Effects of in utero exposure to street drugs

Septo-optic dysplasia with amniotic band syndrome sequence: a case report

INTRODUCTION

De Morsier syndrome, or septo-optic dysplasia, is a rare, heterogeneous, complex condition with a highly variable phenotype. It is characterized by optic nerve hypoplasia, pituitary gland hypoplasia, and midline brain abnormalities, including absence of septum pellucidum and corpus callosum dysgenesis. Diagnosis is made clinically by the presence of any two or more features from the clinical triad.

CASE PRESENTATION

We report a case of a premature African newborn male baby born to nonconsanguineous parents who presented to our institution with agenesis of the septum pellucidum, unilateral optic nerve hypoplasia, and pituitary stalk hypoplasia. However, he had intact central endocrine function. He also presented with limb defects due to constricting amniotic band syndrome. Other dysmorphic features were low-set ears, microcephaly, and bilateral talipes equinovarus. He otherwise had a normal neurological examination result. Over time, he had an adequate weight gain and was managed by a multidisciplinary team.

CONCLUSION

De Morsier syndrome still represents a diagnostic challenge, despite advances in neuroimaging and genetic studies, due to the heterogeneous nature of the disorder. This case adds to existing knowledge on the vascular pathogenesis of septo-optic dysplasia.

A parenting education program for women in treatment for opioid-use disorder at an outpatient medical practice

Opioid use during pregnancy poses serious risks for the mother and the unborn child. Opioid-use disorder may be managed with medication-assisted treatment (MAT) in an outpatient setting, but few MAT practices specifically address the challenges faced by pregnant women. This article describes a medical office-based educational support group for women in MAT for opioid-use disorder who were pregnant and/or parenting young children. Focus groups were conducted to elicit patient feedback. Women indicated that they found the educational support groups beneficial and offered suggestions. In-office educational support groups for pregnant women in treatment for opioid-use disorder are feasible and well received.

Drug Addiction During Pregnancy

Drug use during pregnancy is a significant risk factor for compromised child development. National statistics reveal that many pregnant women smoke tobacco (18%), drink alcohol (9.8%), and use illicit drugs (4%). Animal and clinical data show that prenatal alcohol and tobacco exposure have direct deleterious consequences on child development. Recent large multicenter studies have failed to show that prenatal cocaine or heroin exposure causes devastating child consequences when environmental variables are controlled. However, prenatal exposure to both licit and illicit drug use mostly occurs in the presence of environmental and contextual risk factors that together can impede healthy outcomes. Thus, treating these addiction disorders while addressing other lifestyle factors in a comprehensive way is critical.

Drugs in pregnancy: the effects on mother and her progeny

Drug abuse during pregnancy is a growing problem in all developed countries all over the world. The drugs easily cross the placental barrier into the fetal body and are present also in the maternal milk. Therefore, it may affect the development of the child pre- as well as postnatally. The effects of prenatal drug exposure are long-lasting and persist until adulthood. The present review summarizes the clinical and experimental evidence showing how opioids and psychostimulants can affect maternal behavior of drug-abusing mother and the development of their offspring.

Illicit drug use and neonatal outcomes: a critical review

Although the neonatal consequences of tobacco and alcohol exposure are well established, the evidence related to prenatal illicit drug use is less consistent despite prevalent views to the contrary. The many social, psychosocial, behavioral, and biomedical risk factors for adverse birth outcomes associated with illicit drug use complicate the evaluation of neonatal effects. Placing emphasis on recent research, this review summarizes the epidemiologic literature on the neonatal impact of marijuana, opiate, and cocaine use. Of these drugs, cocaine use is most consistently related to fetal growth decrements and dose-response effects have been observed. However, studies to date have largely failed to control for associated social, psychosocial, and contextual factors. Additional recommendations for future research are provided. It is likely that interventions will need to address the factors surrounding drug use to greatly improve neonatal outcomes (e.g., social circumstances, poor nutrition, stress, infections).

Interdisciplinary Interventions To Improve Pediatric Palliative Care and Reduce Health Care Professional Suffering

OBJECTIVE

To implement and evaluate a quality improvement program of interdisciplinary palliative care education and support intended to increase the competence, confidence and ability to manage personal grief of health care professionals caring for dying children.

SETTING

A children's hospital in an urban academic medical center.

PARTICIPANTS

Pediatric health care professionals of all disciplines caring for children with life-threatening conditions.

