FROM THE AMERICAN ACADEMY OF PEDIATRICS TECHNICAL REPORT Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus Marylou Behnke, MD, Vincent C. Smith, MD, COMMITTEE ON SUBSTANCE ABUSE, and COMMITTEE ON FETUS AND abstract NEWBORN Prenatal substance abuse continues to be a significant problem in this KEY WORDS country and poses important health risks for the developing fetus. The prenatal drug exposure, alcohol, nicotine, marijuana, cocaine, ’ methamphetamine, growth and development primary care pediatricians role in addressing prenatal substance fi ABBREVIATIONS exposure includes prevention, identi cation of exposure, recognition AAP—American Academy of Pediatrics of medical issues for the exposed newborn infant, protection of the THC—tetrahydrocannabinol infant, and follow-up of the exposed infant. This report will provide This document is copyrighted and is property of the American information for the most common drugs involved in prenatal expo- Academy of Pediatrics and its Board of Directors. All authors sure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphet- fi fl have led con ict of interest statements with the American – Academy of Pediatrics. Any conflicts have been resolved through amine. Pediatrics 2013;131:e1009 e1024 a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Substance abuse has been a worldwide problem at all levels of society The guidance in this report does not indicate an exclusive since ancient times. Attention has been directed toward the use of legal course of treatment or serve as a standard of medical care. and illegal substances by pregnant women over the past several Variations, taking into account individual circumstances, may be decades. Almost all drugs are known to cross the placenta and have appropriate. some effect on the fetus. The effects on the human fetus of prenatal All technical reports from the American Academy of Pediatrics cigarette use have been identified and studied since the 1960s,1 the automatically expire 5 years after publication unless reaffirmed, 2–4 revised, or retired at or before that time. effects of alcohol and opiate use have been studied since the 1970s, and the effects a variety of other illicit drugs have been studied since the 1980s.5–7 This report reviews data regarding the prevalence of exposure and available technologies for identifying exposure as well as current information regarding short- and long-term outcomes of exposed infants, with the aim of facilitating pediatricians in fulfilling their role in the promotion and maintenance of infant and child health. PREVALENCE www.pediatrics.org/cgi/doi/10.1542/peds.2012-3931 Prevalence estimates for prenatal substance use vary widely and have doi:10.1542/peds.2012-3931 been difficult to establish. Differences are likely attributable to such PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). things as the use of different sampling methods and drug-detection Copyright © 2013 by the American Academy of Pediatrics methods, screening women in different settings, and obtaining data at different points in time. For example, prevalence will vary depending on whether history or testing of biological specimens is used; whether the biological specimen is hair, urine, or meconium; and whether the specimens are merely screened for drugs or screened and confirmed with additional testing. There also will be differences depending on whether the sample being investigated is a community sample or a targeted sample, such as women who are in drug treatment or are incarcerated. Lastly, prevalence must be interpreted in light of the fact PEDIATRICS Volume 131, Number 3, March 2013 e1009 that the use of specific drugs waxes and cigarette use by pregnant and used for identification, methods of and wanes over time nationwide as nonpregnant women. An additional adulteration of the sample, and ana- the popularity of certain substances important finding from this survey lytical techniques, thus altering the changes. was that the rate of cigarette smoking sensitivity and specificity for each drug Although a variety of prevalence for those 15 to 17 years of age actually of interest. The most common analyt- studies have been conducted over was higher for pregnant women than ical method used for screening bi- the past 2 decades, there is 1 national for nonpregnant women (22.7% vs ological specimens is an immunoassay survey that regularly provides in- 13.4%, respectively). This report details designed to screen out drug-free formation on trends in substance many sociodemographic variables re- samples. Threshold values generally abuse among pregnant women. The lated to drug use in the American are set high to minimize false-positive National Survey on Drug Use and population, and the reader is referred test results but may be too high to Health (formerly called the National to the Substance Abuse and Mental detect low-dose or remote exposure. Household Survey on Drug Abuse), Health Services Administration Web Because immunoassay is a relatively sponsored by the Substance Abuse site