substance exposed newborns marga m figueroa, md neonatologist christ evert children ’ s hospital...
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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
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