INTERVENTIONS

We initiated a quality improvement program of professional education and support consisting of four interdisciplinary activities facilitated by the pediatric palliative care team. The Compassionate Care Network (CCN) provides an open forum for interdisciplinary networking and education. Palliative Care Rounds (PCR) provides education through monthly case-based discussions on selected units. Patient Care Conferences (PCC) facilitate communication and care planning for selected patients with palliative care needs on any unit in the children's center. Bereavement Debriefing Sessions (BDS) offer health professionals the opportunity to manage their responses to grief after a patient's death. EVALUATION MEASURES: From February 2002 to September 2003, we prospectively tracked the frequency of sessions conducted, the number and discipline of attendees, the age and diagnosis of patients discussed, and themes raised at each session. Participants evaluated each session.

RESULTS

One hundred one sessions were conducted (PCR = 31, PCC = 23, CCN = 9, BDS = 38) for 950 participants (PCR = 312, PCC = 188, CCN = 193, BDS = 257). All units and disciplines participated in one or more sessions. Evaluations report that sessions are informative and will influence future professional practice.

CONCLUSIONS

A program of interdisciplinary interventions can successfully educate and support health care professionals in providing palliative and end-of-life care for children. This program model can be applied in diverse pediatric health care settings.

Health services use and growth patterns among older siblings of infants with prenatal drug exposure

The health care use patterns, suspected maltreatment, and growth trajectories of siblings of infants with prenatal drug exposure were examined. Ninety-three siblings of drug-exposed infants were matched with patients from the same primary care clinic. The case patients were found to have significantly fewer health care contacts, more deficient immunizations, and more reports of suspected child maltreatment. Although they did not differ in birth weight, growth curve modeling found that case patients had lower weight gain trajectories. When drug-exposed infants are identified, nursing personnel are in a unique position to assist the siblings of those identified infants obtain needed medical care and services.

The effect of parental race on fetal and infant mortality in twin gestations

Previous work has found that singleton birth outcomes are better if the father is black and the mother is white than if the father is white and the mother is black. We sought to examine the effects of parental race on fetal and infant mortality in twins. We analyzed the fetal and infant mortality rates in four groups [both parents white (W-W), both parents black (B-B), father black and mother white (FB-MW), and father white and mother black (FW-MB)], using the 1995--1997 U.S. twin registry data (249,221 twins). Compared to W-W, the infant mortality for B-B, FW-MB, and FB-MW (respectively, relative risk [RR] 1.84, 95% confidence interval [CI] 1.73-1.95; RR 1.39, 95% CI 1.03-1.51; and RR 1.49, 95% CI 1.26-1.77) were all significantly different from W-W but not from each other. When fetal mortality was added to infant mortality, the combined mortality was highest for B-B (RR 1.66, 95% CI 1.58-1.75), intermediate for FW-MB (RR 1.18, 95% CI 0.92-1.51) and FB-MW (RR 1.37, 95% CI 1.19-1.58) and lowest for W-W. Thus, twin infants born to black parents have higher risk of fetal and infant mortality compared with twin infants born to white parents and infants of mixed race parents generally have intermediate outcomes.

Parenting knowledge among substance abusing women in treatment

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. The effects of a parenting skills training program for this population were evaluated. A Parenting Skills Questionnaire was developed and administered to a sample of 73 pregnant and drug-dependent women during their first week of substance abuse treatment and again approximately 7 weeks later, following parenting skills training. The questionnaire was designed to assess whether group and individual parenting sessions changed the subjects' knowledge and beliefs in four parenting domains: newborn care, feeding practices, child development and drug abuse during pregnancy. Pre-intervention scores for all parenting domains were low. Post- vs. pre-intervention comparisons showed significant increases in all domain scores after individual and group parenting skills training. Preliminary results obtained from this clinic-based sample suggest that these substance abusing mothers lacked important parenting knowledge and that this knowledge improved after comprehensive substance abuse treatment that included parenting training.

[Perinatal drug abuse. Collaborative perinatal care for drug abusers and their infants]

Pregnant drug abusers are a group with very high risk of perinatal morbidity. Intensive prenatal care, with substitution maintenance programs, by a medico-psycho-social team working in concert with ambulatory health and social workers, may prevent perinatal complications and mother-infant separation. The results of such a perinatal program, in a suburban low-socioeconomic population, are described. In comparison with reports in the literature, this approach appears to provide significant perinatal medical and social prognosis for pregnant abusers and their neonates.

