Prenatal Exposure: Diagnosing and Treatment

Do you wonder if your child was prenatally exposed to alcohol or drugs? There may be nothing in the files, but something feels not right? We talk about diagnosing and treating these kids with Dr. Larry Burd, a professor of pediatrics at the University of North Dakota School of Medicine and the Director of the North Dakota Fetal Alcohol Syndrome Center.

In this episode, we cover:

• Most of our audience is foster, adoptive, and kinship parents and professionals. Often they don’t know for sure if a child has been exposed. The US government estimates that about 10% of all children in the US have been prenatally exposed to alcohol or drugs. Do you have a feel for the percentage of children in foster care or who have been involved with the child welfare system? International adoption? Domestic infant adoption?
• Does prenatal exposure increase the likelihood of a disruption to a foster or adoptive placement?
• How is prenatal exposure to alcohol detected or diagnosed?
• What type of training do pediatricians receive during their education or residency on prenatal exposure and on how to diagnose?
• Can you tell at birth or in infancy if a baby has been exposed to alcohol in utero?
• How is prenatal exposure to drugs detected or diagnosed?
• How does birth order change the likelihood that a child who is at risk has been exposed during pregnancy?
• What are the long-term impacts of alcohol exposure? What are the symptoms that are most noticeable to parents, teachers, and other professionals working with these children?
• Alcohol exposure affects multiple systems in the body.
• Does it matter what type of alcohol was consumed?
• Who can diagnose a child with Fetal Alcohol Spectrum Disorder?
• What are the long-term impacts of the following drugs?
  • Opioids
  • Heroin and Fentanyl
  • Depressants (benzodiazepines, such as Valium, Xanax)-Prescribed and unprescribed
  • Stimulants-Prescribed and unprescribed
  • Methamphetamines
  • Marijuana
  • Tobacco/Nicotine
• Do pediatricians have a body of resources to offer parents regarding raising a child with prenatal exposure?
• Tips for parents.

Tronick's Still Face Experiment

Transcript

Please pardon any errors, this is an automated transcript.
Dawn Davenport  0:00  
This is Creating a Family. Talk about foster, adoptive and kinship care. Welcome back to our regular listeners. We couldn't be here without you. So thank you, and a special shout out to our new listeners. We truly, truly appreciate it, and we hope you'll come back next week. I'm Dawn Davenport. I am the host of this show, as well as the director of the nonprofit creating a family.org Today, we're going to be talking about prenatal exposure, diagnosing and treating. This is a topic that for some of you astute listeners, will realize that creating a family is spending more time discussing and providing more resources for it is a topic that is prevalent in the world of adoption, foster and kinship care, and I don't think we discuss it enough, and I don't think there are enough resources that are available to parents and caregivers. So today we are remedying that. We will be discussing diagnosing and treating, which are particularly difficult topics, they're complex, and we're going to be talking with somebody who could truly help us understand and that is Dr Larry Burd. He is a Professor of Pediatrics at the University of North Dakota School of Medicine, and he is the director of the North Dakota Fetal Alcohol Syndrome Center. He is a terrific guest. This is a re air of a show we did a year or so ago. It was very good then, and it's going to be very good now. So enjoy prenatal exposure. Let me just start by saying can be to alcohol or drugs, and the drugs can be both legal and illegal, and quite frankly, often children are exposed to both. In this discussion, we're going to be trying as much as possible to be inclusive of all prenatal exposures, unless we specify otherwise. All right, so let me just jump in. So most of our audience is foster, adoptive and kinship parents as well as professionals, and often they don't know for sure if the child has been exposed. So the US, government estimates that about 10% of all kids in the US, children born in the US, have been prenatally exposed to alcohol and drugs. Do you have a feel for the percentage of children in foster care who have been involved with the child welfare system? Well, certainly in

Speaker 1  2:29  
foster care, prenatal exposure is very high, and I think we conceptualize that by thinking of the circumstances around this. If we had two doors, one door where children enter foster care whose parents have no substance use disorders that would be infrequently used. So the overwhelming majority of children enter foster care because their parents have substance use disorders. And I always like to refer to foster care, and I think this is appropriate as a substance use treatment program, because the overwhelming majority of parents whose children are in foster care are struggling with substance use disorders. So in answer to your question, it would be very high. Be very high thinking foster care, probably very high for many adoptions, and least in my experience, kinship care is a lot like foster care. Somebody else is raising these children because the parents have substance use disorders.

