Impact of Prenatal Exposure to Opioids and Opioid-Use Treatment Medications

Are you considering adopting or fostering a child who was exposed prenatally to opioids or opioid-use treatment medication, such as Buprenorphine, methadone, and Suboxone? Are you a grandparent or aunt raising a child who was exposed? Join our discussion with Dr. Jennifer McAllister, the Medical Director of the NOWS Follow-Up Clinic at Cincinnati Children’s Hospital Medical Center and the Medical Director of the University of Cincinnati Newborn Nursery.

In this episode, we discuss:

• Terminology: What is the difference between opiates and opioids?
• What are the most common opioids being abused?
• What are the common treatment medications/drugs given to those with opioid use disorder? What are the brand names for these medications?
• How do these medications work?
• Are substance-use medications safe to use during pregnancy?
• What are the short- and long-term impacts on infants exposed to opioids?
• What are the short- and long-term impacts of infants exposed to opioid-use medications in pregnancy? Do the impacts differ?
• Does the dosage of opioid-use medications change the impact they have on the baby?
• What are the short- and long-term impacts of infants exposed to fentanyl in pregnancy?
• Is there a safer time for a fetus to be exposed to opioids or opioid-use medications in utero?
• Is it true that if the child is not born experiencing signs of withdrawal or with drugs in their system, the prognosis is better? Or conversely, if the child is born dependent and has to go through withdrawals, they will suffer more impact from in-utero drug exposure?
• How dangerous is drug dependency and withdrawal for the infant?
• How are Neonatal Abstinence Syndrome (NAS) and Neonatal Opioid Withdrawal Syndrome (NOWS) treated in babies?
• If a mom is taking opioid-use medications during her pregnancy, is it recommended that she breastfeed the infant to help with withdrawal? 
• How long does withdrawal in an infant born dependent last?
• How do you foster attachment while the baby is experiencing withdrawal?
• You often hear that “early intervention is key” and that a baby’s brain can be rewired during the first couple of years with the right treatments or therapy. What exactly does that therapy entail? What strategies should you be using at home with your child with a diagnosis of prenatal drug exposure?
• When a child has drug exposure and trauma, is it possible to tell the difference in what is causing specific problems, and is the treatment different depending on the cause?
• Are children who are exposed prenatally to any drug, but specifically to opioids, at a greater risk for substance abuse disorder as teens and adults if they were adopted and not raised in an environment that exposed them to drug use?
• What are the most common blood-borne diseases that women who have IV drug use?
• What is the risk to a baby whose mother has HIV or Hepatitis C?

Transcript

Please pardon any errors, this is an automated transcript.
Dawn Davenport  0:00  
Welcome everyone to Creating a Family. Let's talk about foster, adoptive and kinship care. I'm Dawn Davenport, and I am both the director of the nonprofit Creating a Family as well as the host of this show. So today we're going to be talking about exposure prenatally to opioids and opioid use treatment medications. We'll be talking with Dr. Jennifer McAllister. She is the medical director of the now's neonatal opiate withdrawal syndrome follow up clinic at Cincinnati Children's Hospital Medical Center, and the Medical Director of the University of Cincinnati's newborn nursery, welcome. Dr McAllister, we are so glad to have you here to talk about opioids and opioid use treatment, medications. This is a topic of great interest to our community, those who are adopting and fostering children who have often been exposed prenatally. So

Speaker 1  1:00  
welcome. Thank you, and thank you for the invitation. I'm excited to have this conversation.

Dawn Davenport  1:04  
It's my understanding, if there's confusion whether to say opiates or opioids. It's my understanding that opiates have to do with substances that are derived naturally from the poppy, and opioids is more inclusive, and it includes substances that are also man made. Have, have I got that right? You

Speaker 1  1:23  
are correct. So opiate with the A is, yes, a natural derivative of opium from the poppy seed. And opioids traditionally refer to more of the synthetic opioid medications. Well,

Dawn Davenport  1:36  
let's put some names to this. What are the most common opioids being abused now. So

Speaker 1  1:42  
I think that's difficult to say when we talk about abuse. So typically, I like to describe opioids as either prescribed or non prescribed. And so if we're thinking about non prescribed opioids, that could be just pain medications, right? It could be pain medications that weren't prescribed to you, so things like hydrocodone, Tylenol, three things with codeine, those are in more pill form. The other type of non prescribed opioids would be things that are sometimes used by injection, things like fentanyl, heroin, and those have other types of methods of use as well.

Dawn Davenport  2:18  
And things can be have been prescribed to someone and and used for prescribed purpose, and then have been continued and not used for the original purpose. So it could be street drugs or prescribed drugs that

Speaker 1  2:34  
is correct. So if they're not prescribed, obviously they would be getting those from other means. And if it's not being used under the direction of a physician, that would be non prescribed use. Okay,

Dawn Davenport  2:45  
so now, what are some of the common treatment, medication or drugs, given to those with opioid use disorder?

