Pregnancy and Substance Use

"• Among pregnant women aged 15 to 44, 5.4 percent were current illicit drug users based on data averaged across 2012 and 2013. This was lower than the rate among women in this age group who were not pregnant (11.4 percent). Among pregnant women aged 15 to 44, the average rate of current illicit drug use in 2012-2013 (5.4 percent) was not significantly different from the rate averaged across 2010-2011 (5.0 percent). Current illicit drug use in 2012-2013 was lower among pregnant women aged 15 to 44 during the third trimester than during the first and second trimesters (2.4 percent vs. 9.0 and 4.8 percent).

"• The rate of current illicit drug use in the combined 2012-2013 data was 14.6 percent among pregnant women aged 15 to 17, 8.6 percent among women aged 18 to 25, and 3.2 percent among women aged 26 to 44. These rates were not significantly different from those in the combined 2010-2011 data (20.9 percent among pregnant women aged 15 to 17, 8.2 percent among pregnant women aged 18 to 25, and 2.2 percent among pregnant women aged 26 to 44)."

"Among pregnant women aged 15 to 44 in 2012-2013, an annual average of 9.4 percent reported current alcohol use, 2.3 percent reported binge drinking, and 0.4 percent reported heavy drinking. These rates were lower than the rates for nonpregnant women in the same age group (55.4, 24.6, and 5.3 percent, respectively). Current alcohol use in 2012-2013 was lower among pregnant women aged 15 to 44 during the second and third trimesters than during the first trimester (5.0 and 4.4 percent vs. 19.0 percent)."

"Untreated opiate dependence in pregnant women is associated with many environmental and medical factors that contribute to poor maternal and child outcomes. Illicit opioid consumption is associated with a sixfold increase in obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity (2), foetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neurobehavioural problems, increase in neonatal mortality and a 74-fold increase in sudden infant death syndrome (Dattel, 1990; Fajemirokun-Odudeyi et al., 2006; Ludlow et al., 2004). Neonates born to mothers chronically abusing illicit opioids or provided with maternal medication-assisted treatment, such as methadone or buprenorphine, are frequently born with a passive dependency to those specific agents. Intrauterine exposition to all of the commonly used opioids, including heroin and methadone, but also prescription drugs (OxyContin, Percodan, Vicodin, Percocet and Dilaudid), sedative hypnotics such as benzodiazepines (e.g. Diazepam) and barbiturates can produce neonatal abstinence syndrome (NAS) after disruption of the trans-placental passage of drugs at birth. NAS is characterised by signs and symptoms of the central nervous system, hyperirritability, gastrointestinal dysfunction and respiratory and autonomic nervous system symptoms (Kaltenbach et al., 1998). However, with the current medical knowledge NAS is an easily treatable condition and no infant mortality should occur as a result of NAS."

"Results
"The proportion of pregnant admissions where opioids were the primary substance of use increased from 16.9% to 41.6% during the study period, while the proportion of pregnant admissions with OUD who received pharmacotherapy remained relatively unchanged at around 50%. Overall, pharmacotherapy recipients were generally older and white, more likely to receive treatment in an outpatient setting, be self-referred, and report heroin as the primary substance, daily substance use, and intravenous drug use, and less likely to have a co-occurring psychiatric problem compared to those who did not receive pharmacotherapy. Regional differences in pharmacotherapy utilization exist; the South consistently had the fewest pregnant admissions with OUD receiving pharmacotherapy.

"Conclusion
"Although the proportion of pregnant admissions to substance use treatment centers with OUD has increased since the mid-1990s, the proportion receiving pharmacotherapy has not changed. Significant variations in pharmacotherapy utilization exist by geography and demographic, substance use and treatment characteristics. Utilization of pharmacotherapy at publically funded treatment centers providing care for pregnant women with OUD should be expanded."

