Download Alcohol Use in Pregnancy - Colorado Perinatal Care Quality

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
[email protected]
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
[email protected]
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
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]
Children of Parents with
Substance Abuse Problems


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
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]
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)
How Prevalent?
Nat’l Survey on Drug Use & Health
2008-09 (US Births ’09: 4,131,000)
Substance
(past mo)
Any Illicit
Alcohol
Binge Alc
Cigarettes
1st tri
2nd tri
3rd tri
(National Prevalence)
8.5%
20.4%
11.9%
22.4%
3.2%
6.5%
0.9%
12.6%
2.3%
3.5%
0.8%
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
Obtaining Data Difficulties





The unreliability of mother’s self-reports
The limitations of urine/mec toxicology
techniques
The nature of observable clinical conditions
Lack of uniformity in hospital policies and
procedures
Drug-affected vs. drug-exposed
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
What Drugs?



Legal: tobacco, alcohol, marijuana (?)
Illegal: LSD, (marijuana), etc, etc!
Substances with recognized medical uses:
narcotics, barbiturates, cocaine and
amphetamines
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)
Obstetrical Complications


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
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Abortion
Abruptio placenta
Breech presentation
Previous cesareansection
Chorioamnionitis
Pre-eclampsia
Eclampsia
Gestational diabetes
Placental insufficiency






Intrauterine growth
restriction
Intrauterine death
Post-partum
hemorrhage
Premature labor
Premature rupture of
membranes
Septic thrombophlebitis
Fetal Effects altered by:

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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
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
Neonatal Medical
Complications

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Hyperbilirubinemia
Hypocalcemia
Hypoglycemia
Intracranial
hemorrhage
Intrauterine growth
restriction
Neonatal abstinence
syndrome

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
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

Meconium aspiration
Pneumonia
Respiratory distress
syndrome
Septicemia
HIV Infection
Sudden infant death
syndrome
Cocaine – The Drug
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
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
Cocaine – Effects on the
Newborn





Increased risk for IUGR
Neurobehavioral symptoms - jittery, highpitched 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
Cocaine – Effects on the
Growing Child


Behavior
problems
Small changes
in IQ, language
abilities,
executive
functioning,
impulse control
and attention
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
Cocaine – Effects on
Breastfeeding


May cause
tremulousness,
irritability, startle
responses and
other
neurobehavioral
abnormalities
May even cause
seizures
Methamphetamine – The
Drug
Overview – Pregnancy
and Methamphetamine




Very little information
Studies ongoing
Similar to cocaine exposure
Many challenges
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
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
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)
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
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)
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)
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)
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)
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
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
Methamphetamine –
Effects on Breastfeeding


May cause
tremulousness,
irritability, startle
responses and other
neurobehavioral
abnormalities
May even cause
seizures
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
Meth Labs
Marijuana – The Drug
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)
Marijuana – Effects on
Pregnancy and Delivery


May cause
spontaneous
abortions and
stillbirths
Readily crosses
placenta –
higher in early
pregnancy
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
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)
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 the lateralization and functional
connectivity of multiple brain regions
important in the performance of complex
executive level functioning tasks
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
Opiates (Heroin,
Methadone, Morphine…)
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



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Lack of prenatal care
Poor nutrition
Medical problems
Abuse of other drugs
Opiate Use in Pregnancy
Methadone in a Treatment Program
Eliminates most adverse maternal
factors
Usually normally grown
Significant Neonatal Abstinence Syndr.
Opiate Use in Pregnancy
Neonatal 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
Opiate Use in Pregnancy
Delayed 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
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
Alcohol – The Drug
Alcohol Exposure
“Of all the substances of abuse
(including cocaine, heroin, and
marijuana), alcohol produces by far
the most serious neurobehavioral
effects in the fetus.”
[Blending Perspectives and Building Common Ground, A Report to Congress on
Substance Abuse and Child Protection, April 1999]
Alcohol Use in Pregnancy



Children with both FAS and FAE may exhibit a
number of developmental delays, including
hyperactivity, short attention spans, language
dysfunctions, and delayed maturation
Heavy alcohol consumption has been cited as:
- The leading cause of mental retardation
worldwide
- The oldest known cause of developmental
disabilities (Bible)
Only about 30% of children with FAS are in the
care of their mothers through adolescence
Alcohol – Mechanisms of
Damage to the Fetus


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Alcohol and its primary metabolite
acetaldehyde, are directly toxic to the
developing embryo and fetus
Interferes with the delivery of maternal
nutrients
Impairs supply of fetal oxygen
Deranges protein synthesis and
metabolism
Stimulates excess production of certain
hormones (prostaglandins) that modulate
cellular functions of the body and could
cause fetal malformations
Alcohol – Effects During
Pregnancy and Delivery



