Office of the Child’s Representative
December 16, 2015
2015 Colorado Drug Endangered Children
Kathryn Wells, MD, FAAP Medical Director, Denver Health
Clinic at the Family Crisis Center
Associate Professor, University of
Colorado Department of Pediatrics
Co-Chair, Substance Exposed
Newborns Subcommittee, Colorado
Substance Abuse Trend and Response
Task Force
Jade Woodard Executive Director
Colorado Alliance for Drug
Endangered Children
Prevent Child Abuse Colorado
• Prenatal Exposure &
Breastfeeding
• Caregiver impairment
• Environmental exposure
• Grows/Manufacturing:
Toxin/chemicals/molds
exposure risk
A woman with an addiction who got
pregnant
Desperately wanting a healthy baby
Consumed with guilt
Hypersensitive to signs of withdrawal
Accustomed to disrespect & disdain
Grateful to anyone who treats her
with respect & dignity
Incentive to quit
Added stress
A short time to change
behavior, social life
and relationships
Difficult
Compounded by everyday life stresses
Profoundly affected by mega-stresses of poverty
Complicated and includes:
• Many attempts before someone is successful
• Relapse, back slides and “false starts”
• Commitment that varies from moment to moment
Legal: alcohol, marijuana, tobacco
Illegal: heroin, cocaine, methamphetamines, etc.
Prescription Drugs: narcotics, barbiturates, psychotropics, and amphetamines
Poly-substance use
Wide SPECTRUM of use and abuse
Little data exist on the extent of the problem and successful approaches to address it
Fear of criminal prosecution and child welfare reduces utilization of medical and treatment resources
Need early identification to reduce risks to the infant and enhance success
Social stigma for mothers and families
Fear
Unreliability of mothers’ self-reports
Lack of uniformity in hospital policies and procedures for screening, testing, referrals
Limitations of toxicology testing techniques
• Pregnant women use Alcohol and Other Drugs (AOD)
less than non-pregnant women of their same age
• Except, pregnant teens aged 15-17yrs use AOD
more than non-pregnant teens
• Substance use decreases throughout pregnancy
• Substance use rebounds by 3 months after delivery
and continues to increase
SAMHSA, 2010; AAP. Peds 129:e540,2/2012
Effects are variable -- on mother, baby or both
Alcohol is most dangerous to fetal brain & body
Smoking affects largest numbers (easiest to study)
Illegal drugs – data are often confounded by poly-
substance use, poverty, violence, genetics, etc.
Good home environment helps
No Safe Amount of Drugs or
Alcohol During Pregnancy
Peds 129:e540/2/2012
Infections such as HIV, tuberculosis, hepatitis, syphilis, endocarditis, pulmonary infections
Mental health problems, violence, depression
Poor nutrition due to alcohol and other drugs
Heart problems from cocaine, amphetamines, alcohol
Lung problems from inhalants such as marijuana and tobacco
Liver cirrhosis from solvents (huffing), alcohol
Kidney problems due to heroin
Complications of Pregnancy, Labor and Delivery
Effects on baby differ with different exposure patterns:
• When in pregnancy
oMajor birth defects occur in first 3 months
oBrain damage & poor growth occur throughout
• How much
• How often
• How taken
Small babies
Prematurity
High bilirubin/jaundice
Low blood sugar
Drug Withdrawal
Syndrome
oPhysical Dependence
Meconium aspiration
Other breathing
problems
Infections
Increased risk of death
• Associated increased
risk of SIDS (?)