"• The annual average rate of past month cigarette use in 2012 and 2013 among women aged 15 to 44 who were pregnant was 15.4 percent (Figure 4.5). The rate of current cigarette use among women aged 15 to 44 who were pregnant was lower than that among women who were not pregnant (24.0 percent). This pattern was also evident among women aged 18 to 25 (21.0 vs. 26.2 percent for pregnant and nonpregnant women, respectively) and among women aged 26 to 44 (11.8 vs. 25.4 percent, respectively). Rates of current cigarette use in 2012-2013 among pregnant women aged 15 to 44 were 19.9 percent in the first trimester, 13.4 percent in the second trimester, and 12.8 percent in the third trimester.
"• The annual average rates of current cigarette use among women aged 15 to 44 who were not pregnant decreased from 30.7 percent in 2002-2003 to 24.0 percent in 2012-2013 (Figure 4.5). However, the prevalence of cigarette use among pregnant women in this age range did not change significantly during the same time period (18.0 percent in 2002-2003 and 15.4 percent in 2012-2013)."

Percentage of infants born less than 37 completed weeks of gestation at birth for any/all causes:
2014: 10.0%
2013: 10.0%
2009: 12.2%
2008: 12.3%
2006: 12.8%

Percentage of infants born weighing less than 5 lb. 8 oz. at birth for any/all causes:
2014: 8.0%
2013: 8.0%
2009: 8.2%
2008: 8.2%

"Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome in newborns following birth. The syndrome most commonly occurs in the context of antepartum opiate use, although other drugs have also been implicated.^2-5 In addition to NAS, illicit drug use (specifically opioid dependence) during pregnancy is associated with a significantly increased risk of adverse neonatal outcomes such as low birthweight (2500 g) and mortality.^6-9 Neonatal abstinence syndrome is characterized by a wide array of signs and symptoms including increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress.¹⁰"

"An infant described as 'low birth weight' weighs less than 2500 grams at birth; a 'very low birth weight' infant weighs less than 1500 grams. Low birth weight is a major factor in infant mortality in the U.S. Infants weighing 2500 grams or less are almost 40 times more likely to die during their first 4 weeks of life than the normal birth weight infant. Low birth weight infants are 5 times more likely than normal birth weight infants to die later in the first year and account for 20% of postneonatal deaths. The two major contributors to low birth weight are preterm birth and intrauterine growth retardation (IUGR). Both contribute to inadequate fetal growth. A birth is considered preterm if it has a duration of less than 37 weeks from the last menstrual period. IUGR refers to low weight for a given duration of gestation."

"Our examination of the effects of Pennsylvania’s criminal sentencing reform showed that after the policy was implemented, early prenatal care increased on average and inadequate prenatal care declined. Our fixed effects interrupted time series design used multiple points of comparison to assess whether reductions in incarceration improved racial and socioeconomic health equity. First, we found the benefits for prenatal care were largely limited to counties where prison admission rates declined the most after the policy. Second, we found that improvements were primarily observed among groups that are more likely to be affected by prison admissions, Black birthing people and those with lower levels of education, thus decreasing prenatal care inequities across these dimensions. Both points of comparison bolster confidence in the conclusion that changes in prenatal care were due to the policy and not to secular trends that affected these groups equally.

"These findings underscore the importance of contextual conditions of incarceration for preventative health care access and utilization. Prior research has largely examined individual or household-level effects of incarceration on prenatal care, [21] but prenatal care has not been examined in the prior epidemiologic literature on incarceration as a contextual effect across geographies. Moreover, previous research on incarceration as a contextual predictor of adverse birth outcomes [20, 31] has thus far not tested criminal justice reform policies as potential interventions to reduce exposure to high rates of incarceration in communities.

"Our findings also shed light on how criminal justice reforms may have spillover effects for healthcare utilization and health equity. However, the uneven implementation of the policy across counties underscores that incremental changes to criminal justice policy are unlikely to have broad effects for health equity. Several factors likely contributed to the heterogeneous implementation of the Pennsylvania’s policy, including judicial discretion and adherence to the revised sentencing guidelines. Indeed, policies like the one in Pennsylvania have been critiqued for making a small or negligible reduction in incarceration rates, and for further investing in criminal justice institutions instead of community-based services [28]. Moreover, even in counties where prison admissions declined the most, the magnitude of many of these improvements was small."