Increased obstetrical complications: vaginal
bleeding, placental abruption, fetal distress
Associated with high rates of spontaneous
abortion, miscarriage, and stillbirth
Risk for spontaneous abortion is dose related:
– If averaging 3 or more drinks a day – more
than 3 times more likely to miscarry than nondrinkers
– Even those who consume one or two drinks a
day are at increased risk of miscarriage during
the second trimester
Alcohol – Effects on the
Newborn


Most consistent effects: low birth-weight and
intrauterine growth retardation (IUGR) –
more severe in women who drink heavily
during the last 3 months of pregnancy
IUGR increases risks for infant’s early death
and for respiratory difficulties, feeding
problems, serious infections, and long-term
developmental problems
Alcohol – Effects on the
Newborn
Heavy drinking (avg of 5 drinks/day)
 Alcohol withdrawal: tremors, abnormal muscle
tension (hypertonia), restlessness, sleeping
problems, inconsolable crying, and reflex
abnormalities
 Decreased ability to tune out inappropriate
stimuli
 Poor sucking abilities
 Disturbed patterns of sleep and wakefulness
Fetal Alcohol Spectrum
Disorders (FASD)


Umbrella term that describes the range
of effects that can occur in an individual
whose mother drank during pregnancy
Effects may be lifelong:
–
–
–
–
Physical
Mental
Behavioral and/or
Learning disabilities
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Spectrum
Disorders


Not a diagnostic term used by clinicians
Refers to:
– Fetal alcohol syndrome (FSD) including
partial FAS
– Fetal Alcohol Effects (FAE)
– Alcohol-related neurodevelopmental
disorder
– Alcohol-related birth defects
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Alcohol Use in Pregnancy –
Alcohol Related Birth Defects (ARBD)

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
1 in 200 births worldwide
5% of all congenital anomalies
10-20% of all cases of mental
retardation
U.S. ranks 15th in the world in alcohol
consumption
5-10% of pregnant women are
thought to drink at levels sufficient to
place their fetuses at significant risk
for ARBD
Alcohol Use in Pregnancy –
Fetal Alcohol Syndrome (FAS)



Described in 1973 by a group of
scientists at the University of
Washington in Seattle
At least 5,000 infants are born with
FAS annually
1-3 births per 1,000 live births
Fetal Alcohol Syndrome
Guidelines for Diagnosis
Prenatal maternal alcohol use
Growth deficiency
Central nervous system (CNS)
abnormalities
1.
2.
3.
4.
Structural
Neurologic
Functional
Dysmorphic features
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Syndrome
Guidelines for Diagnosis
Prenatal maternal alcohol use
1.
-
Confirmed
Unknown
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Syndrome
Guidelines for Diagnosis
Growth deficiency
2.
-
-
Confirmed prenatal or postnatal height
or weight, or both, at or below the 10th
percentile
Documented at any one point in time
Adjusted for age, sex, gestational age,
and race or ethnicity
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Syndrome
Guidelines for Diagnosis
3.
Central nervous system (CNS) abnormalities
- Structural – head circumference at or
below the 10th percentile adjusted for age
and sex or clinically significant brain
abnormalities observable through imaging
- Neurologic – neurologic problems not due
to postnatal insult or fever or other soft
neurologic signs outside normal limits
- Functional – global cognitive or intellectual
defecits representing multiple domains of
deficit
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Syndrome
Guidelines for Diagnosis
Dysmorphic features – all 3 features
must be present:
4.
-
Short palpebral fissures
Indistinct philtrum
Thin upper lip
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
Fetal Alcohol Syndrome
(Journal Alcohol Health and Research World, Vol. 18, No. 4, 1994)
Fetal Alcohol Syndrome
Facial Characteristics
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Abnormally small head
Low nasal bridge
Abnormally small eyes
Flat midface
Short nose
Thin upper lip
Fetal Alcohol Syndrome –
Other Physical Characteristics
 Permanent brain damage
 Growth problems
- Underweight
- Small head
 Heart and kidney defects
 Long-term behavior
problems
Alcohol Use in Pregnancy –
Fetal Alcohol Effect (FAE)


At least 50,000 infants annually (3-5 in
1,000)
Includes the behavioral and developmental
problems without the facial features
Alcohol – Effects on
Breastfeeding


Same concentration in
breast milk as in blood rapidly transmitted but is
diluted with body water
Infant’s blood alcohol
content is usually much
lower than mom’s
Alcohol – Effects on
Breastfeeding



