Early childhood consequences of polydrug use during pregnancy

Journal of Neonatal Nursing (2013) xxx, xxxexxx

www.elsevier.com/jneo

ORIGINAL ARTICLE

Early childhood consequences of polydrug use during pregnancy Laurence Simmat-Durand a,*, Louise Genest a, Claude Lejeune b,c a

CERMES3, Universite´ Paris Descartes, PRES Sorbonne Paris Cite´, INSERM U988, CNRS 8211, 75006 Paris, France b Hoˆpital Louis Mourier, APHP, 92700 Colombes, France c Universite´ Paris Diderot, France Available online - - -

KEYWORDS Addiction; Neonatal passive; Drug use; Women; Neonatal abstinence syndrome

Abstract Objectives: Polydrug use in pregnancy exposes children to perinatal consequences, but also to long lasting effects resulting both from their mothers’ abuses and lifestyles or socioeconomic deprivation. Study design: The 167 children born alive from 1999 to 2008 whose mothers used at least two substances at the beginning of their pregnancies were either followed up medically or their locations were traced at the end of 2010. One had died from sudden infant death syndrome. 20 could not be found, their mothers having moved. Results: The intrauterine growth restriction varied considerably according to the number of abused products, and even more so when the mothers used four products or more including alcohol. Prematurity concerned 22.4% of the children but 31.3% when the mothers used four substances or more. If 25 children were separated from their mothers at discharge, at the end of the follow-up 41 had been separated, out of whom 12 were adopted and the others fostered. Six mothers died during this period. Birth defects were assessed, mainly 8 FAS, 1 microcephaly and 1 down’s syndrome. One girl was shaken to blindness. 22.8% of the children were described as having behavioral problems and 13.8% learning difficulties but only 4% benefited from special need education. Conclusions: Compared to the results published in the last two decades, the data from this cohort show a clear decrease in severe birth adverse events, and maternal deaths. The long term prognoses seem influenced mainly by the number of products used during pregnancy, especially alcohol, the mothers’ lifestyles and social deprivation. ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. CERMES3, 45 rue des Saints-Pe `res, 75270 Paris Cedex 06, France. Tel.: þ33 1 76 53 36 13. E-mail address: [email protected] (L. Simmat-Durand). 1355-1841/$ - see front matter ª 2013 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jnn.2013.10.002

Please cite this article in press as: Simmat-Durand, L., et al., Early childhood consequences of polydrug use during pregnancy, Journal of Neonatal Nursing (2013), http://dx.doi.org/10.1016/j.jnn.2013.10.002

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Introduction Children of drug abusing mothers bear the consequences of both the intakes of products and social conditions of their mothers at birth and throughout their lives. Works on adult health show the long lasting effects of being brought up in a family affected by drug abuse (Pilowsky et al., 2009). Many studies have assessed the consequences of substances in the newborns’ development, but they often only mention the possible sociodemographic confounders. Until recently, works have distinguished the effect of illicit substances without controlling the mothers’ other intakes, especially alcohol or tobacco. In the last decade, the role of multiple uses of substances has emerged in literature (Kashiwagi et al., 2005; Mayet et al., 2008; Pinto et al., 2010). For instance, a study on methadone treatment took into account tobacco but also the other products taken by the mother, and show that the high preterm birth rates increase with the number of supplements to the methadone (Almario et al., 2009). Another series showed the aggravating role of benzodiazepines (Dryden et al., 2009; O’Donnell et al., 2009). First, neuroimaging results show evidence of early consequences of drug or alcohol exposure to the structure, function and metabolism of the developing human brain (Roussotte et al., 2010). The consequences of the women’s consumptions during pregnancy are medical, such as preterm birth, intrauterine growth retardation (IUGR), per partum hypoxia or neonatal abstinence syndrome (NAS) and also social, mainly poor parenting capacities, poor bonding, child protection reporting and foster care or adoption. Later, the consequences include reports to child protection, foster care or adoption (Sarkola et al., 2007), schooling and learning difficulties, behavioral problems and social consequences such as delinquency or repeated imprisonment, especially in the case of fetal alcohol syndrome (FAS) disorders (Streissguth et al., 2004; Spohr et al., 2007). A higher degree of healthcare utilization is shown for exposed children, especially when fostered (Sarkola et al., 2011). The works showed a high level of primary care disruption among children of heroin or cocaine abusing mothers (Nair et al., 1997). Works questioning the impact of both drug abuses during pregnancy and the effects of foster care were carried out in the 90’s. The results show that the environment in which the children are raised is more important than the in-utero heroin exposure