• Associated risk of
positional overlay
• Associated risk of very
premature birth and
severe complications
• Studies limited and inconsistent
• More likely to show gaps in problem-solving skills, memory, and ability to remain attentive
• More research needed to separate drug-effect from environmental effects
Difficulties with attention, self-regulation, decision-
making and cognition
Risk of maltreatment and impaired attachment may
require Child Welfare involvement
School problems and employment failure
Behavioral, mental health, substance abuse problems
Significant societal and financial costs
Early Diagnosis is protective
Streissguth. J Dev Behav Pediatrics 2004 25:228
• Names: pot, grass, reefer, weed, herb, Mary Jane, or MJ
• Greenish-gray mixture of the dried, shredded leaves,
stems, seeds, and flowers of Cannabis sativa
• Contains over 600 chemicals, about 70 of which are
cannabinoids
• THC: Psychoactive, mind-altering effect
• CBD: Therapeutic, sedative effect
Inhalation
Smoked
Vaporized
Ingestion
Food
Drink
Topical
Lotions
Oils
• Topicals are NON-psychoactive
• Raw plant is NON-psychoactive
• Must heat plant material to temperature that
releases active ingredients in THC
• Eating cannabis is not the same as smoking it
Edibles Serving Size = 10mg Retail Limit = up to 100 mg Medical Limit = N/A Onset = 30 min to 4 hour
Smoking 5mg= 2 hits on a joint 35mg= an entire joint 130mg= an eighth ounce Onset = Instant
Products Baked Goods – Brownies, Cookies, Cakes, Pies, Granola Bars, Pastries, Nut Clusters Bulk Foods – Cereal, Granola, Trail Mix, Nuts, Popcorn, Crackers, Baking Mixes Chocolate – Bars, Truffles, Candy Coatings Liquid – Cooking Oil, Coffee, Juice, Tea, Soft Drinks, Sauces (Marinara, Wing, Tapenade) Pills – Capsules, Pressed Pills Hard Candy – Suckers, Lozenges Soft Candy – Gummies, Chocolate Chews, Fruit Chews, Licorice, Taffy
• Hundreds of hybrid strains of varying strengths
• THC Levels 1983: 4% average
• THC Levels Today: 9-12% average
• As high as 29% advertised
• 121% increase from 1999 to 2010
• THC content/potency has been steadily increasing over the past
30+ years
• Concerns that consequences could be worse than in the past,
especially among new users or in young people with developing
brains
• Do not know all consequences to the brain and body
• 4-5% of women use marijuana during pregnancy (estimates
range from 2.5 to 27%)
• 60% of cannabis users continued to use ~10 joints/week
throughout pregnancy (60-70% of the level of use the year
before)
• Many women reporting cannabis use for nausea and vomiting
during pregnancy
• Frequently used as part of a poly-drug regimen
• Studies are difficult to find on use of marijuana
alone – under-recognized problem
• Pharmacology is worrisome because THC is a
lipophilic molecule and can be stored for long periods of
time in organs with high amounts of lipids (e.g. the brain)
• Animal research suggests that the body’s endocannabinoid
system plays a role in control of brain maturation, particularly
in the development of emotional responses
• Concern that even low concentrations of THC during prenatal
period may have profound and long-lasting consequences for
the brain and behavior
• Highest level of evidence available longitudinal cohort studies - OPPS Study, MHPCD Study, Generation R Study
• Conflicting results on: • Differences in birth weight and birth length from marijuana
• Neonatal development
• Infant behavior – lower memory functioning and verbal scores
• Child behavior – consistent significant impact as a result of prenatal exposure – more impulsivity and hyperactivity, inattention, detrimental affect of intellectual development, delinquency, problems in abstract and visual reasoning, depressive symptoms
Most common among heavy cannabis users ~ 1 or more joints per day
• There is no known safe amount of marijuana during pregnancy
• THC can pass from mother to the unborn child through the
placenta
• The unborn child is exposed to THC used by the mother
• Maternal use of marijuana during pregnancy is associated with
negative effects on exposed children that may not appear until
adolescence
• The most negatively affected are academic ability, cognitive function and
attention, which may not become evident until adolescence when these
typically develop
• There are negative effects of marijuana use during pregnancy
regardless of when it is used during pregnancy
• Limited data
• Rapidly transmitted into breast milk in moderate amounts and remains there for longer time
• Relative Infant Dose 0.8%
• Milk:plasma ratio is 8:1 (chronic, heavy users)
• Animal studies show could inhibit lactation
• Infants may test positive in urine screens for 2-3 weeks
Clinical data suggests marijuana use during breastfeeding
may be dangerous for the infant
◦ THC is excreted in breast milk
◦ Decrease in Infant Motor & Psychomotor Development
Impact varies based on regular vs. occasional use
Infants should be closely monitored
AAP Statement: Breastfeeding is contraindicated for
women using marijuana
CDPHE Statement: THC can also be passed from the
mother’s breast milk, potentially affecting the baby.
