Documente Academic
Documente Profesional
Documente Cultură
Philip Aggarwal
Amanda Doran
Natalie Laurence
Ana Zarlinski
Summer 2017
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 2
Abstract page
Infant mortality is a noticeable problem in the United States. The United States has a high
infant mortality rate. This literature review was conducted to see if there is a relationship
between substance use and infant mortality in women and men of childbearing age. This
literature review focused on the population of the United States. In this review we looked at 12
articles from various setting such as hospitals, doctor offices, and clinics. The age range used in
the literature review was from prenatal - 24 months of age. It was found that substance use has a
link to birth defects, Sudden Infant Death Syndrome (SIDS), and Neonatal Abstinence Syndrome
(NAS). There was not enough research to conclude that there is a direct relationship between
substance use and infant mortality. More research needs to be done to see if there is a direct
Key terms: USA, substance use, drug use, opioid, pregnancy, infant mortality, Neonatal
Abstinence Syndrome, maternal, birth defects, paternal, marijuana use, Sudden Infant Death
Syndrome, alcohol
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 3
Problem
The problem under the study is that substance abuse is leading to a higher infant
mortality rate, especially in the United States of America. This choice can be related to a lack of
knowledge of the effects of substance use before, during, and after pregnancy. It is up to nurses
to help prove the effects that substance use has on the development of children that can lead to
birth defects or even death. The effectiveness of proving that there is a relationship between
substance use and an increasing infant mortality rate must be carefully evaluated. The purpose of
this research is to help parents comprehend the importance and the effect that substance use has
during pre-natal care, which can lead to defects or death of infants. This literature review was
directed to verify that substance use in men and women of child bearing age has an increasing
We as nursing students looked at 12 research study articles that focused on several major
themes in the articles which were sperm quality, maternal use of substances while pregnant, and
the effects of drugs on infants after pregnancy. Different types of drugs where examined through
many of the medical journals and the same themes were present. The themes were that substance
use effects pre pregnancy, during pregnancy, and post-pregnancy. The theoretical framework for
the research was guided by Jean Watson theory of Human care. The emphasis Watson places on
supportive relationships and transpersonal teaching –learning between nurse and patient provide
framework for examining the effects of drug use between parents and infant mortality. Our
prediction is that those who take drugs have a higher infant mortality rate than those who do not.
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 4
Literature Review
The focus of this study was to examine the effect of opioid dependency while pregnant
and the length of stay of the newborn. The article, Opioid Dependency in Pregnancy and Length
of Stay for Neonatal Abstinence Syndrome fixated on 152 dependent mothers who were on
mothers) therapy. The average age of these women was 25.3 years, which is fairly young in age.
With the use of these treatments and infants had physical, mental deviations and it also increased
the chance of an early delivery as well as low weight. The study claims that up to 94% exposed
gastrointestinal function and other serious problems (Pritham, 2012, p. 182). With this comes the
situation of high costing hospital bills with the increased length of stay and treatment. When
focusing on MMT the research concluded that 29.1% of the births were preterm and additionally
that the finding was increased if a mother abused any form of alcohol or any other illicit drug
while involved with MMT (Pritham, 2012, p. 183), which was a very noteworthy finding.
Although BMT is not official for pregnant mothers but it is permitted if the mother had
conceived at some point while pursuing the therapy (Pritham, 2012, p. 183). The article has
many fascinating findings and warnings, which need to be expressed for professionals who deal
with pregnant women during their practice in the near future. BMT neonates tended to have a
shorter length of stay (14 days) and less complications that are seen in Neonate Abstinence
Syndrome compared to MMT (21 days) and this does not include the additional 8.6 days that are
Also, the researchers make a good claim mentioning their limitations to this study. The one that
stood out to me was that they were limited on information because the mothers mostly
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 5
acknowledged that they had used drugs in the past and are on a form of treatment plan. Due to
this, the researchers pointed out that they may not know the full truth of how long a substance
In the article Maternal Opioid Drug Use during Pregnancy and It’s Impact on Perinatal
Morbitdidty, Mortality, and the costs of Medical Care in the United States data suggests an
imperative need to evaluate, on a national level, not only the negative health outcomes associated
with maternal opioid use during pregnancy, but also the related economic cost burden on the US
healthcare system. Women of reproductive age who use and abuse opioid drugs, both
prescription and illegal, are more likely to have a lower socioeconomic status, family instability,
receive inadequate prenatal care, and suffer from alcohol, tobacco, and illicit drug use. We
looked at a study containing 1,000 participants. In the second model, they also adjusted for
tobacco, alcohol, and drug use, as well as existing medical conditions including obesity, chronic
renal failure, pre-pregnancy diabetes, and pre-pregnancy hypertension that may be related to both
maternal opioid use and the selected pregnancy outcomes. The study included frequencies,
percentages, and rates to describe prevalence of opioid use during pregnancy across maternal
age, racial/ethnic, household income, selected behavioral characteristics, and comorbidities. This
current study builds on the existing works by looking at the impact of opioid abuse during
pregnancy on a wide range of maternal and infant birth outcomes. Despite possible confusion
due to associated comorbidities, the increase in hospital costs and adverse perinatal outcomes in
the current study is likely due to neonatal abstinence syndrome and preterm deliveries. However,
the association between opioid abuse during pregnancy and adverse maternal and infant birth
outcomes persist. The results found that pregnant women who used opioids during pregnancy
were more likely to have other comorbidities, including depression, anxiety, insomnia, diabetes,
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 6
hypertension, renal diseases, and HIV infection. Also in the study, pregnant women who used or
abused opioids were also more likely than nonusers to have a prolonged hospital stay, develop
acute renal failure, and suffer mortality prior to hospital discharge (Aliyu et al, 2014.17-25).
