A Prospective Adoptive Parent Guide to Substance exposure in utero
Disclaimer: THIS IS NOT MEDICAL ADVICE. If you are looking for medical advice, please reach out to your primary care provider.
ALCOHOL IN PREGNANCY
QUICK FACTS:
There is no safe amount of alcohol consumption during pregnancy.
Effects of fetal exposure to alcohol may be lifelong for the baby
There is no exact way to determine the relationship between the amount of alcohol consumed, and the potential damage caused by alcohol in an infant.
Alcohol exposure during pregnancy may cause physical abnormalities, brain and behavioral effects, or no detectable problems1.
A fetus in utero is especially susceptible to the effects of alcohol, because they do not process alcohol as efficiently as an adult and they are at a critical stage of development.2
In some studies, Fetal Alcohol Spectrum Disorder (FASD) has been diagnosed in up to 5% of live births3
POSSIBLE RISKS:
The following risks are POSSIBLE risks. They are not guaranteed and this list is not comprehensive. Alcohol in pregnancy may affect 2 major areas: structural growth and brain development.
Structural Growth Impairment:
Overall growth restriction
Head growth
Heart and other organ growth abnormalities
Skeletal growth abnormalities
Vision and hearing impairment
Brain Development Impairment:
Microcephaly (small head) is a sign of brain growth restriction
Seizures and nerve problems are signs of improper brain development
Cognitive, executive function, memory, and behavioral problems
Fetal Alcohol Spectrum Disorder (FASD):
Broad term used to describe the effects of alcohol exposure in an infant and includes the following4:
Fetal Alcohol Effects (FAE)
Alcohol-Related Birth Defects (ARBD)
Fetal Alcohol Syndrome (FAS)
Partial FAS (pFAS)
Characteristic facial features of FASD as shown here: https://depts.washington.edu/fasdpn/htmls/fas-face.htm
Possible Risks by Trimesters:
Alcohol exposure is dangerous to a fetus in all stages of gestation, but may have different effects at different times.
First Trimester:
Facial and structural abnormalities (classic facial features of FASD and small head)5
Second Trimester:
Risk of miscarriage
Third Trimester:
Weight, length, and brain growth5-7
Exposure in any trimester may cause neurobehavioral effects (brain development that will later affect behavior)
Takeaways:
Exposure earlier in pregnancy may typically cause physical abnormalities and risk of miscarriage.
Exposure later in pregnancy may typically cause more cognitive problems and overall growth restriction.
Neurobehavioral effects may occur with alcohol exposure at any point in gestation.
WHAT TO LOOK FOR:
Signs of Brain Development Impairment8-13:
Infancy:
Irritability, jitteriness, problems regulating states of sleep or arousal, developmental delay
Childhood:
Hyperactivity, inattention, cognitive delay, emotional reactivity, learning disabilities, memory difficulty
Adolescence:
Deficits in social skills, executive function (decision making, school, work, following social norms)
WHAT TO DO:
Early Detection and Intervention is very important for improving outcomes.
The initial workup to diagnose Fetal Alcohol Spectrum Disorder is performed by a multispecialty team.
Talk to your pediatrician or family physician
They can get you started with a multispecialty team to start the workup for a potential diagnosis of FASD
Bring up any concerns you may have that will aid them in early diagnosis
You can receive education about what to look for and when to bring your child in
Most children with FASD benefit from a variety of therapies including physical, speech, occupational, behavioral, and educational therapy.
TOBACOO AND NICOTINE IN PREGNANCY
QUICK FACTS:
A study in 2016 showed that 7.2% of women reported smoking at any point during pregnancy in the United States1
Utah had a rate of 3%
Electronic Nicotine Delivery Systems (ENDS)/ Electronic cigarettes contain less toxins than cigarettes, but may cause developmental harm based on data from animal studies2
Tobacco can cause harm through decreased oxygenation, altered development, and exposure to toxins
The most well studied effect of tobacco use is low birth weight.