SOURCE: Aurelia, G, et al, Journal of Toxicology, 2009
• Use occurs in about 1% of women – rarely used alone
• Constricts blood vessels reducing blood flow to the fetus and diminishing oxygen supply and nutrients
• Fetal anomalies
• CNS abnormalities
• Intestinal abnormalities
• Urogenital system abnormalities
• Malformations of extremities
• May have periods of extreme heart rate variability
• High rate of spontaneous abortion and placental abruption
• Increased rate of premature rupture of membranes, early onset of labor and preterm delivery
• Common knowledge on the streets – may attempt self-induced abortions
• Birth outcomes improve if mother stops drug in the last 3 months of pregnancy – damage to vessels is non-reversible
• Increased risk for IUGR
• Neurobehavioral symptoms - jittery, high-pitched cry, startle at mild stimulation
• Abnormal sleep, poor feeding, tremors and increased muscle tone – attributed to direct effects
• Deficits in ability to habituate or self-regulate, especially under stressful conditions
• May have increased risk for SIDS
• Behavior problems
• Small changes in
IQ, language
abilities, executive
functioning,
impulse control
and attention
• Effects from direct effects on neurotransmitter
systems, vasoconstrictive effects, and fetal
programming (altered expression of genes and
gene networks)
• MRI studies contributed to understanding of
brain effects
• Longitudinal studies with careful control of other
factors need to be done
• May cause
tremulousness,
irritability, startle
responses and other
neurobehavioral
abnormalities
• May even cause
seizures
Very little information
Studies ongoing
Similar to cocaine exposure
Many challenges
• Very similar to cocaine but not as studied
• Increased heart rate in fetus and constriction of blood vessels causing elevated blood pressure
• Increased maternal blood pressure resulting in premature delivery or spontaneous abortion
• Restriction of fetal development due to decreased blood flow
• Considerable transfer of meth to fetal blood where it may remain in fetal circulation longer than in maternal blood
• Newborns may be sleepy and lethargic for the first few weeks, to the point of not waking to feed
• After the first few weeks, behave similar to cocaine-exposed infants
• Later on may have aggressive behavior and poor school performance by 7-8 years of age
Women who use methamphetamine and/or cocaine in
the first trimester are more likely to use during the
third trimester
Nicotine use is universal among drug using pregnant
women
Marijuana and alcohol are secondary drugs, used in
60% of the group
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
Further evaluation of study revealed that methamphetamine use does diminish during pregnancy
However, a substantial proportion of users had consistently high or increasing use
Those that decreased use had a higher incidence of polydrug use
Newborn to 4 Weeks (I)
(Dopamine Depletion Syndrome)
Lethargic – Excessive sleep period
Poor suck and swallow coordination
Sleep apnea
Poor habituation
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
4 weeks to 4 months (II)
Symptoms of CNS immaturity – effects on motor
development
Sensory integration problems – tactile, defensive,
texture issues
Neurobehavioral symptoms – interaction social
development
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
6 months to 18 months (III)
The Honeymoon Phase
Symptom-free period
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
18 months to 5 years (IV)
Sensory integration deficit (same as II)
Less focused attention
Easily distracted
Poor anger management
Aggressive outbursts
(Source: Dr. Rizwan Shah, Blank Children’s Hospital, Des Moines, IA)
Methamphetamine –
Effects on the Growing Child
Too early to know
Behavior problems
Small changes in IQ and language abilities
Later on may have aggressive behavior and poor school performance by 7-8 years of age
Methamphetamine –
Brain Effects
3 MRI studies – small sample sizes
Studies suggest methamphetamine may have a neurotoxic effect on developing subcortical brain structures and prefrontal-striatal circuitry involved in attention and memory
Very recent study suggests that striatal and limbic structures may be more vulnerable to prenatal methamphetamine than alcohol exposure and that more severe striatal damage is associated with more severe cognitive deficit
Methamphetamine –
Effects on Breastfeeding
May cause tremulousness, irritability, startle responses and other neurobehavioral abnormalities
May even cause seizures
• Few cases reported in the media
• Arizona 2002 – breastfeeding infant died from
Methamphetamine overdose
• California 2003 – breastfeeding infant
• California 2011 - current case - ? Breastfeeding
infant
• Heroin, other street narcotics:
• Low birth weight due to symmetric IUGR or prematurity
• Meconium aspiration – fetal distress due to placental insufficiency
• Effects due to mother’s behavior
• Lack of prenatal care
• Poor nutrition
• Medical problems
• Abuse of other drugs
Methadone in a Treatment Program
Eliminates most adverse maternal
factors
Usually normally grown
Significant Neonatal Abstinence Syndr.
• Occurs in 60-80% of heroin-exposed infants
• Onset within 70 hours of birth
• Lasts 2-3 weeks to 4-6 months, even as long as a year
• Involves central nervous system
• Irritability, hyperreflexia, abnormal suck, and poor feeding
• Seizures in 1 – 3%
• GI symptoms include diarrhea and vomiting
• Respiratory signs include tachypnea, hyperpnea, and respiratory alkalosis
• Autonomic signs include sneezing, yawning, lacrimation, sweating and hyperpyrexia
• Subacute withdrawal with symptoms such as
restlessness, agitation, irritability, and poor
socialization that may persist for 4 – 6 months
• Association between SIDS and intrauterine exposure to
opiates
• Delayed physical growth, neurologic performance, and
cognitive development
• Poor weight gain during the first month of life
• Later in life have difficulties with decreased attention
span
• Creates a vulnerability in infants that makes them
more susceptible to poor environments, with subsequent
poor developmental outcomes
Binge drinking females (> 4/episode) - National
• Highest among white and income >$75K
(can afford to “party” on weekends; may
underestimate risk of unintended pregnancy)
SAMHSA, National Survey on Drug Use and Health, 2011
“Of all the substances of abuse (including cocaine,
heroin, and marijuana), alcohol produces by far
the most serious neurobehavioral effects in the
fetus.”