Dawn Davenport  3:40  
Yeah, the vast majority of kinship parents have stepped in because of, at least tangentially, substance abuse, disorder, mental illness as well. But, but oftentimes that's has, it's their substances involved is as well. Do you have a feel for international adoption? Of course, that depends a lot on the country, but from what you see, what it would be the percentages, or how high would it be prenatal exposure and international adoptions?

Speaker 1  4:09  
I think again, it depends part on where the children are from. But surely, if your child is from Eastern Europe or in that general area, then the rate of prenatal alcohol exposure is very high, might well exceed 40, 60% of course, it's very difficult to document that, because the children are separate, separated from their records. They're separated from their the historians, people who could tell us about this, but it's very high,

Dawn Davenport  4:43  
and I will throw out that South Korea, we see acknowledgement of alcohol use, not infrequently, in the referrals that come from South Korea. What about domestic infant adoption, where families are not working through a public agency? The birth parents or birth mother has made a placement on her own for a domestic infant.

Speaker 1  5:06  
You know, that's more complicated, and I probably don't have a good feel for that, except to say that where there's difficulty with children, substance use is very prominent, and so for moms who, for whatever reason, have decided that adoption is the best course of action for them and their child, I think that these poly substance exposures would be quite common

Dawn Davenport  5:39  
going back to foster or adoptive placements. Do you think that prenatal exposure increases the likelihood of a disruption of a placement of either a foster or an adoptive placement?

Speaker 1  5:51  
Yes. So in our clinical setting, in fact, yesterday, I saw one of these very children, if you look at the children who have the highest number of adverse childhood experiences, who have the highest number of placements, the majority of those children, pretty substantial majority, have a fetal alcohol spectrum disorder. Now, often they were exposed to other substances, but the predominant clinical finding is that of Fetal Alcohol Spectrum Disorders Not to be labor this point. But So yesterday, I saw a child with 23 foster care placements who was nine. The record at our center is 31 and the reason for these placements is that children exhibit a pattern of difficulties over and over and over again to make it difficult for them to stay in these homes, two really prominent problems are sleep disturbance. Sleep a couple hours get up, and very few adults can take that kind of schedule. So after a while, the foster parents just no longer can function, and you need a new placement? Well, the foster care system is so overwhelmed, so over stressed right now across the United States that they don't have a way to pick an optimal placement. They just pick the available placement. And this cycle just keeps repeating itself in rural settings, North Dakota, for example, sometimes you'll locate children who have very complicated problems geographically, very far from services, because that's where the foster homes are available. And that, of course, is an additional complicating factor,

Dawn Davenport  8:03  
did you know that we have free, yes, free courses available to you. Jockey being Family Foundation has so kindly supported our being able to offer you 12 free online courses on the creating a family ed.org online Parent Training Center. You can check out these courses at Bitly slash JBf support. That's B, I T, dot, l, y slash JBf support. The courses are all directly aimed at people who are actively parenting kids. So I really think you'll appreciate them. If you're a foster parent, you'll be able to use them for continuing education. So check them out at Bitly slash JBf support. So how is now we're going to separate alcohol with drugs. So how is prenatal exposure to alcohol detected or diagnosed?

