Physician perceptions of and management practices for significant fetal drug exposure

Reproductive Toxicology, Vol. 4, pp. 315-320, 1990

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PHYSICIAN

PERCEPTIONS OF AND MANAGEMENT PRACTICES SIGNIFICANT FETAL DRUG EXPOSURE

FOR

DON C. VAN DYKE, MD,*"~ LEE ANN GRISOLANO, BA,~: and JAMES HULBERT, PhD§ *Department of Pediatrics, 1"Divisionof Developmental Disabilities, ~:Divisionof Developmental Disabilities, and §Biostatistical Center, The University of Iowa Hospitals and Clinics, Iowa City Abstract -- A random sample by questionnaire in 1989 of U.S. physicians' perceptions of and management practices for significant fetal drug exposure in the specialty/sub-specialty areas of genetics, neonatology, pediatrics, family practice, neurology, and obstetrics and gynecology was analyzed. Neonatologists reported the greatest number of cases of significant fetal drug exposure, with 45% seeing at least one case per week. Of all physicians, 88% felt that fetal drug exposure is underreported in medical histories, with no statistically significant differences noted in responses for scope of practice or physician age and gender. Review of management styles showed that most physicians recognize the potential problems of fetal drug exposure and the desired intervention. There was, however, a small group of physicians (less than 10%) who did not follow this pattern. Fetal drug exposure continues to be an area in which continuing professional and public education is desirable. Key Words: fetal drug exposure; physician perceptions; physician management practices.

short-term neurologic signs, depression of interactive behavior, poor organizational responses to environmental stimuli, increased major malformation and dysmorphic features, and physical growth retardation in children (6--8). Although fetal alcohol exposure has occurred for centuries, Clarren and Smith have documented the most recent reports of fetal alcohol exposure (9). A 10-year follow-up of their initial 11 cases of fetal alcohol syndrome showed that of the 8 who could be contacted, all cases experienced growth deficiency and dysmorphic features, 4 demonstrated borderline intelligence requiring remedial education programs, and 4 had severe intellectual handicaps which resulted in out-of-home placement (10). While cigarette smoking has decreased in the general population, it has increased in certain subpopulations, particularly in young women. In the United States, smoking is a major determinant for small for gestational age infants, perinatal mortality, and spontaneous abortion (11,12). The first reports of abnormal effects from the use of coumadin during pregnancy found that fetal exposure to this drug during early pregnancy caused increased fetal wastage and abnormalities of the central nervous system and skeleton (13-16). The most consistent physical features were hypoplastic nose and midfacial abnormalities, with x-ray findings of bony abnormalities of the axial and appendicular skeleton (16). In the past 15 to 20 years, an increased concern has likewise emerged regarding the use of phenytoin and

INTRODUCTION Fetal drug exposure has the potential to cause birth defects such as significant developmental problems, learning disorders, and congenital malformations. As documentation of these abnormalities continues, following the birth of children with in utero exposure to alcohol, cocaine, phenytoin, and other drugs or substances, researchers have increased their focus on the role that such exposures might play in children born with significant developmental and physical problems. The concern in the medical community now extends not only to the use of prescription medications (ie, phenytoin, isotretinoin, coumadin), but also to "street" drugs (ie, heroin, cocaine, PCP), over-the-counter medications, and other environmental exposures (ie, smoking/ nicotine, alcohol) that might raise concern for the welfare of the child. In the 1980s, the use of cocaine, phencyclidine (PCP), and other similar drugs that act on the central nervous system has increased exponentially, resulting in reports from some urban medical centers of positive drug screens in over 16% of infants born in this type of facility (1-5). Current research demonstrates that fetal exposure to cocaine, PCP, and other central nervous system drugs can produce abnormal brain wave patterns,

Address correspondence to Don C. Van Dyke, MD, 213 University Hospital School, The University of Iowa, Iowa City, IA 52242 Received 19 December 1989; Revision received 30 March 1990; Accepted 29 April 1990. 315

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other anticonvulsant medications during pregnancy (1618). Researchers report that 10% to 30% of children exposed to phenytoin in utero were born with congenital malformations and/or developmental problems (16-19). Retinoic acid is a potent teratogen that induces multiple anomalies in rats, mice, and hamsters (20-22). Isotretinoin, a form of retinoic acid used to treat severe, recalcitrant cystic acne, is a potent human teratogen. If taken by pregnant women, it poses at least a 25% chance of causing fetal deformity (23,24). A teratogenic embryopathy has been associated with first trimester exposure to isotretinoin which may include external ear malformations, cleft palate, micrognathia, truncal heart defects, ventricular septal defects (VSD), aortic malformations, and certain brain malformations (23,24).