L. Simmat-Durand et al. (Ornoy et al., 1996). Studies following drug abusing women highlighted their increased risk of morbidity and mortality (Kahila et al., 2010), resulting in foster care for their children. Recent studies show changes in the laws affirming the rights of children to be raised in their own families, as well as in the professionals ‘representations of drug abuse in pregnancy. Works from Street et al. compared the risk of child protection involvement in the children of drug users to controls, and showed the overall risks after birth and five years later. They did not include alcohol but illicit drugs and medications (Street et al., 2008). In the United States, the effects of drug use were compared to those of socio economic status and adoption: they showed that adoption even by higher socio economic status families do not mitigate the effects of drug exposure on the behavioral problems among adolescents (Ornoy et al., 2010). Concerning the school performances of the children, a lot of studies exclude the question of alcohol, or even tobacco, alcohol and cannabis, to assess that children exposed to cocaine have similar IQ to those not exposed, and that the low results are to be blamed on social adversity (Wasserman et al., 1998). But these authors also remarked that the intelligence level of the mothers is hardly ever taken into account. Numerous studies focused on behavioral problems, for instance after an OMT (Sundelin Wahlsten and Sarman, 2013), or on the link between drug abuse and ADHD. Comparing children exposed to street drugs and to alcohol, a study concluded that the first were somatically healthy but had an increased risk of ADHD (Elgen et al., 2007). In this paper, we want to assess the influence of the combination of products and of the social conditions in which the mothers lived during their pregnancies, on the newborns’ conditions at birth and a few years later, focusing on how many substances were used.

Materials and methods From 1999 to 2008 in a hospital in the suburbs of Paris, 170 neonates out of whom three were stillborn from mothers reported as using at least two substances at the beginning of their pregnancies were included. The women’s maternity and “addiction” files formed the basis of the first data collected. When a mother had given birth in another hospital, data were sought in the relevant maternity ward. The database included 168 variables describing the

Please cite this article in press as: Simmat-Durand, L., et al., Early childhood consequences of polydrug use during pregnancy, Journal of Neonatal Nursing (2013), http://dx.doi.org/10.1016/j.jnn.2013.10.002

Consequences of polydrug use during pregnancy mothers’ living conditions, their reproductive histories, and uses of psychoactive substances, neonatal characteristics, and data on the children’s fathers and siblings (Lejeune et al., 2013; Simmat-Durand and Claude, 2012). The second part of the data was collected in 2010 by the pediatrician who questioned the families, the GPs or the Free Mother and Child Clinic doctors, and used the pediatric files when available. He inquired about the children’s early years: their health, school trajectories, family histories and eventual foster care. Twenty children (12%) were lost because their mothers moved away; one woman denied to participate; and one child died. Finally, enough information was available on 145 children aged between one and eleven. All the women were informed of the implementation of the survey and its aims. The overall protocol received approval from the CEERB (Comite´ d’Evaluation de l’Ethique des projets de Recherche Biome´dicale) GHU Nord, in March 2009, under the reference number 09-010. The statistical processing was performed with Modalisa6 and SPSS18. The severity of the neonatal abstinence syndrome was assessed using the Lipsitz’s score (American Academy of Pediatrics, Committee on Drugs, 1998; Lipsitz, 1975). A medical treatment with morphine hydrochloride (dose of 0.5 mg/kg/ day in 4 or 6 times) was discussed for a score higher than 9 twice in 3 h. A score from 10 was considered severe. The variable “polydrug use score”, for quantifying the number of different substances used by each woman, was constructed from nine substance variables: opiate medication (treatment or street procurement), tobacco, alcohol, cannabis, cocaine or crack, ecstasy or amphetamines, heroine, benzodiazepines, and other psychotropic medication. A “deprivation score” was also calculated, integrating the isolation of the mothers, their lives in collective housing or shelters, primary educational status or lower, place of birth outside Europe, CMU (state health cover for the destitute), unemployment or disability status, state benefits as main incomes, and their having three or more children.