Speaker 1  2:54  
That's a good question. So as you as you know, with opioids, it does create a dependence, and so often patients wishing to kind of either have more stable regimens or are prescribed medications for opioid use disorder. Often those are longer acting opioids, so it kind of creates a steady state in their system, the most common being methadone and buprenorphine. But there's other options now, including injectable medications that last a little bit longer. Okay?

Dawn Davenport  3:23  
And what are some of the brand names for the buprenorphine that we might know or methadone? I mean, what are the brand names that people might

Speaker 1  3:30  
prefer? Methadone is pretty traditionally just known as methadone. Often those. You have to get those from a clinic on a daily basis, and so those aren't usually ones that you would pick up a pharmacy are prescribed kind of for like traditional home use. Buprenorphine is the opioid component found in Subutex or Suboxone, depending on whether they have that Naloxone, which is the antagonist portion of the medication used with it. And so those are probably the most common that we

Dawn Davenport  3:57  
see. I've also heard of Naltrexone is that one still commonly used? Or no,

Speaker 1  4:03  
it is, and with my kind of lens, um, seeing kiddos, uh, you know more from the pediatric side or newborns, we see it in use in pregnancy, but not as common as buprenorphine or methadone, but it is often used for as a medication for opioid use disorder.

Dawn Davenport  4:18  
So how do these medications work? I think some people are under the impression that we're just substituting one drug for another, and maybe perhaps that's true. So how do these how do these medications work?

Speaker 1  4:30  
Yeah, that's a great question. I don't think that concept is actually incorrect, as I mentioned, because the body is kind of physiologically dependent on opioids. It is important to in order for a patient who has a substance use or opioid use disorder to not experience withdraw that they have a steady state of that opioid in their system. And so these medications provide that steady state levels without kind of highs and lows, with the ability to hopefully eventually lean off over. Time if that's suitable for the patient.

Dawn Davenport  5:02  
So it is possible, and that might be the end goal would be to start slowly reducing dependency on our use of these medications. Is that correct?

Speaker 1  5:14  
Yes, and everybody's goal is different. And you know, disclaimer, I am not a prescriber of these medications, but I think many people the goal would be to ultimately no longer take any opioids, but it kind of starts with achieving physiologic balance first. So

Dawn Davenport  5:31  
are the Suboxone, the methadone, the Bucha orphans? Are they safe to use during pregnancy? Are they safe for the fetus,

Speaker 1  5:41  
that's a great question. They are absolutely safe and recommended and actually standard of care for women with opioid use disorder. We know from evidence that women who are in treatment and those who are receiving medications for opioid use disorder do much better in their stability with their substance use when they are taking these medications and are in treatment, and we know often that the outcomes for their infants and their newborns are better as well.

Dawn Davenport  6:09  
Before we continue, I have a favor to ask. We have exciting news. First that we are now rated as number 12 in the list of top 100 parenting podcasts. That's the good news. The bad news is, when I went in, we're looking at the other podcasts that were rated above us as well as below us. It turns out, we have fewer reviews than those other podcasts. And you and I both know we are a great podcast, and we really need more reviews. So will you please use whatever app you're using to listen to this podcast? Pop over there, there's going to have the ability for you in the show notes to rate the podcast, you could give us a star rating that takes probably less than 30 seconds, let's be honest. But if you're feeling generous with your time and your comments, you can also leave us a written review. We would be very appreciative of either one of them, so please do that for us. And now back to the show. Are there short term and long term impacts on infants who are exposed to let's start with opioids in general. Then we'll move to the medication, the buprenorphines and the methadone. So what are the short and long term impacts that research has found on infants as children, young adults and whatever, for when they're exposed to opioids in pregnancy.

Speaker 1  7:25  
So short term, because the baby receives kind of the same blood as mom through the placenta, they actually are also seeing the fetus is also seeing the opioids as well, and so they do have a little bit of a physiologic dependence, depending on lots of factors, but can experience withdrawal symptoms after they're born, when they're no longer seeing those medicines or those substances. And so the short term would be that they may experience some withdrawal symptoms, which may require prolonged hospital stay, occasionally medications to kind of help them through that process, sometimes feeding difficulties, muscular concerns, like tight muscles, tremor, shaking things like that. That is short term, though, that usually lasts hours to days to not usually longer than weeks. And then once they kind of are over that initial period, we do see sometimes that these children with prenatal opioid exposure are at some higher risk for some medical and developmental complications through infancy and childhood as well.

Dawn Davenport  8:29  
What are some of the medical and developmental implications?

Speaker 1  8:33  
So the difficulty with this type of research is that we don't live in silos, and so it's really hard to just say, a baby who was exposed to opioids at two years has, you know, maybe a speech difficulty, that it's not necessarily causality. And so I really want to make that clear that even though we see some of these associations, we don't 100% know from the science and the evidence that it's a result of their prenatal exposures.