atrics from the American Academy of Pediatrics. Selection for the six national listings was random in an alphabetical sequence. The national membership list varied in size, from the American Society of Human Genetics with a membership of 525 physician medical geneticists, to the American Academy of Family Physicians, with a membership of 33,485. The breakdown of respondents from each group was: American Society of Human Genetics, 9.3%; American Academy of Family Physicians, . 10%; American College of Obstetrics and Gynecology, .12%; American Academy of Neurology, .34%; American Academy of Pediatrics, General Pediatrics, . 13%; American Academy of Pediatrics, Perinatal Pediatrics, 4.4%. The questionnaire had three parts: a) demographic information; b) questions designed to determine the physician's observations, knowledge, and management styles; and c) multiple-choice responses to two case histories. Three months after the initial mailing, a reminder mailing followed. Of the 630 questionnaires sent to physicians in the U.S., 46 were returned undelivered. Of the 584 delivered, 268 (46%) were returned; of those returned, 33 were disqualified. Respondents were disqualified if they had not completed the returned questionnaire, or if the responses were illegible or unintelligible. We received the largest number of usable returns from geneticists, followed in rank return order by neonatologists, pediatricians, family practitioners, obstetricians/gynecologists, and neurologists (Table 1). All suitable responses were tabulated for computer entry. We determined 14 variables assessing demographic information and 56 variables for observations and management styles. Calculations of descriptive statistics were assigned for each of the analyzed variable and response patterns.

METHODOLOGY The objectives of this study were two-fold: 1) to identify physician perceptions and observations of fetal drug exposure; and 2) to identify physician management styles to cope with families at risk for having children with potential problems secondary to significant fetal drug exposure. Using a questionnaire to contact a random sample of 630 physicians in the U.S. who have specialty or subspecialty training in genetics, neonatology, obstetrics and gynecology, general pediatrics, family practice, and neurology, we selected names from the national membership roster of the American Society of Human Genetics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Neurology, and General Pediatrics and the subspecialty listing of Perinatal Pedi-

Table 1. Characteristics of physician population (%) Specialty/ Subspecialty

N

Pediatrics (%)

44 (19)

% Type of Practice Gender Age Scope of practice Medicaid HMO/ Male Female (mean) Urban Suburban Rural (mean) Univ Private Group Military Other 30 (68)

14 (32)

47 41

Neonatology (%) Genetics (%) Fam Prac/Int Med (%)

43 (18) 49 (21) 32 (14)

34 (79) 33 (67) 27 (84)

9 (21) 16 (33) 6 (16)

Neurology (%) Obstetrics/Gyn (%) TOTAL

34 (14) 33 (14) 235

30 (88) 29 (88) 183

4 (12) 4 (12) 52

18 (28)

(49)

(23)

(16)

(59)

(18)

(5)

(2)

(67)

(24)

(2)

(2)

(5)

(90)

(8)

(0)

(0)

(2)

(13)

(59)

(16)

(3)

(9)

(33)

(49)

(6)

(6)

(6)

(12)

(73)

(15)

(0)

(0)

39 (75)

(14)

(11)

45

30 (61)

(22)

(17)

(16)

(47)

(38)

(63)

(27)

(10)

42

16

45

16

45

12 (57)

(32)

(11)

Physician perceptions • D. C. VAN DYKE ET AL.

RESULTS

317

ulation is 79% Caucasian, 12% Black, 7% Hispanic, with 12% using Medicaid.

Demographics We performed demographic analysis on gender, age, scope of practice, percent of patients receiving Medicaid, and type of practice (Table 1). The following describes general physician and patient profiles based on scope of practice:

Frequency of Exposure Neonatologists reported the largest caseload of infants with fetal drug exposure, with 45% seeing at least one case per week, and 84% seeing at least one case or more per month (see Table 2). Of the six specialty/subspecialty areas sampled, genetics had the second largest caseload of infants with fetal drug exposure, with 35% of geneticists seeing one or more cases per week, and 89% seeing one or more cases per month. The primary care specialties of general pediatrics and internal medicine/family practice, and the subspecialty areas of obstetrics/gynecology reported at least one to two cases of significant fetal drug exposure per year. There was a wide range, however, from more than two cases per month to less than one case per year. Obstetrics/gynecology respondents formed two groups; one group with a frequency of two or more cases per month, the second with a frequency of one to two times per year, This may reflect differences between a primary care obstetric/gynecology service compared with highrisk obstetrical service.