Results We analyze and discuss the children’s follow-up results according to four themes described in the literature as having a main influence on their future: their birth measurements, their health

3 status or birth defects; the separations between the children and their mothers; the pathologies and school results; and finally the particular impact of alcohol. 1. The role of polydrug use in pregnancy A significant proportion of the mothers who combined four products or more at delivery did not want to be pregnant and had a poor follow-up of their pregnancies (Table 1). They lived in more deprived conditions, alone, and depended mostly on social benefits. These women had a reproductive history with numerous previous pregnancy terminations, either abortions or miscarriages. Their weight gains during pregnancy were low compared to other women with a rather good correlation (r ¼ 0.319) with the birth weights of their newborns. Preterm birth globally concerned 22.4% of the newborns and 31.3% when the mothers used four products or more. Only three newborns had a gestational age under 33 weeks, two of whom had mothers using four substances or more. The children’s measurements were affected by the number of substances: they significantly differed in terms of their weights, heights and head circumferences but not in their gestational ages (Table 2). The children whose mothers used four substances or more stayed longer in incubators or neonatal units and were discharged later. The Lipsitz score was significantly increased with the number of associated products, especially with the use of opiates alone or in combination with benzodiazepines. The probability of having a Lipsitz score higher than 9 was multiplied by 16 when the mothers took heroin during pregnancy. 2. Separations between the children and their mothers Six mothers died during the follow-up among whom five had had their children fostered due to their poor life conditions or health status (respectively from tuberculosis, leukemia, overdose, alcoholism and two accidents). One child died from sudden infant death syndrome (SIDS) at the age of 8 months. If 25 children were separated from their mothers at discharge from the maternity, at the follow-up in 2010, 41 children had been separated at one time or another (Table 2). Among the 25 immediately separated, six had a mother who disappeared from hospital or just after her discharge and three were born from unknown

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L. Simmat-Durand et al. Table 1

Newborns’ measurements according to the number of substances used by their mothers at delivery.

Mean mothers’ ages Deprivation scores Ages at first visit in weeks Ages at first ultrasound Previous abortions Previous terminations Previous miscarriages Parity Mothers’ weight intakes Mean scores of substances Gestational ages Mean birth weights in g. Mean birth lengths in cm Mean head circumference in cm Mean Lipsitz score Tube feeding in days Nb of days in incubator Newborn ages at discharge in days Hospital discharge of the mother at day Mean durations in neonatal unit in days Mean ages of newborns at discharge in days % Mothers using at delivery Tobacco Alcohol OMT Heroine Cocaine Benzodiazepines Other medication Cannabis Ecstasy or amphetamines

0e3 Substances

4e9 Substances

Global

p value

30.92 1.99 15.46 15.07 0.86 1.13 0.27 2.08 13.14 2.17 38.1 2837.33 48.19 33.4 6.87 3.47 2.07 8.74 7.43 17.35 13.45

31.85 2.86 19.38 19.52 1.62 1.87 0.38 2.42 7.37 4.72 37.61 2644.69 46.95 32.64 8.57 7.88 11.06 14.69 10.77 25.22 25.61

31.26 2.32 16.86 16.64 1.14 1.37 0.31 2.21 11.55 3.13 37.92 2764.38 47.72 33.11 7.72 5.06 4.63 10.7 8.66 21.38 18.11

p p p p p p p p p p p p p p p p p p p p p

¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼

0.308 0.001*** 0.008** 0.001*** 0.001*** 0.003** 0.661 0.074* 0.001*** 0.001*** 0.281 0.044** 0.025** 0.018** 0.013** 0.025** 0.001*** 0.006** 0.006** 0.036** 0.001***

91.5 19.8 40.6 3.8 4.7 32.1 92.5 39.4 0.9

98.4 50.0 82.8 31.3 36.5 23.4 56.3 58.7 6.3

94.1 31.2 56.5 14.1 16.6 28.8 78.8 46.7 3.0

p p p p p p p p p

¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼

0.112ns 0.001*** 0.001*** 0.001*** 0.001*** 0.001*** 0.001*** 0.022** 0.132ns

ns: not significant. *p < 0.05, **p < 0.01, ***p < 0.001.

mothers (in France one woman can give birth without giving her identity). Out of these nine abandoned newborns, six had been adopted, two returned in their families and one was fostered. Among the 16 other children, only four had a mother with stable personal accommodation, six were street homeless and six lived in shelters. These 41 children have lived in 85 different situations. Among them seven children have undergone three or more situations, for instance they first went to a nursery, then to a foster family and finally to an adoptive family. 3. Adverse problems and school retardation Eight newborns were diagnosed with a FAS and one with a Down’s syndrome. One child became blind after a shaken baby syndrome and was adopted at 6. One was seropositive by mother-tochild HIV contamination (14/156 mothers tested positive).