"It is important to note that, contrary to alcohol, benzodiazepines and nicotine, opioids do not have teratogenic potential (3). Thus, special attention needs to be paid to dependence and abuse of legal substances and prescription drugs that can have severe consequences for the foetus and newborn, such as foetal developmental disorders or sudden infant death syndrome (Fetal Alcohol Spectrum Disorders Center for Excellence, 2013; McDonnell-Naughton et al., 2012)."

"Many economic, psychosocial, behavioral, biological, and health services factors have been implicated in these adverse perinatal outcomes.^14,15 Among them are two that seem to be inextricably associated, namely low levels of PNC [Prenatal Care] utilization and exposure to IDU [Illicit Drug Use] in pregnancy.^16–21 The overlap between these factors is evident in the population we studied, with a prevalence of 4.2% IDU in mothers with adequate PNC, 26.2% in women with inadequate PNC, and 55.2% in mothers with no PNC."

"Recent research stresses the multiple determinants of poor birth outcomes, with important factors including maternal poverty, poor nutrition, homelessness, a history of domestic violence, and lack of prenatal care.³ Because it is difficult to untangle the complex causal relationships between maternal drug use and other contributors to poor birth outcomes,²⁴ it is both simplistic and short-sighted to focus solely on drugs as the source of fetal and childhood harm."

"Urine, hair, and meconium samples are sensitive biological markers of substance use. Urine drug screening can detect only recent substance exposure, while neonatal hair and meconium testing can document intrauterine use because meconium and hair form in the second and third trimester, respectively.^38–41 By itself, a single positive test result cannot be used to diagnose substance dependence. Although child protection agencies sometimes request hair analyses, neither hair nor meconium is appropriate for routine clinical use because of the high costs and propensity for false positive results."

"The principal import of existing research is not that drug and alcohol use during pregnancy is 'safe,' but rather that no scientific or legal basis exists for concluding that exposure to these substances will inevitably cause harm or that the risks presented by use of these substances are any greater than those associated with many other conditions and activities common in the lives of all people, including pregnant women.

"In spite of scientific fact, prosecutors continue to use medical misinformation to justify new arrests of pregnant women and to ask courts to radically rewrite state law to permit the prosecution of pregnant women.ⁿ³⁵ It is time for criminal defense attorneys to zealously challenge the junk science at the heart of these prosecutions."

"Another constitutional argument [against prosecuting pregnant women] is based on the right to privacy: the prosecution of a pregnant drug-addicted woman infringes upon a woman’s right to privacy, as established in Roe v. Wade.¹¹¹ In Roe, the Supreme Court held that the right to privacy, 'whether it be founded in the Fourteenth Amendment’s concept of personal liberty and restrictions upon state action ... or ... in the Ninth Amendment’s reservation of rights to the people, is broad enough to encompass a woman’s decision whether or not to terminate her pregnancy.'¹¹² Advocates of the right to privacy contend that a woman does not lose her right to privacy simply because she becomes pregnant, and the constitutional right to privacy 'extends to both women and men, regardless of their biological differences.'¹¹³ Advocates therefore contend that because the Constitution does not differentiate among persons who are able to enjoy the right to privacy, the pregnant woman remains a 'person' as defined and protected under the Constitution.¹¹⁴ Hence, the State’s mechanisms — prosecution by child abuse, endangerment, controlled substance abuse, manslaughter, and homicide statutes — infringe upon a drug-addicted woman’s fundamental right to privacy because these mechanisms punish her simply for exercising her constitutional right to procreate.¹¹⁵"

"A difficult dilemma is created by State laws that require the reporting of nonmedical use of controlled substances by a pregnant woman or that require drug testing after delivery if illicit drug use is suspected. These laws can have the unintended effect of women not seeking prenatal care. Drug testing during pregnancy, or postnatally, can have severe consequences. In many States, pregnant and parenting women can be reported to child protective services, even though the courts have struck down criminal charges against women who are pregnant and use drugs. Women have the right to refuse drug testing (American College of Obstetricians and Gynecologists, 2008); however, if drug abuse is suspected that is contributing to child abuse, reporting to child protective services is necessary."

