Alcohol- and Other Drug-Related Birth Defects

DEFINITIONS/SYMPTOMS

• Fetal alcohol syndrome (FAS), the leading known cause of mental retardation (PS Cook, et. al., Alcohol, Tobacco and Other Drugs May Harm the Unborn, US Department of Health and Human Services {USDHHS} Pub. No. {ADM} 90-1711, 1990, p. 17), is caused by maternal alcoholism or heavy drinking during pregnancy (N Day, "The Effects of Prenatal Exposure to Alcohol," HHS, National Institute on Alcohol Abuse and Alcoholism {NIAAA}, Alcohol Health & Research World {AHRW}, Vol. 16, No. 3, 1992, p. 238).
  
  
• Features of FAS include growth deficiency before and after birth; effects on the central nervous system such as intellectual impairment, developmental delays and behavioral problems; and changes in facial features such as a flattened midface, a small jaw, and a thin upper lip (Ibid.) .
  
  
• Fetal alcohol effects (FAE) is used to describe individuals exposed to alcohol in the womb who exhibit only some of the attributes of FAS and do not fulfill the diagnostic criteria for FAS (NIAAA, Ninth Special Report to the U.S. Congress on Alcohol and Health, 6/97, p. 193, Alcohol and Birth Defects: The Fetal Alcohol Syndrome and Related Disorders, USDHHS Pub. No. {ADM} 87-1531, 1987, p. 12).
  
  
• Children with FAS commonly have problems with learning, attention, memory, and problem solving, along with incoordination, impulsiveness, and speech and hearing impairments (NIAAA, "Fetal Alcohol Syndrome," Alcohol Alert No. 13, 7/91, p. 1).
  
  
• Although many of the physical characteristics associated with FAS become less prominent after puberty, intellectual problems endure and behavioral, emotional and social problems become more pronounced (NIAAA, Ninth Special Report, op. cit., p. 229).

USE OF ALCOHOL AND OTHER DRUGS DURING PREGNANCY

• In the first nationally representative survey of drug use among pregnant women, 20.4 percent or 820,000 women reported smoking cigarettes; 18.8 percent or 757,000 women reported drinking alcohol; and 5.5 percent, or 221,000 women, used an illicit drug at least once (HHS, National Institute on Drug Abuse {NIDA}, National Pregnancy and Health Survey, NIH Publication No. 96-3819, 1996, p. xxi-xxii).
  
  
• Frequent drinking during pregnancy was more prevalent among women older than 35; women of all racial/ethnic groups other than white; women with household incomes of $10,000 or less; and unmarried women. The proportion of frequent drinkers also increased as smoking level increased, and was more than three times higher among women receiving no prenatal care than among those who received prenatal care (Centers for Disease Control and Prevention {CDC}, "Update: Trends in Fetal Alcohol Syndrome--United States, 1979-1993," Morbidity and Mortality Weekly Report {MMWR}, Vol. 44, No. 13, 4/95, pp. 262-263).
  
  
• The rate of alcohol use among white women was significantly higher than the rate for Hispanics, while rates of cigarette use for both whites and blacks were significantly higher than the rate for Hispanic women. In regard to age, rates of alcohol use for women ages 25-29 and 30 and older were both significantly greater than the rate for women under age 25. For cigarette use, differences between rates among the three age groups were not statistically significant (National Pregnancy and Health Survey, op. cit., p. xxii).
  
  
• Marijuana was used during pregnancy by an estimated 2.9 percent or 119,000 women; cocaine by 1.1 percent or 45,000 women; and a psychotherapeutic medication without physician orders by 1.5 percent or 61,000 women. Crack was the form of cocaine use most frequently reported. Observed rates of use for each of the other illicit drugs included in the survey appeared to be much lower (Ibid.).
  
  
• Black women had significantly higher rates than white women for use of any illicit drug and cocaine, and significantly higher rates than Hispanic women for use of any illicit drug and marijuana. However, the estimated number of white women using any illicit drug or marijuana was substantially greater than the number in other race/ethnic groups. In comparing differences in illicit drug use among age groups, the rates of crack cocaine use in women ages 25-29 and 30 and older were significantly higher than the rate for those under age 25. Differences by age within race/ethnic groups appeared to vary by drug, but the statistical significance of these differences was not determined (Ibid., pp. xxi-xxii).
  