Dawn Davenport  9:01  
We also don't know if they may have been exposed to opioids, and you might know that, but they could also have been exposed to alcohol, marijuana, tobacco, meth. I mean, there's dual exposure is not uncommon either,

Speaker 1  9:15  
absolutely. And again, I think that speaks towards the importance of being in a treatment program, and which really helps with kind of other co exposures. But certainly we know that a lot of women with substance use disorder and opioid use disorder also use tobacco, and we know that nicotine is not necessarily good for a developing fetus as well. So kind of taking all of these, not only exposures in utero, but then there's also environmental factors after they're born that can play into this, but some of the associated things that we have seen include some muscle issues, including like, tight muscles, like I mentioned, we've published on babies that have kind of a tighter neck, or tortoise where they're kind of tilted to one side and require a little therapy within the first few months of life to help with that. There have been published studies that show, kind of in the larger cohorts of studies, that there may be things like speech delay, cognitive delay and other behavior concerns, but again, pointing out that many of these are not high quality research studies, and so I don't think anything really, truly definitive has been shown. But I think the really important point to take home is that these kids may be at higher risk, and it's really important to have close follow up and to advocate if there's any concerns that are being seen,

Dawn Davenport  10:31  
and to be thinking in terms of if you do start seeing things, trying to remember back and you know, it may be eight years after birth, a child may be eight years old, and to think, Okay, wait a minute. Could this be connected to the child having been prenatally exposed?

Speaker 1  10:46  
Think that's partially true, but I also think, you know, again, it's really hard to say eight years back that that what happened in utero was a result of kind of what, where they're being seen and at hate. But I think these are the things that we're really trying to study and learn in a really more prospective way where there's less confounders and less variability, so that we really can understand this a lot better. I think a lot of the promising research that's coming out, and even with some of my colleagues at Cincinnati children, is looking at brain imaging and studies, and we actually have been able to demonstrate that there are slight brain changes in babies with prenatal opioid exposure compared to those without exposure. So I think really being conscientious about how we're doing these studies will really help inform some of the outcomes and data that we're seeing.

Dawn Davenport  11:35  
Why has there been a lack of it seems like opioids have been around for a while. Why is there a lack of design? But the children wouldn't be that old, so we really do need to follow them. So I could see that. But why is there a lack of good research in this area?

Speaker 1  11:51  
Think it's a really difficult and vulnerable population. I think it's very hard to tease apart the opioid itself. As we're talking nothing is in a silo. And so, you know, really accounting for all these other factors, we know that other social determinants of health and adverse child experiences can affect some of these things, and it's it's just really difficult to account for all of these variables that can contribute to medical and developmental concerns that are very similar to what we would see maybe with opioid exposure. I also think it's difficult to get a lot of funding full disclosure kind of behind some of this as well. And also, I think there's a lot of stigma associated with substance use. And so really finding researchers that are honestly interested in really supporting these populations without presenting it in a non judgmental and non biased way, is really important to do high quality research.

Dawn Davenport  12:48  
Yeah, right. And some of the research has been used to remove children from families, and I think that has made it hard for researchers, because that wasn't the intent of their research, and it makes them fearful, which is unfortunate too, because once kids have been removed, I do think it's important for families, or regardless of whether they've been removed, I think it's important for parents to know and have good research to guide them to help these kids truly thrive. But that's I guess, neither here nor there. I do

Speaker 1  13:21  
think there's a lack of trust within the health system too. And so really recruiting participants to be part of this research when there are negative ramifications, potentially for results that could be used punitively against them, is really difficult. And so personally, I wouldn't be hesitant to enroll myself or my child when you know legality concerns come in. There's some states in which prenatal substance exposure is still considered child abuse, and these types of judgments and thoughts need to change before we can really advance the science.

Dawn Davenport  13:57  
Good point. So now we've talked about the long and short term impacts on the use of exposure of opioids. What about the medication used to treat opioid use disorder, the buprenorphines and the methadones. How does that impact infants? Yeah,

Speaker 1  14:15  
that's a great question. These are all still opioids, and so they all still act at the same receptors throughout the body, and so it's really been difficult to tease apart the medication that's been prescribed or not prescribed when it's still an opioid. And so what the science really shows is that we're not sure that there's necessarily a difference in outcomes, except for the fact that, again, women who are stable in treatment, I think their babies tend to do better, but we really haven't had enough powerful research to really determine prescribed versus non, or, you know, synthetic versus not, does

Dawn Davenport  14:50  
the dosage of the medication that you the buprenorphine or the methadone, does the dosage change the impact on the baby? Okay,

Speaker 1  15:00  
that's a great question. What we've learned is it really doesn't I think we all metabolize and experience opioids differently, and so a mom who may be taking a very high dose of methadone, their baby may or may not experience withdrawal and may or may not have issues, whereas somebody taking a very low, low dose of buprenorphine, the opposite may be true. So really, what we've learned over time, it's really not dose dependent as much as we'd like to be able to predict some of these outcomes, what's really important is for the mom to be on a dose of medication that is right for her, and I think that was where we had the best outcomes for mom and baby. And