Speaker 1  8:59  
Well, I think there's two versions this. There's one in theory, you had interviewed the birth mother, she'd be completely forthcoming and factual, and you'd get a very detailed explanation of prenatal alcohol exposure. Then there's a reality based version of this, where many of the mothers aren't close to the children. They're incarcerated, they're struggling with their addiction. The children have been removed from their care, termination of parental rights. So it's very seldom, and I emphasize very seldom, to get interviewed the birth mother, so then you're stuck with looking through the medical records, a very poor source of information about alcohol use. You can go through the foster care records, another very poor source of information about alcohol, much better about drug. Works, but very poor for alcohol, and then you're stuck with trying to find somebody who can give you some information. I saw her drinking. I'm her brother. She lived a mile from me. You know, that kind of thing. My last comment on this sometimes we get upset about these moms, and we say I don't understand how she could do that. How could she continue to drink well, one metric that might be very helpful is if people understand that if you have a child diagnosed with a fetal alcohol spectrum disorder, the birth mother is 44 times more likely to die prematurely than the mother of a child who does not have FASD. And since we're talking about young women, we're really talking about a marker for mortality, early death that exceeds any other markers we have available for women that age, and I think that tells us how severe the disease is among these women.

Dawn Davenport  11:12  
I think there's a misperception that that we could just run a test on a newborn and determine if the newborn has been exposed to alcohol. But does that exist?

Speaker 1  11:22  
So we have tests. They're very infrequently used. There's lots of problems with interpretation. I think a good example of that's in Toronto over the last year and a half or so, where there's been very serious problems using these tests up there. So we have a meconium test, the baby's first stool. We can send that in, have that analyzed for alcohol exposure, that will tell us about the last 20 weeks of pregnancy. Oh,

Dawn Davenport  11:52  
wake up even going for as far back as 20 weeks.

Speaker 1  11:55  
Yeah. Well, this works best, you know, for the last trimester, but meconium starts being formed around 20 weeks. There's a hair sample, there's tissue and blood methods, but the point is, these are very infrequently used. Hospitals might routinely test for drugs, but they rarely test for alcohol exposure. That's

Dawn Davenport  12:24  
what we have seen too. So what type of trainings do pediatricians receive during their education or residency on prenatal exposure in general and how to diagnose it?

Speaker 1  12:36  
I think it's inadequate. It's inadequate on interviewing the mother about exposure. It's inadequate in diagnosing fetal alcohol spectrum disorders, and it's extremely inadequate when it comes to management of these children. And clearly, we have to do a much better job across professions, social workers, pediatricians, family medicine doctors, obstetricians, neonatologists, etc. So I think we're maybe beginning to make some progress there. But slow, yeah,

Dawn Davenport  13:18  
I would, from my experience, it is slow. We hear from pediatricians that even when they suspect it, they don't want to raise it with the parents after the child is already born, because at that point they feel like it will interfere with their working relationship. Because when you raise it as an issue, there is a shame associated it is something that is caused by behaviors of the birth mom or of the mom so they don't want to raise it because they feel like at that point that it will do more harm than good. Yeah,

Speaker 1  13:50  
I find that to be an odd consideration, that they think not diagnosing a problem which lasts a lifetime, which is highly likely to result in foster care placement, extremely likely to result in the child having mental health problems, school failure, development of substance use, contact with the mental health system, and a high rate of mortality is not something they want to do, and I think it's among that particular group of doctors where you can see the lack of training, because often they'll tell us, well, we're already doing everything we could for this child. What would we do different if they're diagnosed? And I think when that comes up, it's time to give serious thought to getting a new doctor.

Dawn Davenport  14:48  
So how is now moving to drugs? How is prenatal exposure to drugs detected or diagnosed in infants at newborns or infancy?

Speaker 1  14:58  
So, uh. Many, many methodologies for doing that, particularly for drugs like opioids, where, in some settings where opioid use is prevalent, pretty much all newborns get screened, amphetamines, marijuana, all these have very robust biomarkers that you can elicit from meconium and often other tissues, hair, etc. So in a lot of places, they do a pretty good job of screening for those things, but they don't screen for alcohol in those very same places.