  
• Overall and within race/ethnic groups, rates of use during pregnancy of marijuana, cocaine, and cigarettes often were significantly higher for women who were not married, currently not employed, had less than 16 years of formal education, or relied on public aid for payment of the hospital. This pattern was reversed for alcohol use, with significantly higher rates found in women who were currently employed, had completed college, or had private insurance (Ibid., p. xxii).
  
  
• Of those women who reported no illicit drug use during pregnancy, only 6 percent had used both alcohol and cigarettes. In contrast, 32 percent of those using at least one illicit drug during pregnancy also used both alcohol and cigarettes (Ibid.).

INCIDENCE/PREVALENCE OF ALCOHOL AND OTHER DRUG-RELATED BIRTH DEFECTS

• Each year 4,000 to 12,000 babies are born with the physical signs and intellectual disabilities associated with FAS, and thousands more experience the somewhat lesser disabilities of FAE (Substance Abuse and Mental Health Services Administration {SAMHSA}, Center for Substance Abuse Prevention, Toward Preventing Perinatal Abuse of Alcohol, Tobacco and Other Drugs, HHS Publication No. (SMA) 93-2052, 1993, p. 1).
  
  
• Estimates of the prevalence of FAS vary from 0.2 to 1.0 per 1,000 live births (CDC, Fact Sheet: Fetal Alcohol Syndrome, 4/97).
  
  
• Making a diagnosis of FAS/FAE at birth is difficult because facial characteristics are difficult to discern (B Anderson & E Novick, Fetal Alcohol Syndrome and Pregnant Women Who Abuse Alcohol: An Overview of the Issue and the Federal Response, HHS, 1992, p. 4) and some features such as behavioral and cognitive functioning problems are not observable at birth (N Day, op. cit., p. 239). As a result, data on FAS/FAE incidence based on use of medical records and registry of birth defects are low (NIAAA, Eighth Special Report to the U.S. Congress on Alcohol and Health, 9/93, p. 204).
  
  
• Estimates show 40,000 to 75,000 drug-exposed babies (1 to 2 percent of live births) to 375,000 (11 percent) are born each year. These numbers reflect maternal use of illicit drugs only and would be much larger if alcohol and nicotine were included (Cook, op. cit. p. 3).
  
  
• Research has found that when screening and testing for drug use is uniformly applied among pregnant women, a much higher incidence of drug-exposed infants are identified. The average incidence of drug-exposed infants born at hospitals with rigorous detection procedures was close to 16% of those hospitals' births, as compared with 3% at hospitals with no substance abuse assessment (U.S. General Accounting Office, Drug-Exposed Infants: A Generation at Risk, GAO/HRD-90-138, 1990, p. 4).
  
  
• One study has found that the problem of drug use during pregnancy is just as likely to occur among privately insured patients as among those relying on public assistance for their health care (Ibid., p. 5).

RISKS AND CONSEQUENCES

• Over 75% of all perinatally-acquired HIV infections are secondary to intravenous drug use by an infected mother or her sexual partner (Maternal Drug Abuse and Drug-Exposed Children: Understanding the Problem, HHS Pub. No. {ADM} 92-1949, 1992, p.11).
  
  
• The extent of damage caused by prenatal alcohol exposure depends on the stage of fetal development, biological and environmental variables, and the amount and timing of the mother's alcohol consumption (NIAAA, Eighth Special Report, op. cit. p. 204).
  
  
• Maternal age, ethnic and/or socioeconomic differences, genetic influences and the severity of alcoholism in women while pregnant are factors that may make their children more vulnerable to FAS (NIAAA, Ninth Special Report, op. cit., p. 210).
  
  
• Once a woman bears a child with FAS, the probability that subsequent children will have FAS is 70 percent (N Day, op. cit., p. 239).
  
  
• Pregnant women consuming between one and two drinks per day are twice as likely as nondrinkers to have a growth-retarded infant weighing less than 5.5 pounds (Cook, op. cit., p. 16).
  
