Babies, Addicted and Drug-Exposed

Addicted babies are infants who are born physically dependent on drugs because of drug use by the mother during her pregnancy. Doctors consider babies addicted if they have a high level of exposure to drugs before birth. Each year in the United States some 320,000 babies are born exposed to alcohol and illegally used drugs while in the uterus, or in utero. A far larger number have been exposed in utero to sedatives and nicotine. Since the 1970s, an increasing number of women have begun to use both legal and illegal drugs. As a result, society is more aware of the problem of drug-exposed babies.

Drug-addicted women often use more than one substance at a time. Use of multiple drugs includes depressants (alcohol, marijuana, opioids such as heroin and methadone, and tranquilizers) and stimulants (cocaine and nicotine). The drugs are carried in the mother's blood across the placenta to the fetus. The baby's condition at birth depends on the substance the mother used, how much she used and how often, and the time between last use and delivery. The most severe withdrawal occurs in infants whose mothers have taken large amounts of drugs for a long time.

The Effects of Depressants

Infants exposed to heroin and other opioids suffer from the following problems:

• withdrawal in 55 to 94 percent of cases
• slowed growth rate in the uterus
• low birth weight
• premature birth

Premature birth or low birth weight can lead to such complications as immature lungs, difficulties in breathing at birth, bleeding in the brain, low sugar and calcium levels, infections, and jaundice. Low-birth-weight infants account for a large number of infants who test as mentally retarded (I.Q. of 70 or below), as well as children who have great difficulty in school because they are poor learners. In addition, low-birth-weight infants have an increased incidence of cerebral palsy and malformations that lead to death.

If the mother has used a large dose of a depressant drug (e.g., alcohol, any number of sedative-hypnotics, or heroin) immediately before delivery, the newborn, or neonate, may have difficulty breathing and may require resuscitation . If the mother has used one of these drugs regularly during pregnancy, the baby may have the following problems:

• neonatal withdrawal syndrome, with symptoms of irritability, tremors (shaking), and increased muscle tone
• nervous system irritability, which might include inconsolable fussiness and crying, involuntary twitching, excitability, and severe startling to sounds and movement
• gastrointestinal disorders that lead to poor feeding, vomiting, and diarrhea
• extreme difficulty with feedings because of a poor sucking reflex, leading to malnutrition , dehydration , weight loss, and, if symptoms go untreated, shock, coma, and death
• high-pitched crying
• difficulty in sleeping
• sneezing, sweating, yawning, nasal stuffiness, rapid breathing, and seizures

With heroin, the baby's withdrawal generally occurs within forty-eight hours of birth. With methadone, a longer-acting drug, the withdrawal can happen a bit later. In the withdrawal of alcohol-exposed infants, seizures are more likely to occur.

Sudden Infant Death Syndrome (SIDS). Sudden infant death syndrome is defined as the sudden and unexpected death of an infant between one week and one year of age. The infant's death remains unexplained after an autopsy , a full history of the child and family, and an investigation of the death site. Infants exposed to drugs appear to have an increased risk of SIDS, because drug-using groups share many other high-risk factors for SIDS. These include poverty, low birth weight, young age of the mother at the time of giving birth, black racial category, and maternal smoking. So the cause of higher rates of SIDS might not be the drug use itself but instead other factors, such as poverty or the young age of the mother, that typically go along with drug use. In an extensive study of New York City SIDS rates, mothers who used opioids such as heroin had a three to four times greater risk of losing an infant to SIDS than did the general population.

The Effects of Stimulants

Expectant mothers who use stimulants such as cocaine and nicotine also put their newborns at risk.

Cocaine. Cocaine exposure in utero produces a chain of responses:

• constriction of blood vessels that deliver oxygen to the fetus
• decrease of oxygen delivery to the fetus
• neonatal stroke as a result of oxygen deprivation

Cocaine-exposed babies may suffer from growth problems and abnormal organ development and have an increased risk of brain hemorrhage and SIDS. Infants who were exposed to cocaine shortly before birth often appear less alert and less responsive to external stimuli, such as faces, voices, bells, lights, and rattles, than normal newborns. Babies exposed to cocaine in utero have an increased chance of language problems as they mature, and they may also show unusual behaviors, such as an inability to play, unresponsive moods, and difficulty paying attention.