[Blending Perspectives and Building Common Ground, A Report to Congress on Substance Abuse and Child Protection, April 1999]
• Alcohol and its primary metabolite acetaldehyde, are directly toxic to the developing embryo and fetus
• Interferes with the delivery of maternal nutrients
• Impairs supply of fetal oxygen
• Deranges protein synthesis and metabolism
• Stimulates excess production of certain hormones (prostaglandins) that modulate cellular functions of the body and could cause fetal malformations
• Increased obstetrical complications: vaginal bleeding, placental abruption, fetal distress
• Associated with high rates of spontaneous abortion, miscarriage, and stillbirth
• Risk for spontaneous abortion is dose related:
• If averaging 3 or more drinks a day – more than 3 times more likely to miscarry than non-drinkers
• Even those who consume one or two drinks a day are at increased risk of miscarriage during the second trimester
• Most consistent effects: low birth-weight and
intrauterine growth retardation (IUGR) – more
severe in women who drink heavily during the last
3 months of pregnancy
• IUGR increases risks for infant’s early death and
for respiratory difficulties, feeding problems,
serious infections, and long-term developmental
problems
Heavy drinking (avg of 5 drinks/day)
• Alcohol withdrawal: tremors, abnormal muscle
tension (hypertonia), restlessness, sleeping
problems, inconsolable crying, and reflex
abnormalities
• Decreased ability to tune out inappropriate stimuli
• Poor sucking abilities
• Disturbed patterns of sleep and wakefulness
• Umbrella term that describes the range of effects
that can occur in an individual whose mother drank
during pregnancy
• Effects may be lifelong:
• Physical
• Mental
• Behavioral and/or
• Learning disabilities
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
• Not a diagnostic term used by clinicians
• Refers to:
• Fetal alcohol syndrome (FSD) including partial FAS
• Fetal Alcohol Effects (FAE)
• Alcohol-related neurodevelopmental disorder
• Alcohol-related birth defects
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
1. Prenatal maternal alcohol use
2. Growth deficiency
3. Central nervous system (CNS) abnormalities
- Structural
- Neurologic
- Functional
4. Dysmorphic features
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
1. Prenatal maternal alcohol use
- Confirmed
- Unknown
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
2. Growth deficiency
- Confirmed prenatal or postnatal height or
weight, or both, at or below the 10th percentile
- Documented at any one point in time
- Adjusted for age, sex, gestational age, and race
or ethnicity
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
3. Central nervous system (CNS) abnormalities
- Structural – head circumference at or below the 10th percentile adjusted for age and sex or clinically significant brain abnormalities observable through imaging
- Neurologic – neurologic problems not due to postnatal insult or fever or other soft neurologic signs outside normal limits
- Functional – global cognitive or intellectual deficits representing multiple domains of deficit
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
4. Dysmorphic features – all 3 features must be
present:
- Short palpebral fissures
- Indistinct philtrum
- Thin upper lip
(Source: SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder)
(Journal Alcohol Health and Research World, Vol. 18, No. 4, 1994)
Permanent brain damage
Growth problems
- Underweight
- Small head
Heart and kidney defects
Long-term behavior
problems
• At least 50,000 infants annually (3-5 in
1,000)
• Includes the behavioral and developmental
problems without the facial features
• Same concentration in
breast milk as in blood -
rapidly transmitted but is
diluted with body water
• Infant’s blood alcohol
content is usually much lower
than mom’s
Risks not well defined
Effects directly related to the amount the mother
ingests
When the breastfeeding mother drinks occasionally or
limits her consumption to one drink or less per day, the
amount of alcohol her baby receives has not been
proven to be harmful
Passes freely into mother's milk, peaks about 30 to 60
minutes after consumption (60 to 90 minutes when
taken with food)
Excess levels may lead to drowsiness, deep sleep,
weakness, and decreased linear growth in the infant
Chronic or heavy consumers of alcohol should not
breastfeed
Source: La Leche League's The Womanly Art Of Breastfeeding;
La Leche League's The Breastfeeding Answer Book
• Prenatal Exposure &
Breastfeeding
• Caregiver impairment
• Environmental exposure
• Grows/Manufacturing:
Toxin/chemicals/molds
exposure risk
FEBRUARY 3, 1997 VOL. 149 NO. 5
SPECIAL REPORT
FERTILE MINDS FROM BIRTH, A BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING
CONNECTIONS THAT MAY SHAPE A LIFETIME OF EXPERIENCE. THE FIRST
THREE YEARS ARE CRITICAL
BY J. MADELEINE NASH
“Symbiotic Oneness”
8.3 million (12% of U.S. children) live with at least one
parent who is alcoholic or in need of substance abuse
treatment.