for the full report (http://www.oas. nonspecific test, positive results re- and Mental Health Services Adminis- samhsa.gov/nhsda.htm). quire confirmation by using gas tration (http://www.oas.samhsa.gov/ chromatography/mass spectrometry. nhsda.htm), is an annual survey pro- IDENTIFICATION OF PRENATAL In addition, confirmation of the presence viding national and state level in- EXPOSURE of a drug is not always associated with formation on the use of alcohol, Two basic methods are used to identify drug abuse. Alternative explanations in- tobacco, and illicit drugs in a sample drug users: self-report or biological clude passive exposure to the drug, in- of more than 67 000 noninstitu- specimens. Although no single ap- gestion of other products contaminated tionalized people older than 12 years. proach can accurately determine the withthedrug,oruseofprescription Data are combined into 2-year epochs presence or amount of drug used medications that either contain the drug and include reported drug use for during pregnancy, it is more likely that or are metabolized to the drug.14 Thus, pregnant women between the ages of fetal exposure will be identified if careful patient histories remain essen- 15 and 44 years. Current illegal drug a biological specimen is collected tial to the process of identification. use among pregnant women re- along with a structured interview.8 The 3 most commonly used specimens mained relatively stable from 2007– Self-reported history is an inexpensive to establish drug exposure during the 2008 (5.1%) to 2009–2010 (4.4%). and practical method for identifying prenatal and perinatal period are These average prevalence rates are prenatal drug exposure and is the only urine, meconium, and hair; however, significantly lower than reported method available in which information none is accepted as a “gold standard.” current illicit drug use rates for non- can be obtained regarding the timing Urine has been the most frequently pregnant women (10.9%). Importantly, of the drug use during pregnancy and tested biological specimen because of the rate of current drug use among the amount used. Unfortunately, self- its ease of collection. Urine testing the youngest and possibly the most report suffers from problems with identifies only recent drug use, be- vulnerable pregnant women was the veracity of the informant and recall cause threshold levels of drug highest (16.2% for 15- to 17-year-olds, accuracy.9,10 Histories obtained by metabolites generally can be detected compared with 7.4% among 18- to 25- trusted, nonjudgmental individuals or in urine only for several days. A no- year-olds and 1.9% among 26- to 44- via computerized survey forms; ques- table exception to this is marijuana, year-olds). Table 1 summarizes these tions referring back to the previous the metabolites of which can be ex- data along with information regarding trimester or prepregnancy usage, not creted for as long as 10 days in the current alcohol use, binge drinking, current use; and pregnancy calendars urine of regular users15 or up to 30 TABLE 1 Comparison of Drug Use Among used to assist recollection each im- days in chronic, heavy users. Urine is Women 15 to 44 Years of Age by prove the accuracy of the information a good medium as well for the de- Pregnancy Status: 2009–2010 obtained.11–13 tection of nicotine, opiate, cocaine, Pregnant Nonpregnant Several biological specimens can be and amphetamine exposure.16,17 Women, % Women, % used to screen for drug exposure. Each Meconium is also easy to collect Illicit drug use 4.4 10.9 Alcohol use 10.8 54.7 specimen has its own individual var- noninvasively. It is hypothesized that Binge drinking 3.7 24.6 iations with regard to the window of drugs accumulate in meconium through- Cigarette use 16.3 26.7 detection, the specific drug metabolites out pregnancy, and thus, meconium is e1010 FROM THE AMERICAN ACADEMY OF PEDIATRICS FROM THE AMERICAN ACADEMY OF PEDIATRICS thought to reflect exposure during the laws required the reporting of women major structural development is second and third trimester of preg- who used drugs during pregnancy to complete, drugs have more subtle nancy when meconium forms. How- the legal system through states’ child effects, including abnormal growth ever, use of meconium to determine the abuse statutes. In 2003, the Keeping and/or maturation, alterations in timing or extent of exposure during Children and Families Safe Act (Public neurotransmitters and their recep- pregnancy is controversial18 because of Law 108-36) was passed by Congress, tors, and brain organization. These are alackofstudiesregardingtheeffects requiring physicians to notify their considered to be the direct effects of of the timing and quantity of the post- state child protective services agency drugs. However, drugs also can exert partum specimen collection as well of any infant identified as affected by a pharmacologic effect on the mother as the effects of urine or transitional illegal substances at birth or experi- and, thus, indirectly affect the fetus.