What do adoptive and foster parents need to know about the impacts of prenatal exposure to opioids, Suboxone, and Methadone. What are the risks to a baby born with Neonatal Abstinence Syndrome or Neonatal Opioid Withdrawal Syndrome (NOWS)? We talk with Dr. Julian Davies, a pediatrician at the University of Washington’s Center for Adoption Medicine and their FASD and Prenatal Exposure Clinic.
In this episode, we cover:
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What do adoptive and foster parents need to know about the impacts of prenatal exposure to opioids, Suboxone, and Methadone. What are the risks to a baby born with Neonatal Abstinence Syndrome or Neonatal Opioid Withdrawal Syndrome (NOWS)? We talk with Dr. Julian Davies, a pediatrician at the University of Washington’s Center for Adoption Medicine and their FASD and Prenatal Exposure Clinic.
In this episode, we cover:
Support the show (https://creatingafamily.org/donation/)
Please pardon the errors. This is an automated transcription.
Welcome, everyone to Creating a Family Talk about Adoption and Foster Care. I am Dawn Davenport. I'm the host of this show, but I'm also the executive director at Creating a Family. You can find all of our resources and we have lots of resources on this topic, and you can find them at our website CreatingaFamily.org. Today we're going to be talking about the impact of opiates, methadone, Suboxone and other common drugs, prenatal exposure to the impact of these drugs on fetuses, and later on children. We're going to be talking with Dr. Julian Davies. He is a pediatrician at the University of Washington's center for adoption medicine, and their FASD and prenatal exposure clinic. Welcome Dr. Davies, to creating a family.
Hello, it's nice to be back.
All right, let's start we're going to be focusing today primarily on opiates, methadone and Suboxone, but we're going to touch on other common drugs for what we'll talk about the reason we're going to touch on other drugs as well. But let's start by talking about what are opiates both what are their street names? And what are the legal and illegal opiates that we might know?
You bet. And there's actually, you know, two different terms that get used sometimes interchangeably with this topic, though, although they're a little bit different. So the opiates, generally referred to the natural opioids, ones that are derived from natural products like heroin, or morphine or codeine, those are opiates, and opioids is the broader category. And that's you'll see that in use more now, because it pulls in the semi synthetic and synthetic opioids that like fentanyl, and booper, no friend and things like that. So the kind of umbrella term is opioids, and then opiates are some of the substances under that.
Yeah, I'm so glad you made that distinction, because it is not always clear. The difference. Okay, so what are some of those? And how would we, what are some of the names that we would have heard them?
Sure. I mean, certainly, you've heard of kind of street drugs such as heroin, and certainly prescription pain relievers can be used or, you know, misused, you know, an oxycodone, hydrocodone coding morphine, you've heard about some of the more powerful synthetic opioids like fentanyl, and then there's also the kind of prescription drugs used for opiate maintenance therapies, and that'd be like methadone and buprenorphine, sometimes known as Suboxone or subutex.
Yeah, they're used for more for treatments. Okay. And we'll talk about that in a minute. Okay, so, and all of these are the more common opioids that would be used during pregnancy then, or do you see some being used more than others?
No, I mean, we see the mix. There's definitely been a rise in the sort of misuse of prescription pain relievers, and that's contributed a lot to the dramatic increases in rates of opioid exposures during pregnancy and neonatal abstinence syndrome. Okay.
So now let's talk about non opiate or non opioid drugs that are being used by pregnant women. What are some of the more common ones that you see from women using during pregnancy that are impacting their fetuses and children?
Yeah, you bet. So the general category of substance use during pregnancy includes things that can be legal right so tobacco or nicotine products, alcohol in some states, including mine, cannabis products, THC, and so on. So legal for some, then there's their prescription drugs use and also misuse, right. And we've talked about the opioids and painkillers, but also said sedatives, stimulants, psychiatric medications, those can be things that fetuses are exposed to. And then you got your generally illegal drugs, illegal use of stimulants such as cocaine, amphetamines, methamphetamines, ecstasy, or MDMA. hallucinogens and in some states, the cannabis products, okay. Now there's other more obscure ones, but those are the ones that we you know, we see.
Yeah, common, the more common ones, right. Okay. So what are the common treatment medications or drugs that are given to those struggling with addiction, addiction to opioids? Who are and they're trying to get off the opioids?
Sure. So the one that folks are probably quite familiar with is methadone, right. That was one of the original prescription medications used to treat opioid use disorder. And methadone is what's called a set schedule to controlled substance. So it's just harder to access, right? It's only certain centers can prescribe it, there's a certain amount of monitoring and and we'll talk about some potential disadvantages when it comes to its use in pregnancy. What I think folks will encounter a lot more these days are the medications that are based on buprenorphine. And buprenorphine by itself is called subutex. The brand name but also folks will see a lot of Suboxone, which is a combination of Lupron orphan and the law And those are what are called scheduled to medicines. So they basically can be prescribed by more doctors who have been trained and certified and gotten sort of a waiver to prescribe those to treat opioid use disorder.
So, okay, so it so we would use what would be the correct with methadone and Suboxone be correct to use when describing these?
Yeah, absolutely. I mean, those, those are definitely more common medications given to pregnant women that have opioid use disorders. And kind of the difference is that methadone results in heroin like effects, but it has a really long half life, right. So it typically prevents withdrawal symptoms if you're receiving a daily dose. So that's that's the advantage of methadone over use of shorter acting opioids. And what's been great about the buprenorphine products is that it can prevent withdrawal symptoms, but doesn't produce as much of a high are sort of euphoric effects. And, and so the first one that was released was buprenorphine by itself, which is the subutex kind of a dissolving medicine. But, you know, some folks figured out ways to abuse subutex variously and so they developed Suboxone, which combines the Bluefin orphan with Naloxone to sort of deter abuse. And what's cool about Naloxone is it sort of blocks the effects of the opioid, the opioids, which prevents it's misused, to get high, basically. And so that's why you'll you'll see a lot of Suboxone being used over subutex. Well, I
think you may have answered it, but how does how does? How do either of these medications help with addiction? It sounds like that in some way? Well, let me just ask that, how are they helping? Why are they prescribed as a treatment for addiction? Right?