National Survey on Drug Use and Health Report 4/16/2009
Have poorer developmental
outcomes (physical, intellectual,
social and emotional)
3X more likely to experience
physical, verbal, or sexual
abuse
4X more likely to be neglected
3 to 8X greater risk for
substance abuse themselves
CASA Columbia, 2005
Substance Abuse Affects Parenting
Pediatrics 2009, 124:285; CASA Columbia, April 1999
Impaired attachment
Impaired judgment and priorities
Inability to provide the consistent
care, supervision, necessities, and
guidance children need
Substance abuse is a critical
factor in ~7 out of 10 child
welfare cases
Impaired Caregivers
◦ Lack of Supervision
◦ Lack of Necessities
◦ Abuse or Neglect
Injurious Environment
◦ Access to Marijuana/Edibles
◦ Access to Paraphernalia
◦ Cultivation Aspects
• Prenatal Exposure &
Breastfeeding
• Caregiver impairment
• Environmental exposure
• Grows/Manufacturing:
Toxin/chemicals/molds
exposure risk
Drug Routes of Entry
Ingestion – most common - hand to mouth behavior, lack of discretion in ingestion
Inhalation – smoking, growing
Absorption – no warning
Contact – skin and eyes
Puncture – chemical injection
• Short-Term
• Similar to adults, but children are not just “small
adults”
• Symptoms occur at lower doses
• Long Term
• Unknown
• Boros et al, 1996
- 2 cases of cannabis-induced coma following accidental ingestion of
cannabis cookies
• Macnab et al, 1989
- British Columbia’s Children’s Hospital
- 6 children in 4 years with cannabis toxicity
• 3 presented in coma, including one with airway obstruction
• Appelboem and Oades, 2006
- Reviewed total of 9 cases reported to date
- Youngest recorded case was of an 11-month-old girl
• Amirav et al, 2010
• Case of 18 month old child who presented in coma after ingestion of
cannibis
Colorado cases
Retrospective chart review October 2009 - March 2010 for patients less than 5 year of age with marijuana ingestion
5 cases identified – 10 months to 4 years
4/5 had medical marijuana card
All presented to ER with abnormal neurologic exams with lethargy, somnolence and one with bradycardia
Source: GS Wang, et al, Child Abuse & Neglect 35 (2011) 563-565.
Colorado Children’s Hospital reports an increase in treatment of
children (8 mo - 12 yr) for unintentional exposure to marijuana
◦ 2005 – 2009: 0 marijuana exposures
◦ 2009 – 2011: 14 marijuana exposures
8 of the exposures were from medical marijuana
7 of the exposures were from marijuana-infused food products
8 admitted, 2 admitted to the pediatric intensive care unit
Symptoms
◦ 9 had lethargy
◦ 1 had ataxia
◦ 1 had respiratory insufficiency
Source: Pediatric Marijuana Exposures in a Medical Marijuana State; GS
Wang, G Roosevelt, K Heard; JAMA Pediatrics, July 2013; 167;7;630-633
Rocky Mountain Poison Drug Control centers report :
2006–2008 = average # of exposures for ages 0 to 5 = 4 per year
◦ 7% of all marijuana exposures children 0 – 5 = 2x the national average
2009–2012 = average # of exposures for ages 0 to 5 = 12 per year
◦ 16.2% of all marijuana exposures children 0 – 5 = 3x the national average
Arizona study
18 kids aged < 13 years
Confirmed oral methamphetamine poisoning
Drugs left out in easy access to kids
Agitation (9), inconsolability (6), increased heart rate (18), abdominal pain, vomiting (6), seizures, muscle breakdown, fever (1), ataxia (1)
Treatment included CT head (5), spinal taps (3), Spider (Centruroides sculpturatus) Antivenom (3)
Anaphylaxis to antivenom (1)
(Kolecki, 1998 Ped Emerg Care (1998) 14:385-387)
• Few cases reported in the literature
• 11 month old boy with irritability and
transient cortical blindness/ involuntary
turning of the head
• Symptoms resolved after 12 hours
• Mom’s history: Found the infant chewing on
a small plastic bag
• Tox studies of blood via GC/MS revealed
meth value of 88 ng/ml
(Gospe SM Jr, Ann Emerg Med, 1995, 26:380-2)
• Kharasch et al, 1991 - Pediatric ER patients at Mass General (Boston)
- 6/250 (2.4%) positive for benzoylecognine (BE-major metabolite of cocaine)
