. Pediatrics, 1997, 100(2)
Most studies support that the quality of the
environment is the most important factor
Stress on the system
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DCFS caseloads
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Healthcare/Medicaid expenses
Substance abuse treatment
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Foster care availability
Funding/Access
Monitoring compliance Law enforcement time
and money
School readiness/failure
Judicial costs
Law enforcement resources
Costs
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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.”
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Joyce, et al. Health Serv Res. 1995
Jun;30(2):341-58.
Follow-up of substance-exposed
infant
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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
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