Right. What we want is sort of a steadier maintenance therapy, rather than sort of a cycle of looking for an illicit drug and, and having your fork effects are high and then having the withdrawal symptoms. That's not ideal if for the mother, but it's also really not ideal for the developing fetus. And so particularly when it comes to pregnancy, there have been studies that show better pregnancy outcomes, if you use one of these treatment approaches. And the goal is to prevent withdrawal symptoms, prevent cravings, ideally, kind of lower the motivation to look for, you know, illicit, you know, versions of these, and they do it by having a longer half life. In the case of the methadone or buprenorphine, it's only sort of a partial, it only kind of partially matches the opioid receptors. So it kind of, you know, prevents some of the withdrawal symptoms, but it also doesn't give you as much of a high.
So methadone will also give you something of the high that you will be getting off of one of the opioids.
Yes, but my okay.
Yeah. Okay, but milder. All right. So let's talk now about some of the short and then as well as long term impacts of infants who were exposed to any of the opioids in pregnancy, and then we'll move on to talking about the differences we might see when they're using one of the treatment medications.
Yeah, anything it kind of long, long term, long term impacts.
Let's start with short and then we're going to talk about Okay, yeah, let's Yeah, let's start with short term impacts for an infant exposed to any of the opioids.
Right. So the biggest short term? Well, I mean, there's pregnancy impacts, right. So particularly with the illicit use of these medications, we can see impacts on fetal growth, we can see a higher risk of prematurity. So there can be some some some kind of pregnancy impacts. When it comes to the short term after kids are born. The main thing we're thinking about is the neonatal abstinence syndrome, or sometimes called neonatal opioid withdrawal syndrome arcserve. Now, and that one's kind of specific to the opioids that we're talking about. And neonatal abstinence syndrome is kind of generally speaking, withdrawing from substances. And those substances are usually opioids, right? That's the one that's got the much, much highest risk of having a neonatal abstinence syndrome. It's a little controversial about other substances that might also lead to withdrawal symptoms. But that's, that's the main short term issue.
So the short term issue is is the baby could be born premature, obviously, probably an increase in risk miscarriage rates, but prematurity and small birth weight, all right. Okay. And then after birth, neonatal abstinence syndrome, which is primarily meaning that the baby will be born, dependent, and will have to generally go through some form of withdrawal. And we'll, we'll swing back and talk about that in a minute. Now, let's talk about some of the long term impacts because there's been a lot of interesting research on that, on exposure prenatally to opioids,
right? And here's what's generally when really challenging about this topic. And this is gonna apply to any substance that we talk about, right? These studies are really hard to do in a way that controls for all of the other things that go into the mix, right? It's very rare to have a pregnancy where kids were only exposed to one substance, right? So poly substance exposure is so common. And it's really difficult for us to tease those out. The use of substances during pregnancy carries other risks, right, poor prenatal care, nutrition, maternal mental health influences, other things that are going to impact the pregnancy, the impacts of these substances on fetal growth or prematurity? Well, being born small and premature, has its own risks, right. And then, of course, after you're born, all the sort of childhood experiences and caregiving experiences and life experiences that you're going to have, if you have parents with substance use disorders, you know, you, you know, are in a lot of situations, you know, at a disadvantage in terms of childhood experiences. And those researchers have tried really hard, right, and they do their best to control for those things. Sometimes they'll look at twin studies, sometimes they'll look at foster care and adoption studies, which is really relevant to what we're thinking about here. But, but it's tough, right? And so, for most of these substances, there's a lot of I don't really know, you know, we see signs of this, but other studies disagree sort of stuff. So that's like the, my usual big caveat about this, this topic, right? It's
That said, having said that,
the opioids, you know, have been linked to a variety of risks. But among the prenatal substance exposures, it's the one where there's been a lot of variability in terms of what the substance what the different studies See, right. Some studies have shown maybe some some neuro behavioral challenges, kind of challenging behaviors, slight risk of ADHD sort of stuff, perhaps some sort of cognitive impacts in terms of somewhat lower scores on early childhood problem solving skills, and so on, and maybe lower academic achievement, maybe some higher, you know, risks of of needing mental health supports in childhood. But some studies have not found the same outcomes. And what's really encouraging to me as an adoption and foster care doc, is that in particular, the studies that looked at kids that were fostered or adopted at birth, really have had better outcomes in that, you know, there was one study from Canada that looks at kids who are prenatally exposed, and they were adopted at birth and fall it out into adolescence. And really, when it comes to their cognitive abilities, and their academic achievement, and so on, they were doing fairly equivalently compared to kids that weren't exposed to opioids, there was a little bit higher risk of depression in that study. And it's, you know, it's not clear if that was the opioid itself or other factors, but they are a
genetic predisposition, or Yeah, it's hard to tell
exactly. Or adoptive parents, understandably, and probably wisely have a lower threshold to seek mental health evaluations, right? You know, so lots of things to do that. But But really, a number of studies have suggested protective effects of foster and adoptive care when it comes to opioids. And that may be some of the risks with the opioids are sort of, you know, influenced then by your caregiving after you're born both, you might be at higher risk for impacts from less ideal caregiving. And also, there's a protective, you know, benefit from better caregiving. So that's, that's my optimistic read of the literature about opioids.
And these babies, certainly been followed for a while. So it's not like this is a brand new area of research. The crisis may be at a peak now, but it's certainly been been growing. And so they've been able to follow these children through research, at least through
right. And the only thing that sort of tricky here is that they've kind of followed kids on sort of the older school versions of these opioids, but we don't have very long term stuff, for example, on Suboxone, or the blueprint orphan type of medications, it appears that at least in the earlier studies, that to have been reliably maintained during pregnancy on something like Suboxone is likely to lead to better pregnancy outcomes, maybe a lower risk of withdrawal compared to methadone, and maybe better, you know, neurodevelopmental outcomes, but that that research is younger, right? So we don't have kind of teenage outcome studies on that.
