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Alcohol and Pregnancy

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Alcohol and Pregnancy Parental Substance Use and Neglect Sue Flynn and Gabby Bisson Drug Liaison Midwives Springfield Team WHY SPECIALIST SERVICE Ø To improve the provision of maternity/parenting services to drug and alcohol users in Leeds by improving the integration of available services. Ø Minimize late referral and emergency action. Ø Develop a proactive service. Ø Provide continual support and ongoing risk assessment for complex substance misusing families Ø To enable better parenting and harm reduction/ stabilisation of drug use in pregnancy and the postnatal period How abuse in infancy affects children u Babies under one are particularly vulnerable to abuse and neglect. One third of serious case reviews in England relate to babies under the age of 1 year (11). In England and Wales, babies are seven times more likely to be killed than older children (12). u Abuse has life-long impacts, and early adversity can cast a long shadow. Recent neurological and psychological research highlights more clearly than ever before how critical pregnancy and the first years are to a baby's development. They provide the essential foundations for all future learning, behaviour and health. Think Family Ø Think Family means securing better outcomes for children, young people and families with additional needs, by co-ordinating the support they receive from children’s, young people’s, adult’s and family services Ø Children are more susceptible to risk of harm where they are living with an adult who has one of the vulnerability factors listed below, the risk increases where more than one factor is present. Ø Children may be at increased risk of harm or in need of additional help in families where adults have Ø Mental health problems Ø Substance and alcohol misuse Ø Learning difficulties/complex needs Ø Domestic Violence (Working Together 2013 – HM Government) Substance Use & Pregnancy u Drug and alcohol misuse is a factor in a significant number of children in need and child protection cases. Research suggests alcohol is a factor in at least 33% of child protection cases, and drug and alcohol misuse is a factor in up to 70% of care proceedings. Parental substance misuse has been found to feature in 25% of serious case reviews. (Public Health England, 2013). Which Substances? EFFECTS IN PREGNANCY DUE TO ILLICIT DRUG USE u Withdrawal & over dosage u Amenorrhea u Infections/hepatitis/ HIV u Nutritional deficiencies u Respiratory u Thrombosis u Hypertension u APH EFFECTS ON BABY u Congenital malformations u IUGR u Prematurity u Functional development u Fetal distress u IUD u NAS HEROIN- SPECIFIC PROBLEMS u Not teratogenic u Low birth weight u Fetal distress u Withdrawal. The majority of symptoms appear within 24-48 hours after birth. u NAS u Affect the ability of mother to look after the baby u Increased SIDS. METHADONE SUBSTITUTION Ø Main treatment Ø Advantages § Stability § Long half life § Relieve social pressures § Allows assessment and life style changes Ø Disadvantages § Neonatal abstinence syndrome BUPRENORPHINE SUBSTITUTION Ø Advantages Ø Disadvantages § Stability § Lack of knowledge/ § Long half life experience § Allows life cycle § Difficulty in change initiating treatment § Possible reduction in incidence and/or severity of NAS. § Study by Jones et al 2010 concluded buprenorphine as acceptable treatment for opioid dependence in pregnancy & reduction in severity of NAS compared to methadone DIAGNOSIS, MANAGEMENT & TREATMENT OF NAS “Neonatal abstinence syndrome (NAS) continues to be a significant problem” Dryden et al (2009) WHAT IS NAS? Ø NAS is a generalised disorder characterised by signs and symptoms of central nervous hyperirritability, gastrointestinal dysfunction, respiratory distress and vague autonomic symptoms that include yawning, sneezing, mottling and fever. WHICH SUBSTANCES CAUSE NAS? Ø Opiates Ø ?Cocaine § Methadone Ø ?Amphetamines § Codeine Ø ?Cannabis § Bupernorphine Ø Benzodiazepines TREATMENT FOR NAS u PHARMACOLOGICAL Ø NURSING SUPPORT § Follow local § Light swaddling guidelines § Environment § Leeds policy - 2 § consecutive scores Noise reduction >8, start treatment § Decrease light § Feeding regime § 1ST line treatment § Use of pacifiers Ø - morphine sulphate § Skin care § 90% units using morphine as § Scratch mitts first line treatment § Ø 2nd line treatment Nappy care § Variety of agents used – phenobarbitone most frequent BREASTFEEDING Advantages. Disadvantages. Ø Development of Ø Chaotic drug use - mother/baby erratic doses for attachment. neonate. Ø Provision of Ø Culturally maternal unpopular. antibodies. Ø Thought to decrease neonatal withdrawal. COCAINE ADDICTION Ø Addiction is more psychological § chaotic lifestyle Ø No suitable substitute drugs Ø Binge use Ø Vasoactive drug § specific problems to the baby § placental abruption § direct fetal vascular effects § preterm labour COCAINE- NEONATAL EFFECTS Ø Hypertonia Ø Hyperactive startle reflex Ø Tachypnoea Ø Loose stools Ø Reduced sleep BENZODIAZEPINES Ø Stabilisation/ reduction § diazepam Ø Problems § cleft palate/lip § IUGR Ø Neonatal withdrawal § hypotonic § hypothermia § feeding difficulties § respiratory difficulties/apnoea Ø Delays onset of NAS CANNABIS Ø The effect of Cannabis in pregnancy is uncertain as it is commonly used with tobacco. Associated effects are: Ø Low birth weight Ø Irritability Ø Tremors Ø SIDS Which Substances? Alcohol in pregnancy Ø Maternal alcohol consumption can harm the developing fetus or the breastfeeding baby. Ø It is the nations leading preventable cause of developmental disabilities and birth defects. Other adverse health outcomes of maternal alcohol consumption u Infertility –alcohol misuse is associated with an increased risk of infertility and higher rates of menstrual disorders. u Increased risk of miscarriage u Pre-term delivery u Stillbirth u Antepartum haemorrhage u Placental abruption u IUGR u Prenatal alcohol exposure may be associated with an increased risk of sudden infant death syndrome (SIDS) u FASD/FAS The scale of the problem u According to the UK Health Survey 2015, 51% of women of childbearing age exceeded 4 units on at least one day in the last week and 42% drink more than twice that amount.(5) u Approximately 80,000 babies under 1 are living with a parent who is classified as a ‘hazardous or harmful’ drinker(6) u Approximately 31,000 babies are living with a parent who would be classified as a dependant drinker (6) u Alcohol misuse is considered to be an important risk factor in cases of injury and death due to co-sleeping.(7) u Data suggests that over 40% of pregnancies in the UK are unplanned (8,9) u Babyhood is a time of particular vulnerability as they are more likely to suffer abuse and neglect and are seven times more likely to be killed than other children (10) FASD u Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term for several diagnoses that are all related to prenatal exposure to alcohol. These are: o Fetal Alcohol Syndrome (FAS) o Partial Fetal Alcohol Syndrome (PFAS) o Alcohol Related Neuro-developmental Disorder (ARND) o Alcohol Related Birth Defects (ARBD) FAS u Alcohol is a teratogen, a toxic substance to a developing baby, and can interfere with healthy development causing brain damage and other birth defects. u Drinking heavily during pregnancy can cause a baby to develop fetal alcohol syndrome (FAS). FAS is a serious condition, in which children have: o restricted growth o facial abnormalities o learning and behavioral disorders, which are often life long. Executive functions Executive functions of the Effects of alcohol exposure prefrontal cortex related to executive function u Motivation u Need external motivators to complete menial tasks u Planning u Inability to apply consequences from past actions u Inhibition u Socially inappropriate behaviour u Problem solving u Inability to figure out solutions spontaneously u Sexual urges u Inability to control sexual impulses, esp. in social situations u Time perception u Difficulty with abstract concepts or time and money u Internal ordering u Difficulty processing information u Memory u Storing and/or retrieving information u Judgment u inability to weigh pros and cons when making decisions u Regulation of emotion u Moody roller-coaster emotions, exaggerated u Empathy u Diminished sense of remorse, inability to understand others u Self monitoring u Needs frequent cues, requires policing by others u Verbal self regulation u Needs to talk to self out loud, needs feedback Prevalence u The exact prevalence of Fetal Alcohol Spectrum Disorder (FASD) in the United Kingdom is not known. International prevalence studies in countries such as the United States, Canada, Australia, Finland, Japan and Italy state that at least 1 in 100 children are affected. This would equate to at least 6,000–7,000 babies born with FASD each year in the UK (cited NOFAS, 2017). u There is limited and inconsistent data on alcohol consumption during pregnancy but overall, alcohol consumption among women has declined over recent years but instances of heavy drinking remain high (BMA, 2016). Most women either do not drink alcohol (19%) or stop drinking during pregnancy (40%) {DoH, January 2016}. If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all in order to keep the risks to your baby to a minimum. Drinking in pregnancy can lead to long- term harm to the baby; with the more Department you drink the greater the risk. of Health The risk of harm to the baby is likely to (DoH) be low if a woman has drunk only small amounts of alcohol before she knew she Guidelines was pregnant or during pregnancy. Women who find out they are pregnant 2016 after already having drunk during early pregnancy, should avoid further drinking, but should be aware that it is unlikely in most cases that their baby has been affected (DoH, August 2016). Case Study PAST Ø 37 year old woman Ø Multiparous woman (5 children – none placed in her care) Ø Domestic violence Ø Poor engagement with all services Ø Sex working Ø Chaotic lifestyle Ø Minimal social support Ø Continued illicit drug use whilst on methadone medication Ø Debt problems Several years later she is pregnant again and presents at Forward Leeds.
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