Dawn Davenport  15:35  
as far as whether the baby will experience neonatal abstinence syndrome, I have heard that the methadone and the Bucha orphan, given that they're longer lasting, those babies may well experience even longer than if it was taking the unprescribed drugs. Yeah,

Speaker 1  15:53  
that's kind of an interesting way to think about it. They may have withdrawal symptoms longer, just because those medications stay in their system longer, and so the half life is longer, which is the benefit of those medications for the mother. And so we are often observing the babies for anywhere from five to seven, four to seven days for mothers who are taking those medications, whereas something like heroin or fentanyl is very short has a very short half life, and in and out of the system quite quickly, but not necessarily different in the true rates of pharmacologic withdrawal or withdrawal requiring pharmacologic treatment.

Dawn Davenport  16:28  
Something that we are seeing more now is babies being born having been exposed to fentanyl in utero. What do we know it's, it's, I don't think there's a huge amount of research, because it hasn't been around that long. I don't think what do we know about the short and long term impacts for a child who was exposed to fentanyl?

Speaker 1  16:51  
Actually, fentanyl has been around for a while. I think it kind of goes in waves, as far as how it's used in non prescribed means. And so I think, you know, certainly like, you know, we saw heroin as kind of a higher ups and downs to fentanyl as is as well. So I've been kind of following these babies over 10 years now, and we've certainly seen fentanyl from the beginning. Fentanyl is also a medication that we use for pain disorder and other things like that,

Dawn Davenport  17:17  
but not so often in pregnant women. I wouldn't have thought, maybe not, maybe so

Speaker 1  17:21  
not typically, chronically. I would agree with that. So what

Dawn Davenport  17:24  
are you seeing in these children that you've been following? I'm not

Speaker 1  17:27  
seeing much of a difference between fentanyl and other opioids. I know there has been some reports about a potential fentanyl syndrome, and that's not something that actually has panned out in the hundreds over 1000s of babies actually we see in our region, you know, I don't really know if there's other co exposures with the fentanyl. Certainly, we know along that same time where we saw a lot of fentanyl use, there was also other things that were adulterated into the fentanyl. So, you know, I think we've heard of like tranquilizing medications and other things. And so I'm not 100% convinced, personally, myself, that it was specifically the fentanyl that was causing some of the birth defects that we're seeing kind of on case reports, because as certainly, as I've mentioned, we've seen fentanyl for quite some time, and haven't seen those consistently.

Dawn Davenport  18:16  
Does the timing and the pregnancy of when the fetus was exposed. Does that matter? Does that change the prognosis or the degree of impact? Not specifically. Is there a safe time? But is there a safer time in pregnancy, if the mom used in her the first trimester, but got clean in the second and third? Is there anything we know about from the timing? We

Speaker 1  18:41  
do know that babies, you know early on in fetal development, that you know any type of exposure can be potentially detrimental, as you know some of the organs are forming, I don't know that we really have enough data to specifically say, like opioids in the first trimester from a fetal development looks any different, but certainly physiologically, that would be a case that could be made. We do know, though, that if mothers are no longer taking opioids by the time they deliver, that baby will not, will not experience withdraw, because they are no longer physiologically dependent on that because they are not seeing that opioid traditionally has been a practice not to wean mothers during pregnancy, or, you know, reduce their use, because it was unsure of what would happen to the fetus while mom was kind of weaning down on her medications. Although, more recently, I think it's been done fairly successfully in certain parts of the country where they are able to wean moms either down on their medications for opioid use. So we're actually off completely, and I'm not sure that they've had a lot of adverse effects. I think this is very specific for the the woman and the dyad and the treating physician, but certainly, depending on that timing, we can see, you know, withdrawal effects that would be different. We certainly don't have the long term research that was a really kind. Of inform what those longer term outcomes may or may not be.

Dawn Davenport  20:05  
Let me take a moment to interrupt this great interview to tell you about our weekend wisdom podcast. You may well know about it. It is a short form that appears in this feed. It's about five minutes, maybe 10 minutes, and we answer your questions, so please, what we need from you is to send us your questions. You can send them to info at creating a family.org and now back to the interview. So many parents believe that, and I speak of adoptive and foster parents, believe that if the baby is not born experiencing signs of withdrawal or with drugs in their system, that the prognosis is better, that the child will have fewer impacts long term. And conversely, if the child is born dependent or has to go through or does go through withdrawal, that they will have greater impacts from the in utero drug exposure. What's the research show on this? I