Pediatricians. 47 years of age, male (68%), practicing in a suburban private practice, seeing primarily Caucasians, with 18% on Medicaid. Neonatologists. 41 years of age, male (79%), practicing in academic, urban medical centers. Patient population is 56% Caucasian, 28% Black, 16% Hispanic, with 39% using Medicaid. Geneticists. 45 years of age, male (67%), practicing in urban/suburban academic medical center. Patient population is 70% Caucasian, 21% Black, 10% Hispanic, with 30% using Medicaid. Family practice~internal medicine. 42 years of age, male (84%), in private practice in suburban/rural areas. Patient population is 85% Caucasian, 11% Black, 13% Hispanic, with 16% using Medicaid.

Physician perceptions and opinions regarding fetal drug exposure

Neurologists. 45 years of age, male (88%), academic/private practice in urban/suburban medical setting. Patient population is 73% Caucasian, 18% Black, 9% Hispanic, with 16% using Medicaid.

We asked six questions about physician perceptions and opinions of fetal drug exposure. These questions covered such areas as the report of fetal drug exposure in medical histories, prevention, and parental anxiety. Descriptive statistical analyses appear in Table 3. A

Obstetrics~Gynecology. 45 years of age, male (88%), in urban/suburban area in private practice. Patient pop-

Table 2. Frequency of physician observation of significant fetal drug exposure SPECIALTY FP/ Int Medd Neue

Frequency

GP~

Netb

Genc

Once/per week (%) 2/per month (%) Once/month (%) 1-2/per year (%) less than 1 per year (%) Never (%)

2 (5) 6 (12) 9 (23) 20 (27)

18 (45) 11 (22) 7 (18) 7 (9)

14 (35) 17 (34) 11 (28) 4 (5)

0 (0) 3 (6) 5 (13) 18 (24)

1 (3) 2 (4) 4 (10) 13 (86)

4 (10) 10 (20) 3 (8) 11 (15)

6 (27) 1 (17)

0 (0) 0 (0)

1 (5) 0 (0)

4 (18) 2 (33)

6 (27) 3 (50)

5 (23) 0 (0)

~GP = general pediatrics. bNeo = neonatology. CGen = genetics. dFP/Int Med = family practice/internal medicine. *Neu = neurology. fOb/Gyn = obstetrics/genecology.

Ob/Gynf

Missing data

ALL MD's

1

40 (17) 50 (21) 39 (16) 74 (31)

1 -1

22 (9) 6

(3)

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Table 3. Physician perceptions and opinions regarding fetal drug exposure (% of physicians mildly to strongly agreeing with statement) Statement Fetal drug exposure is underreported in medical histories. Elimination of fetal drug exposure is important in prevention of developmental delay and congenital malformations. Fetal drug exposure causes no significant problems. Efforts at decreasing fetal drug exposure require an over-utilization of time and resources. Decreasing fetal drug exposure may be a significant variable in the prevention of birth defects. Discussion of fetal drug exposure with parents raises parental anxiety and is of no positive benefit.

Total

Gen Peds

Neonatal

Genetics

FP/Int Med

Neurology

Ob/Gyn

88

86

86

86

87

88

94

83

86

79

75

87

79

76

15

18

15

16

13

10

24

7

7

5

7

7

3

17

88

93

90

78

84

91

91

9

10

8

7

3

3

27

chi-square analysis by scope of practice, age, and gender appears in Table 4.

Management styles We assessed management styles through a series of questions and two case studies which included: 1) maternal cocaine/heroin use, fetal alcohol exposure, maternal smoking, and 2) coumadin, phenytoin, and isotretinoin exposure. Descriptive statistics were reviewed by scope of practices for management styles. No definite pattern emerged within the widely varying responses. As a group, physicians were fairly interactive, with only a minor percentage (less than 10%) either doing nothing or providing no intervention (Table 5).