Dawn Davenport  15:38  
Yeah, and you know, when you described the what it would take, because, as you point out, very few mothers are forthcoming. We've done a good job of educating. I think we could certainly do a better job, but most people know they shouldn't be drinking during pregnancy, and therefore there's a shame associated with it, and there's also a fear, because they're fearful that the child could be removed. So for all of those reasons, as you point out, it is rare for a mom to be forthcoming about the full extent of her alcohol use or drug use, although, as you point out, what drugs are, they're routinely drug tested and then going and finding extended family members to give you history and stuff just I mean, very few pediatricians or obstetricians have that time in order to, you know, go and interview people who are not in their care. So it just doesn't it just doesn't happen. Doesn't happen frequently. And one of the frustrating things is that often even screening for drugs is done. They have to. It has to be done in some hospitals. They don't do everyone they do if we have reason to believe, which means that that it is not universal, for sure, and also means that probably a disproportion of of moms of color are being tested in and white moms are not. So we see all of those things that that also can happen. It's just not universal, although some hospitals do universally do it. All right, if you are some in our audience will be, as I said before, foster, adoptive and Kid parents. So one piece of information they will have, they will know where this child that they are, either considering fostering or adopting, is, has falls in the birth order. Is there a correlation between birth order and the likelihood that a child would be exposed if indeed, the mom is struggling with substance abuse? Quite

Speaker 1  17:32  
a crucial question. Quite, quite, quite a crucial concept so broadly put, people ask, Well, why screen for alcohol use during pregnancy, for a newborn infant? Well, one of the primary reasons is to identify a mother who needs treatment, to identify an infant who's been exposed, and, extremely importantly, to prevent exposure and subsequent pregnancies. And these three reasons are so compelling, it just shocks me. So if we think about this and we look at a SIB ship of several children, the younger children in the SIB ship tend to have a higher prevalence of being diagnosed with fetal alcohol spectrum disorder. They tend to have more severe symptoms, and I think their mortality risk is higher. So it's it's important that we share with people that identifying prenatal alcohol exposure is worthwhile. It gives you an opportunity at its lowest level to prevent exposure in future pregnancies.

Dawn Davenport  18:54  
Is, is the reason that subsequent children, subsequent born children, are more likely, is that, is that just the nature of substance abuse disorder, that it tends to increase in severity as and as stress, as time goes on and stress goes on, is that the reason,

Speaker 1  19:11  
I think that's potentially a good reason, the generalized health of the Mother decreases over time. It's possible that other things are operating here, but yeah, I think it's likely that this just has a generalized effect on the well being of the mother.

Dawn Davenport  19:32  
So what are some of the long term impacts of alcohol exposure in utero?

Speaker 1  19:40  
So a good way to think about this is if we take a large group of women who are drinking, the majority of them are going to drink during the first part of pregnancy, because they're going to be pregnant quite some time before it becomes clear to them they are pregnant. In it. So exposure during the first six, 810, weeks of pregnancy is very high. If we follow that group of women to the end of pregnancy, and we look and see how many of them we can demonstrate drank during pregnancy, one out of 12, a very high number. One out of 12 women in the United States, I think, are drinking during pregnancy. So prenatal alcohol exposure, if we think of it like this, when a mom drinks whatever Her blood alcohol concentration is, it's the same for the fetus. Alcohol primarily impacts the brain. So every episode of drinking is an episode of brain damage during pregnancy. So when these babies are born, they have many neuro developmental problems, low muscle tone, difficulty relating Well, some of them have health problems. Prematurity is very common, increased risk for late term still birth. Then as they get older, of course, we see increasing numbers of difficulties as they go along, delayed milestones, needing early intervention, increased rates of vision and hearing problems, high rates of Attention Deficit Hyperactivity Disorder, many of them are going to need preschool programs. Rates of school difficulties are very high, and when you go forward from there, then you see huge impacts on the mental health system. Lots of these children are going to develop substance use disorders. Why is

Dawn Davenport  21:53  
that? Why are they more at risk for substance abuse disorder themselves? If they were prenatally exposed to substances. I think

Speaker 1  22:01  
they have the magic duo. They have a genetic predisposition to this, often from both parents. Often it's multi generational in these families, and for many of them, they've had a difficult early life, lots of adverse childhood experiences which increase the risk for substance use later in life. So identifying these children is important so parents can orient themselves to thinking about these upcoming problems, implementing strategies to decrease risk for these problems, and the idea that any diagnosis will do we're already doing everything that could be done is really ridiculous when you look at the developmental course for these disorders.