Chronic exposure to high doses
of alcohol is potentially
dangerous as infants oxidize
alcohol more slowly than adults
Heavy drinking decreases milk
supply and inhibits the milkejection reflex
Nursing babies of mothers who
regularly consume alcohol may
be irritable, drowsy and have
abnormal weight gain
All Exposures –
Increased Infant Mortality



Associated
increased risk of
SIDS (?)
Associated risk of
positional overlay
Associated risk of
very premature
birth and severe
complications
The Facts…
Infants born to women with
addictions are at risk for birth
defects, premature birth, and
complications after birth such as
withdrawal. In addition, these infants
display a higher incidence of child
abuse and neglect.
Prenatal Exposure to
Drugs and Alcohol


Small proportion of the
children affected and
potentially endangered
by substance abuse
Not identified - fear of
prosecution or losing
their children
FEBRUARY 3, 1997 VOL. 149 NO. 5
SPECIAL REPORT
FERTILE MINDS
FROM BIRTH, A BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING
CONNECTIONS THAT MAY SHAPE A LIFETIME OF EXPERIENCE. THE FIRST THREE
YEARS ARE CRITICAL
BY J. MADELEINE NASH
What We Don’t Know

Effect of other factors
•
•
•
•


Other exposures
Environment
Brain effects
Labs
Long-term outcomes
Most effective approach
What Happens Next?


Most go home – 75-90% of substanceexposed infants go home undetected
Why?
– Many hospitals don’t screen or test or don’t
systematically refer to CPS
– State law may not require report or referral
– Urine test only detects very recent use
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
No One Agency
Issue Demands:




Comprehensive services
Provided along a continuum of
prevention, intervention and treatment
At different developmental stages in
the life of the child and family
NO single agency can deliver all of
these
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Needed Partners








Hospitals
Private physicians
Health care management
plans
Maternal and child health
Children’s and adult
mental health
Domestic violence
agencies
Child welfare
Drug and alcohol
prevention, treatment,
and aftercare






Developmental disabilities
agencies
Schools and special
education
Family/dependency courts
Child care and
development
Employment and family
support agencies
And more…
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Emerging Issues




Increasing number of pregnant women and
children affected by maternal use of
methamphetamine
Advancing research on fetal alcohol
spectrum disorders and Alcohol-related
Neurodevelopmental Disorders
Renewed proposals of State legislation
aimed at both fetal alcohol exposure and
maternal abuse of illegal drugs
Child Abuse Prevention and Treatment Act
(CAPTA) amendments of 2003 and 2010
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Child Abuse Prevention and
Treatment Act (CAPTA)

Reauthorized in 2003

Established new legislative responsibilities
regarding prenatally exposed infants
Child Abuse Prevention and
Treatment Act (CAPTA)

Stated that states must have in place:
106(b)(2)(A)(ii) “Policies and procedures
(including appropriate referrals to child
protection service systems and for other
appropriate services) to address the
needs of infants born and identified as
affected by illegal substance abuse or
withdrawal symptoms resulting from
prenatal drug exposure,”
Child Abuse Prevention and
Treatment Act (CAPTA)
(ii) “including a requirement that health care
providers involved in the delivery or care of
such infants notify the child protection
services system of the occurrence of such
condition in such infants,”
Child Abuse Prevention and
Treatment Act (CAPTA)
(ii) “except that such notification shall not be
construed to:
(I) Establish a definition under Federal law that
constitutes child abuse; or
(II) Require prosecution for any illegal action”
Child Abuse Prevention and
Treatment Act (CAPTA)
(iii) “The development of a plan of safe care
for the infant born and identified as being
affected by illegal substance abuse or
withdrawal symptoms”
Defining the Problem



Little data exists on the extent of the
problem and successful approaches to
address it
Need early identification to reduce risks to
the infant and enhance success
Potential for criminal prosecution reduces
utilization of medical and treatment
resources
Underlying Common
Themes




Addressing the issue of the continuum
Better relationships are needed (Legal
Community, DHS, Treatment, Medical
Providers)
Education is critical
Supporting and enhancing treatment is
imperitive
Five Points of Intervention
1.
2.
3.
4.
5.
Pre-Pregnancy
Prenatal Screening and Services
Screening and Testing at Birth
Post-Natal Services to Infants and
Children
Post-Natal Services to Parents
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Five Points of Intervention
1. Pre-pregnancy awareness of
substance use effects
2. Prenatal screening
and assessment
Child
4. Ensure infant’s safety and
Respond to infant’s needs
5. Identify and respond
to the needs of
infant/preschooler
child/adolescent
3. Identification
At Birth
System
Linkages
System
Linkages
Initiate enhanced
prenatal services
Parent
Respond to parent’s
needs
Identify and respond
to parents’ needs
1. Pre-Pregnancy
 Public education campaigns
- Warning signs at points of sale
- Warning signs at other venues
 Work with institutions of higher
education to disseminate the message
 Studies suggest that message is not
getting to critical group of pregnant
women
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Five Points of Intervention
1.
2.
3.
4.
5.
Pre-Pregnancy
Prenatal Screening and Services
Screening and Testing at Birth
Post-Natal Services to Infants and
Children
Post-Natal Services to Parents
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
2. Prenatal Screening and
Services