"Research and clinical experience teach that when, as here, the personal risks of seeking medical care are raised to intolerably high levels, it is more likely that prenatal care and patient candor - and not drug use - will be what is deterred, often with tragic health consequences."

"The American 'fetal protection' movement is unique among developed and developing nations. While other nations also have children who are born 'at risk' and populations of poor pregnant women whose lives are highly dysfunctional or who are addicted to alcohol and other drugs, only in the United States are these women criminally prosecuted or civilly committed based on their conduct while pregnant.⁴ Only in the United States do prosecutors take the position that embryos and fetuses should be protected as full human beings while in utero.⁵ At the same time, the United States stands alone among developed countries in failing to guarantee access to health care to women and children throughout their lives and in failing to provide other economic, legal, and social supports (including treatment for drug and alcohol addiction) in order to increase the chances that women can nurture and provide for their children, as well as reduce the incidence of women's addiction. Almost all the women targeted by American "fetal protection" warriors exist at the very margins of society. In addition to their to alcohol or drug addiction, the overwhelming majority of these women have histories of mental illness and/or mental retardation; there is significant evidence that much of their drug use is an attempt to self-medicate for depression or other illnesses.⁶ The targeted women are overwhelmingly women of color, and they are almost always poor.⁷ In many cases, they are victims of childhood sexual abuse and current domestic violence.⁸"

"In addition to the principles laid out in Robinson,* punishing women for their behavior during pregnancy is precluded by the Cruel and Unusual Punishment Clause’s principle of equality. This principle prohibits the selective and arbitrary application of penalties against minority groups.²²⁴ The Cruel and Unusual Punishment Clause’s principle of equality is different from that of the Equal Protection Clause because the principle of equality is not premised on the different treatment of a judicially-identified 'suspect class.' Instead, under the Cruel and Unusual Punishment Clause, the principle of equality is concerned with the unequal treatment of minority groups in comparison to more socially accepted groups.
"In punishing drug-addicted women for their behavior during pregnancy, state prosecutors target one of society’s most unpopular groups and single them out for selective and arbitrary punishment."

"The Constitution does not provide an individual with the right to use drugs. Nevertheless, the Court in Robinson held that the Constitution prohibits the State from punishing an individual simply due to his status as a drug user.¹⁹⁸ The State is only constitutionally permitted to punish individuals for an act, not their status. In Robinson, the Court gave three reasons why the California statute criminalizing drug addiction violated the Cruel and Unusual Punishment Clause: (1) the statute did not acknowledge the status/act distinction; (2) the statute criminalized an unalterable condition; and (3) the punishment for violating the statute was not proportionate to the offense.¹⁹⁹"

"Since there were not, and still are not, any statutes on the books specifically criminalizing drug use during pregnancy, women have been prosecuted under statutes that deal with child abuse, assault, murder, or drug dealing [150]. One of the newest attempts in prosecuting women is using statutes related to the delivery of drugs to a minor. However, it is much more difficult to convince a judge and jury of prosecuting on these grounds because there is no explicit language in any statute delineating that a fetus can be considered a minor, entitled to all the rights and privileges afforded thereto [151,152]."

"Ferguson v. City of Charleston (2001) is an important case in the family law domain because MUSC’s [Medical University of South Carolina] policy of testing pregnant women for illegal drugs raises issues at the intersection of public health and constitutional law. The public-health aspects concern the very real and significant risks to maternal, fetal, and societal well-being of drug use during pregnancy; in addition, the policy raises constitutional questions about what constitutes a reasonable search and seizure and women’ s privacy right to reproductive autonomy. Ultimately, the case addresses how best to strike the sometimes competing interests between mothers and their unborn children.