Most children older than five were attending school normally (Table 3) but 12 of them showed school retardation, with a significant difference according to the number of substances. They are described in Table 4: 3 presented FAS, 7 were premature, and 7 were born with IUGR. Six of them were separated from their mothers, two of them for more than a year, and finally were adopted. Different variables described by the literature as having an effect on school capacities are provided for these 12 children; this small number prevented us from giving quantitative data. 4. The role of alcohol The women were questioned about their consumptions at the beginning of the pregnancy and at delivery. 19.5% declared having drunk every day and 27% occasionally at the beginning of their pregnancies, these percentages having decreased to respectively 13 and 16.2% at delivery. When we

Please cite this article in press as: Simmat-Durand, L., et al., Early childhood consequences of polydrug use during pregnancy, Journal of Neonatal Nursing (2013), http://dx.doi.org/10.1016/j.jnn.2013.10.002

Consequences of polydrug use during pregnancy Table 2

5

Newborns’ measurements according to their mothers’ use of substances at delivery.

Newborns Birth weights in g Birth heights in cm Head circumferences in cm % Separated from mothers Mothers % Mothers with personal accommodation Mean number of substances Mean number of abortions

0e3 Substances no alcohol

0e3 Substances with alcohol

4e9 Substances no alcohol

4e9 Substances with alcohol

Global

Fisher test

2888.86 48.49 33.63

2776.15 47.83 33.13

2778.52 48.04 33.07

2547.03 46.16 32.32

2764.38 47.72 33.11

* ** **

14.3

8.5

37.0

51.4

24.6

***

75.4

71.4

44.4

40.5

61.8

***

2.16

2.18

4.52

4.86

3.13

***

0.73

1.0

1.32

1.83

1.14

***

ns: not significant. *p < 0.05, **p < 0.01, ***p < 0.001.

combined all the answers, 53.6% of the women did not drink at all during the whole pregnancy, 17.8% stopped drinking and 28.6% went on drinking. When we separated the women into those using less than four substances or four and more, drinking and not drinking during pregnancy, fetal growth restriction is significantly increased when alcohol is added to other substances (Table 2). Thus there were 43.2% IUGR in the group of mothers using four substances or more and drinking versus 29.2% in the total population whereas the differences were not significant when only the number of substances was compared. The women using four substances or more and drinking alcohol had had more miscarriages and abortions, higher deprivation scores and psychiatric histories. One in two children in this group was fostered versus one in ten from the group using less than four substances and no alcohol. Among the three fetal deaths observed, two were from drinking women. Among the 7 newborns with a head circumference below the third percentile, six had a drinking mother, the other one was a heavy preterm twin.

Comments Most recent studies tend to take into account all substances abused by the mothers during pregnancy. For instance, Topley et al. showed that babies were mostly exposed to three or more products (Topley et al., 2008). Goel et al. (2010) noted that six women in ten were polydrug users

excluding alcohol and tobacco, and 97% including them. Their results are close to ours, with differences in consumption usually reported in statistics in the two countries: more cannabis and cocaine in France and more amphetamines in the UK. Prematurity levels were the same. The discharge outcomes from the maternity ward were slightly higher in the UK with 24/137 versus 25/167 in France placed in foster care. Some factors are described in the literature as having heavy consequences on the children’s prognoses such as prematurity, very low weights, per partum hypoxia, HIV, life environment and separations. All these factors are described as majored for children born to drug abusing women (Robins and Mills, 1993). We showed in this paper that these variables are linked to the number of substances abused, alcohol use and the mothers’ lifestyles. But we have to mention that we observed few very adverse consequences, as only 11 newborns were either born very premature or needed intensive care; one seropositive child and one battered child. These results show the progresses yielding by a better following-up of these at risk pregnancies (Winklbaur et al., 2008). The mothers’ nutrition during pregnancy needs to be addressed, as we noted that the birth weights significantly depended on the mothers’ weight gains. The specific role of alcohol is to be noticed. As shown elsewhere, any decrease of the consumption during pregnancy can limit the adverse consequences: 30.4% of the babies whose mothers did not change their alcohol intakes were preterm