Dawn Davenport  22:58  
Did you know that most people find out about podcasts by word of mouth. They talk with their friends, they talk with somebody, they meet at the park, and they see that they're listening to something, they ask. I certainly know I am a pot I am a podcast addict. I love to listen to podcasts, and I certainly know for myself that that's where I find out about most of the podcasts I listen to. So you could do us a HUGE favor, if you would please tell your friends, your family, whatever about the creating a family.org podcast. Our mission is to inspire and strengthen the adoptive, foster and kinship community, and you are a valuable partner in our doing that. Does it matter we we certainly hear people say, Well, I only drank beer or I only drank wine. I didn't do hard didn't drink hard liquor. Does it matter the type of alcohol that was consumed by the mom? So I have

Speaker 1  23:56  
two comments on that one. No, it doesn't matter. All alcohol is the same. If you get your alcohol from beer, wine, bourbon, you're drinking some product that has alcohol in it that's not designed for consumption. It's all the same. It's the amount of alcohol, how often use it, when you use it, that makes a difference. I think a second point is that for many people, their pattern of use is problematic. Before they become pregnant, they go out on Friday and Saturday nights with the intent of consuming multiple drinks when you do that and you have unprotected sex, then it's likely that if you become pregnant, you're going to be drinking through the first part of pregnancy before you learn you're pregnant and you can decide if you're going to quit or not. It so all alcohol is the same. It's the amount of it and the duration of usage that makes

Dawn Davenport  25:07  
a difference. That makes sense. What type of doctor can diagnose a child or a baby with fetal alcohol spectrum disorder?

Speaker 1  25:18  
Well, certainly we have to tool up a pediatrician so this becomes a routine diagnosis in their office. Right now, in quite a few centers in the United States, there's this multi disciplinary diagnostic team. Well, those are incapable of seeing even a tiny fraction of the actual number of kids with FASD fetal alcohol spectrum disorder in the United States, or even evaluating children with other drug use. So this is a job for, I think, primarily three groups of doctors, initially, pediatricians, neonatologists and obstetricians, all three of those groups need to take their chunk out of this. Need the obstetricians need to a much better job about screening for and putting in the medical record issues about substance use, especially alcohol, because, as we know, it's the most concerning substance of all. None of the rest of these things are nearly as harmful as alcohol. The neonatologists need to be involved in this as many of the most complicated children end up going to the NICU, staying for weeks, being treated for all kinds of complicated problems, but maybe not getting in the chart or reflecting that The most complicated problem is prenatal alcohol exposure. All children need to be screened more than once at a well child visit, or the doctor routinely sets down When was your last drink. Very effective screening question, not complicated, and when they ask about depression, domestic violence, running water, all this kind of stuff. They ask about these questions, a question like that as well.

Dawn Davenport  27:28  
Well, you've certainly described an ideal situation. What we see now is exactly what you say, that most places, it is hard to get a diagnosis because pediatricians don't feel competent. You could go to a developmental pediatrician or a clinical geneticist, but as you point out, that limits the number of people who are actually going to be seen, and we know it is more common than that. Yeah,

Speaker 1  27:55  
I just have a couple thoughts on geneticists I think are helpful for a very small number of these children, and that's the children where there might be another disorder present. But by and large, geneticists are not particular, don't have particular expertise in brain function for children, and the outcomes from drinking during pregnancy are primarily damage to the developing brain. So pediatricians, psychologists, neurologists, school psychologists, psychiatrists, all need to develop additional expertise, because that's who these children see in very large numbers.

Dawn Davenport  28:42  
That makes sense. You've already mentioned that of all the substances that children can be exposed to prenatally, alcohol has the greatest impact. It's the greatest teratogen. But let's talk about some of the other commonly abused drugs we've got opioids, heroin, increasingly fentanyl to presence, benzodiazepines, both prescribed and unprescribed, stimulants, methamphetamine, things such as that, cocaine, crack. What do we know about the long term impacts of these drugs?