"Although the policy was discontinued before the Supreme Court’s ruling and the Court held the policy to be unconstitutional, all the components of the decision—majority, concurring, and dissenting opinions—point to ways in which a similar policy could be designed so as to avoid the constitutional pitfalls encountered by the policy in Ferguson (2001). The petitioners won, but their victory is likely to be short lived. Recent developments in a number of states, combined with ongoing public concern about drug abuse, especially by pregnant women, suggest that despite Ferguson’s outcome, pregnant women should not feel too secure from state intervention when receiving prenatal care. Such interventions are likely to have significant consequences for pregnant women’s legal rights, as well as for their health, their fetuses’ health, and their behavior during pregnancy."

"Criminal prosecutions for prenatal substance abuse create a de facto gender classification in that only mothers are prosecuted for their children's injuries.⁸⁶ Initially it may appear that men and women are not similarly situated for the purposes of childbearing, because women and not men carry children to term and it is women's lifestyle choices that most obviously impact the health of the fetus.⁸⁷ In fact, at least one study indicates that drug use by men can likewise impact fetal health.⁸⁸ Further, holding women alone responsible for injuries sustained by their children as a result of parental substance abuse perpetuates the stereotype that women alone bear the responsibility for childbearing and fetal health.⁸⁹

"Although it is true that holding men responsible for drug use that harms future children is highly impractical⁹⁰ it does not follow that women alone can constitutionally be prosecuted. '[A]dministrative ease and convenience' are not sufficiently important governmental objectives to permit otherwise impermissible gender classifications.⁹¹"

"Illicit drug use by women is also not new. By the end of the 19th century, almost two thirds of the nation's opium and morphine addicts were women [2]. The issue of drug use during pregnancy garnered the national spotlight starting in the 1960's when public attention began to focus on the possible harm to the unborn child. Less than 15 years after Chuck Yaeger shattered the sound barrier, several events combined to shatter the placental barrier – the notion that the fetus was protected and even invulnerable. The placental "barrier" suddenly became quite porous. The rubella (German measles) epidemic and, in particular, the tragedies caused by two drugs, thalidomide and diethylstilbestrol (DES), amplified public sentiment about the need for protecting the fetus from risks from drug use. Thalidomide was approved for marketing in 1958 and was used primarily as a sedative and antidote for nausea in early pregnancy. By 1962, evidence showed that a rare set of deformities, mostly limb malformations, were caused by the drug and 8,000 children had been affected [10]. DES was a synthetic hormone prescribed in the 1940s and 1950s to prevent miscarriage. By the late 1960s and 1970s, the side effects of the drug became known: the daughters of women who had taken DES during pregnancy developed a rare adrenocarcinoma of the vagina. Licit and illicit drugs became suspect as possible teratogens, and the activities, diet and behaviors of pregnant women have been under close scrutiny ever since [11]."

"We found that alcohol consumption up to moderate levels had no independent effects on weight or HC [head circumference] at birth, and there was no evidence of longer-term effects at 5 years. There was an apparent effect of binge drinking on birth weight, but this was due to confounding by cigarette use. Cigarette exposure, not binge drinking, adversely affected HC and birth weight."

"The lack of adverse outcomes due to consumption up to moderate levels is consistent with several previous studies of effects on either weight or HC in children ranging from birth to 24 months [9,12,24,30–42]. One study that measured children at birth and then again at 6 years also found no effects associated with measures of actual alcohol consumption, although reduced HC and length were associated with a measure of indications of problem drinking [24,51]. Of particular interest is a study that investigated a group who would be considered to be at high risk of adverse outcomes since it involved disadvantaged mothers with a history of alcohol abuse [31]. Although detrimental effects on weight, length, and HC appeared to be due to alcohol consumption, they were no longer significant once covariates such as maternal smoking and race were taken into account."

"Descriptions of deleterious effects of alcohol consumption on the fetus have appeared early in history, although the first scientific study documenting alcohol’s harmful effects was not published until 1968 (70). Fetal Alcohol Syndrome (FAS), characterized by pre- and post-natal growth retardation, facial dysmorphology, and central nervous system (CNS) dysfunction, was recognized in 1973 as a consequence of chronic alcohol exposure during pregnancy (31). Since then, major and minor malformations, spontaneous abortion, and decreased birth weight have been among the many reported consequences of heavy alcohol use during pregnancy."

