Substance Exposed Newborns

• Marga M Figueroa, MD

• Neonatologist

• Christ Evert Children’s Hospital at

• Broward General Medical Center

• Pediatrix Medical Group/ Mednax

Objectives

To understand the background of infants product of alcohol and drug user mothers

To understand the pathophysiology of alcohol and drugs in the unborn fetus

To identify the clinical presentation of alcohol and drug withdrawal infants

To understand the treatment and follow up needed for this infants

550,000-750,000 children born each year exposed to drugs and/or alcohol. This number has continued to increased.

women have fa hx of substance abuse, sexual and domestic violence and a psychiatric comorbidity

increased risk of child abuse and neglect if they stay in the same household of the drug/alcohol abusive parents

1 in 3 children end up in out of home care

Background

All systems are affected but brain is the most affected

when exposure occurs in the first 20 weeks damage is related to cytogenesis and cell migration. After 20 weeks is related to brain growth and differentiation

Background

Neural wiring and associative connections that allow developing brain to learn and mature affected

Drugs affect the fetus 2 way : 1. most drugs freely cross the placenta 2. indirect methods like vasoconstrictive properties of the drugs

Background

Alcohol

most abused substance in US

no amount of alcohol is safe, binge or chronic

damage can be decreased if use is stopped by second trimester

Fetal Alcohol Syndrome: seen in 1:1000 births in US fetal effects seen in 1 :100 births

withdrawal appears at 3-12 hrs of birth and may last up to 18 mths of life

Fetal Alcohol Syndrome

3 things : growth retardation, characteristic facies, and CNS dysfunction

growth retardation ( pre and postnatal) which may be irreversible. Low BW, Short length, small head circumference.

postnatal failure to thrive

Fetal Alcohol Syndrome

congenital anomalies i.e.absent or indistinct philtrum, thin upper lip, flattened nasal bridge, abnormally formed ears, small lower jaw , cleft palate, limited flexibility of joints, epicanthic folds and short upturned noses

irreparable damage to central nervous system (mental retardation, hyperactivity, learning disabilities) , Heart, visual, hearing, immune system and speech problems

Fetal Alcohol effects poor motor skills

short attention span

below normal for age performance

easily distracted, constantly moving

unable to learn in group setting

Fetal Alcohol effects

vision and/or hearing problem

immature social behaviors

delayed speech

difficult with syntax, grammar and articulation

Cocaine

causes spasm of blood vessels and a rise in blood pressure

increase in placental abruption, still births, brain strokes and bowel infarcts in utero

can cause chromosomal abnormalities, kidneys and genital deformities

Cocaine

Irritability, tremors, high pitch cry, excessive sucking, abnormal ABR and EEG results

f/u 2y/o fine motor difficulties, sensory system problems ( fear of quick movements and poor movement control) and speech and articulation difficulties

Heroin/Methadone

50% show growth retardation

in utero violent kicking if mother withdraws, treatment recommended is to slowly wean methadone to less than 20mg/day

10% have chromosome abnormalities

Heroin/Methadone

precipitous births, meconium fluid and perinatal asphyxia

withdrawal seen in 70-90% of infants, sx are worse for methadone than for heroin, appears anywhere from 48hrs to 3weeks of life

Heroin/Methadone

hyperventilation, respiratory distress, sneezing, sweating, nasal stuffiness, vomiting and diarrhea, jaundice and seizures

5X increased risk of SIDS

Heroin/ Methadone

withdrawal lasts 2-6 months

decreased bonding and learning, speech and language delay

1-2 y/o show hyperactivity , short attention span , delayed cognitive/perceptual/fine motor skills

Marijuana

28% of adults 18-25 y/o use THC, 10 % are women

mother who smoke more than 5 cig /day have decreased visual response to light, tremors, startles and shrill cries

sx also include hypotonia , severe developmental delay when mixed with PCP

found in urine 7-30 days after use

PCP/Angel dust/Ketamine/LSD/Flakka

mostly used in veterinary medicine because it causes severe personality changes and psychosis

microcephaly and dysmorphic features

Street drugs, aka designer drugs, aka synthetic drugs

Flakka use has drastically increased in the past 3 years ( from 0 case 2013 to more than 275 cases reported by May 2015)

Antidepressants/ SSRI

withdrawal vs resolution of hyperserotonergic state ( serotonin syndrome)

infants show jitteriness, respiratory distress, irritability restleness, feeding difficulty, hypoglycemia, seizures, etc

Hydration is very important in the early stages, levels of CK ( creatinine phosphokinase) can be very high

Nicotine

fine tremors, hyper and hypotonia, poor self regulation and increased need for handling.