Maternal support in the delivery room and birthweight among African-American women

OBJECTIVES

We performed a hospital-based case control study of African-American mothers to explore the relationship between maternal support by a significant other in the delivery room and very low birthweight (VLBW).

METHODS

We administered a structured questionnaire to mothers of VLBW (less than 1,500 g; N=104) and normal birthweight (greater or equal to 2,500 g; N=208) infants.

RESULTS

The odds ratio for VLBW comparing women without social support in the delivery room to those with a companion was 3.5 (2.1-5.8). Several traditional risk factors were not associated with VLBW, but older maternal age and perceived racial discrimination were.

CONCLUSIONS

Maternal support in the delivery room or factors closely associated with it significantly decreases the odds of delivering a VLBW infant for African-American women.

Family-Focused Substance Abuse Treatment: A Program Evaluation

Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes of pregnant and parenting women. It also provides a mechanism for early identification and intervention for children.

Intrauterine growth of full-term infants: impact of prenatal cocaine exposure

OBJECTIVE

The objectives of this study were to estimate the effect of prenatal cocaine exposure on fetal growth and gestational age after controlling for exposure to alcohol, tobacco, and marijuana and other covariates; to evaluate whether prenatal cocaine exposure has a disproportionate adverse effect on head circumference compared with overall somatic growth; and to assess whether the effect of prenatal cocaine exposure on fetal growth is mediated by cocaine's suspected effect on gestational age.

METHODS

The study population includes 476 neonates participating in the Miami Prenatal Cocaine Study, a longitudinal follow-up of in utero cocaine exposure. The sample, restricted to full-term neonates born to African-American inner-city mothers, included 253 infants exposed prenatally to cocaine (with or without alcohol, tobacco, or marijuana exposure) and 223 non-cocaine-exposed infants, of whom 147 were drug-free and 76 were exposed to varying combinations of alcohol, tobacco, or marijuana.

RESULTS

Evidence based on structural equations and multiple regression models supports a hypothesis of cocaine-associated fetal growth deficits (0.63 standard deviation) and an independent mild effect on gestational age (0.33 standard deviation). There was no evidence of a disproportionate adverse effect on birth head circumference once the impact on overall growth was estimated. There was evidence that some but not all of the cocaine effect on fetal growth was direct and some was indirect, acting via an intermediate influence of cocaine on gestational age.

CONCLUSIONS

Cocaine-associated growth deficits, symmetrical and partially mediated by gestational age, were observed in this sample of inner-city African-American full-term infants prospectively enrolled at birth. Long-term implications will be the subject of future reports from this longitudinal investigation.

Preventive counseling during prenatal care: Pregnancy Risk Assessment Monitoring System (PRAMS)

BACKGROUND

Prenatal care provides an opportunity for counseling about behaviors and experiences that increase the likelihood of adverse maternal and fetal outcomes.

OBJECTIVE

To document (1) prevalence of preventive health counseling during prenatal care, (2) prevalence of women in higher need of counseling about specific health concerns, and (3) whether women in higher need for counseling were more likely than women in lower need to have received counseling.

METHODS

Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS), a state-specific, population-based, random sample of postpartum women, was performed by using data from 14 states for births during 1997 or 1998, for a total of 24,620 participants. Outcome measures included report of preventive health counseling during prenatal visits by specific topic as well as behaviors and experiences about cigarette use, alcohol use, breast-feeding, partner violence, and preterm labor.

RESULTS

The percentage of women that report preventive counseling during prenatal care is relatively high (> or =75%) for 9 of 13 topics. However, the percentage of women that report counseling is relatively low (<75%) for partner violence, seat belt use, illegal drug use, and human immunodeficiency virus (HIV) risk. Except for counseling about cigarette and alcohol use, women in higher need, compared with women in lower need, for three other health topics were not significantly more likely to receive counseling.

CONCLUSIONS

Preventive health counseling for partner violence, seat-belt use, illegal drug use, and risk of HIV could be increased across prenatal settings. Counseling should involve assessment of risks, with focused counseling related to those risks.