Speaker 1  29:18  
I think broadly, we know some useful things, substance use is associated with a late start for prenatal care and few prenatal visits, two important clues for concerns about this. As an aside, we've done two studies now looking at women who go to the emergency room, and bizarrely, we have found that if you were pregnant, you are screened very infrequently for drug and alcohol use compared to non pregnant women, so there is an increase. Correct assumption there that pregnancy is somehow protective and simply not true. So substance use late start for prenatal care, fewer prenatal visits. When we try to look at these, one of the most confounding and complex problems is that people tend to use multiple substances at once, and I'll give you an example of how important this is. So when you drink during pregnancy, you produce a certain amount of risk separately. When you smoke during pregnancy, you produce a certain amount of risk prematurity, you know, but when you drink and smoke together, those two exposures multiply the risk factors, so they're not additive, as you would expect, they're multiplicative, so you have this huge increase in risk for adverse outcomes from moms who both drink and smoke. I hear a lot of people say, well, in our setting, it's mostly drugs that's a problem here. And of course, that's not true. If you look at the alcohol sales for communities. I just gave a talk in North Carolina. I think alcohol sales in the two years I looked at had increased 13% a huge amount of this alcohol is being consumed by women. We've just got to get our thinking clear on this so it's not mostly drug use, it's mostly poly substance use and heroin opioids. Now, fentanyl used to be associated with fairly high mortality rates because of the neonatal withdrawal syndrome. Now as complicated as that is, it is a routine problem in neonatal nurseries. They identify this with regularity. They worked out complex treatment protocols for it. They know what they need to use for treatment. How long treatment needs to go on? So the mortality for children exposed to opioids has gone down substantially. The long term outcome improved. Some drugs are so problematic that there are many adverse outcomes. Methamphetamine, really, really addictive substance, takes a huge toll on the mother's health when she's pregnant. Often folks with meth addiction, or meth probably addiction is not the right term, but methamphetamine dependency. Live in really difficult circumstances. They're not eating well, they're not getting prenatal care. Their vitamin intake is very low. They use a huge range of substances in addition to methamphetamine, so broadly, we could say the opioids nowadays, in almost all settings, well identified, well treated. The children are well managed. When they leave the hospital, they go into a follow up system, they're doing much, much better. Amphetamines a lag behind that. And amphetamines, I would say there's a lot we don't know about the effects of amphetamine use on child development. Methamphetamines a fairly new drug. There's a couple of versions of methamphetamine. The most recent version, I think, is going to turn out to be much more detrimental than the previous versions of this. And so that's going to be complicated. I am particularly worried about the effects of marijuana use on development. I

Dawn Davenport  34:25  
was going to raise that as an issue, because I I know I have heard of pregnant women saying, Well, I'm going to smoke pot because I don't want to drink, and thinking that that there is and of course, it's becoming legal. And so that is leading to the idea that perhaps it's not that that harmful. What do we know about the impact of cannabis on fetuses?

Speaker 1  34:49  
So I think in general, cannabis use decreases birth weight because it's a version of smoking. Many of these children have a peer. Period of habituation, so they were getting regular exposure to cannabis during pregnancy. They're delivered, they're not getting it. Now, that requires some adjustment in their thinking. And as these studies come forward cannabis users, one of the things we have to think about is the potency, the amount of the active material. THC, in this is increasing dramatically. It's many fold greater than it used to be 15 or 20 years ago. So the potency of the cannabis and the likelihood of an adverse effect, I think, is going up a lot. So you watch these children, and of course, many of them are going to end up with modest learning and development problems that ideal families. Early Intervention would make a difference for but many of them don't live in a setting where that's going to be provided, so I think quite a number of them were going to struggle.

Dawn Davenport  36:14  
What about CBD?

Unknown Speaker  36:18  
I have no knowledge of that, all right, I'm

Dawn Davenport  36:20  
just curious, because that's even more I think that the number of people who are taking benzodiazemine, Valium, Xanax, things like that. I don't know if it's increasing. I believe it is, but I think that it is certainly both the prescribed and the and the unprescribed use of benzos is high. What do we know? And being a depressant, you would think that it would have a significant impact on the fetus. What do we know about fetal exposure to Valium, Xanax and others?