Prenatal screening - standardize
No states require prenatal screening
for substance abuse
Consider prenatal testing as standard
of care
Give pregnant women priority status in
entering treatment, in accord with
Federal requirements
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
2. Prenatal Screening and
Services



Referrals of pregnant women to treatment
and progress in treatment are not
monitored on a Statewide basis
Extensive wait lists in some states,
especially for residential care
Admissions of pregnant women are a very
small percentage of total admissions
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
2. Prenatal Screening and
Services




Special Connections Program – only
7% referred from medical community
Women in the criminal justice system
Encourage prenatal medical care
Consider a public health outreach
approach to pregnant women in need
of treatment
2. Prenatal Screening and
Services

CO HB12-1100 !!! reduces risk of
prosecution of pregnant women:
No information relating to substance use not otherwise
required to be reported pursuant to C.R.S. 19-3-304,
obtained as a part of a screening test for purposes of
prenatal care, of a woman who is pregnant or
determining if she is pregnant, shall be admissible in
any criminal proceeding. Nothing in this section should
be interpreted to prohibit prosecution of any claim or
action related to such substance use based on
independently obtained evidence.

CO HB12-1100 signed 3/9/12!!
ACOG Resources







http://www.womenandalcohol.org/
Alcohol screening and brief intervention at a glance
– Pocket card
Tips for working with women who drink
iPhone app for identifying and intervening with
women who drink at risk levels
ACOG Committee Opinion: At risk drinking and
alcohol dependence: Obstetric and gynecologic
implications
Additional clinician resources
Community resources
Five Points of Intervention
1.
2.
3.
4.
5.
Pre-Pregnancy
Prenatal Screening and Services
Screening and Testing at Birth
Post-Natal Services to Infants and
Children
Post-Natal Services to Parents
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
3. Screening and Testing
at Birth




Policies on screening at birth are not
at State level – local hospital policy
Hospital policies vary widely, with few
standardized protocols that are
consistently implemented
Reporting requirements – recent
legislation
Defining substance exposure as
evidence of abuse or neglect
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Colorado Law
Title 19 Children’s Code
19-1-103. Definitions
(1)(a) “Abuse” or “child abuse or neglect” …
means an act or omission in the following
categories that threatens the health or welfare
of a child:
(VII) Any case in which a child tests
positive at birth for either a schedule-I … or
schedule-II controlled substance … unless the
child tests positive for a schedule-II controlled
substance as a result of the mother’s lawful
intake of such substance as prescribed
3. Screening and Testing
at Birth



States do not monitor screening and
referrals
Detection of and response to FAS and
FASD is inconsistent with policy and
practice
Fear of prosecution and child welfare
involvement
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Screening (verbal)
should be routine!
 Screen for tobacco and alcohol as well as
illicit drugs
 Need to use a standardized tool and follow
an objective protocol
 SBIRT model (Screening, Brief Intervention,
Referral to Treatment) –
www.healthteamworks.com (billing codes,
trainings)
 Great potential for preventing negative
outcomes if identified early
Testing


Infant vs mother
Need to follow an objective protocol
 Universal vs. targeted testing
 Reliability and fairness
 Cost from financial or civil rights
perspective
 Don’t miss the “big picture”
Urine Testing

Rapid Drug Screening
– Pros: Inexpensive, fast, sensitive
– Cons: Cross-reactivity, false positives
– Needs confirmation

Gas Chromatography/Mass Spectroscopy
–
–
–
–
Confirmation
Sensitive and specific
Lower limits
May be “send-out”
Duration of Positive Tests
(Urine)
Amphetamines
Alcohol
Barbiturates
Valium
Cocaine
Heroin
Marijuana
Methadone
48 hours
12 hours
10 – 30 days
4 – 5 days
24 – 72 hours
24 hours
3 – 30 days (rare)
3 days
(USDHHS, SAMHSA, CSAT TIP #5, 1993)
Urine Screening - Opiates


Most detect: Morphine, Codeine, 6monoacetylmorphine, Hydrocodone
Most will NOT detect: Methadone,
Hyrdopmorphone, Oxycodone,
Fentanyl, Propoxyphene,
Buprenorphine
Meconium Testing



High sensitivity –
not for meth
Easy collection
Detects illicit
drug use from 24
weeks gestation
until birth
Other Testing Methods

Hair
– 3rd trimester
– May stay positive for 3 months after birth

Umbilical cord
– Newer
– Looks close to meconium in sensitivity

Serum
– Better for medications that require levels
– Alcohols
– Better dose-response curve
What Happens Next?