"Alcohol is a potent teratogen with a range of negative outcomes to the fetus, including low birthweight, cognitive deficiencies, and fetal alcohol disorders.¹⁵"

"The escalating 'war on drugs' has often been stoked with inflamed portrayals of drug-involved women in the popular media. In the mid-1980s, pregnant addicts giving birth to ailing 'crack babies' became drug-enforcement icons. Twenty years later there is scant evidence to substantiate the dire predictions of permanent and severe damage to their children due to their drug use. Neither hysteria about 'crack babies' nor increased resources for drug court programs has produced a significant effort to increase access to effective drug treatment for pregnant women. Yet current media depictions of women addicted to methamphetamine are fueling the same hysteria with respect to pregnant women’s drug use."

"Our study found significant cognitive deficits with cocaine-exposed children twice as likely to have significant delay throughout the first 2 years of life. The 13.7% rate of mental retardation is 4.89 times higher than that expected in the population at large, and the percentage of children with mild or greater delays requiring intenvetion was 38%, almost double the rate of the high-risk noncocaine- but polydrug-exposed comparison group. Because 2-year Mental Development Index scores are predictive of later cognitive outcomes, it is possible that these children will continue to have learning difficulties at school age.^37,38

"Cognitive delays could not be attributed to exposure to other drugs or to a large number of potentially confounding variables. Further, poorer cognitive outcomes were related to higher amounts of cocaine metabolites in infant meconium as well as to maternal self-reported measures of amount and frequency of cocaine use during pregnancy, providing further support for a teratologic model. Developing neural systems of the fetal brain may be directly affected by cocaine’s adverse effects on monoaminergic system development or indirectly affected through vascular constriction with subsequent decreases in placental blood flow and generalized hypoxemia."

"We conclude that comprehensive prenatal care may improve outcome in pregnancies complicated by cocaine abuse; however, the perinatal morbidity associated with cocaine abuse cannot be eliminated solely by improved prenatal care."

"The popular preception is that any prenatal exposure to cocaine is almost certainly associated with devastating effects on the neonate. However, these data suggest that most potentially detrimental effects (including neonatal size,³⁸ neonatal behavior,^12,13 and central nervous system lesions⁴⁷) of prenatal cocaine exposure occur disproportionately among the heaviest users, a phenomenon also noted for alcohol and cigarette exposure.²³"

"Abstract: To determine whether the risk of sudden infant death syndrome (SIDS) among infants exposed to cocaine in utero may be elevated, we assessed the risk for SIDS in a large, well-described, prospective cohort of infants whose mothers had or had not used cocaine during pregnancy. Of 996 women consecutively enrolled while registering for prenatal care, 175 used cocaine during pregnancy. Only one infant of the mothers who used cocaine died of SIDS, a risk of 5.6 in 1000, compared with four infants among the 821 nonexposed infants, a risk of 4.9 in 1000. The relative risk for SIDS among infants whose mothers used cocaine during pregnancy compared with those whose mothers did not use cocaine was 1.17 (95% confidence interval 0.13, 10.43), suggesting that there is no increased risk of SIDS among infants exposed in utero to cocaine."

"Although numerous animal experiments and some human data show potent effects of cocaine on the central nervous system, we were unable to detect any difference in Performance, Verbal or Full Scale IQ scores between cocaine-exposed and control children at age 4 years."

"Our data are from one of the first population-based studies in which trends for defects potentially caused by maternal cocaine use are examined; the results of our study show no significant change in the prevalence of multiple vascular disruption defects over time. We suspect that if cocaine is a teratogen, its teratogenicity is weak or is associated with a small subset of birth defects that are yet to be identified."

"After controlling for confounding variables, prenatal cocaine exposure was not associated with lower full-scale, verbal, or performance IQ scores at age 4 years, but did predict significant deficits in specific cognitive skills underlying intellectual functioning and attenuated the incidence of IQ scores above the normative mean, even for children in better home environments. Further, higher concentrations of cocaine metabolites in infant meconium were significantly related to lower verbal IQ and arithmetic scores. Importantly, however, the quality of the caregiving environment appeared to have substantial compensatory effects on cocaine-exposed children placed in adoptive or foster care. Cocaine-exposed children placed in adoptive care achieved performance similar to nonexposed children living in less stimulating, lower socioeconomic status home environments. Indeed, environmental intervention through foster or adoptive care was associated with a lower likelihood of mental retardation among cocaine-exposed children, despite heavier drug exposure."