So let's talk about so we know that if that it makes sense to think about somebody who is abusing opioids in the wild, so to speak, and is not being treated that there going to be a lot more variations, a lot more highs, literally and figuratively and lows both. And so what what's being with one of the med treatment medications methadone or Suboxone is that it even things out. So in theory, you would think okay, so the the Mom, as well as the fetus are not experiencing the highs and the lows. Does that hold out? Let's see. You've just mentioned Suboxone. And so it's there is some expectation that perhaps it will although it is a drug that hasn't been studied as long and in the impact of prenatal exposure, what about methadone?
Right. You know, it's been hard to draw a strong distinction between the long term impacts of prenatal methadone exposure to the to the use of other opioids. I think it's generally favorable. And it's definitely standard of care and pregnancy to prefer something like methadone, compared to, as you said, the sort of more unstructured unsupervised, you know, use of illicit opioids. So, I would say the literature suggests that maybe the outcomes are maybe going to be better with with methadone, and that is generally preferred.
Does the dosage of either methadone or Suboxone have an effect on the baby and on the outcome of impact of the baby on the baby?
It's not clear that it does. And I'm not saying that it doesn't. Right. But I think what's really felt to be most important by the folks that are managing those pregnancies is that the treatment of maternal substance use disorder is effective and consistent. So I would prefer the effective dose of you know, of this medicine and not worry as much about, you know, the precise amount, at least when it comes to neonatal abstinence syndrome, or the opioid withdrawal syndrome at birth. There's so many variables that go into, you know, if you're going to have it and how long it lasts, and it's not entirely clear that the dose, for example of methadone dramatically influences the risk of neonatal abstinence syndrome. Interesting.
All right. And between the two, I think I know the answer from what you've said before, but between the two, is there a difference in neonatal abstinence syndrome if the mom was on methadone or Suboxone?
You know, we are the literature is kind of promising and and pushing the OBS in the direction of the buprenorphine, Suboxone type of type of medications away from methadone. I wouldn't say it's definitive yet. But it does seem that both the pregnancy outcomes and the and the risk of and duration of the needle absent syndrome is probably better with Suboxone type medicine than methadone.
So a mom who has a baby who is exposed to a treatment level of either of these drugs, let's say methadone To start with, will that baby still have the risk of being born dependent?
Going through an absolutely, yeah, no, the rates of having an NES or no Ws is is is variable, but generally pretty high in in studies that look at kids exposed to any organoids in utero. And and so the chances of having that abstinence syndrome or that withdrawal syndrome, about 50 to 80%. If there is prenatal opioid exposure, and what goes into the timing of it sort of depends on the half life of the substance that you're using. And what if what do you mean by that? So if the infant was exposed to something like heroin, which has a short half life, then generally withdrawal signs are going to begin within maybe 24 hours of birth, where as if the child has been exposed to methadone or buprenorphine, which have our longer acting, the withdrawal symptoms are delayed, right, and they might show up somewhere between 24 to 72 hours after birth, right. And for any opioid, sometimes the symptoms of withdrawal are delayed up to four or five days. So the general recommendation is that if kids been exposed to opioids of any kind, that you really want to have sort of a minimum hospital stay so that they can be observed for signs of withdrawal. And different nurseries will have different policies, but that minimum stay, I would say would be, you know, somewhere between three to five or seven days, you know, it depends on the substance. But if you know that the child was exposed to one of the longer acting ones like methadone or Suboxone, really keeping them ideally at least four to five days would be would be wise.
And because methadone has a longer Half Life, does that mean that the baby will go through withdrawal are in a s or in our nows and no Ws? for a longer period of time?
Yes. Generally speaking, and again, there's a lot of unpredictable variables. But yes.
Okay. I think there's a myth out there that if if the mom has been on a treatment drug, that the the baby will not be born independent, and that simply is not the case.
Right, right. Yeah, they they're at least are at risk of withdrawal symptoms and ones that take, you know, maybe a couple days to show up. Okay.
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There doesn't seem to be a classic neonatal withdrawal syndrome or neonatal abstinence syndrome, which is not to say that kids can't be born with sort of similar symptoms. But what's controversial in this field is what is withdrawing from a substance versus what's the toxic impact of a substance, or what's maybe seeing impact that that substance had on the developing brain. So not sure it would be considered withdrawal symptoms, but but, you know, kids can be, you know, more challenging, you know, in the infancy period when they've been prenatally exposed to stimulants like speed or methamphetamines.
And the is that also for the same type of period of time that we talk about the impact of na, S and AWS? Are is that do you mean longer?
I mean, longer. And what's challenging about math, and this gets to kind of what you talked about the opioids had been here, right? And meth is not brand new, but relatively newer in terms of how common its uses, especially in certain states. So our research around this sort of long term impacts of prenatal methamphetamine exposure is not there yet. Right. And so we've got some studies that have followed kids up to early school age. And what those two have shown is maybe some more challenging, kind of acting out behaviors, maybe some higher levels of parenting stress, as a result, sometimes more difficult to sort of manage as infants and toddlers, but we really don't have what I'm dying to have, which is data on the developmental impacts on, you know, memory, language, intelligence, academic achievement, and so on. We don't know yet and what's there isn't horrible. You know, it's it's not seeming, you know, as scary perhaps has some other prenatal substances like heavy prenatal alcohol exposure, but we just we don't have it yet. And if I had to guess as a condition, it might end up in sort of the same category as other stimulants like cocaine, for example, where there are impacts but probably more in the mild to moderate gene less likely to be in the severe neurodevelopmental disability range. But we just don't know yet because the research isn't there yet.
Yeah. And, and there's no way to we just have to wait and continue to follow those kids. That's all we can do.
