Impact of maternal substance use during pregnancy on childhood outcome

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Summary

The impact of maternal substance abuse is reflected in the 2002–2003 National Survey on Drug Use and Health. Among pregnant women in the 15–44 age group, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. Maternal pregnancy complications following substance use include increases in sexually transmitted disorders, placental abruption and HIV-positive status. Effects on the neonate include a decrease in growth parameters and increases in central nervous system and autonomic nervous system signs and in referrals to child protective agencies. In childhood, behavioral and cognitive effects are seen after prenatal cocaine exposure; tobacco and alcohol have separate and specific effects. The ongoing use of alcohol and tobacco by the caretaker affects childhood behavior. Therefore, efforts should be made to prevent and treat behavioral problems as well as to limit the onset of drug use by adolescent children born to women who use drugs during pregnancy.

Introduction

Currently, about 11% of the adult population of the United States suffers from a substance-abuse problem during any one year. The cost to society of this drug use is estimated at over US$300 billion annually; this figure includes the costs of crime, heath-related problems and reduced work productivity. The impact of maternal substance abuse is reflected in the 2002–2003 National Survey on Drug Use and Health, which found that, of pregnant women aged 15–44, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. In 2002, the approximate numbers of births complicated by maternal use of drugs were 172,934 for illicit drugs, 723,911 for tobacco and 394,129 for alcohol.1 Thus, from the public health perspective, the impact of substance use during pregnancy in the United States extends far beyond the health of the mother and affects a large number of the unborn population.

In the 1980s, the ‘war on drugs’ associated with the crack-cocaine epidemic focused national attention on to the relationship between drug use and social and economic problems in society. Early reports on the effects of prenatal cocaine exposure created a public frenzy and prompted the myth about ‘unfit to parent’ women and their damaged ‘crack babies’. This in turn had an impact on legal and policy decisions made by individual US States and affected women who use illegal drugs during pregnancy. However, studies performed since the 1980s have failed to support significant associations between prenatal cocaine exposure and the increased prevalence of serious newborn congenital malformations and medical complications at birth.

The focus of this paper is the impact of substance use on maternal, neonatal and preschool child outcome. Data from recent cohort studies, and from studies using state-of-the-art methods of documenting substance use, will be examined.

Section snippets

Acute maternal and neonatal effects

The risk of congenital malformations following fetal cocaine exposure was evaluated in a prospective study of 154 prenatally identified cocaine users and 154 controls matched for race, parenting and location of care.2 It was noted that the infants who were exposed to cocaine in utero had a higher rate of premature birth, lower birth weights and smaller birth length and head circumference; however, no difference in the type or number of congenital abnormalities was noted between the

Neonatal size at birth and subsequent growth

Percentile estimates for birth weight, length and head circumference in MLS have revealed that growth deceleration in cocaine-exposed infants is evident after 32 weeks gestation.13 After controlling for confounders, at 40 weeks gestation, cocaine exposure was estimated to be associated with decreases of 151 g in birth weight, 0.71 cm in length and 0.43 cm in head circumference. Smoking has a negative impact on all growth measurements, with some indication of a dose–effect relationship. Heavy alcohol

Utilization of healthcare resources following substance use during pregnancy

Data on utilization of healthcare resources by substance-abusing women are limited. Maternal hospital costs are higher among illicit drug users and neonatal hospital costs have been found to be higher due to increased length of stay.20

In a study that matched cocaine-exposed with non-cocaine exposed infants, those exposed to cocaine were noted to have an increased length of hospital stay, more investigations for sepsis, more admissions to the NICU and more social and family problems delaying

Neurobehavior in children prenatally exposed to illicit drugs

No major neurological deficits in motor development have been found after intrauterine exposure to cocaine. When motor skills were assessed in the same infants—using the NICU Network Neurobehavioral Scale (NNNS) at 1 month, the posture and fine motor assessment of infants (PFMAI) at 4 months, the Bayley Scale of Infant Development at 12 months and the Peabody Developmental Motor Scales at 18 months—it was noted that infants with exposure to cocaine showed lower motor skills at their initial status

Statistical implications

The MLS is a prospective, observational study examining long-term effects of prenatal cocaine exposure in a predominantly minority and low-socioeconomic-status population. Analysis and interpretation of the MLS data therefore present several statistical challenges, some of which are briefly outlined below.

Conclusions

Maternal substance use has been demonstrated to be related to an increase in maternal pregnancy complications, more sexually transmitted disorders and increases in abruptio placenta and in HIV-positive status. Effects on the infant include decreased birth weight, birth length and head circumference; increased neonatal CNS and ANS signs and an increase in referrals to child protective agencies. Patterns of substance use during pregnancy impact on fetal growth. Healthcare resource utilization is

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