"In the OPPS [Ottawa Prenatal Prospective Study], no association with marijuana use and subjects’ miscarriage rates, types of presentation at birth, Apgar status, and the frequency of neonatal complications or major physical abnormalities (Fried 1982; Fried et al. 1983) were found. No patterns of minor physical anomalies were noted among the offspring of marijuana users although two anomalies, true ocular hypertelorism and severe epicanthus, were observed only among children of heavy users of cannabis (O’Connell and Fried 1984). In general, researchers have not reported an association between prenatal marijuana use and morphologic abnormalities in offspring (e.g., Day et al. 1991) and, as reviewed elsewhere (Dalterio and Fried 1992; O’Connell and Fried 1984), the few reports of increased physical abnormalities may reflect a lack of control for confounding factors (e.g., prenatal exposure to alcohol) and/or the relative risk status of the women in the study."

"Since marijuana crosses the placenta, it is reasonable to think that it may have a direct, adverse effect on the fetal brain or on fetal growth, but the small number of studies performed to date have failed to identify major birth defects or a consistent effect on neurobehavioral function. Results regarding the relationship of prenatal marijuana exposure to lowered birth weight are inconsistent."

"Marijuana has not been implicated as a human teratogen. No homogeneous pattern of malformation has been observed that could be considered characteristic of intrauterine marijuana exposure.⁶ Among 202 infants exposed to marijuana prenatally, the rate of serious malformations was no higher than the rate among infants whose mothers did not use marijuana."

"The failure to find an association between prenatal marijuana exposure and a variety of cognitive outcomes persisted in the OPPS sample until the offspring were 4 years of age. At 2, although there was a negative association with language comprehension, this relationship did not retain significance when the home environment was statistically controlled (Fried and Watkinson 1988). At 3 years of age, after controlling for confounding factors, prenatal marijuana exposure was not associated with language expression and comprehension or decreased cognitive scores (Fried and Watkinson 1990)."

"Cannabinoids are known to enhance appetite by activating cannabinoid (CB1) receptors. This phenomenon is exploited to combat cachexia and loss of appetite in cancer and AIDS patients. The endocannabinoid 2-arachidonylglycerol (2-AG) is present in milk. Evidence is presented supporting a critical role for CB1 receptors in survival of mouse pups. Thus neonates do not gain weight and die within the first week of life when their receptors are blocked. This is due apparently, to an inability to ingest maternal milk. This suggests that the endocannabinoid-CB1 receptor system is unique in its absolute control over the initiation of the neonatal milk suckling response. It is further proposed that cannabis-based medicines should be developed to benefit infant failure to thrive."

"The newer hype about so-called 'meth babies' is similarly unjustified. In 2005, a national expert panel reviewed published studies concerning the developmental effects of methamphetamine and related drugs and concluded that 'the data regarding illicit methamphetamine are insufficient to draw conclusions concerning developmental toxicity in humans.'ⁿ²⁰ In that same year more than 90 leading medical doctors, scientists, psychological researchers, and treatment specialists released an open letter requesting that 'policies addressing prenatal exposure to methamphetamines and media coverage of this issue be based on science, not presumption or prejudice.' These experts warned that terms such as 'meth babies' lack medical and scientific validity and should not be used."

"Although research on the medical and developmental effects of prenatal methamphetamine exposure is still in its early stages, our experience with almost 20 years of research on the chemically related drug, cocaine, has not identified a recognizable condition, syndrome or disorder that should be termed 'crack baby' nor found the degree of harm reported in the media and then used to justify numerous punitive legislative proposals.

"The term 'meth addicted baby' is no less defensible. Addiction is a technical term that refers to compulsive behavior that continues in spite of adverse consequences. By definition, babies cannot be 'addicted' to methamphetamines or anything else. The news media continues to ignore this fact.