DISCUSSION The greatest number of cases of significant fetal drug exposure were reported by neonatologists: 45% reported a caseload of one or more cases per week, and 84% reported one case or more per month. As a referral service, 89% of geneticists in the study reported identifying one or more cases per month. The specialties of general pediatrics, internal medicine, family practice, and obstetrics/gynecology reported the fewest number of significant fetal drug exposure cases. Of those physicians responding to this survey, 88% felt mildly to strongly that fetal medical histories underreported drug exposure. No significant differences emerged on chi-square analysis by scope of practice, age, or

Table 4. Analysis of physician perceptions and opinions regarding fetal drug exposure (scope of practice, age, gender)

Statement Fetal drug exposure is underreported in medical histories. Elimination of fetal drug exposure is important in the prevention of developmental delay and congenital malformations. Fetal drug exposure causes no significant problems. Efforts at decreasing fetal drug exposure require an over-utilization of time and resources. Decreasing fetal drug exposure may be a significant variable in the prevention of birth defects. Discussion of fetal drug exposure with parents raises parental anxiety and is of no positive benefit.

Scope" P value

Age P value

Gender P value

.903

.086

.472

.046

.143

.545

.705

.605

.867

.408

.975

.665

.283

.063

.227

.018

.148

.163

aScope of practice = general pediatrics, family practice, ob/gyn, neonatology, genetics,and neurology,

Physician perceptions • D. C. VANDYKEETAL. Table 5. Physician management styles for fetal drug exposures (% of physicians mildly to strongly agreeing with statement) Substance Heroin/Cocaine Take a maternaldrug history Obtain a social work consultation Refer to neonatal service File a child abuse report Refer to a high-riskinfant follow-up program Watch infant closely No intervention Coumadin Would counselthe pregnant woman myself Obtain ob/gyn consultation Obtain genetic consultation Obtain internal medicineconsultation No intervention Alcohol Would counsel pregnantwoman myself* Would obtain ob/gyn consultation Would obtain genetic consultation* Would refer pregnantwoman to alcohol treatmentprogram Would refer child to developmental center for evaluation Do nothing*

%

100 77 79 64 97 94 2

68 85 49 57 4 70--75 77 55-56 88 89 3--6

Smoking/Nicotine Would counselpregnantwoman myself Send mother to "smoke enders" clinic Obtain genetic consultation Obtain ob/gyn consultation Do nothing

84 81 16 67 6

Phenytoin Would counsel pregnantwoman myself Obtain neurologyconsultation Obtain ob/gyn consultation Obtain genetic consultation Do nothing for pregnant woman Refer child for developmentalevaluation

78 68 72 54 5 76

Isotretinoin Would counsel pregnantwoman myself Obtain ob/gyn consultation Obtain genetic consultation Do nothing

68 81 71 4

*Range of responses due to multiplequestions.

gender. Only 15% of all physician respondents indicated that fetal drug exposure was not a significant problem (Table 3). In general, the literature reflects the perception that decreasing drug exposure will have a small but important effect on the overall frequency of malformations. Eighty-three percent of respondents agreed with this perspective and felt that prevention of fetal drug exposure may play an important role in reducing the incidence of developmental problems and congenital malformations in children. Only 7% felt that efforts to decrease fetal drug exposure were of minimal benefit.

319

Chi-square analyses by scope, age, and gender showed that physician responses could be divided into two groups by scope of practice. The specialty areas of general pediatrics, internal medicine, family practice, and neurology (those who saw the l e a s t number of children with fetal drug exposure) agreed the most with this prevention statement. The specialty areas of genetics, obstetrics/gynecology, neonatology (those who saw the m o s t children with fetal drug exposure) were the least likely to agree that efforts to decrease fetal drug exposure are of minimal benefit. Chi-square analysis (Table 4) of statements three to six revealed no significant differences by scope, age, or gender, with the exception of statement six. In the analysis of statement six, obstetricians expressed significantly more concern (27%) than the other five groups (3% to 10%) that any discussion of fetal drug exposure might unduly increase parental anxiety and produce little positive benefit. Most physicians recognized the potential harm that can result from fetal drug exposure. Analysis of descriptive statistics by scope of practice of management styles showed a wide variation in practice styles but no definitive pattern. There was, however, a small group of physicians (less than 10%) who would do nothing because they either did not recognize potential problems or were non-interventional in their approach.

Acknowledgments -- We wish to thank Scott Lindgren, PhD, Mark

Wolraich, Mo, James Hanson, MD, and Andrew Brunskill, MaaS,MPr~, for professional critique, and Susan Eberly, M. Joan Soucek, and Margaret Adamek for editorial assistance. This work was supported in part by a grant from the Special Projects DevelopmentFund.

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