And funded. You know, it's funny, I
reached out to
this group, there's this big group called the ideal study, and it was multicenter it looked at, you know, and it was tracking kids, and they were publishing lots of stuff. And then it's been, at least as far as I can tell crickets for the past couple years. And it was just when the kids were getting school age where you could do that testing. So yeah, I want to know, did did that study run out of money to do this sort of expensive IQ and other testing? Or have they done it? And they're just like, packaging it up to just release it to the world? Like I'm dying? Oh, no, but
I wish I could tell you I know of that study, because I've have also fallen in the past. I darn I don't know. And we surely that would be so. Oh, that'd be so frustrating. Yeah.
It'd be totally irresponsible. Yeah, no. And I did email one of the authors, but you know, he's a busy guy. I haven't heard back, but I hope to see more from them. Yeah, I
hope so. Let me know if you hear because I would love to reward on it when they when it comes out. salutely. All right. Now let's talk about marijuana or cannabis. That's an interesting thing, because as you point out, you're in Washington State. It's legal there. It's illegal in many states and I suspect within the coming next short term, it will be illegal and even more states and as a result, we are certainly seeing it's almost become it's like it's the okay drug for pregnant women to use and maybe we preach so much about alcohol. And this one seems like it's not getting the same. This one Marijuana is not getting the same attention in the at least in the common press from the from dangerous. And so let's talk about is marijuana dangerous? Yeah, in pregnancy?
It appears to be. And and I agree with you Yes. I mean, we know that the rates of you know, prenatal THC and cannabis exposure are going up right with legalization and also this kind of perception that it's natural, right. And this whole, like health halo around CBD treats everything. I mean, there's so much hype around cannabis derived products, most of it like not really supported by, you know, research, but you know, it's it's a booming industry, with lots of marketing and and and what we know, with those same caveats I mentioned upfront about how difficult it is to do high quality research. We do know that with cannabis products, that it has maybe a modest impact on fetal growth. There might be some subtle infant neuro behavioral effects. And what I mean by neuro behavioral effects is just kind of, you know, what are perceived as Foster, you're challenging babies, right? They may not smoothly move between sleep and alert and a little hungry, and you feed them and they go back, no more kind of jagad, you know, moves between, you know, sleep and awake and fussy and harder to console sorts of stuff. So we see some subtle impacts like that, as you follow kids out to school age with prenatal cannabis exposures, there is some subtle, increased risk of ADHD or delinquency type of behaviors, the sort of bigger category of issues that might be the impact of cannabis is what are called the higher level executive skills deficits. Right. And those executive skills are your sort of Planning Organization, checking your work, making the right choice, you know, they're the things that develop in our particularly are teens and 20s. And
learning from cause and effect, things like that. Yeah. Yeah.
Yeah. So executive skills impacts might be a sort of bigger area of cannabis impact. And there's a study that came out in the past year or two, that's, you know, preliminary, but it's a little concerning, because it showed a higher risk of autism spectrum disorders in kids who are prenatally exposed to cannabis versus not. And that's not definitive. That's one study, but it was sort of a safety signal that was concerning to a lot of folks.
Was it a pretty large study? How many was it tracking a
I'd have to dig it up. But I, you know, it's one of those kind of chart review studies that looked at lots of kids and looked at diagnoses of autism. So it wasn't like following a small group of kids. But you know, it was a larger group that way. So, right, but you're right, people use it because they perceive that it's natural. They're sort of wanting to self treat anxiety. They're using it for nausea and vomiting of pregnancy.
Oh, honestly, what I hear is that we like I can't drink it's, you know, I've got to have some fun. And that type of pros, you know, I'm, I'm doing the right thing I'm not drinking. So yeah, yeah. And are the impacts of marijuana different from those that you would see from tobacco? May both being inhaled substances? Is there a difference? Because you mean, we certainly know that babies whose mom's smoke tend to be smaller in birthweight and we seeing a bit but the impact from cannabis is different. Yeah,
good point about how you use this stuff because how you use these products is really multiplied right and and on the cannabis side, there's edibles there's vaping there's dabbing. There's you know, all of these things and and also for the tobacco products, too. There's been an explosion of vaping and we don't have great data yet about you know, all that stuff that's in vape juice and how that might affect a pregnancy but you are right the in general, tobacco and cannabis products seem seem to be different. You're right that tobacco has a bigger impact on birth weight. Tobacco can can also increase the rates of spontaneous abortions or late fetal deaths or prematurity. There's definitely an increased risk of SIDS crib death with premium tobacco exposures maybe with ear infections and asthma but not
that but you don't see this in marijuana exposure
less so lesser impact on growth at least and since since I don't have great data about I'd be more worried about it with with tobacco though. Gotcha.
And okay, so that you had alluded to this but I didn't think I'm not sure I got the answer. It there are so many different ways to imbibe in cannabis products. Do you see a difference between edibles versus smoking or vaping
I'm not enough to confidently I wouldn't recommend either I mean you can you can think that with edible you might avoid some of the harms associated with you know burning leaf right and and all the other compounds that get released when you you know, smoke it but yeah, but I so perhaps an edible would be safer, but still, those impacts from even THC could be could be notable.
Right so it's the THC that gets in your blood regardless of whether it gets in through your stomach are through Your lungs, right? Okay. So does the timing of exposure and pregnancy affect the prognosis for the child a long term? Well, in short term, the child's birth weight, propensity towards withdrawal, and as in AWS and AWS, is there a safer time for a fetus to be exposed to drugs in pregnancy?