- 4 under 12 months, all under 24 months
• Rosenberg et al, 1991 - Pediatric ER patients at Children’s Hospital of Michigan
- 25/460 (5.4%) positive for benzoylecognine
- All children between 1 and 60 months of age
• Rosenberg et al, 1995 - 41/942 (4.4%) positive for benzoylecognine
- 46/942 (4.9%) positive for opiates
- All children between 1 and 60 months of age
• Lustbader et al, 1998
- Prospective analysis of 122 children under 1 year of age at
Yale-New Haven Hospital ER
- 45/122 (36.3%) positive for cocaine and/or cocaine
metabolite
- Tested at lower thresholds than standard (>/= 50 ng/ml of BE
equivalents)
- Highly correlated with lower and upper respiratory tract
symptoms and sought medical care more often
• Garland et al, 1989
- Case of a 9 month old who ingested cocaine
- Caretaker denied presence of cocaine in home
• Ernst and Sanders, 1989
- 4 cases of unexpected cocaine ingestion manifested by sudden
onset seizures
- One infant developed mild learning disability
• Garcia-Algar et al, 2005
- MDMA (Ecstasy) intoxication in infant in Pediatric Emergency
Department
- Apparent febrile seizures and cardiovascular side effects
resolved within one day of treatment with benzodiazepines
- Segmental hair analysis evidenced chronic cocaine exposure
• Used a standard motel room, smoked 2.45 g in a total of 4 “smokes”, with none inhaled.
• Significant meth levels were present in the air during the smoke and present on all surfaces after the smoke.
• If meth has been smoked in a residence, it is likely that children present within that structure will be exposed to airborne and surface meth.
Presence of:
Weapons
Money
Packaging
Paranoia
Exposure to:
Potential for Violence
Potential for Burglary
Organized Crime
Unpredictable Environment
Unknown Adults
SOURCE: Detective Darren Bloom, Longmont Police Department, 2011
• Prenatal Exposure &
Breastfeeding
• Caregiver impairment
• Environmental exposure
• Grows/Manufacturing:
Toxin/chemicals/molds
exposure risk
Presence of:
Growing Rooms
Processing Rooms
Hash Oil Labs
Hazards:
Electrical
Chemical
Air Quality
THC
Mold & Fungus
SOURCE: Detective Darren Bloom, Longmont Police Department, 2011
SOURCE: Detective Darren Bloom, Longmont Police Department, 2011
• Occurring on a regular basis (weekly)
• 31 from Jan to April 2014 (20 in 2013)
• 10 people treated for 2nd & 3rd degree burns
Meth Labs and Children
About 30-35% of labs seized have children
35% - 70% of children from meth labs test positive for meth
10% of children from homes of heavy users test positive for meth
Meth Lab Hazards for Children
Fires/Explosions
Inhalation of toxic fumes
Clothing and skin in contact with improperly-stored
chemicals
Hazardous wastes dumped in play areas
“Booby traps”
Food and drinks contaminated
• A mixture of acetone, water and other chemicals were
boiling in a pan on the stove as part of the
manufacturing of methamphetamine
• The liquid ignited
• Caretaker grabbed the pan to put it in the sink. The
flaming contents of the pan spilled out onto the child,
causing the burns
• 5 year old found gasping and vomiting in the kitchen
near open bottle of Liquid Fire – commercial cleaner
containing sulfuric acid
• Intubated for respiratory distress
• Severely burned lips, tongue, and oropharynx;
partial-thickness burns to hands
• Multiple linear and pattern marks on chest, abdomen,
flank and back
• Medical evaluation revealed esophagitis and gastritis
as well as extensive burns of uvula, tonsils, epiglottis,
and vocal cords
• Required tracheostomy and gastrostomy tubes
• Developed esophageal stricture and fistula between
esophagus and airway
• Required extensive surgical intervention
• Reported to CPS due to pattern marks, LE investigated
due to concerns for methamphetamine production –
chemicals and drug paraphernalia found in home
• Urine testing negative, hair testing positive
Farst, et al, Annals of Emergency Medicine, 2007, 49(3), 341-343.
