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babies + substance exposure
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Did you know?
Getting good prenatal care is the single most important thing you can do to have a healthy pregnancy and a healthy baby.
Prenatal care can eliminate many of the risks associated with substance use.

El-Mohandes A, Herman AA, Nabil El-Khorazaty M, Katta PS, White D, Grylack L.
Prenatal care reduces the impact of illicit drug use on perinatal outcomes. J Perinatol 2003;23:354–60.

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According to the Centers for Disease Control (CDC), 75% of people who are trying to get pregnant do not stop drinking alcohol, and the national prevalence of Fetal Alcohol Spectrum Disorder (FASD) is estimated to be between 2-5% (4). 

Some babies prenatally exposed to alcohol do not develop FASD. We don't understand why. More research is needed to identify other risk factors and precise etiology (causes and contributing factors of the condition) . 

FASD effects are permanent, except for the characteristic facial features which fade with age.

The effects of alcohol exposure during pregnancy can include physical anomalies (sometimes called "birth defects"), low birth weight (LBW), organ defects, and intellectual disability. 

There is insufficient evidence to establish a dose dependent response *, or a period of pregnancy with reduced risk. 

              CDC Vital Signs-Alcohol and Pregnancy: Why Take the Risk?

* If the effects of the substance change when the dose of the substance is changed, the effects are said to be dose-dependent. But with alcohol, the risk of a baby developing fetal alcohol spectrum disorders varies widely. Some people whose babies develop FASD drank moderately during their pregnancy. Some people who binge drink deliver babies who are unaffected. That is why the guidance states that "there in no known safe amount" of alcohol use during pregnancy.

Binge drinking is defined as a pattern of drinking that brings a person's blood alcohol concentration (BAC) to 0.08 g/dl or above. This typically happens when men consume 5 or more drinks or women consume 4 or more drinks in about 2 hours. 4. Most people who binge drink do not have a severe alcohol use disorder.

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Nicotine + Smoking

Most of the information we have about the effects of tobacco and nicotine on pregnancy comes from research about smoking during pregnancy. Most of that research is on pregnant people who smoke cigarettes. 

Nicotine is a stimulant found in tobacco. The FDA places nicotine in pregnancy category D.


"Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks."


Smoking and use of nicotine products during pregnancy has been linked to:


See The Chemicals in Cigarette Smoke & Their Effects


While there is insufficient evidence to evaluate the effects of e-cigerettes in pregnancy or lactation, switching from smoking to e-cigarettes results in reduced short term adverse health outcomes and may improve periodontal health (5), which is important in pregnancy.


There is limited evidence of a withdrawal syndrome associated with prenatal exposure to cigarettes (12, 13).

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There is some evidence of temporarily decreased developmental scores and possible mood disturbances in exposed offspring (8), and there is also evidence of no effect (9), and of slightly increased developmental scores (10-12).


There is some evidence of lower birth weights associated with heavier cannabis use, but data are unclear about whether this risk is clinically significant. There is no evidence of congenital anomalies ("birth defects"), cancer, preterm delivery (birth before 37 weeks gestation), or feeding problems (3). The effects, if any, appear to be mild, and are poorly understood.

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Long term opioid agonist treatment (OAT) remains the gold standard of care during pregnancy and lactation because it reduces negative effects on the pregnant person and fetus/newborn and alternatively, detoxification increases the risk of relapse and overdose death (13, 14).

Higher doses of methadone are not associated with increased length of hospital stay for NOW (neonatal opioid withdrawal, also often called "NAS" or neonatal abstinence syndrome) treatment (15).


Opioid administration in pregnancy has not been associated with congenital anomalies (2, 16, 17), except possibly for codeine, for which data is inconclusive (2). 


Slightly increased rates of maternal and fetal mortality have been associated with opioid use, but no causal link has been established (18, 19). 


Some studies find lower birthweights that are still within the normal range for gestational age (20-22), and some do not (15, 23). 


Preterm labor and delivery less than 37 weeks gestation is sometimes found to be associated with prescribed and unprescribed chronic opiate use (19, 20, 22), but not always (15, 23). 


Lack of adequate control for confounding variables in studies of this population causes difficulty in drawing conclusions, but it is probable that “maternal drug use is not the most important factor in how opiate-exposed infants and children develop.” (24). 

Newborn infants should not be given naloxone if their mothers are known to have taken opioids regularly during pregnancy due to the risk precipitated withdrawal. 


Long term outcomes are similar to peer group, and services provided to pregnant people who use opioids should be similar to standard services (2, 24).

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The FDA places most BZD medications in pregnancy category D or X.


There is some evidence of increased risk of congenital malformations and low birth weight (3, 4, 5). It is unclear whether or not these possible effects are due to BZD use, or sleep disturbances, for which BZDs are often prescribed (6).


Withdrawal signs have been reported in newborns prenatally exposed to BZD (7).

Infants exposed to BZD via breastmilk may exhibit signs of sedation such as apnea (8). Apnea is a respiratory event where there is a pause in breathing that lasts 20 seconds or longer.

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Similar to trends for other illicit substance use in pregnancy, people who use stimulants tend to decrease their use over the course of the pregnancy, which dramatically decreases risks (4, 5).


The Food and Drug administration places methamphetamine, cocaine and caffeine in pregnancy category C (1).


Stimulants have not been linked to congenital anomalies or placental previa (6, 7, 3, 9, 8, 4, 10, 11).


Stimulants may lower birth weights and gestational age at delivery, increasing the risk of small for gestational age (SGA) or low birth weight (LBW) and accompanying morbidity (3, 7, 45, 12, 13, 14, 8, 15).


Many studies find that these differences disappear when controlled for confounding factors related to socioeconomic status and access to prenatal care (16, 17), or that findings of decreased birth weight, while statistically significant, are still within normal range (4).

The evidence for a causal link with cocaine to placental abruption is of very poor quality and does not adequately control for confounding factors (18-24).


There is no evidence based neonatal withdrawal from stimulants. 

Stimulants are present in the breastmilk of parents who use them, and infant exposure should be limited (25-27).


Abstinence from stimulants during lactation is recommended, but in the case of a relapse, waiting at least 24 hours after cocaine use and 48 hours after methamphetamine use to provide human milk is recommended (26, 28). 

Low to moderate caffeine use is considered safe during pregnancy and breastfeeding, but high doses could result in lower birth weights and spontaneous abortion (27, 29, 30-32).


There is no evidence of increased risk of congenital anomalies. Safer doses during pregnancy and lactation are likely to be around 200 mg/day (30).

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The references and sources for each class of substances can be found at the bottom of each of these webpages:

When considering a urine drug test (UDT) to screen for substance use
Ask Yourself:  What does pee tell you?
The Answer:   Not a lot.
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