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L. Simmat-Durand et al. Table 3

Measures for the 145 children in 2010e2011 according to their mothers’ uses at delivery. 0e3 Substances

Last known caregiver Mother or both parents Foster care Judicial measures Home child protection Adoption School Normal schooling School retardation Too young Problems (% with) Learning difficulties Behavioral problems Type of schooling Special need education

Alcohol

11.3 10.9 10.0 8.0 9.0 10.3 10.0 9.0 8.3 7.0 5.0

þ

FAS

þ

þ

þ þ þ

þ

þ þ

P value

86.2 13.8

46.6 53.4

70.3 29.7

10.3 5.7

22.4 12.1

15.2 8.3

46.0 3.4 50.6

46.6 15.5 37.9

46.2 8.3 45.5

10.3 24.1

19.0 20.7

13.8 22.8

0.22 0.773

0

10.3

4.1

0.021

0.079 0.302 0.043

in good stable/nurturing home, even in the case of FAS (Streissguth et al., 2004). The care disruptions are always a cause of concern for the future of the children, and the pros and cons of separating mothers and children must be thought carefully. The duration of separations before final adoptions is a sensitive matter in this cohort. Six women died during the follow-up, which can be considered a good result in such a population of substance abusers; compared to controls, a study in Finland showed that the mortality rate of drug-abusing women was 38 times higher (Kahila et al., 2010). Concerning the school performances of the exposed children, a large majority was attending school with their age group, but 14% were described as presenting learning difficulties and 22% behavioral problems, but these consequences can be observed for all substances even tobacco

Description of the 12 children with school retardation.

Age

5.0

Total

0.001

compared with 17.9% when the mothers did not drink and 20% when they drunk less (Toutain et al., 2010). The roles of tobacco and alcohol are well known but their influence was usually under evaluated in drug abusing women because the professionals were more preoccupied by their illicit drug uses (Bailey et al., 2012). We also showed in this cohort the role of benzodiazepines for the severity of NAS, but other studies assessed their role in preterm delivery (Calderon-Margalit et al., 2009). The remaining difficulties in this population are the high probability of separations between children and mothers, at birth or in the next few years, and the learning difficulties and/or problem behaviors. The outcomes for substance exposure are described as worst when the children are not reared Table 4

4e9 Substances

þ

TMSP

Pathology

Nb of substances

5 8 8 10 17 7 4 14 8 9 11

?

7 5 5 5 5 2 3 4 5 2 5

Down

Microcephaly Blind (SBS) Epilepsy

7

6

Nursery

þ

þ þþ; A þ þ

Preterm þ þ þ þ þ þ

Treated for NAS

Problems

Anxiety þ þ þ

Agitation Language Agitation

þ

Eating disorders Agitation

Nursery: þþ more than a year; A adopted.

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Consequences of polydrug use during pregnancy (Linnet et al., 2005). Compared to other countries, the very low rate of the children benefiting from special need education is to be deplored, particularly for children with FAS, who cumulate adversities and experience school retardation from the start. Concerning the risks previously described in the literature (Robins and Mills, 1993), the analyses of our cohort showed a low incidence of heavy neonatal pathologies: three still births, no neonatal death, less than 5% of the newborns needed resuscitation; only one case of vertical transmission of HIV; only one case of severe child abuse and one SIDS. But we assessed high rates of IUGR (18%) and preterm births (22%) yielding the long term risks of metabolic syndrome (Chan et al., 2010); and of separations (24.5%) and life disruptions for the children. The long term prognoses seem mainly influenced by the number of products used during pregnancy, especially alcohol, the mothers’ lifestyles and social deprivation.

Acknowledgments Anne-Marie Simonpoli, Marie Alvarez, Catherine Crenn-He ´bert, for their help in gathering the data.

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Please cite this article in press as: Simmat-Durand, L., et al., Early childhood consequences of polydrug use during pregnancy, Journal of Neonatal Nursing (2013), http://dx.doi.org/10.1016/j.jnn.2013.10.002