POSSIBLE RISKS:
Risks to the pregnancy:
Modestly increased chance of miscarriage
Nearly 50% increase in stillbirth3
Increased chance of pregnancy complications and birth complications
Preterm labor
Placental abruption
Preterm premature rupture of membranes
1.5 to 3.5 times Increased chance of Low Birth Weight Infant4
Decreased risk of preeclampsia5
Risks after birth:
Neurobehavioral effects (effects on the brain that may impact behavior)6,7
Higher stress response
More excitable brain (irritable, restless)
Increased muscle tone
Behavioral problems (conduct disorders, ADHD)8-11
Tourette’s syndrome or Tic disorders12
There is no good evidence that prenatal nicotine exposure causes neonatal withdrawal syndrome.
Sudden Unexpected Infant Death (also called SIDS)13
Risk of SIDS is much lower if infant is not exposed to cigarette smoke after birth
4 times increased chance of Diabetes as young adult if exposed to heavy smoking14
Unclear evidence of cognitive problems
Increased chance of asthma15
WHAT TO LOOK FOR:
Risk is minimal after a successful pregnancy and birth.
After birth you can look for irritability, restlessness and increased muscle tone, however the only treatment is to help them feel comfortable
Stay aware of the child’s behavior but behavioral disturbances may or may not be related to tobacco exposure
WHAT TO DO:
Talk to your pediatrician about any concerns you may have
Once you have a healthy baby, there are likely no major issues to be worried about from tobacco exposure
STIMULANTS
QUICK FACTS
The most common stimulants are Cocaine, Methamphetamine (Meth), and Amphetamine (ADHD medication known commonly as Adderall)
Cocaine, Meth, and Amphetamine cross the placenta
Cocaine causes vasoconstriction (narrowing of blood vessels) which can cause problems associated with poor blood flow1
POSSIBLE RISKS
Cocaine:
Growth Related Issues2:
Small for gestational age (measures small during pregnancy)
Reduced birth weight (measures small at birth)
Shorter gestational age at delivery (earlier birth than the average)
Preterm birth (born before 37 weeks)
Neurobehavioral effects3,4 (brain and behavior symptoms) may occur within the first 3 days of life. These are likely transient and do not show long term effects.
Tremors/jitteriness
High pitched cry
Irritability
Excessive suck
Vital sign changes (blood pressure, heart rate, respiratory rate)
Other rare risks may include miscarriage, placental abruption, and small intestinal atresia (poor formation of the small intestine)
Amphetamine and Methamphetamine:
Growth related issues5-8:
Fetal growth restriction
Preterm birth
Reduced birth weight
Smaller head circumference
Small for gestational age
Pregnancy and Birth risks:
Preeclampsia
Placental abruption
Neonatal and Infant death9
Risk of cognitive problems is unclear.
WHAT TO LOOK FOR
Cocaine:
Look for signs of growth restriction
Size
Weight
Head circumference
Look for signs of neurobehavioral problems within the first 3 days of life:
Tremors/jitteriness
High pitched cry
Irritability
Excessive suck
Vital sign changes (blood pressure, heart rate, respiratory rate)
Look for long term cognitive problems:
Risk for long term cognitive and behavioral issues is unclear. Some studies show no evidence for cognitive and behavioral issues while some show10,11:
Attention deficits
Behavioral self regulation (self control) deficits
Some minimal language and cognitive delays
Minor processing and executive function deficits
Amphetamines:
Look for signs of growth restriction
Size
Weight
Head circumference
Look for long term cognitive problems:
Risk of cognitive problems is unclear. Some studies show no evidence for cognitive problems while others show12,13:
Learning and memory difficulty
Motor delays (movement/muscle tone)
Brain structure changes
Attention deficits
WHAT TO DO
Watch for any growth related delays and seek appropriate medical treatment and/or therapy as early as detected.
Watch for any behavioral problems as listed above and seek early intervention.
Talk to your pediatrician about any concerns you may have about your child’s health and development including social and behavioral concerns.
