Prenatal Exposure to Drugs & Theories Flashcards
Addiction
-“Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry.”
Components of Addiction
- Inability to abstain
- Impaired behavioral control
- Craving
- Diminished recognition of problems resulting from addiction
- Dysfunctional Emotional Response
Family and Addiction
- Addiction of grandparents and other family members
- Lack of access to resources and support
- Low socio-economic status
- Domestic violence
- Abusive behavior (physical, emotional, sexual)
- Mental health issues in mother and other family members
How extensive is the addiction problem?
- 3 million 12 year olds and up used illicit drugs for the first time in 2010
- 8100 people a day used illicit drugs for the first time in 2010
- Average age of initiation was 19.1 years
- Finnegan scale is used to access infants who are prenatally exposed.
- Whatever age a person starts using drugs is their mental age.
Pregnancy and Illicit Drug Use 1
- 6% of pregnant women ages 15-44 reported non-medical use of prescription type psychotherapeutic drugs in the past year
- 4.5 % of pregnant women used illicit drugs the month before
- Types of drugs:
- 4.4% pain relievers
- 2% Tranquilizers
- 1.3% Stimulants
- 0.8 % Methamphetamines
- 0.3% Sedatives
- Infants are often exposed to more than 1 drug
- Some pregnant women will use opiates and anti-depressants
Pregnancy and Illicit Drug Use 2
- 4.4% of pregnant women reported current drug use:
- 22 % Crack/Cocaine
- 21% Methamphetamine
- 17% Marijuana
- Of the estimated 4.4% of pregnant women (ages 15-44), that continue to use illicit drugs:
- 16.2% 15-17 year olds
- 7.4% 18-25 year olds
- 1.9% 26-44 year olds
NAS-Neonatal abstinence syndrome
- “A generalized disorder characterized by central nervous system hyper-irritability, gastro-intestinal dysfunction, respiratory distress and vague autonomic symptoms.” (Finnegan & Weiner, 1993)
- Occurs due to exposure in-utero to either licit or illicit drugs of abuse or from postnatal iatrogenic effects
- Opiods (ex. Methadone, codeine, oxycodone, heroin) are the most common drugs from which infants withdraw
- Exposure to opiates can lead to NAS in 60-90% of infants (up to 60% require pharmacologic treatment)
- Opiod withdrawal is one of the few disorders that can be treated
- Different than prenatal exposure to drugs (all babies do not get addicted)
- Actually addicted to the drugs
- Neonatal withdrawal usually occurs in 48-72 hours, but in some cases it can take 2-4 weeks
- Most severe symptoms (tremors/sweating) can take 6 months-1 year
General Risks Associated with Prenatal Exposure to Drugs
- SIDS
- IUGR-intrauterine growth restriction
- Pre-term labor and delivery
- Learning disabilities
When to screen for NAS- Infant red flags
- Prematurity
- IUGR (unexplained)
- Neurobehavioral Abnormalities
- Atypical CVA’s
- Myocardial Infarctions
- NEC (Necrotizing enterocolitis)
- NEC-bowel needs to be resected
- preterm infants, less than 30 weeks have less chance of experiencing withdrawal because their CNS has not developed completely
When to screen for NAS- Mother red flags
- Lack of prenatal care
- Unexplained fetal demise
- Placental abruption
- Severe mood swings
- CVA’s
- Myocardial Infarctions
- Repeated spontaneous abortions
How do we test for NAS
- Urine Drug Screening- usually only shoes recent exposure
- Meconium Drug Screening- (most accurate)
- Umbilical Cord Toxicology Screening
- Hair Testing- detect drug use for several months
Do all infants with NAS look the same?
- Presentation differs based on 3 primary factors:
- Type (not amount) of drug abused
- Time between last use by mother and delivery
- Maternal / infant metabolism and excretion
- Other factors may impact how infant presents
- They don’t all look the same
The signs and symptoms of NAS
- Neurological Excitability- tremors, increased wakefulness, high pitched crying, exaggerated reflexes, a lot of sneezing and yawning, 2-11% opiate withdrawal have seizures
- Gastrointestinal Dysfunction-poor feeding, uncoordinated suck, vomiting, diarrhea, dehydration
- Autonomic Signs- sweating, nasal stuffiness, fever, modeling, temperature instability
Feeding the infant with NAS
- Poor Feeding
- Uncoordinated Suck
- Vomiting
- Diarrhea
- Dehydration
- Poor Weight Gain
Managing poor feeding in the infant with NAS
- Low lactose, soy, or elemental formula (helps will feeding intolerance and cramping)
- Mylicon (avoid use of sucrose)
- Manage environment
- Decrease extraneous noise
- Consistency
- Dim lighting
- Managing GERD
- Elevating head of bed
- Thickening feedings (though research doesn’t support use of thickened liquid as reliable for managing reflux)
- Increase frequency / reduce volume of feeding
Managing Poor Feeding in the Infant with NAS (Sucking)
- Uncoordinated sucking prevents infant from efficient intake
- Frustration increases due to inability to take in liquid efficiently
- Hyperactive gag – may be exacerbated by incoordination
- Swaddling may support organization
- External pacing may be required
- Temperature control may influence organization
Vomiting & Diarrhea in NAS
- Lead to dehydration/poor weight gain
- Increased caloric expenditure secondary to increased activity/agitation
- Increasing caloric density may promote weight gain (24-27 cal/oz)
- May use Immodium if diarrhea causes too much weight loss
- Clonidine
Breast Feeding the Infant with NAS
- Minimal amounts of methadone cross into the breast milk so the advantages outweigh the issues
- MBM is more easily tolerated
- Indirectly decreases symptoms of NAS
- By decreasing gastrointestinal irritation scores are lower (good)
- Improved gastrointestinal tolerance results in better growth
- Lowered NAS scores result in less dosage of meds needed to treat the infant for withdrawal
When not to breast feed with NAS
- If mother is taking:
—-Marijuana – fat soluble
—-Amphetamines- irritability, sleep problems
—-Cocaine- irritability, vomiting, seizures
—-Heroin- irritability
Pharmacologic Treatment of NAS
- Morphine (primary)
- Methadone (primary)
- Clonidine (secondary)
- Phenobarbital (secondary)
- babies are on a very rigid feeding schedule because of medication
Marijuana
- Dried material from hemp plant.
- Cannabis Sativa
- Passes rapidly into blood
- 8-9 tetrahydrocannabinol (THC) primary psychoactive component
- THC binds to cannabinoid receptors (CB1) and modifies the release of neurotransmitters
Fetal and Neonatal Effects of Marijuana
- THC easily crosses the placenta and is present in amniotic fluid
- High lipid solubility, slow elimination, prolonged fetal exposure
- Cannabinoid receptors present in early gestation which modifies neurotransmitters (serotonin, dopamine, GABA), altered neuronal growth, maturation and differentiation, and structural or functional abnormalities
- Impact generally subtle, outcomes usually associated with heavy or frequent use
Complications of Fetal Exposure to Marijuana
- Intrapartum
- Dysfunctional labor
- Meconium stained AF (amniotic fluid)- can happen in infants that are not exposed to drugs (indicates distress) - Neonatal
Prematurity
- Long Term
- Tremors (fine)
- Poor sleep
- Visual reasoning poor- reading
- Poor memory and verbal skills
- Abnormal attention
- Slightly increased risk for SIDS
Cocaine (4)
- Alkaloid extracted from leaves of Erythroxylon coca bush
- Forms:
- Coca paste- 80% coke
- Cocaine HCI- snorted or injected
- Alkaloidal base- freebasing
- Crack Cocaine- most popular form