Speaker 1  21:05  
would say, actually, that's probably not a true statement. I really do think it kind of depends more on kind of the earlier questions about chronicity of exposure, rather than what the baby's experiencing immediately after birth. We have done a lot of work at really trying to reduce the number of babies we treat pharmacologically for withdrawal after babies are born, most hospitals are using the Eat, sleep console method of assessing and treating babies, which really puts a lot of emphasis on non pharmacologic care, and really reducing the amount of babies needing treatment for withdrawal. And so I think when people talk about whether they have nows or not have nows, it's very much a spectrum. Some babies have very few symptoms. Some babies have a lot of symptoms, but not all of them will require medications, and especially with these non pharmacologic care bundles, less are being treated. So we actually did some research looking at a similar question as to whether or not babies were treated for withdrawal, so requiring medications, and what their outcomes were, just kind of retrospectively looking at diagnoses like developmental delays, speech delays, things like that. And what we found was it really didn't matter whether you were treated for withdrawal or not, the outcomes were pretty similar between both groups. And both groups were at higher risk for some of these things, as I mentioned, compared to babies without exposures. So if I were an adoptive parent, any parent of a baby with prenatal opioid exposure, I think the important thing is really trying to help, maybe be through that initial period whether or not they needed treatment or not, and then just really being vigilant about potential outcomes as they continue to grow and develop. When

Dawn Davenport  22:52  
you spoke that the move is to try to feed, console and comfort that the child, as opposed to giving the baby medication. If the baby needs medication, what are the medications that are predominantly used? It

Speaker 1  23:10  
is a little bit region specific. We are actually in the midst of some hopefully multi center NIH, sponsored trials in which we are kind of looking at the different medications that are used. But I would say probably the most common is morphine, in which the babies kind of started on some morphine depending on their symptoms, if they kind of meet a certain threshold for requiring it if their symptoms are severe enough, and that is kind of tapered down or weaned down or just given more sporadically. In the Cincinnati region in which I practice, we use buprenorphine, actually as our primary agent to treat these babies if their symptoms are so severe that we think they need medicines, and we kind of start at a dose and then lean them down over a few days,

Dawn Davenport  23:52  
if the mom is taking one of the medications used to treat opioid use disorder, buprenorphine or methadone? Is it recommended that she breast feed the baby to help with withdrawal? And you're particularly good to ask this question too, because I noted that you are also an international board certified lactation consultant. So what's the thoughts on that? Yeah,

Speaker 1  24:17  
two passions near and dear to my heart 100% yes, we should support these women in breastfeeding, if that is their desire. We know that these medicines are safe. With breastfeeding, very little goes into the breast milk. So I know sometimes there's concerns that maybe if mom stopped breastfeeding, the baby would experience withdrawal from because they weren't, you know, getting those medicines through the milk, and that's actually not the case. We also know that breastfeeding provides so many additional benefits, specifically for this population. Research has shown that babies who are breastfed require less pharmacologic treatment than those that aren't. Sometimes reported better bonding, and then just overall, we know that breastfeeding so beneficial for babies in general and so certainly it. Be recommended and encouraged and supported in women's staple and treatment. Well,

Dawn Davenport  25:06  
one of the challenges is in the population that we're dealing with very often that the mom is placing the child for adoption, or the child will be placed in foster care for other reasons, and it can be challenging to them breastfeed, challenging and from the emotional standpoint. So I think the question was, if it's a way of weeding the child off and it's safe for that standpoint, then it might be presented that way to the birth mom, which might sway. But her decision, on the other hand, if very little transfers through the breast milk, then she should still obviously be given the choice, but perhaps it shouldn't be presented in a way that makes her feel like, okay, I should do this because this would be best for the baby. Am I reading your what you say correctly? That it really wouldn't be particularly helpful. I

Speaker 1  25:55  
mean, I think breastfeeding is always helpful, but I never really feel like we should present it in a manner in which we're pitting moms desires or outcomes versus babies. I think certainly breastfeeding is a choice for the mom, and if she wishes to provide colostrum, even in those first few days or initiate breastfeeding, it's 100% her choice. I do appreciate that there would be difficulties, especially in these situations in which mom and baby may be separated after those first few days, and I think that's probably a very individualized, personal decision, and they should be provided all the the data about just how breastfeeding colostrum that early, those early few days is beneficial. But certainly, many, many babies are also not breastfed, and would be safe to not do that and would not be detrimental. From a now's perspective, I think that's very much a maternal decision.