  
• Newborns whose mothers drink heavily (an average of five drinks per day, especially during the last three months of pregnancy) may show signs of alcohol withdrawal such as tremors, sleeping problems, inconsolable crying, and abnormal reflexes (Cook, op. cit., p. 17).
  
  
• Cigarette smoking during pregnancy has long been associated with adverse outcomes, including low birth weight, preterm birth, and intrauterine growth retardation and with infant morbidity and mortality (including sudden infant death syndrome) (CDC, "Advance Report of Final Natality Statistics, 1993," Monthly Vital Statistics Report, Vol. 44, No. 3 Supplement, 9/95, p. 11.).
  
  
• Increased tremulousness, altered visual response patterns to a light stimulus, and some withdrawal-like crying have been noted in the newborn infants of women who smoked marijuana heavily while pregnant (Cook, op. cit., p. 26).
  
  
• Cocaine use can precipitate miscarriage or premature delivery because it raises blood pressure and increases contractions of the uterus (NIDA, "Drug Abuse and Pregnancy," Capsules, 6/94, p. 2).
  
  
• Babies born to cocaine-using mothers appear to have fewer clearly discernible withdrawal symptoms than babies exposed to heroin and other narcotics in the womb. Although cocaine-exposed newborns tend to be jittery, to cry shrilly, and to startle at even the slightest stimulation these effects have generally been attributed to neurobehavioral abnormalities than withdrawal (Cook, op. cit., p. 31).
  
  
• The long-term effects of perinatal cocaine exposure are yet to be established. The most consistent findings show obstetrical complications, low birth weight, smaller head circumference, abnormal neonatal behavior, and cerebral infarction at birth. Children with this exposure are easily distracted, passive and face a variety of visual-perceptual problems and difficulties with fine motor skills (SAMHSA, Office for Substance Abuse Prevention, Identifying the Needs of Drug-Affected Children: Public Policy Issues, HHS Pub. No. {ADM} 92-1814, 1992, p. 3; Maternal Drug Abuse, op. cit., p. 19).
  
  
• Dramatic withdrawal symptoms are the most frequently observed consequence to newborns from prenatal narcotics exposure. Restlessness, tremulousness, disturbed sleep and feeding, stuffy nose, vomiting, diarrhea, a high-pitched cry, fever, irregular breathing, or seizures usually start within 48-72 hours. The heroin-exposed infant also sneezes, twitches, hiccups, and weeps. Occasionally, these symptoms do not begin until 2-4 weeks after delivery. This irritability, resulting from overarousal of the central nervous system, usually ends after a month, but can persist for 3 months or more (Cook, op. cit., pp. 37-38).
  
  
• Growth disturbances and other behavioral effects such as hyperactivity, shortened attention spans, temper tantrums, slowed psychomotor development, and impaired visual motor functioning have been noted in infants and older children born to opiate-dependent mothers (Ibid., p. 39).
  
  
• Caffeine intake before and during pregnancy has been associated with an increase risk of fetal loss (C Infante-Rivard, et. al., "Fetal Loss Associated with Caffeine Intake Before and During Pregnancy," Journal of the American Medical Association, Vol. 270, No. 24, 12/93, p. 2940).

COSTS

• Newborns with perinatal alcohol and other drug exposure have hospital stays three times longer than those born to mothers who are drug-free (National Center on Addiction & Substance Use at Columbia University, The Cost of Substance Abuse to America's Health Care System, Report 1: Medicaid Hospital Costs, 1993, p. 40).
  
  
• The economic costs associated with FAS were estimated at $2.1 billion for 1990 (NIAAA, Ninth Special Report, op. cit., p. 388).
  
  
• The total annual cost of treating the birth defects caused by FAS was estimated at $1.6 billion in 1985. For persons over 21 years the cost was $1.3 billion. Neonatal intensive care for growth retardation due to FAS accounted for $118 million (Anderson, op.cit., p. 1).
  
  
• Special education needs of children prenatally exposed to cocaine or crack cost $352 milion annually (NIDA, press release, 10/22/98).
  

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