That's really hard to say. Generally speaking, when we think about, you know, how the fetus develops, those first three months are about, you know, organ systems forming and cells getting to where they need to be, and sort of laying the template. And there's like a big deal. trimesters. Yeah. Big deal. Big deal, right? So if you if you're talking about something that has, that's a term Ratigan like alcohol, right, that has the ability to damage those structures as they're being formed, then yes, the first trimester is the riskiest period for something like alcohol. The second and third trimester being more about growth, and further development and migration stuff. But there's a lot of growing that happens there. You know, the other kind of question is for some of these substances, well, when do the receptors even develop in the fetal brain to be impacted by these things? So I think it depends on whether you're talking about a substance that's a tragedy and causes birth defects, versus something that can have maybe more subtle impacts on the developing nervous system. So for alcohol, I'd said first trimester is riskiest, second and third trimester not good either. Right. But, um, but with the other substances. I would say that, particularly when we're talking about the opioids, you know, that as the closer you get to delivery, right, the higher the chances are, you're going to have withdrawal symptoms, right, if there'd been some opioid use in second trimester, but none during third. And of course, the question is, how reliably Do you know that right, but if there really was no opioids recently before delivery, then your risk of the withdrawal symptoms goes down?
A lot? Yeah. But in some way, isn't the witness the fetus also, then? Maybe this is a dumb question, but it seems like the fetus would still be withdrawal drawing, you just wouldn't see it because it would be in utero? I mean, it would. Does that make sense? I mean, there's still the fetus is coming off of having been, you know, withdrawal is having is the with whispers the removal of a substance that your body has become dependent upon. So wouldn't the baby still be experiencing it? But just you don't happen to notice it?
Maybe? And the reason I'm complicating it is this is there's this kind of odd fact when it comes to neonatal abstinence syndrome, which is that preemies are at lower risk of neonatal abstinence syndrome compared to term infants. So the more premium they are, the lower the at least the symptoms of varities are. What we don't know is is is that because our symptom scales were developed for term infants, and it's happening for the preemies, it just looks different, or we're not seeing it, right. So that's possible. But also, it may be that the receptors in the brain, you know, aren't as detailed or as sensitive, maybe, you know, they have less fat, so there's less fat deposition of the substance, maybe they haven't been exposed as long Of course, you know, if you come out early versus term, so we're not sure why premiums have lower rates of na s, but they do so. So that's that kind of complicates the knowing how impactful with withdraw and the you know, second, early third trimester would be for the fetus.
That's fascinating. Okay, so many parents believe that if in fact that it seems to be almost universal belief, it when people we talk with that they've the, if the child is not born dependent, or does not have drugs in their system, it's not going through na s are announced that the long term prognosis is better, that they will have fewer impacts from the drug exposure is this trip?
I'm honestly, I'm not sure that it is. I mean, there are you can you can think of, you know, the symptoms of the, you know, absence syndrome is being destroyed, distressing. And that's kind of potentially impactful for the newborn. Right. And and, you know, what I'd say to that, is that because of the explosion in the rates of this, you know, nursery staff, generally these days are fairly sensitive to what to look for. Most nurseries have protocols in place where they're monitoring for those symptoms. So I think if we're treating, and they asked her now's appropriately, you know, we'll talk about that, that I think hopefully, we can mitigate some of those impacts on the baby. So I think I would say that I'm not necessarily reassured by the absence of neonatal abstinence syndrome, if we know that there was significant pregnancy substance exposure, just earlier,
see, seems to me, all it means is that the baby was not exposed within the month or so prior to birth. And that doesn't say anything about the degree of exposure before that, right. Yeah, so it seems like it's all it's telling you is that for whatever reason, in the last month or so, the mom was Not using Yeah. Are was head reduced? Yes, you bet. And it could simply be, yeah, she was in jail, or she was in a treatment program or something. And it doesn't tell you anything before that. Yeah. So how serious, it's it's hard to witness a child going through withdrawal and as nails. But how serious is it for the child?
I mean, if it's, especially if it's if it's not recognized, as such, you know, can be serious. I mean, the this terms, which we'll talk about in a minute can be can be quite significant for the baby. And there can be some other neurological things that go along with it. Some studies have suggested you can see seizures, maybe in about two to 10% of kids who are having neonatal abstinence syndrome. If you put ecgs, you know, looking at brain electrical activity on babies, about 30% of eg changes, right. The other thing that's serious about it is how long it can last, right, and it can last kind of days, two weeks, depending on the again, the half life of the opioid that was being used, and also how it's being managed, and how well it's being managed by the nursery staff.
Well, you know, this seems it's easy to say, Well, this is not a big impact. But it is hard to parent, a child going through this, it's and and that puts additional stress on parents. And so that can impact a baby with parents who are getting no sleep at all, and are not able to be able to comfort that that inability to be able to help your child calm and soothe undermines your confidence, especially if you don't know the reason that you're not being successful. So all of that has an impact.
Yes, and that's why a lot of that sort of nursery approaches here do involve kind of caregiver education, and kind of, you know, teach teaching how to recognize you know, the symptoms and how to respond in a sensitive and kind of ideally matched to that baby and their kind of sensory needs. So yeah, so so so teaching is a big, big part of that.
So how do we treat children it got children and infants who are experiencing na s or now's
right. You know, the first big push is recognition, right? So when it comes to the symptoms of neonatal abstinence syndrome, there's a couple of categories that are being looked at right and and so we can see kids with sleep and wake difficulties, you know, difficulties sleeping for longer than an hour sort of bouncing in and out of sleep. They can have motor or muscle tone differences, right. So they can be stiffer, they can have very kind of prominent startle and other kind of infant primitive reflexes, they can have tremors, and sometimes the tremors can be bad enough that the skin kind of gets raw and they have to use diaper. And other very augments to protect the skin from the tremors. There can be irritability and high pitched cry, and just difficulty consoling the infant within a certain amount of time. Feeding difficulties like coordinating, sucking and swallowing and being having some oral sensitivities are common. And then some gi symptoms like gassiness, or vomiting or loose stools are common. And the other thing that the nursery is definitely looking for is what's called autonomic dysfunction. And that's like sweating, or having trouble keeping your temperature in range, or sneezing or nasal stuffiness or yawning, or these other signs. So these symptoms have scoring systems that have been developed, that can can sort of monitor them and put a number to them and help the team make decisions about, you know, what level of care does this kidney?
So what are the treatment options there? Yeah, at that point, right.