"In utero physiologic dependence on opiates (not addiction), known as Neonatal Narcotic Abstinence Syndrome, is readily diagnosable and treatable, but no such symptoms have been found to occur following prenatal cocaine or methamphetamine exposure."

Opiates

"Infants born to mothers who use opiates do not have birth defects due to the effects of the opiates, but do have impaired growth, smaller head size, and significant neurobehavioral dysfunction due to withdrawal. Women who use opiates usually use other illegal and legal drugs, are poorly nourished, and frequently have other health problems, all of which contribute to adverse newborn outcomes, especially poor growth and small head size."

"Any regular, daily antenatal opioid exposure (e.g., morphine, codeine, oxycodone, methadone, or buprenorphine) can produce neonatal withdrawal, also known as neonatal abstinence syndrome [NAS]. Estimates show that up to 96% of infants display withdrawal symptoms, and a smaller proportion require pharmacotherapy.^{4,68,116,117,120,121} NAS is characterized by respiratory, gastrointestinal, central nervous system, and autonomic symptoms (Table 6). Onset of withdrawal symptoms is dependent on the opiate’s halflife; the longer the half-life, the later the onset of withdrawal. Heroin-exposed infants may demonstrate symptoms within 24 hours of birth. In comparison, methadone-maintained infants have a delayed presentation at more than 24 hours, usually within 48 to 72 hours after birth and at up to 4 weeks of age.¹²² The length of monitoring is based on the specific drug exposure. Treated neonatal withdrawal has not been associated with any long-term complications."

"There are numerous benefits of methadone use during pregnancy, including improved prenatal care,^12,107–109 longer gestation,^50,110 higher birth weight,^111,112 and increased rates of infants discharged home in the care of their mothers.^{4,12,18,49,101,108,113–118} Although infants of methadone-treated women tend to be smaller (lower birth weight, length, and head circumference) than drug-free controls, studies have shown a catch-up of growth by 12 months of age.^118,119"

"In utero exposures due to smoking during pregnancy may increase the risk of both diabetes and obesity through programming, resulting in lifelong metabolic dysregulation, possibly due to fetal malnutrition or toxicity. The odds ratios for obesity without type 2 diabetes are more modest than those for diabetes and the scope for confounding may be greater. Smoking during pregnancy may represent another important determinant of metabolic dysregulation and type 2 diabetes in offspring. Smoking during pregnancy should always be strongly discouraged."

"Consistent with previous studies, we found that maternal cigarette smoking was associated with reduced birth weight and an increased risk of LBW,^3-8 shortened gestation and an increased risk of preterm birth,^8,27-29 and intrauterine growth restriction.^3,9,10 Our data indicate that maternal cigarette smoking likely affects infant birth weight via both reduced fetal growth and shortened gestation. More importantly, our study shows consistent evidence that the adverse effects of maternal cigarette smoking on infant birth weight and gestational age were modified by maternal CYP1A1 and GSTT1 genotypes. Our data demonstrate that a subgroup of pregnant women with certain genotypes appeared to be particularly susceptible to the adverse effect of cigarette smoke, suggesting an interaction between metabolic genes and cigarette smoking."

"Maternal smoking during pregnancy produces adverse effects for the fetus through several pathways. First, cigarette smoke interferes with normal placental function. As metabolites of cigarette smoke pass through the placenta from mother to fetus, they act as vasoconstrictors to reduce uterine blood flow by up to 38% [62]. The fetus is deprived of nutrients and oxygen, resulting in episodic fetal hypoxia-ischemia and malnutrition [63]. This is the basis for the fetal intrauterine growth retardation seen in many infants born to smoking mothers. Studies have shown that smoking is responsible for 20–30% of all infants of low birthweight, and that infants born to smoking mothers weigh an average 150–250 grams less than infants born to nonsmoking mothers [64].
"Second, the nicotine in cigarette smoke acts as a neuroteratogen that interferes with fetal development, specifically the developing nervous system [65]."