The impact of substance abuse treatment modality on birth weight and health care expenditures

During the 1990s, substance abuse treatment programs were developed for pregnant women to help improve infant birth outcomes, reduce maternal drug dependency and promote positive lifestyle changes. This study compared the relative impact of five treatment modalities--residential, outpatient, residential/outpatient, methadone and detoxification-only--on infant birth weight and perinatal health care expenditures for a sample of 445 Medicaid-eligible pregnant women who received treatment in Massachusetts between 1992 and 1997. Costs and outcomes were measured using the Addiction Severity Index and data from birth certificates, substance abuse treatment records and Medicaid claims. Multiple regression was used to control for intake differences between the groups. Results showed a near linear relationship between birth weight and amount of treatment received. Women who received the most treatment (the residential/outpatient group) delivered infants who were 190 grams heavier than those who received the least treatment (the detoxification-only group) for an additional cost of $17,211. Outpatient programs were the most cost-effective option, increasing birth weight by 139 grams over detoxification-only for an investment of only $1,788 in additional health care and treatment costs. A second regression using five intermediate treatment outcomes--prenatal care, weight gain, relapse, tobacco use and infection--suggested that increases in birth weight were due primarily to improved nutrition and reduced drug use, behaviors which are perhaps more easily influenced in residential settings.

Risk assessment

Risk assessment is the process by which clinicians screen for conditions that, if unmanaged, result in complications of pregnancy or adverse birth outcomes and for which an intervention would improve the well-being of the mother, child, and family. One of the major US health care goals is that by the year 2000, at least 90% of pregnant women will receive risk appropriate care. This article discusses the major risks to the mother and child during pregnancy, and presents tools to assess pregnancy well-being.

Mediators of ethnic-associated differences in infant birth weight

PURPOSE

To examine whether ethnic differences in low birth weight babies of low-income women may be explained in part by group differences in prenatal health behaviors and psychosocial factors.

METHODS

A prospective, survey of 1,071 low-income, primiparous African-American and Mexican-origin women was conducted in Los Angeles County, California. In face-to-face interviews, data were obtained on substance use, prenatal stress, social support, attitudes toward pregnancy, initiation of prenatal care, and medical risk. Medical chart data were abstracted regarding medical risk factors and labor, delivery, and neonatal data. Interview data were linked with birth outcome data retrieved from maternal medical records. Structural equation modeling was used to test a hypothesized model in which differences in birth weight were expected to be mediated by ethnic differences in substance use, psychosocial factors, and medical risk.

RESULTS

As expected, African-American women delivered babies of earlier gestational age and lower birth weight than did women of Mexican origin. Direct predictors of low birth weight were use of drugs and cigarettes, prenatal stress, and positive attitudes toward pregnancy; together, these factors accounted for the observed ethnic differences in birth weight.

CONCLUSION

These data contribute to our understanding of the factors that may account for ethnic-associated differences in low birth weight.

The responsive use of self in community health nursing practice

This interpretive study examined the expertise that is often unrecognized in the everyday practice of community health nurses. Twenty-five nurses participated in the study and were asked to describe meaningful clinical situations during group and individual interviews. Field notes of observations of clinical situations and transcribed interviews were analyzed as a text. A major finding of the study involved the nurse's responsive use of self. Responsiveness to the other enabled the nurse to gain a situated understanding of clients' lives and to cultivate clients' strengths and connections to a responsive community.

[Management of drug addict pregnant women and their children]

Children of substance abuse mothers have an increased risk of severe pathological disorders such as perinatal diseases (prematurity, intrauterine growth retardation, infections) with their neurological and respiratory complications and sequelae, and transmission of drug addiction related infections, ie human immunodeficiency virus, hepatitis B and C virus, syphilis. Many of these children present a drug withdrawal syndrome characterized by restlessness and jetteriness during the neonatal period. This is frequently followed by a post withdrawal period of several weeks duration with crying, excitement, sleep and feeding difficulties. Although these drug withdrawal manifestations have no incidence on the vital prognosis, it severely impairs the mother-infant interaction. Despite these disorders it appears that the outcome of these children is mainly related to their familial environment which is exposed to many risk factors: mother-child separation, violence, delinquency, precariousness, unhealthy housing, prostitution, drug dependency, parental death or imprisonment... Early medico-psycho-social intervention starting during pregnancy and a prolonged support for several years are the only way to improve their spontaneously poor outcome.

