Kathryn Wells, MD, FAAP · 2019-10-22 · Office of the Child’s Representative December 16, 2015 2015 Colorado Drug Endangered Children Kathryn Wells, MD, FAAP Medical Director,

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

[email protected]

Jade Woodard Executive Director

Colorado Alliance for Drug

Endangered Children

Prevent Child Abuse Colorado

[email protected]

mailto:[email protected]

mailto:[email protected]

• 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


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


6 months to 18 months (III)

The Honeymoon Phase

Symptom-free period


18 months to 5 years (IV)

Sensory integration deficit (same as II)

Less focused attention

Easily distracted

Poor anger management

Aggressive outbursts


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


1. Prenatal maternal alcohol use

2. Growth deficiency

3. Central nervous system (CNS) abnormalities

- Structural

- Neurologic

- Functional

4. Dysmorphic features


1. Prenatal maternal alcohol use

- Confirmed

- Unknown


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


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


4. Dysmorphic features – all 3 features must be

present:

- Short palpebral fissures

- Indistinct philtrum

- Thin upper lip


(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


Breastfeeding





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


Breastfeeding





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


Breastfeeding





exposure risk

Presence of:

Growing Rooms

Processing Rooms

Hash Oil Labs

Hazards:

Electrical

Chemical

Air Quality

THC

Mold & Fungus



• 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


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


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


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


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


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


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

Documents

Kathryn Wells, MD, FAAP · 2019-10-22 · Office of the Child’s Representative December 16, 2015 2015 Colorado Drug Endangered Children Kathryn Wells, MD, FAAP Medical Director,