Referral for services/report to
DHS
Care plan established
Support services
Monitoring of progress
Five Points of Intervention
1.
2.
3.
4.
5.
Pre-Pregnancy
Prenatal Screening and Services
Screening and Testing at Birth
Post-Natal Services to Infants and
Children
Post-Natal Services to Parents
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
4. Post-Natal Services to
Infants and Children


Early intervention policies and process
for referrals
Child welfare developmental
assessments of substance-exposed
infants or older children just entering
the system
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
Treatment of Drug Exposed
Infants and Children




Symptoms may vary
Diagnosis based on a detailed evaluation
including a detailed history of drug/alcohol use
during pregnancy
Treatment based on symptoms that the
infant/child is exhibiting, not solely on the history
of drug/alcohol exposure
Not all drug/alcohol exposed infants and children
will have problems
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
5. Post-Natal Services to
Parents




Consider setting aside supplemental
federal funding for treatment for
pregnant and parenting women
Family-centered services
Significant gaps
Capacity of programs not sufficient to
serve all those in need of treatment
(Source: S Gardner, N Young, National Center on Substance Abuse and Child Welfare)
ASAM (American Society
on Addiction Medicine)



Released July 2011
Public policy statement on women, alcohol
and other drugs, and pregnancy
Addresses three aspects:
– Harms that alcohol and other drugs may cause
to the woman and her developing fetus
– Provides policy recommendations
– Summary statement regarding the use of alcohol
during pregnancy

http://www.asam.org/docs/publicy-policystatements/1womenandpregnancy_7-11.pdf
Colorado State Meth Task
Force SEN Subcommittee



Began in September 2009
Multiple disciplines including
healthcare providers, substance
treatment, mental health, child welfare
and criminal justice
Finalizing recommendations for policy
and practice –
www.coloradodec.org/substanceexpos
ednewborns.html
Pregnancy Is Only A
Part….
Factors in the
postnatal
environment
mediate prenatal
factors in predicting
developmental
outcomes
The Solution?



Treatment is needed for mothers
who choose to use drugs during
pregnancy
Criminalizing this activity will not
solve the problem and will likely
result in avoiding prenatal care
Helping these mothers access
treatment is a better solution
than criminalization
Women’s Treatment
 Addressing more than substance abuse
alone:





mental illness
domestic violence
HIV/AIDS
low incomes
inadequate or unsafe housing
 Must remove all barriers to successful
treatment and recovery
 Recovery will only be successful to the extent
that the issues which precipitate it are also
ameliorated
Successful Treatment
Programs for Women
 Removed barriers to attendance
 allowing children
 transportation
 Addressed children’s emotional and behavioral
problems
 therapeutic child care
 children’s social skills training
 substance abuse education for the children
 Provide parent support services
 Parenting classes
 Home visitation
 Job skills training
Motherhood as Incentive


Motherhood is often the
only legitimate social role
valued by drug dependent
women
Most women in treatment
are very concerned about
how their substance abuse
had affected their children
 Pregnancy and motherhood are times of
increased motivation for treatment
Drug Treatment





Treatment for drug (including
methamphetamine) addiction is effective
Important component in order to break the
cycle
Involved professionals can influence a
parent’s desire to participate in treatment
Addiction is not a moral failing but rather a
brain disease
Every child deserves a parent whose abilities
are not hampered by substance abuse or
addiction
Family Drug Courts?





Offers the client the opportunity to contract with
the court to seek treatment instead of potentially
losing their child
Referred through the county’s regular judicial
system, the department of health or other
governmental agency
One- to two-year process of outpatient treatment
and aftercare, culminating with educational, jobtraining or work programs
Report to case manager and judge on a regular
basis
Drug tested at least once a week
Recovery
Recovery is
a lifetime
journey,
not an
event
Building a Stronger
Continuum of Interventions



Strengthened
partnerships
between multiple
agencies are key to
many of these
innovations
Possible with little
or no additional
expenditures
Compromise on a
unified plan
Drug Exposed Children
 NOT “doomed” for life!
 Need:
 Patience
 Consistency
 Love
 Hope
THANK YOU!
Questions?