Options for Recovery: California's perinatal projects

In response to the increasing magnitude of problems related to perinatal exposure to alcohol and other drugs, a novel interagency collaboration was formed that involved the California Departments of Alcohol and Drug Programs, Developmental Services. Health Services, and Social Services. This collaboration was named Options for Recovery (OFR). Its mission was to promote the recovery of pregnant, postpartum, and parenting chemically dependent women and the enhancement of the health of their children by providing comprehensive and coordinated alcohol and other drug treatment, case management, and recruitment and training of foster parents and relative caregivers. Seven OFR pilot projects were selected. Findings from the three-year evaluation of the pilot projects showed that the initiative was successful in connecting women with essential services, promoting perinatal recovery and child health, and increasing family reunification of children in foster care. Women who were most likely to complete alcohol and other drug treatment were younger, high school graduates, mandated to treatment, or those who participated in treatment 150 days or more. Participants reported high levels of satisfaction with OFR. The findings indicate that OFR served the unique needs of high-risk perinatal populations. Future efforts should try to reach women early in their pregnancies and should provide a wide array of alcohol and other drug treatment approaches that are responsive to the myriad needs of women and their children.

The developmental outcome of children born to heroin-dependent mothers, raised at home or adopted

In the present investigation we were interested to study the possible role of in-utero exposure to heroin and of the home environmental in the etiology of long-term developmental problems in children born to heroin-dependent parents in comparison to matched controls. The children were examined at .5-6 years of age by a developmental pediatrician and a developmental psychologist using, for the children up to 2.5 years of age, the Bayley Developmental Scales, and for children aged 3-6 years the McCarthy Scales for Children's Abilities. We examined 83 children born to heroin-dependent mothers, and compared the results to those of 76 children born to heroin-dependent fathers and to three control groups; 50 children with environmental deprivation, 50 normal children from families of moderate or high socioeconomic class, without environmental deprivation, and 80 healthy children from kindergartens in Jerusalem. There were five children (6.0%) with significant neurological damage among the children born to heroin-dependent mothers and six (7.9%) children among those born to heroin-dependent fathers. The children born to heroin-dependent mothers had a lower birth weight and a lower head circumference at examination when compared to controls. The children born to heroin-dependent parents also had a high incidence of hyperactivity, inattention, and behavioral problems. The lowest DQ or IQ among the children with cognitive levels above 70 was found in the children with environmental deprivation, next was the DQ or IQ of children born to heroin-dependent fathers, then the DQ or IQ of the children born to heroin-dependent mothers. When the children born to heroin-dependent mothers were divided to those that were adopted at a very young age and to those raised at home, the adopted children were found to function similarly to the controls while those not adopted functioned significantly lower. Our results show that the developmental delay and behavioral disorders observed among children born to drug-dependent parents raised at home may primarily result from severe environmental deprivation and the fact that one or both parents are addicted. The specific role of the in-utero heroin exposure in the determination of the developmental outcome of these children (if they do not have significant neurological damage), seems to be less important in comparison to the home environment.

Moderate prenatal alcohol exposure and psychomotor development at preschool age

OBJECTIVES

This study investigated the effect of moderate prenatal alcohol exposure on psychomotor development of preschool-age children in a longitudinal study.

METHODS

Pregnant women were interviewed about their alcohol consumption at their first visit to the maternity hospital in Roubaix, France. Alcohol consumption before pregnancy and during the first trimester was assessed with a structured questionnaire. The psychomotor development of 155 children of these women was assessed with the McCarthy scales of children's abilities when the children were about 4 1/2 years old.

RESULTS

Consumption of 1.5 oz of absolute alcohol (approximately three drinks) or more per day during pregnancy was significantly related to a decrease of 7 points in the mean score on the general cognitive index of the McCarthy scales, after gender, birth order, maternal education, score for family stimulation, family status, maternal employment, child's age at examination, and examiner were controlled for.

CONCLUSIONS

This study showed that moderate to heavy alcohol consumption during pregnancy, at levels well below those associated with fetal alcohol syndrome, has effects on children's psychomotor development.

Cessation of cocaine use during pregnancy: a preliminary comparison

This preliminary study examined differences between cocaine-dependent pregnant women who received "baseline" drug treatment (N = 13) and those requiring additional "intensive" treatment (N = 9). Baseline drug treatment consisted of weekly individual counseling sessions. Intensive treatment, in the form of contingency management procedures, was added for patients who showed no reduction in cocaine use during the first 4 weeks of treatment. There were no differences between the two groups in terms of demographic and pregnancy characteristics or history of cocaine use. Significantly more patients in the baseline treatment group were cocaine-free at intake and had a higher rate of compliance with scheduled prenatal clinical visits. These findings may indicate a decision to cease cocaine use prior to entering treatment, and a high degree of motivation to remain drug-free. Despite the small sample size, the finding that a substantial proportion of cocaine-dependent pregnant women remain cocaine-free during treatment is encouraging.