Speaker 1  36:54  
So a little bit of background might be helpful. Prior to COVID, rates of anxiety were increasing. One measure of the prevalence of anxiety is that if you go to a university campus and go to Student Health and you say, What's the most common problems, people come to see you for almost always, three of the top five will be different anxiety disorders. So it's extremely common among young people. When COVID came, the rates of anxiety have been increasing dramatically in adults and children of all ages since so the amount of time we spend on anxiety disorder in the clinic I'm in is going up very rapidly, tragically, now we're seeing young children who have significant anxiety. So when you're studying this, you have to untangle two problems. One is the mother's use of this particular class of substance, benzodiazepines, etc. Second is the effect of the mask. And there's a very nice little video available if you type still face into the search bar, you'll get see an experiment showing what happens when moms don't react to babies overtures. We'll include a link to that, and the baby, in just seconds, becomes aware of this and starts ramping up their behavior, demanding some kind of response. But I think people have forgotten is we're now dealing with a couple years of babies who were born and cared for by people who spent a long time wearing a face mask, and we have no idea if using a face mask around infants is safe or not.

Dawn Davenport  39:05  
You're not talking about, let me I think I was going a different direction. You're not talking about the effect of moms who are taking depressants, valiums and Xanax and others for anxiety that it it mutes their responses and their emotions. It sounds like you're talking literally about these all parents, regardless of whether they're taking benzodiazepines or other depressants. So you're talking both, or you're talking just exclusively about the effect of face masks in general. So

Speaker 1  39:37  
I'm talking about the ultimate in lack of responsiveness. You hang something over your face so the baby cannot see your facial expressions. This promotes an anxious, agitated state in babies. Huge amounts of their care during COVID have been provided by. People wearing face masks in that group are moms who use different types of benzodiazepines and likely cannabis use fits into this category, who are less responsive to their babies than they would otherwise be. So many of these infants are getting a kind of a double dose of problems designed to make them more agitated anxious, have more difficulty controlling their behavior than they otherwise would. And surely we are saying that now huge increases in anxiety, well,

Dawn Davenport  40:45  
and also many of these children would like to also have been exposed. If their moms were taking these drugs during pregnancy, they also have the added insult of having been exposed prenatally.

Speaker 1  40:57  
Yes, lots of moms use these medicines during pregnancy,

Dawn Davenport  41:03  
and it's one thing if their obstetrician is aware of it, and and they're controlling dosage and and it may be actually better. It may it's if they're needing the drug that's maybe said to control anxiety. It may be something that is useful, but they're the dosage is being controlled. It's being overseen by a doctor. It's another thing when they're self medicating with these medications.

Speaker 1  41:23  
Yeah, nothing. None of my comments should be designed to have women change advice from their doctor, right?

Dawn Davenport  41:32  
There's actually some interesting studies that exist as far as in taking antidepressants in pregnancy versus experiencing the depression, both are harmful. Are potentially harmful, I should say so. Do pediatricians or neonatologists or family practitioners and obstetricians? Do they have resources commonly available or readily available resources to offer parents regarding raising a child with prenatal exposure. I think we know that they have resources to say that using alcohol or drugs during pregnancy is ill advised. But what about for raising children who may have been exposed.

Speaker 1  42:24  
So if we just look at prevalent studies and we say, well, fetal alcohol spectrum disorder is twice as common as autism, so there's two times as many kids with FASD at any age level as there are with autism. FASD is much more common than Down syndrome, probably, you know, 234, other common childhood conditions, and pediatricians have quite a bit of expertise in those areas. The American Academy of Pediatrics does have some materials. They are updating these once in a while on fetal alcohol spectrum disorder. But I think when you look at what the Academy does, when you look at the publications in their journals, information about fetal alcohol spectrum disorder is dwarfed by information about autism, rare genetic conditions where there's so much more published.

Dawn Davenport  43:24  
I know. Why is that? You're spot on? But why is that? Well,

Speaker 1  43:29  
I think it gets back to this idea that they're fearful, they're they will have a problematic relationship with the mother if they bring this up, or that they might upset the grandmother if they bring this up, or that the foster parents don't want to hear this news. I've never found this to be the case. Could be I just see a different population, but I think people often are secretly worried about this problem. They'd have great relief if their doctor brought it up, they could talk about it in a forthright manner, and the doctor actually knew had an action plan for it. So, you know, we see these kids have been evaluated six, seven times for different problems, but fetal alcohol spectrum disorder is never really brought up. The foster parents, the adoptive parents, the grandmothers, figure this out, make an appointment, bring these kids in. I think we just need better from our health care providers.