So being aware of monitoring, tracking the symptoms, and then you know, depending on the level of the symptoms, generally the preferences for non medication or non pharmacological care, right, and, and those are individualized for the baby and what their sensitivities seem to be, but the general things that seem to help are sort of reducing stimulation overall, right? So we try to, you know, be in the hospitals terrible, like, interruptions and beeps and bloops and getting checked and having your temperature checked and changing your diaper, right. If you've been in the hospital, you know, it's the least stressful place, you know, there is right? So we try to cluster infant care, right, and assessments around feeding times where they're already sort of awake and then really let them have some uninterrupted time, right? We try to keep kids off monitors that beep and alarm unless you know there are if there are morphine therapy, you know, you have to kind of monitor their oxygen and, you know, heart rate levels, but otherwise, try and get them off monitors if it's safe to do so right. turn down the lights, reduce stimulation, have them be in a quieter room, you know, because of the stiffness and the motor movements in the tremors some swaddling techniques Some rocking techniques to help kids kind of the sensory issues there. And then of course, the big push is to involve caregivers in in a healthy sort of way. Right. And that, you know, whether it's the birth parents or the adoptive parents, really we want rooming in, right? You don't put the kid in the special care nursery, or the newborn ICU unless they need that level of monitoring, right? Have them in a quieter, calmer room with the parents, teaching those parents about those ways to not overstimulate the kid to swaddle and rock them, the use of skin to skin care, the use of breastfeeding if it's available and safe to do so. Those sorts of kind of more parent dyad related measures are useful. So that's kind of the spectrum of non medication
treatments. And so how many, what percentage of children have to go on medication?
You know, that depends on the the center and I, I'd have to look it up. But what it is, is you start with the sort of non pharmacological measures. And then if if, if the scores are either so high to begin with, or they're not responding to the non pharmacological measures, some centers will do at least a one time morphine dose to see if it helps, so sort of do a trial of it. And if there's a substantial improvement, or if that child really has high enough symptoms, then yeah, generally, centers will use liquid morphine and do a sort of tapering approach where they're adjusting the dose of the medicine in response to the to the symptoms.
So they start with morphine. And how is the morphine administered?
orally, typically, as elicit, yeah,
so they will be giving in, they would be gradually reducing it, depending on so that the baby suffers less during this period of time.
Exactly. Yeah. And you were asking about, you know, who needed morphine. You know, there's a local on a couple of local hospitals that just did an initiative, that kind of quality improvement project that really worked on training on all those non pharmacological methods. And they also shifted from an old scoring system called the Finnegan scoring system to something called the eat sleep console protocol, which is sort of simpler and honestly more caregiver friendly, right? Because we want caregivers to be aware of these. And so it's really kind of simplifies into how well is this child eating? Can they sleep more than an hour? And can you console them within a certain amount of time, like 10 minutes or so right? And you get, it's a simpler scoring system. And so when they did this whole training, and they switched to the ESC protocol, they found that the average length of hospital stay went down from nine to six days. And the morphine use for these local hospitals went from 57% to 23%. Right. So they cut that more than in half. Yeah. Um, so that's an example of what what some of those Yeah, interventions can do. And roughly what the morphine uses.
A practical question we often will get is families that are adopting at a state and they're concerned about how soon they're going to be able to travel home with their baby, if she has been born dependent, and is going through withdrawal. So what what what can we advise those parents of knowing, first of all, that they can't know going in, because they don't know how their baby is going to be? So they won't know going in? But what are some of the information you could give them that will help give them an idea?
Right? I mean, definitely pack for a longer stay, right, some some of the older, you know, literature around this dis, you know, discusses hospital stays of up to several weeks. Right. And that's not as commonly how it's done. Again, with those better approaches, you can get the hospital stay down to maybe under a week. Generally, kids are not going to go to adoptive parents care still on morphine, right, we want to get them off of the substances. For kids that need a longer taper. Sometimes kids will get discharged from the hospital to sort of an interim Care Center where it's like a special care nursery with super savvy staff who deal with this with the sort of more prolonged neonatal abstinence syndrome. So I do have some babies that go from hospital to interim care to adoptive parents. But yeah, I mean, pack for days to a few weeks. And ideally, try to make plans ahead of time with the care team and the birth parent, you know, through the adoption agency, about what's going to be allowed as far as rooming in with the baby. And, you know, try to set up a way that the adoptive parents can really be in the hospital as much as possible in room with the baby as much as possible, getting teachers from the nursing and staff as much as possible. Because we know that that's one of the big parts of the non med, you know, non medication care is caregiver training, rooming in skin to skin and so on.
So how long does withdrawal and an infant born dependent last?
Again, you know, days days to a few weeks is is how I think of it. Okay.
So if a baby test positive, or or we see that the baby is going through withdrawal, is it possible to determine what drug the baby was born exposed to? Is there a blood test? That can be right? I mean, assuming that you're not able to get the information.
Yeah, it depends a drug testing is tough, right? Because every lab has their own panel of tests. Right. So your standard opioid screening tests are typically going to be detecting morphine, which is a metabolite of heroin, codeine and all the other sort of natural opioids, but the synthetics, right, fentanyl, methadone, etc. You need specific tests for so I mean, the the drug testing companies are kind of savvy to the fact that now there's this broader range of opioids. So what you learn about what opioid it is depends on, you know, how many sub tests that the the testing company tends to do, right. And you're right, that there's ways to test it, right. There's a maternal urine drug screen, there's a infant urine drug screen, there's baby's first poop meconium, which is a way to get back earlier into pregnancy. There's umbilical blood, there's an umbilical cord tissue, which is sort of a newer approach to testing for prenatal substances. And they all have their strengths and weaknesses. And it's a little bit wild west, in that some of these aren't necessarily super FDA approved yet. They're sort of newer, you know, testing protocols.