Dawn Davenport  26:54  
So when witnessing a child who is has been born dependent, it can be hard to say, as you point out the range of impacts varies greatly, and it's interesting that it's not necessarily dependent on the dosage. That's quite interesting, but nonetheless, it's frightening for parents to see and heartbreaking at times. But how dangerous is it? How dangerous is drug dependency and withdrawal for an infant? I

Speaker 1  27:19  
first want to kind of point out a little bit of semantics, but these babies aren't necessarily dependent in the way, the way I think we use the word, and I think that's kind of why some of our terminology from like neonatal abstinence syndrome, has moved towards neonatal opioid withdrawal syndrome, because there's not really a behavior component to this,

Dawn Davenport  27:36  
sure. Well, I think of dependency as non behavior specific anyway, but yeah, I appreciate that terminology matters, and we do want to use the correct terminology absolutely,

Speaker 1  27:46  
I think for the most part, as long as we are kind of keeping a close eye on these kiddos, withdrawal is not necessarily life threatening for them. I think the things that we really need to pay attention to are kind of what we actually have talked about with the eat sleep console model is that, are they able to eat where they're, you know, gaining weight and not losing excessive amounts? Are they able to sleep where their bodies can rest and recover? And then are they able to consult when they are upset? Because we do know these kiddos certainly experience fussiness that is beyond what a typical newborn is, and, you know, other symptoms like that. And so if they are able to do all of those functions, normal baby functions, then that is reassuring, that they're in a pretty good safe space. And so I think kind of thinking about how we look at these kids and how we evaluate them is part of the reason we've kind of transitioned to this functional based model to really say, what does this baby need to do to be a baby, rather than kind of looking at specific symptoms of withdrawal, and if they're unable to do some of those things, that's when we usually pull the trigger and say, maybe we need to help them through it, which is when they may need medication treatment. But certainly I think maybe I'm I'm tooting my own horn, but I feel like in the newborn nursery, we really try to do a good job of monitoring these babies and really making sure that they're in a safe space before going home absolutely and while they're in the hospital.

Dawn Davenport  29:09  
So families that adopt out of state are often concerned about how soon they can travel home with the baby. If they're experiencing now and they're going through withdrawal, how soon can they travel home? I think

Speaker 1  29:21  
sometimes that's kind of individualized, specifically, depending on what medications or substances they may have had exposure to, and how long those half lives may be in that baby system. So if we're thinking, if we're talking about medications for opioid use disorder, where it could be up to, you know, five plus days, I think, you know, certainly they need to be in the hospital, being monitored for that whole time. I won't speak to kind of the legal and other issues that there may be for, like, actually physically leaving the

Dawn Davenport  29:50  
state. Yeah, that's different. Yeah, that's different, yeah.

Speaker 1  29:53  
But from the medical standpoint, I think if we feel like they are safe to discharge home, it would probably be safe to try. Travel out of state with the caveat that, like anytime you bring a baby, either on a plane or in a long car ride, there's extra precautions and things that we tell for all of our families that are have those same limitations or same concerns so that don't have opioid exposure. I don't, I don't know that I would my counseling would be actually any different than any other adopted family that would be going out of state. Okay,

Dawn Davenport  30:26  
so how do you foster attachment with a baby who is experiencing withdrawal?

Speaker 1  30:33  
Think the same way you would foster attachment with baby not experiencing withdrawal. I think all our human newborns need the same, same same type of physiologic responses. We need somebody, you know, when we're upset, if we're fussy, we need somebody to attend those needs. And so human babies do not discriminate who that person is. They just need somebody to kind of attend to their needs. So really, if you were a foster, adoptive mom or a parent, and you were identified early on. I think early is always best, if possible, really getting in the hospital actually. Again, the model I keep honing back to this es, eat, sleep console model. But part of the concept is actually to have a caregiver there. 24/7, where they are, like the treatment for these babies. They are the ones providing all of that non pharmacologic care, that skin to skin, that holding, the swaddling, all of that where those babies are able to kind of feel that physiologic response. And I think, you know, our natural hormones and everything like that really play a role in these early few days. And certainly the same can be, can be done after a baby goes home, too, but really just kind of spending the time doing lots of skin to skin contact. Those are, those are really all helpful. I do know, though, and you know, sometimes these babies are difficult. Sometimes their sleeping is a little bit more jumbled than other babies. Sometimes they are fussier than others, and just don't console much as easy. And I think we try to do a lot of anticipatory guidance in the hospital to, like, help the families through that, that when they are there, but also when they go home, because those first few days can be rough for all new parents, but certainly those with babies who may still have some mild withdrawal symptoms. And so I think really being cognizant of what things my baby really likes to calm and really kind of queuing in on your specific baby's needs is really important and and when your baby knows that you're there to like help them, that's when that attachment forms.

Dawn Davenport  32:36  
Let me pause here to shout out a huge thanks to a long time supporter of creating a family the nonprofit as well as this podcast, and that is hopscotch adoptions. They are a Hague accredited international adoption agency placing children from Armenia, Bulgaria, Croatia, Georgia, Ghana, Guyana, Morocco, Pakistan, Serbia and Ukraine. They specialize in the placement of kids with special needs, including Down syndrome. They also do a lot of kinship adoptions. They place kids throughout the US, and they offer home study services and post adoption services to residents of North Carolina and New York. Thanks, hopscotch for your long time support. And now I'll let you get back to this interview, we often hear that early intervention is key and that the baby's brains can be rewired during the first couple of years of life with the right treatments. And you've alluded to the fact that parents need to be very cognizant and aware and get early intervention for these kids if they need it. So what type of intervention might parents seek? What? What type of treatment should they be looking for if they do see as their child ages, that the child is beginning to struggle with some of those developmental, language and other other issues that you refer to? That's