• 2 year old brought to ER with drooling, difficulty breathing and skin
blistering to neck, face and abdomen
• Caregiver reported child ingested Liquid Lightening – drain opener
containing sulfuric acid
• Child intubated due to respiratory distress
• Skin with partial-thickness burns of the neck, chest and abdomen – 11% BSA
– burns also noted on lips and in oral cavity
• Urine screen positive for amphetamines
• Medical evaluation revealed pharynx and esophagus injury
• Developed esophageal stricture
• Gastrostomy tube placed
• Required skin grafting of burns
• Reported to CPS – investigation of home revealed methamphetamine lab
Farst, et al, Annals of Emergency Medicine, 2007, 49(3), 341-343.
Effect of other factors
o Other exposures
o Environment
o Brain effects
o Meth Lab/MJ grow exposures
Long-term outcomes
More effective approaches
Comprehensive services & collaborative relationships
Provided along a continuum of prevention, intervention and treatment from pre-pregnancy through childhood
At different developmental stages in the life of the child and family
Education & Treatment are critical
NO single agency can deliver all of these
Gardner S & Young N, National Center on Substance Abuse and Child Welfare
Significant numbers of the
children affected and
potentially endangered by
substance abuse ARE NOT
IDENTIFIED before or at birth
75-90% of substance-exposed
infants go home undetected
and without services
Gardner S, Young N, National Center on Substance Abuse and Child Welfare
Began in September 2008
Multiple disciplines including healthcare providers, substance treatment, mental health, child welfare and criminal justice
Passed HB12-1100, creating CRS 13-25-136
CRS 13-25-136 reduces risk of prosecution of
pregnant women:
No information relating to substance use not otherwise required
to be reported pursuant to C.R.S. 19-3-304, obtained as a part
of a screening or test for purposes of prenatal care, of a
woman who is pregnant or determining if she is pregnant, shall
be admissible in any criminal proceeding. Nothing in this section
should be interpreted to prohibit prosecution of any claim or
action related to such substance use based on independently
obtained evidence.
Created through HB12-1100 & Signed 3/9/12
Focused specifically on issues related to prenatal
substance exposure
Released Report
Serving Families Impacted by Prenatal Substance
Abuse: Recommendations for Policy and Practice
www.coloradodec.org/substanceexposednewborns.html
Addressing the impacts across a continuum –
The Five Points of Intervention
Gardner, S. & Young. N., National Center on Substance Abuse and Child Welfare
Prenatal
Birth
Post-Natal
Throughout Childhood
Pre-pregnancy
SEN Steering Committee Recommendations:
Increase awareness (billboards, points of sale, etc.)
Integrate Prevention & Education Info into Public
Education System
Standardize information about SEN in the training
curricula for providers that serve women
Recommendations from SEN Steering Committee:
Increase utilization of available treatment programs
for pregnant women in Colorado
Medical providers:
oGuidelines and Standards of Care
oUniversal baseline and ongoing screening–
standardized tools and scripting
oEnhance referral networks
oUniversal baseline and periodic ongoing testing–
With or without consent
New Colorado law protects information
Recommendations from SEN Steering Committee:
Criminal Justice
oUniversal screening for AOD Use
oReferrals to Treatment and Prenatal Care
oMultidisciplinary Planning around Birth Options in Case of
Incarceration
Child Welfare, Behavioral Health, Human Services &
Community Organizations
oUniversal screening for AOD Use
oReferrals to Treatment and Prenatal Care
Week 5 6 7 8 9 10 14 18 22-38 40
Central Nervous System
Heart
Arms
Legs
Ears
Teeth
Eyes
Palate
External Genitalia
Missed Period Noted Typical time of first prenatal visit
Recommendations from SEN Steering Committee:
Universal screening for AOD Use
• Scripting, tools, documentation, further assessment
Testing mothers- clearly defined indications
• Scripting, documentation, further assessment
Testing infants- clearly defined indications
• Including mother’s positive screen/test
• Scripting, documentation, further assessment
• Referral to DHS required by law for illegal substances,
recommended for all AOD use
Do you consider one of your Parents to be an addict
or alcoholic?
Does your Partner have a problem with drugs or
alcohol?
Have you had a problem with drugs or alcohol in the
Past?
Have you ever used drugs or alcohol during this
Pregnancy?