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right. That's where those non pharmacal logical measures come in. So rooming in skin to skin being aware of those sensory over and under sensitivities, and so really being responsive is as you know, responsive and care, erring on the side of lower stimulation, and it's natural, as a parent, when your baby's fussing or having a hard time to sort of do more sort of be louder, get more eye contact going on to sort of, and sometimes that level of involvement is overstimulating. And so your contact with that child, at least during these sort of withdrawing stages, you might want to do touch only, or the soft sound of your voice only, or gentle eye contact, if that's not overwhelming to the kid. And that's where the very experienced and excellent nurses that helped manage, you know, withdrawal symptoms can be really good at kind of helping parents troubleshoot and teaching them effective swaddles and rocking techniques and so on. There are some studies that suggest improve outcomes with neonatal abstinence syndrome with with breastfeeding, which, you know, isn't going to be an option for most of our adoptive parents unless they've done a sort of adoptive parent milk stimulation protocol, which isn't very many parents, in my experience, there are some ways if adoptive mothers are interested in doing what's called site sidestream supplementation, which is where you put formula or donor breast milk in a little syringe that kind of goes to a tube at their nipple, so you can have the experience of nursing. But what's going in is is is formula or donor milk,
donor milk better than formula? So So is it the Is it the Is it the breast milk that is helping? Or is it the the act of the skin to skin touching with the breast and the baby?
It's both. And the question of donor milk is a tough one. I feel like we've done a terrible job in this country of having, you know, well run donor milk systems, right where there is sort of protocols around collecting it around testing it for substances and infectious diseases and so on. And so sort of what's out there now for for donor milk is kind of a trust base system, right? You have to trust who you're getting it from that they've collected in a proper fashion that they haven't been using substances that they don't have any infectious diseases and so on. So I think people have very varying levels of comfort with donor breast milk, and so I am fine as a pediatrician if that's not an option or adoptive parents don't choose to use donor milk. I think formula does a pretty great job at helping kids feeding grow.
Okay. So you have alluded earlier to talking about alcohol and we know that That we have many, many resources and courses on the impact of alcohol and fetal alcohol spectrum disorders. So we know it's a major traton. But one of the things is that because we have stressed so much that drinking in pregnancy is is bad and wrong, we often don't get an honest report because there's a shame a factor that you don't want to admit. So it's hard to know sometimes. But so my question is, how common in your experience is it for women who use drugs during their pregnancy to also drink excessively during their pregnancy? A poly exposure type scenario.
It's it's very common. And unfortunately, I don't have perfect statistics to share with you. But But I would say that in my experience as a kind of adoption, and foster care doc, that that, you know, if there are substances, I will generally assume that there are more than the identified substance and that, you know, things especially like alcohol, and tobacco may be cannabis that are easier to get, probably in the mix. You'll sometimes hear this sort of myth that if opioids are someone's substance of choice, that that means they don't drink, and I haven't been able to find evidence for that. I mean, I think that that, that the risk may be lower if opiates are your kind of true substance of choice, but I mean, the studies I've seen, you know, they're still substantial, you know, co occurring alcohol, you know, in those situations, so I wouldn't take that as a as reliable.
Yeah, you do hear that, that you hear that? If somebodies if the high they seek is coming from an opioid, that alcohol is not going to get them there. So it's not it doesn't whether they drink Yes, but they it's, it's more social, not to the extreme. But you're saying you that's not what you see.
Right. And that may be true, I just, you know, I don't have great evidence to say, yeah,
I've often wondered that. It's like one of those wives tale that we hear the sayings that we hear. But it's hard to know, if it's wishful thinking, one of the things that we hear a lot is that early intervention is key, and that a baby's brain can be rewired during the first couple of years, with the right therapy not being raised in a home where substance abuse is a problem, things like that. Have you seen evidence of that? And what exactly is so what exactly does that therapy entail?
Generally speaking, yes, kind of optimal parenting, you know, especially in early years, seems to lower mitigate some of the some of the impacts of prenatal substance exposures. Certainly those first three years or first five years are a critical time for brain growth, development, forming new connections and so on. And so absolutely, we want to intervene early, right. And so one of the main ways to do that is with what are called birth to three programs, which are state and federally supported programs that are sort of regionally based, right. So there'll be there'll be a birth to three center for your for where you live, right. It can be referred by your pediatrician or social worker, but honestly, you can self refer to those centers, and they'll do a screen. And you can get in based on having a delay. But also a lot of them will let you in based on a risk factor like prenatal substance exposure, right. So Birth to Three services are fantastic. And don't result in a lot of out of pocket expenses. Because there's state support for that. After age three, you can call up your school district and what's called their child find line and you can arrange for evaluations and testing if you have development or behavioral concerns, like a lot of Children's Hospital centers will have what are called high risk infant follow up clinics, again, if kids are born premature, but also if they were exposed prenatally to substances, they might be able to get into this sort of monitoring clinic that may that follows kids up until school age periodically. And so those sort of monitoring intervention programs are fantastic.
Can parents request if they know that they exist? Or they might exist? Can they request that their child be enrolled their baby?
Absolutely. Right. And the the what gets you qualified for services is going to vary based on your state and the end the center's But absolutely, prenatal substance exposure should be something that may open the door to some of these services. And if it's not, but you have behavioral developmental concerns, that that will probably get you through the door. So it
doesn't have to be at the hospital where the infant is born. It can be if you go back to your state, the baby's born of the state, you go back to your state, the local larger hospitals near you may well have such a program. Right? Okay, so you have to grow?
Absolutely, you want to discuss it with your pediatrician. There's I think there's stigma for adoptive parents too, about not wanting their child to be labeled as a child that was prenatally exposed to substances and they don't want schools to see it and so on. And I understand that but That prenatal exposure is what gets you through the door, right? Or what is unlock some of these services. And so I don't think it's helpful to hide it, I really think it's, it's, it's an important part of that, you know, that child's kind of risk, you know, whole package of risk and resilience factors. And it's important to share.