Nicotine. Prenatal exposure to smoking is harmful in several ways. Carbon monoxide and high doses of nicotine obtained by inhaling tobacco smoke can reduce the oxygen supply to the fetus. This loss of oxygen may interfere with the development of the central nervous system. A child who was exposed to nicotine in utero may then have problems with:

• memory
• learning
• understanding

Other problems include:

• damaged respiratory system of the fetus
• respiratory illness in the infant
• low birth weight

Even passive smoking—that is, from the father or another person in the vicinity of the mother—seems to affect an infant's weight. The weight of newborns whose mothers smoked is on average 200 grams less than those with nonsmoking mothers. Heavy smokers are at the greatest risk for low-birth-weight babies. Women who stop smoking in pregnancy prevent the full effects of low birth weight, and studies have shown that the earlier a woman stops smoking during pregnancy, the lower the risk of a low-birth-weight baby.

One of the most dangerous risks of prenatal smoking is SIDS. A higher mortality rate exists for infants whose mothers have smoked compared to those who have not. The risk of SIDS is also greater among infants exposed to both prenatal and postnatal smoking compared to those only exposed to postnatal smoking. The greater the exposure to smoke both before and after birth, the higher the risk of SIDS.

Managing the Problem

Pregnant women with a drug addiction often stay away from medical facilities for fear of getting in trouble with authorities. Often they do not get badly needed prenatal care. Solving this major health problem requires that drug-treatment programs be designed to meet the specific needs of women.

Once a drug-addicted expectant mother seeks medical care, medical personnel should obtain a thorough alcohol and drug history from her. They should also test the urine of both mother and newborn for alcohol and other drugs. Newborns should be closely monitored for signs of withdrawal for a minimum of forty-eight to seventy-two hours, and longer when the mother has been on methadone -maintenance treatment. Because symptoms of withdrawal can be confused with a variety of infections or other medical problems, doctors and nurses should look for other simultaneous illnesses to explain any symptoms.

Most hospital nurseries use a standard scoring system to determine whether a baby is in withdrawal. After the infant is born the hospital monitors the baby's sleep habits, temperature, and weight. If the newborn exhibits withdrawal symptoms, the infant is treated with intravenous fluids, swaddling, holding, rocking, a low-stimulation environment, and small feedings of a special formula with a high calorie count to help the baby gain weight. If symptoms continue or increase, the baby may need medication to calm and sedate its irritable nervous system until the effects of withdrawal pass. Common medications include paregoric, phenobarbital, and diazepam.

Medical personnel must also question the mother of an infant with withdrawal symptoms to get a sense of the home environment. Addicted babies are often at high risk for either abuse or neglect or both. Normal bonding between mother and infant is difficult when the baby is irritable and unresponsive because of exposure to drugs. Irritability, poor feeding, inability to sleep regularly, and sweating may persist for three to four months. The mother may be feeling guilty and critical of herself, making bonding even more difficult. She may be poor and have inadequate housing as well as an abusive or absent partner or parent. In such cases health-care workers must contact child protection services, asking them to intervene to take steps to make sure the newborn is safe.

Some medical professionals and others involved in the care of addicted babies feel that separating them from their addicted mothers is the best course of action. But this solution may not be practical in cities where social services and courts are already understaffed and overworked. Decent foster care is expensive and hard to find. In general, pediatricians feel that mothers and infants should not be separated except in extreme situations. In addition to drug rehabilitation and medical treatment, these women need education, job training, outpatient care, and counseling to become productive citizens and loving mothers.

Outcome

Given the medical complications, the lack of prenatal care, and the prematurity of the infants at delivery, it is not surprising that the death rate for addicted babies is higher than for infants born to nonaddicts. The outcome for addicted babies depends on any permanent medical conditions resulting from addiction. It also depends on the quality of care the baby receives after leaving the hospital. After babies born with an addiction have been sent home, long-term follow-up on their care and development is very difficult. In some cases the effects of drug exposure on a child may not become apparent for many months or years.

The drug-addicted mother's lifestyle is often characterized by poverty, poor nutrition, violence, and prostitution, any or all of which may result in a high risk for medical problems. Needle use may cause the mother to become infected with hepatitis B and HIV. These conditions create a chaotic and potentially dangerous environment for babies and children. The mother will have great difficulty caring for an infant when she herself is in great need of care.

Methadone-maintenance programs for heroin-addicted mothers generally offer medical and social services to help new mothers cope with the effects of addiction. Although the mother continues to be addicted, these programs contribute to the improved outcome seen in their babies.

Babies born with drug exposure and addiction require ongoing special attention from doctors, schools, community organizations, and government agencies to ensure that they reach their highest potential.

see also Cocaine; Fetal Alcohol Syndrome (FAS); Gender and Substance Abuse; Heroin; Nicotine.