Parental Substance Use and Neglect

Sue Flynn and Gabby Bisson

Drug Liaison Midwives

Springfield Team

WHY SPECIALIST SERVICEØ 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 FamilyØ 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 problemsØ Substance and alcohol misuseØ Learning difficulties/complex needsØ 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 Amenorrheau Infections/hepatitis/

HIVu Nutritional

deficienciesu Respiratoryu Thrombosisu Hypertensionu APH

EFFECTS ON BABY

u Congenital malformations

u IUGRu Prematurityu Functional

developmentu Fetal distressu IUDu NAS

HEROIN- SPECIFIC PROBLEMS

u Not teratogenicu Low birth weightu Fetal distressu Withdrawal. The

majority of symptoms appear within 24-48 hours after birth.

u NASu Affect the ability of

mother to look after the baby

u Increased SIDS.

METHADONE SUBSTITUTION

Ø Main treatmentØ Advantages§ Stability§ Long half life§ Relieve social pressures§ Allows assessment and life style

changes

Ø Disadvantages§ Neonatal abstinence syndrome

BUPRENORPHINE SUBSTITUTION

Ø Advantages§ Stability§ Long half life§ Allows life cycle

change§ 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

Ø Disadvantages§ Lack of knowledge/

experience§ Difficulty in

initiating treatment

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§ Methadone§ Codeine§ Bupernorphine

Ø Benzodiazepines

Ø ?CocaineØ ?AmphetaminesØ ?Cannabis

TREATMENT FOR NASu PHARMACOLOGICAL§ Follow local

guidelines§ Leeds policy - 2

consecutive scores >8, start treatment

§ 1ST line treatmentØ - morphine sulphate

§ 90% units using morphine as first line treatment

Ø 2nd line treatment§ Variety of agents used –

phenobarbitone most frequent

Ø NURSING SUPPORT§ Light swaddling§ Environment§ Noise reduction§ Decrease light§ Feeding regime§ Use of pacifiers§ Skin care§ Scratch mitts§ Nappy care

BREASTFEEDING

Advantages.Ø Development of

mother/baby attachment.

Ø Provision of maternal antibodies.

Ø Thought to decrease neonatal withdrawal.

Disadvantages.Ø Chaotic drug use -

erratic doses for neonate.

Ø Culturally unpopular.

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 HypertoniaØ Hyperactive startle reflexØ TachypnoeaØ Loose stoolsØ Reduced sleep

BENZODIAZEPINES

Ø Stabilisation/reduction§ diazepam

Ø Problems§ cleft palate/lip§ IUGR

Ø Neonatal withdrawal§ hypotonic§ hypothermia§ feeding difficulties§ respiratory

difficulties/apnoeaØ 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

ØMaternal 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 miscarriageu Pre-term deliveryu Stillbirthu Antepartum haemorrhage u Placental abruption u IUGRu Prenatal alcohol exposure may be associated with an

increased risk of sudden infant death syndrome (SIDS)u FASD/FAS

The scale of the problemu 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 growtho facial abnormalitieso learning and behavioral disorders, which are often

life long.

Executive functionsExecutive functions of the prefrontal cortex

u Motivationu Planningu Inhibitionu Problem solvingu Sexual urges

u Time perception u Internal orderingu Memoryu Judgment

u Regulation of emotion u Empathy

u Self monitoringu Verbal self regulation

Effects of alcohol exposure related to executive function

u Need external motivators to complete menial tasksu Inability to apply consequences from past actionsu Socially inappropriate behaviouru Inability to figure out solutions spontaneouslyu Inability to control sexual impulses, esp. in social

situationsu Difficulty with abstract concepts or time and moneyu Difficulty processing informationu Storing and/or retrieving informationu inability to weigh pros and cons when making

decisionsu Moody roller-coaster emotions, exaggeratedu Diminished sense of remorse, inability to understand

othersu Needs frequent cues, requires policing by othersu 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}.

Department of Health (DoH) Guidelines 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 you drink the greater the risk.

The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.

Women who find out they are pregnant 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 StudyPAST

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.

Using a Think Family approach to ensure that issues are addressed restoratively, how would you proceed?

Outcomeu Pre-birth child and family assessment undertaken.

u Good engagement with all services

u Safe delivery of live infant at term

u Eventual abstinence from illicit substances and maintenance on methadone medication

u Baby home with parents on a robust child protection plan with regular MDT meetings and contact with parents.

Questions ?

References

1. British Medical Association (June 2007, updated February 2016) Alcohol and pregnancy. Preventing and managing fetal alcohol spectrum disorders. BMA.org.uk

2. DoH (January 2016) “UK Chief Medical Officers’ Alcohol Guidelines Review. Summary of the proposed new guidelines” Department of Health

3. DoH (August 2016) “UK Chief Medical Officers’ Low Risk Drinking Guidelines” Department of Health.

4. National Organisation on Fetal Alcohol Syndrome – UK (2017) “Information for GP’s” NOFAS UK, London. nofas-uk.org.

5. NHS England. 2015. Health survey for England 2015. [ONLINE] Available at: http://www.content.digital.nhs.uk/catalogue/PUB22610. [Accessed 21 September 2017].

References:6. Manning V. (2011) Estimates of the numbers of Infants (under the age of one year)

living with substance misusing parents. NSPCC

7. Raynes G, Dawe S, Cuthbert C (2013) All Babies Count – Spotlight on drugs and alcohol. NSPCC

8. Rudd AO, Osborne S, Burl L et al. The Morning After – A Cross Party Enquiry into Unplanned Pregnancy: 2020 health.org, 2013

9. British Medical Association. Alcohol misuse: tackling the UK epidemic. BMA 2008

10. Smith K. (ed) et al (2012) Home Office statistical bulletin: homicides, firearms offences and intimate violence 2010/2011: supplementary to volume 2 to Crime in England and Wales

11. Brandon,M. et al (2012) New learning from serious case reviews: a two year report for 2009-2011 London: Department for Education.

12. Office for National Statistics (2015) Focus on violent crime and sexual offences, 2013/14. Newport: ONS

13. Dryden C. et al (2009) Maternal methadone use in pregnancy: Factors associated with the development of neonatal abstinence syndrome and implications for health care resources. British Journal of Obstetrics and Gynaecology 116 (5) pp 665-671.