Speaker 1  33:56  
an excellent question, I think you know, starting from the hospital, having those conversations with what it may look like, as we just discussed going home, and how that may be different and and when to seek care, if it's you know, when is it not normal? Just for those normal first few days after that, I think, really frequent visits or or just making sure that your pediatrician or your primary care provider is aware of kind of the potential exposures, or which exposures the baby may have had, is important. I'm not sure that all parents have access to the tertiary care, sub specialty care that I provide in Cincinnati, but if there are developmental clinics in which your hospital system would be affiliated with, kind of getting plugged in for those for specific medical and developmental screening for this population, I think is helpful. And then I think you know, really knowing what's normal for what's normal for a two month old, what's normal for a four month old, really looking at those milestones is really important. And use your your gut instinct we you know you know your baby the best. And if you feel like things aren't really where they should be seeking. Help. I would say one of the best things that we have seen is that in many states, there's been great advocates to have nows or NAS as a automatic qualifier for the state sponsored early intervention programs, zero

Dawn Davenport  35:12  
to three or one of those. Yes, exactly. And

Speaker 1  35:15  
so in Ohio, it's helped me grow. In Kentucky, it's first steps. Indiana is also first steps. In my region, Ohio, is the only of the three, though, in which NAS or now is as an automatic qualifier. And so from day one, our babies would be eligible to receive, even if it's a developmental intervention, and certainly, if there is a specific concern that arises, you know, they could receive PT, OT, speech, whatever that therapy is needed in the home, which is super important for our population, which has a lot of needs. Yeah.

Dawn Davenport  35:48  
And then there usually are then programs that follow that, that would follow that all preschool correct, that they may be eligible for as well. That's wonderful that some states are allowing neonatal abstinence syndrome or neonatal opioid withdrawal syndrome. Trying not to use acronyms here, no problem. There are so many similarities between and you've alluded to this that it's awfully hard to tease out exactly what has caused the impact you may be seeing. And one specific thing that some of the kids that we deal with have experienced is early life trauma, and many of that there are many similarities between the impacts that we might see from drug exposure in pregnancy and then trauma that's happened after birth, and it can affect their learning behavior and things such as that. So when a child does have both of these challenges, is it possible to tell the difference in what is causing this specific problem that we're seeing? And then the second question would be, is the treatment different depending on what the cause is?

Speaker 1  36:52  
Yeah, I think I would say I don't know that I could personally tell the difference. And I think kind of, going back to what we've talked about, is that I'm not sure that I would feel comfortable saying any of the things that I see in this population is absolutely caused by prenatal opioid exposure. I think that causality is really, really difficult to pinpoint, but certainly we see associations, and I agree that many of these babies or infants or children do experience trauma. I think having all these variables that impacts their development is really important to at least just be aware of. As far as treatment, I really do think it depends on what we're seeing in the kiddo, if it's just behavior issues, if it's other developmental concerns, and I think treating that, but with the lens of trauma, informed care. And so whenever we work with this population, whether it's pregnant women, whether it's our infants, whether it's families, caregivers, etc, I think we always as healthcare providers try to use like trauma, informed, non judgmental care. But I also think it's important for providers that are giving care to these kiddos to really think about other adverse child experiences these kids have, and looking at it with that lens, Cincinnati has tons of great resources where we have programs that actually provide integrative behavior therapy and parent therapy through some of our programs in which We can kind of almost tailor our treatment for all of those things that you mentioned. So, you know, really kind of wrap around multi disciplinary services that kind of try to tackle the challenges from many different aspects.

Dawn Davenport  38:33  
So are the children who are exposed prenatally to, well, any drug? But specifically, let's talk about opioids, are they at greater risk for substance abuse disorder as teens and adults? And let me say specifically, if you know of the research that would separate out having been raised in an environment where parents are struggling with substance abuse disorder versus we're specifically interested if the child has been removed from that environment through adoption or foster care, but most specifically, probably adoption, if it's going to be long term. So if the child has been removed, Are there studies that say that these kids absence the environmental influence of being raised in a home where drugs are being abused? Are they at greater risk for substance abuse disorder themselves? I would

Speaker 1  39:20  
say the evidence isn't strong that there is necessarily an association for higher substance use. I think what we do know, though, and just other populations, is that there are some genetic components to addictions in general. So certainly, to your point about whether this is environmental versus genetic, I think there could be, you know, some genetic predisposition, but I'm not sure that we really have strong enough evidence to say one way or the other about risk for future substance use.

Dawn Davenport  39:51  
Okay, so another risk factor for moms and babies is if the mom is using drugs intravenously, and I. Might pick up a blood borne disease? What are the most common blood borne diseases that we worry about with IV drug use? That's a great question.