Well, and sometimes honestly, adoptive and foster parents have less stigma about identifying it, because it doesn't reflect on them. Therefore, there's less hesitancy. On the other hand, they are aware that just about anything that goes in your child's file will follow them throughout their school years. And so there's a concern there. So you're correct. You know, there are similarities between the impact of prenatal drug exposure, and the impact of early life trauma, and how it affects children to learning and behavior and things such as that. When a child has both of those challenges, is it possible to tell the difference? So what is causing this specific problem? Is it? Is it because the child was prenatally exposed? Or is it because the child experienced trauma? And that was removed from their home? You know, at the age of 18? months? Do we know that is how do we tell and is a treatment? It doesn't really matter? Because the treatment is a different?
Oh, boy, that is such a good question. And I really don't think we are able to really disentangle those. Right? Because, you know, you can even imagine, you know, the things that go along with prenatal substance exposures can involve a certain amount of what's considered kind of trauma during prep. Sure.
Well, I mean, prenatal exposure is trauma. I know I'm right. That to me, like that is a form of trauma. But I did mean, other forms of trauma, you know, ya know, in an island,
you're born, you know, absolutely, those things, unfortunately, tend to go together, there's that synergy between parents using substances and neglect or other adverse childhood experiences. And yes, I mean, the rates of kids entering the foster care system, because of parent or substance use disorders is rising, you know, certain significantly, so. So they're really difficult to disentangle because we're honestly still kind of struggling to arrive at, you know, a consensus definition of what is developmental trauma disorder, or complex trauma, right? We tried to get it into the DSM five, you know, the manual for psychologists and psychiatrists and didn't really succeed with the last addition. Right. So I, you know, and because these sort of symptoms in terms of behaviors, and also impacts on learning and cognition, because you can get those from trauma, they overlap so much that, yeah, I don't feel as a clinician, that I can tease them apart. And the I think you since you need to individualize the approaches to you know, that child's profile has strengths and weaknesses. I think with my patients, I'm generally trying to individualize their developmental supports, right to their unique profile strengths and weaknesses. And yeah, when it comes to therapy, I definitely want trauma informed and, you know, attachment informed, you know, therapies that that, you know, if there is a history of trauma. Yeah, absolutely. That we're trying to do evidence based therapies there, too.
That's a great question.
Yeah, it's, it's, as you point out, so many of our kids have both. So it's Yeah. So this is a question we get very often are children who are exposed prenatally at greater risk for drug abuse as teens and adults, if they were adopted, and not raised in an environment that exposed them to drug use?
The answer is vaguely Yes, there appears to be an interaction between maybe some of the genetic vulnerabilities that come with having birth parents that were, you know, had substance use disorders, as well as the being exposed to it in utero sort of developing a taste for it, I'm oversimplifying it, but those risks appear to interact with each other. And and, and so I generally do think of kids who are exposed prenatally as being an increased personal risk for substance use disorders later. And so what I'm trying to do with my adoptive families is to, you know, have developmentally appropriate education about the risks of substance use, you know, starting at an early age and have adoptive parents be kind of mindful about, you know, the modeling that they do around use of substances in the home and so on. And it's definitely not guaranteed that that child is going to have an issue, but I do think of them as at higher risk
at a higher risk. The good news is if we know our children are at higher risk, we could start educating early and on that risk, and so that is, it's you know, it's it's not like they, they that you aren't that at a very early age, you can be talking about the fact that you are at a higher risk.
Right, right. And with younger kids, sometimes we use the sort of allergic to alcohol or allergic to substances, which is an oversight, not exactly exactly how it works, but it makes sense to younger school aged kids. Sure. They've all got classmates with allergies to things. And then when they go older than Yeah, they can explore their kind of birth family history a little bit more and understand just the complexity of risk a little bit better. But
so my last question is that, and this is not so much drug related specifically, but we know that a moms who use injectable drugs, legal or illegal, but particularly if they're it's illegal, are at higher risk for certain blood borne diseases such as hep B and Hep C, hepatitis B and hepatitis C. Is that true? So do our children whose moms were injecting their drugs of choice? Are they are the moms at higher risk for hepatitis B, or C? And if so, what are the odds that the baby will be at risk?
Yeah. So yes, they are at higher risk to have you know, hepatitis B, or C, or HIV, or those other kinds of infections that are at higher risk with IV drug use. But the good news is, is that the risk to the baby is actually still quite low, right? The obese are generally going to be testing for those things in the birth mothers. And so if, for example, with hepatitis B, if we know that the birth mother has it, or we don't know that she doesn't, as it like, you know, showed up and hadn't had testing, then generally we're going to give that baby their first hepatitis B vaccine very promptly, as well as something called immune globulin, which also lowers the risk of getting it. And in some studies, you can knock the risk down of getting Hepatitis B to as low as 1%. If you get right on both of those treatments in the in the newborn period,
and this is for a mom when the mom absolutely has it. So this is 01 percent
mom has Yeah, okay.
Yeah. And then with hepatitis C, we don't have that those. We don't have a vaccine, we don't have the immune globulin. But still, the risks of getting hepatitis C for the baby are about 5% or so. Unless the birth mother is co infected with HIV. And there the risk might be about 10% or so.
So it's relatively low. Yeah. Yellow. Okay, which is, which is good, which is good. Well, thank you so much, Dr. Julian Davies. This has been very helpful, and I think will be very informative to for so many parents. So thank you so much for talking with us today about opiates, opioids, methadone, Suboxone and prenatal exposure to those. Let me remind everyone that the views expressed in this show are those of the guests and do not necessarily reflect the position of creating a family, our partners or our underwriters. Also, keep in mind that the information given in this interview is general advice. To understand how it applies to your specific situation. You need to work with your medical professional. Hey, I have a favor to ask, please hop over to iTunes or Stitcher or whatever podcast app you are using and give us a rating. ratings are how people find us. It is how we get increased listenership that is really important to us and our mission. And we would really appreciate it doesn't take very long and the appreciation is huge. Thank you. Thanks for joining me today and I will see you next week.
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