OPIOIDS AND PRESCRIPTION DRUGS
QUICK FACTS:
Types of opioids:
Natural opiates such as Morphine, Heroin, and Codeine
Synthetics commonly known as the pain pills Oxycodone, Hydrocodone, and Hydromorphone
Opioid use in pregnancy has become a public health crisis.
Maternal Opioid-related Diagnosis (MOD) in hospital deliveries more than doubled between 2010 and 2017 (clean up indentation after bulletpoints on website) (increased from 3.5 to 8.2 per 1000 deliveries)1
Individuals who use opioids typically have other coexisting problems (medical, psychological, financial, social) that make it difficult to distinguish the direct effect of opioids on pregnancy and birth related complications.
POSSIBLE RISKS:
Increased risk of obstetric complications including2-4:
Intrauterine growth restriction (slow growth during pregnancy)
Placental abruption (placenta separation from uterus)
Preterm Labor
Miscarriage or Stillbirth
*It is difficult to determine how much risk is associated with Opioid use versus other coexisting medical problems and substances
Neonatal Abstinence Syndrome (NAS):
NAS is withdrawal from any substance in an infant that was exposed during pregnancy.
Most commonly due to Opioids
Symptoms include5,6:
Fragmented sleep cycle
Difficulty staying alert
Hypertonicity (stiffness) or jitteriness
Autonomic dysfunction (sweating, sneezing, fever, nasal stuffiness, frequent yawning)
Sensitivity, irritability, and crying with any stimuli
Difficulty feeding/swallowing
Withdrawals can occur as early as within the first 24 hours and almost always occur within the first week5-8.
Infants will be observed for 3-7 days if NAS is suspected.
NAS is NOT associated with death
WHAT TO LOOK FOR:
Watch for the above symptoms within the first week of life.
Keep in mind that any time illegal substances are used, other substances are much more likely to be used concurrently.
WHAT TO DO:
NAS is almost always going to occur at the hospital under the care of the medical team, so you will likely not need to do anything besides be there for your baby.
The long-term effects of opioid use in pregnancy are not well understood, so there is no action that you need to take to help your child long term.
If you have any concerns, talk to your pediatrician.
MARIJUANA
QUICK FACTS:
The impact of marijuana use in pregnancy on the baby is poorly understood. More studies are warranted.
There is some limited data suggesting marijuana can affect the babies growth and brain development, but the data is conflicting.
POSSIBLE RISKS:
Growth Related Issues
Some evidence of decreased birth weight or small for gestational age1-3
Some evidence of preterm birth, complications during delivery, and the need for Neonatal Intensive Care Unit (NICU) care2
Some studies found that after adjusting for confounding variables, there was no association between marijuana use in pregnancy and adverse outcomes for the baby4
Brain Development
Some limited evidence of increased rates of autism and intellectual disability in babies that were exposed to marijuana in utero5
Some evidence of a negative effect on brain development including6-16:
Attention
Visuospacial function
Hyperactivity
Problem solving
*The bottom line is that the impact of marijuana exposure in utero is not clear, so the guidelines continue to recommend avoidance of marijauna use during pregnancy and breastfeeding.
WHAT TO LOOK FOR:
Signs that your baby is not growing adequately
Signs of autism or intellectual disability
WHAT TO DO:
Talk to your pediatrician about any concerns you have about your child’s development.
“Hi, I'm Jeremy. I am a recent medical school graduate, husband to an amazing wife, two-time adoptive parent, and Dad to my two beautiful daughters. I created this resource to help others learn about substance use in pregnancy, and how it could possibly affect your family in adoption situations. I hope you find this resource valuable and that you will share it with others in the adoption community.”
-Jeremy Stone, DO
Resources Used:
Infants of mothers with substance use disorder
Substance use during pregnancy, overview of selected drugs
Substance use during pregnancy, screening and prenatal care
Fetal Alcohol Spectrum Disorder, clinical features and diagnosis
Overview of management of opioid use disorder during pregnancy
Cigarette and tobacco products in pregnancy: Impact on pregnancy and the neonate