Speaker 1  40:07  
So typically, we think about infectious diseases such as hepatitis C and HIV, and those are probably the two most common. Hepatitis C, I would say, is much more common than HIV at one point in some of our patients with exposures to IV drug for moms who had a history of IV drug use, almost 50% had perinatal hepatitis C exposure. Hepatitis C is a is a disease, though, in which about 20 to 30% of patients actually may clear the infection automatically themselves, and so without any treatment, may treat themselves. It's a difficult disease in the fact that historically, we did not test children that were perinatally exposed to hepatitis C till around 18 months, because we were doing like antibody tests, which require time for maternal antibodies to kind of clear the system. And so it was not a great system, because we lost a lot of babies to follow up. Or, you know, may not always have been noted on their chart that these kiddos required testing, so those recommendations for testing for that actually have changed. And so we are trying to do a better job of identifying those with perinatal hepatitis C exposure and true disease where we're testing as early as two months in these kids, there is treatment for both adults and children, children starting at the age three. So although it's, you know, not ideal, obviously, to have exposure or hepatitis C, there is treatment for it. HIV is a disease that we test all pregnant women for. And so hopefully, again, knowledge is power, and so that if we know that there is potential for perinatal HIV exposure, we are doing a lot of precautions in the newborn nursery to provide medications to both mom and baby and do frequent testing to prevent any potential transmission to the infant.

Dawn Davenport  41:56  
What are the steps that can be taken to prevent a baby from getting through the birth process either Hep C or HIV. Are there specific things that can be done, or is it going to be the baby will have it through, going through the placenta and sure, everything else?

Speaker 1  42:13  
Yeah, that's a great question. So with hepatitis C, specifically, there's nothing we really do to prevent transmission, because the risk of transmission is actually quite low. It's only about 5% of mothers with active Hep C infection that could potentially transmit to the baby. I had mentioned how some people either naturally clear on their own or can have have been treated. And so we really want to know if mothers have an active viral load or active disease in their blood during pregnancy, because those are the only women that can really transmit the disease to the baby. If they've just had a history of it, they may test positive on their antibodies, meaning that they've cleared it, but they wouldn't transmit it to their babies. So we don't necessarily do anything in pregnancy. We just kind of wait test baby, and then if you know they're, unfortunately, one of those 5% we can treat baby down the road, or even a third of those babies will clear on their own as well. HIV is a very different story. If moms have HIV, we are treating her throughout pregnancy, just kind of depending on how much virus she has, what type of virus, etc. And then we are treating her right before she delivers. And we are also providing treatment for baby and testing for baby until we know there's baby has not been infected, we are very successful in this, and so certainly we have very, very few rates of perinatally acquired HIV because of these precautions.

Dawn Davenport  43:33  
So I'll give you the last word if the family is considering adopting or fostering. But let's specifically think in terms of adopting here, because it's a permanent relationship. If they're considering adopting a child who was exposed prenatally to opioids or the opioid use treatment medications, what would you tell them?

Speaker 1  43:55  
Thank you. I mean, I think, I think if a mother makes the difficult decision to put our baby up for the adoption. I think, you know, all these babies need loving homes. And I think that's probably another thing that I would say, is that provide as much love support as you can for these kiddos. I think it's scary always to think about, you know, potentials of what, what ifs what can happen. But I really think nurturing a loving environment goes a really long way. I I have had the pleasure, I said, of doing this for 10 years, and I have had families who have either adopted or grandparents, who have taken care of now their fourth kiddo, and the family. And these are the ones that stick with me and you, and these are the ones that even if they're the children, have challenges, like they thrive because they've been in the stable environment with somebody who really is looking out for them and caring for them. And so I know there are going to be rough days, just as there are rough days for all parents, but I really think it's something that's so important for these children. My heart goes out to. Everybody who who is able to do this. I also, you know, we were talking about adoptive because of that permanent relationship, but many of the adoptive families that I actually work with started as foster parents. And I would say that's probably the majority of what I see is foster to adopt. And so they may or may not have been this may have not been what the original plan or what was in the cards, and that's what I think really hits home with me, is that they were willing to take the situation in which it may not have been a permanent, you know, desire option, and they love these kids so much that they are willing to kind of take on the responsibilities for them.

Dawn Davenport  45:37  
And I'm glad you raised grandparents as well, because 100% we see that a lot as well, where grandparents are stepping in. And the predominant reason grandparents end up raising grandkids is because their child, the baby's parents, are struggling with substance abuse disorder, and so without a doubt, many of them are raising and you're right. The vast majority of adoptions are through foster care, and they start off as foster parents, and for whatever reason, reunification has not been possible. Well, thank you so much. Dr Jennifer McAllister for talking to us today about this topic. It's like, I say it's of huge importance to our audience, and we really appreciate your expertise. Yeah, my pleasure.

Unknown Speaker  46:20  
Thanks for the invitation. You.