Babies have a low birth weight and small head circumference. Usually can show catch up growth

Clinical Presentation

Low birth weight

Prematurity

Intrauterine growth retardation

Shorter than average height

Smaller head circumference

Genito urinary malformations

Bone/skeletal defects

Missing fingers or toes

Clinical Presentation

Cerebral infarctions

Apnea

Upper respiratory infections/ Asthma, allergies

Tremors

Seizures

Fevers/ Sweating

Tearing

Mottling , vasomuscular instability

Clinical Presentation

Frequent yawning

Hypertonic/Hypotonic

Hyperactive or hypoactive reflexes

Visual difficulties

Sleep abnormalities

Eating difficulties

Easily overstimulated

Difficulty consoling or comforting

Lethargy

Treatment

Monitor scores and clinical sx

occupational and physical therapy

increased caloric intake

40% don’t need medication tx, minimizing environmental stimuli, adequate sleep and rest could be enough

Treatment

swaddling, hold and provide slow movements (snuggly:)

place on a quiet area, low lights, gentle handling, pacifiers, bath and massages, butt balm to prevent diaper rash

Treatment

developmental stimulation only when infant calm and one stimulus at a time stop if any signs of discomfort

slowly increase amount and time of daily developmental activities

Treatment

encourage self calming behaviors and self control of his own body movements

Feed often ( smaller amounts and allow to rest during the feed), feed upright and place on left lateral position for digestion

Treatment

respond to specific needs with predictability and regularity

if shows poor control and temper tantrums: use books, pictures, doll play and conversation to help the child explore and express feelings, remove and calm the child, redirect attention , explain expected behavior, reflect the child’s feelings. Praise attempts towards adaptive behavior. Set CONSISTENT LIMITS

Treatment

• Tantrums are usually a healthy release of rage and frustration. First protect the child from harm. Place on neutral area. If child wants to be alone observe and interact once child is calm. Some do not respond to physical contact ( hugging). Adult must remain calm, use soothing voice, do not shout or threaten to spank , show control.

• Encourage the child to use words to describe emotions, help child gain control by using eye contact, sitting next to them , give verbal reassurance and offer physical comfort. Know reason for tantrums and avoid them as much as possible

Treatment

if ignores verbal or gesture limit settings : talk to the child through to the consequences of the action

if shows decreased compliance with simple routine commands : provide explicitly consistent limits of behavior

Treatment

• if presents tremors with movements: observe , note onset of tremors , duration, and how the child compensates for them . Provide toys to enhance developments and refinement of small motor skills ( legos, blocks, puzzles, water, sand)

Treatment

if unable to finish or let go of a favorite object or activity : give attention and time to children behaving well, provide opportunity to take turn with friends and adults during daily activities

Treatment

if delayed receptive and expressive language : create a stable environment where child feels safe expressing feelings, wants and needs ( stories, records, songs and hands on activities)

Follow Up

early intervention and developmental follow up: 1 in first 6 mths, 1 at 12mths, yearly until 5-6 y/o

child protective services follow up

general pediatrician

Prognosis

growth deficiency :

1. Nicotine exposed babies can catch up but have smaller lungs ( decreased resp drive in response to CO)

2. Amphetamine/cocaine expose babies can catch up within 2years

3. Opiate exposed babies usually have no change in growth parameters

Prognosis

• cognitive and developmental defects:

1. Nicotine : high score on the auditory habituation but lower in orientation tests on the Brazelton test

2. Alcohol: mental retardation ( 33% of all MR children are FAS), also show language delay and sleep dysfunction as well as decreased muscle tone

Prognosis

3. Cocaine: +/- if is all due to it but they can have altered behavior ie poor state regulation, decreased alertness and orientation, abnormal reflexes, tone and motor maturity, EEG changes, abnormal brainstem responses, prolonged behavioral and language delays

Prognosis

4. Opioids : difficulty being consoled and increased overall activity on newborn behavioral assessments tests

5. Marijuana: problems with attention span

However in a structured and nurturing environment , many of these children can grow and develop normally

Thank you and God bless you for the great job you all do !!!!

ReferencesPicture Fetal alcohol syndrome digital millenium health search website

Child Psychologist Dr Joan Figueroa, PHD

The National Institute of Drug Abuse (NIDA) part of the National Institutes of Health (NIH), a component of the U.S. Department of Health and Human Services

Patrick,et al (2012) Jama, Patrick,et al (2015) Journal of Perinatology

www.OTISpregnancy.org

O’Donnell, M., Nassar, N., Leonard, H., Hagan, R., Mathews, R., Patterson, Y., & Stanley, F. (2009). Increasing Prevalence of Neonatal Withdrawl Syndrome: Population Study of Maternal Factors and Child Protective Involvement. Pediatrics, 123, 614-621.

Wang, M. (2010). Perinatal Drug Abuse and Neonatal Drug Withdrawl

ReferencesAAP Neonatal Drug Withdrawal, PEDIATRICS Vol. 129 No. 2 February 1, 2012 pp. e540 -e560 (doi: 10.1542/peds.2011-3212)

Grady, M., Hopewell, J., & White, M. (2009). Management of neonatal abstinence syndrome: a national survey and review of practice. ADC Fetal & Neonatal edition, 94, 249-252.

Johnson, K., Gerada, C., & Greenough, A. (2003). Substance misuse during pregnancy. The British Journal of Psychiatry, 183, 187-189

Laine, Ket al. Effects of exposure to selective serotonin reuptake inhibitors during pregnancy on serotonergic symptoms in newborns and cord blood monoamine and prolactin concentrations. Arch Gen Psychiatry. 2003;60(7):720

http://www.drugabuse.gov/drugs-abuse/emerging-trends