Screening, Brief Intervention, Referral to Treatment
oStandardized Tool
oMedicaid billable
oTraining Available
Supported by:
oAAP
oACOG
oCDC
oSAMHSA
oNIAAA
oWHO
oUSPSTF
www.healthteamworks.org; www.improvinghealthcolorado.org
Rapid Drug Screening
• Pros: Inexpensive, fast, sensitive
• Cons: Cross-reactivity, false positives
• Needs confirmation
Gas Chromatography/Mass Spectroscopy
• Confirmation
• Sensitive and specific
• Lower limits
• May be “send-out”
Amphetamines
Alcohol
Barbiturates
Valium
Cocaine
Heroin
Marijuana
Methadone
48 hours
12 hours
10 – 30 days
4 – 5 days
24 – 72 hours
24 hours
3 – 30 days (rare)
3 days
USDHHS, SAMHSA, CSAT TIP #5, 1993
High sensitivity – except for methamphetamine
Easy collection
Detects illicit drug use from 24 weeks gestation
until birth
Hair of Baby
oReflects 3rd trimester exposure
oMay stay positive for 3 months after birth
Umbilical cord (available sample)
oNewer, more expensive, delayed results
oLooks similar to meconium in sensitivity
Serum
oBetter for medications that require levels
oAlcohols
(1) A child is neglected or dependent if:
◦ (g) The child tests positive at birth for either a schedule-I controlled
substance, as defined in section 18-18-203, C.R.S., or a schedule-II
controlled substance, as defined in section 18-18-204, C.R.S., unless the
child tests positive for a schedule-II controlled substance as a result of the
mother’s lawful intake of such substance as prescribed.
Tetrahydrocannibinol (THC) = Schedule I
◦ Schedule I defined as no current accepted medical use and high potential
for abuse. (CRS 18-18-203)
SOURCE: Colorado Revised Statutes & Colorado Children’s Code
Recommendations from SEN Steering Committee:
Medical
oClear plan for follow up care and transfer of information at
time of discharge
Infant: Complete info to pediatric provider
oFollow up appointment within 48-72 hours
oSystem for follow up if appointment is missed
oCared for in a Medical Home
oDevelopmental screening and referrals
Mother:
oMedical and behavioral health, including postpartum
depression screens
Recommendations from SEN Steering Committee:
Child Welfare
oPartner with families & service providers
oUse standardized questions at time of referral
oAssess other children in the home
Criminal Justice, Behavioral Health, Human Services
oPartner with families & service providers
Education about AOD use while breastfeeding
Educate and support caregivers, family, and all service providers
Integrate services and eliminate barriers
Recommendations from SEN Steering Committee:
Educate, support and provide linkages for families of
children with increased needs due to substance
exposures
Increase capacity for developmental assessments
Work with public education system to understand
impacts, communicate and collaborate to serve
children and families
Recommendations from SEN Steering Committee:
Increase training for service providers to identify
children throughout lifespan
Provide prevention programming for these kids
regarding risk of future AOD use
Communicate across systems and integrate care
strategies
Support for the whole family in sustaining long term
recovery
• Tell me more about your use. How often? For what purpose? What are you like when you use?
• Where are your children when you use?
• How do you store your marijuana?
• What steps have you taken to protect your children?
Ask the Parent
• Do I believe that the conditions in this home could reasonably result in harm to a child?
Ask Yourself
• Age & Vulnerability of the Child
• Children’s Medical & Developmental Needs
• Accessibility of the Substance
• Sober Caregivers
• Level of Impairment
• Use Patterns
• Presence of Other Caregivers
• Environmental Aspects
• Second Hand Smoke
• Cultivation Aspects
• Distribution Risks
• Living Conditions
• Domestic Violence
• Every child needs an aware, involved, engaged caregiver – parent, grandparent, babysitter
• Provide age appropriate supervision, nutrition, connection
• Crisis Ready – able to respond and ensure child health, safety, and well being in any situation
Safe Sober Caregiver
• Drug & Paraphernalia Storage - lock box, child proof packaging, stash your stash
• Environmental Factors – smoke free zone, homes free from drug dealing, meth labs / precursor chemicals, unsafe grows, hash oil labs, violence, strangers, criminal activity
Safe Healthy Home
• Statewide toll-free Family Support line by Families
First and Prevent Child Abuse Colorado:
o1-800-CHILDREN (1-800-244-5373)
o1-866-LAS-FAMILIAS (1-866-527-3264)
• Information for women on local substance abuse
treatment resources and other community services
• Parental support; compassionate listening
• Public information
www.smartchoicessafekids.org
• Mandatory Reporting ▫ To have reasonable cause to know or suspect that a child
has been abused or neglected.
▫ To have observed conditions which would reasonably result
in abuse or neglect.
▫ Testing Positive at Birth?
• Illegal Activity • Drug Distribution
• Manufacturing