Increase Awareness of Risks of SUD on the Baby

Introductory Paragraph

Substance use during pregnancy can affect both the user and their babies. This article covers the risks to the baby which are associated with two substance -- alcohol and opioids.

Key Information

Fetal Alcohol Syndrome

Alcohol use during pregnancy can lead to what is known as Fetal Alcohol Syndrome (FAS), characterized by low birth weight, cognitive deficits, increased risk of birth defects, and behavioral problems later in life. Impacts on the fetus are vast and vary by the specific substance. Consuming alcohol, however minor the amount, increases the baby’s risk of FAS, preterm birth, teratogenicity, neuro-developmental disorders, miscarriage, and stillbirth. FAS impacts the baby’s physical growth and appearance, along with its emotional, behavioral, and cognitive health. Exposure to illicit drugs may have the following consequences:

• low birth weight and growth restriction
• preterm birth
• miscarriage
• stillbirth
• sudden infant death syndrome
• exaggerated startles and diminished crying response
• neonatal withdrawal or abstinence symptoms
• transient central and automatic nervous system symptoms
• congenital heart malformations
• abnormal physical developments

Neonatal Abstinence Syndrome (NAS)

Pregnant people may use opioids as prescribed, may misuse prescription opioids, may use illicit opioids such as heroin, or may use opioids (opioid agonists and/or antagonists) as part of medication-assisted treatment for opioid use disorder. Regardless of the reason, people who use opioids during pregnancy should be aware of the possible risks during pregnancy and potential treatment options for opioid use disorder.

Opioid use in women aged 15–44 years has increased at a similar rate to the dramatic increase in opioid use in the United States. During 2008–2012, about 1 in 3 reproductive-aged women filled an opioid prescription each year. As such, opioid use during pregnancy is not uncommon. There have been significant increases in opioid use disorder during pregnancy. For example, the number of people with opioid use disorder at labor and delivery more than quadrupled from 1999 to 2014. Opioid exposure during pregnancy has been linked to negative health effects for both mothers and their babies. These include maternal death, stillbirth, and NAS. Birth outcomes for infants exposed to opioids during pregnancy include an increased likelihood to:

• Be born preterm (born before 37 weeks of pregnancy)
• Have poor fetal growth
• Have longer hospital stays after birth
• Be re-hospitalized within 30 days of being born
• Possible birth defects

The effects of prenatal opioid exposure on children over time are largely unknown. However, using opioids as prescribed or for treatment of opioid use disorder during pregnancy may be necessary and may outweigh the risks. Opioid use and medication assisted treatment for opioid use disorder during pregnancy can lead to NAS which is a group of conditions occurring when newborns withdraw from certain substances including opioids which they were exposed to before birth. Withdrawal caused by opioids during the first 28 days of life is sometimes also called neonatal opioid withdrawal syndrome (NOWS). Withdrawal symptoms in newborns usually occur 48–72 hours after birth. Drug withdrawal symptoms may include:

• Tremors (trembling)
• Irritability, including excessive or high-pitched crying
• Sleep problems
• Hyperactive reflexes
• Seizures
• Yawning, stuffy nose, or sneezing
• Poor feeding and sucking
• Vomiting
• Loose stools and dehydration
• Increased sweating

The symptoms a newborn might experience and their severity depend on different factors. These include the type and amount of exposure before birth, the last time a substance was used, whether the baby is born full-term or premature, and if the newborn was exposed to more than one substance before birth.

Relevant Research

• Opioid Use and Opioid Use Disorder in Pregnancy. This report provides an extensive literature review and includes recommendations and conclusions from the American College of Obstetricians and Gynecologists.

• Longer-Term Developmental Outcomes. There is limited information about longer-term outcomes of children exposed to opioids prenatally, including those with or without NAS. Not all babies exposed to opioids during pregnancy experience signs of NAS, but they may still have longer-term outcomes which are not obvious at birth. Results from a recent study suggest that children with NAS were more likely to have a developmental delay or speech or language impairment in early childhood, compared with children without NAS. It is not clear if these impacts are due to opioids specifically, other substance exposures, or other environmental influences. Findings about long-term outcomes of children exposed to opioids during pregnancy are inconsistent. More research is needed to better understand the spectrum of possible outcomes related to opioid exposure during pregnancy.

• This article titled "Narcotic Addiction, Pregnancy, and the Newborn," provides a 19-year overview of cases at one hospital. Although it is dated (1978), it potentially provides a baseline for comparison to conditions five decades ago.

• This study showed that real-time ultrasound feedback focused on the potential effects of smoking on the fetus may be an effective treatment adjunct to improve smoking outcomes. This could be adapted and used to treat people with other types of SUDs as well.

Impactful Federal, State, and Local Policies

• Medicaid. Numerous Medicaid authorities, including the state plan, waivers, and other demonstration programs, can be used to provide SUD treatment and recovery support services to pregnant people with SUD as well as specialized services for infants with NAS.

• West Virginia has a state plan amendment on NAS services that provides for an all-inclusive prospective bundled payment based on the daily treatment of Medicaid beneficiaries.

Available Tools and Resources

• SAMHSA has published comprehensive clinical guidance for optimal care for pregnant and parenting people with opioid use disorder and their infants.

• SAFE Project:
  • "Addiction and Mental Health Resources for Women." This SAFE Project guide includes a variety of resources specifically providing support during pregnancy.
  • See the wiki titled "Improve Care for Babies Born Drug Dependent" for more information on babies who are born with Neonatal Abstinence Syndrome and how they can better receive compassionate treatment/care.

• The American College of Obstetricians and Gynecologists (ACOG) has published a report titled, "Opioid Use and Opioid Use Disorder in Pregnancy." This provides recommendations and clinical guidance. They also provide a FAQ sheet on "Opioid Use Disorder and Pregnancy" that identifies the most effective treatment for opioid use disorder during pregnancy to be opioid replacement medication, which includes medication-assisted treatment such as Methadone and Buprenorphine. The FAQ sheet also covers ways that behavioral therapy and counseling can assist with providing support and tools for ongoing recovery.

• The University of Baltimore has published "Supporting Mothers and Infants Impacted by Perinatal Opioid Use: A Cross-Sector Assessment." This collaborative assessment resulted from a community-level intervention initiative that was funded by the Center for Drug Policy and Enforcement. The report provides information on process, lessons learned, and resources that may help others engaged in similar projects and collaboratives.

Promising Practices

Baptist Health System. The Baptist Medical Center in San Antonio is a nationally recognized Center of Excellence for NAS Care.

Maternal Opioid Misuse (MOM) Model is promoted through the Center for Medicare and Medicaid Innovations. The primary goals are to:

• improve quality of care and reduce costs for pregnant and postpartum people with OUD as well as their infants
• expand access, service-delivery capacity, and infrastructure based on state-specific needs
• create sustainable coverage and payment strategies which support ongoing coordination and integration of care