Dawn Davenport  44:37  
I would agree. I spoke with a clinical geneticists. That part, a great part of his practice is diagnosing FASD and he said that in his years of practice, and he had been practicing for over 30 years, he could count on one hand the number of birth parents who brought their kids in for a diagnosis suspected by. Prenatal exposure to in this his case, it was alcohol that he was talking and I said, Well, who's bringing them in? He goes, almost always. It's adoptive, Foster, our grandparents.

Speaker 1  45:12  
You know, I think we can make some changes in the way we talk to people. So one of the things I teach medical students, and train quite a few of them is when this issue comes up, step out of your office and go get two cups of coffee, or two Diet Cokes or two sprites come in, give the mom one you sat down with one so you can talk about this. This sets a condition for discussion that's important. Many moms are just desperate for information about whether or not their drug use, their alcohol use, caused problems for their baby, and by avoiding that, we increase the stigma around it. Instead of treating this like we do every other problem, we ratchet up stigma because it becomes an unmentionable thing from the doctor to you, and are you going to bring that up with the doctor? No, so we make it worse by doing this.

Dawn Davenport  46:28  
I mean, I understand it. If you're bringing up autism, there is no reason to believe that anything you as a parent did cause your child to have autism. But when we're bringing up fetal alcohol spectrum or issues associated with drug use during pregnancy, there is something that the parent did that caused the problem, so you can understand it. But as you say, there, it's not that there aren't things that we can do early we know that some of the best protective factors for these children and indicating a better outcome for these kids is early recognition, early diagnosis, early recognition in getting the support of services. Yeah,

Speaker 1  47:05  
and what's one of our goals? One of our goals, if you didn't strap your child in to a car seat when you were driving to the store, you get in a car accident and they're injured, we're going to take care of both you and the child. If you used drugs during pregnancy, we're going to take care of both you and the child. If used alcohol during pregnancy, we need to take care of both you and the child. And this idea that somehow this is some separate path we have to travel simply not true. We don't know what causes autism, so we can't say it was nothing parents did. We can't say that it was because we have no evidence of that. We do know that moms who have substance use disorders increase the risk for adverse outcomes for their baby. Most of them already know this. They're looking for care, they're looking for compassion, understanding,

Dawn Davenport  48:05  
and what can I do now? Yes, yeah. Okay, so if you were going to leave parents with a couple of tips, if we're talking of parents who are now raising kids who have been prenatally exposed, what tips would you have for those parents?

Speaker 1  48:20  
First, if your child was in foster care, if your child is adopted, your child's in kinship care, the risk for prenatal exposure to alcohol and other substances was high. Earlier, identification of this problem is going to provide you with more information on upcoming problems you can minimize, or successfully avoid. Fetal alcohol spectrum disorder itself a very long term problem. It's unlikely you're going to be successful managing this by treating these children for something else. We need to identify this so that we utilize treatment interventions designed for children with prenatal alcohol exposure, poly substance exposure, and for those that have fetal alcohol spectrum disorder, it's all about anticipating what's coming up. I'll kind of conclude the way I started the record in our place is a child with 31 foster care placements.

Dawn Davenport  49:39  
That's heartbreaking. This is

Speaker 1  49:43  
a preventable problem. By not recognizing this, we've done damage to this child that's hard to calculate. So we can do better by thinking about this. And acting on it.

Dawn Davenport  50:03  
Thank you so much, Dr Larry Bird for being with us today to talk about prenatal exposure. As you can tell, this is a topic that I feel really passionate about, and that creating a family is spending a lot of resources on creating a lot of resources to try to help families. And I truly appreciate your expertise and your sharing it with our audience today.

Unknown Speaker  50:23  
Thank you. I really appreciate this opportunity. You.