In a study called Association between Stillbirth and Illicit Drug Use and Smoking During
Pregnancy from March 2006-September 2008 attempted to include all stillbirths and
representative live born controls by freezing umbilical cord samples for cases and controls and
frozen for analysis. Women who participated in the study whose delivery resulted in one or more
stillbirths and for women who had live births. Maternal serum was also collected at delivery. For
663 still birth deliveries 63 % had cord homogenate and 87% had maternal cotinine performed.
For 1,932 live births 1,050 had cord homogenate toxicology report as a positive result. A
uniform pathology evaluation was performed by a perinatal pathologist for the stillborn in the
study. The most common drug that was found in the study was cannabis. The study over
cannabis, smoking/second hand smoke, and illicit drug use found an increased risk of having a
stillbirth. There was an increase in the stillbirth odds ration with increasing amounts of self-
reported smoking in the third trimester. Women with stillbirths were twice as likely to report
having been addicted to illicit drugs. A positive toxicology drug screen for illicit drugs had a 2-3
fold increase in stillbirth risk. The study found that further investigation needs to happen
between to investigate what THCA can do and more affects that smoking has in fetuses during
In this study called, The Association Between Maternal Alcohol Use and Smoking in
Early Pregnancy and Congenital Cardiac Defects Alcohol use is said to be an extremely
widespread, but preventable risk factor among women seeking to become pregnant. Many
women continue to use alcohol in the early stages of pregnancy before they know they are
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 7
pregnant. Several variables were used to study the relationship between several measures of
alcohol use, including binge drinking and binge drinking on more than once occasion, and the
interaction between alcohol use and smoking. There was a significant increase in congenital
cardiac defects was found among mothers who reported binge drinking more than once in the 3
months prior to pregnancy compared to mothers who did not report binge drinking (Mateja,
In Illicit Drug Use Among Pregnant Women Enrolled in Treatment for Cigarette Smoking
outcomes such as complications, infant death, and increasing risk for infertility. In Nationwide
surveys, it was found that pregnant smokers report more illicit drug use than pregnant women
who were nonsmokers. Urine specimen from 115 women who were in there 10 th week of
pregnancy and when they were in their 28th week. The trial participants smoked around 18
cigarettes a day and were found to be less than 25 years old, Caucasian, had a high school
education, and did not have private insurance. 34% of specimen from *the intake visit and 25%
from the FAP assessment tested positive for illicit drug usage. Most common substance that was
detected was marijuana, which was 90% of the drug that tested positive in the specimen. Women
who tested positive for illicit drugs also tested positive at the FAP assessment. At the end of the
study it was shown that around a quarter to a third of the pregnant women in the trial were
determined to use illicit drugs. Women who were in the study participated in trials examining the
efficacy of an incentive based smoking cessation program. They were assigned to either an
abstinence contingent where they got vouchers for retail items or non-contingent where they
received vouches for independent smoking status (Gaelema, Higgins, Pepin, Heil,& Beinstein,
2013. 987-991).
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 8
In Infant Birth Outcomes Among Substance Using Women: Why Quitting Smoking
During Pregnancy is Just as Important as Quitting Illicit Drug Use, suggests that smoking and
illicit drug use has had an effect on the infant, whether it be by physical or mental characteristics.
The article believes that smoking is just as harmful as illicit drug use, but concludes that there
needs to be in depth studies done to appropriately validate this claim. In study through different
requirements the total of number of participants that were looked at where 652, but went down to
265 women that meet all requirements. Participants were paid $20 per interview, which were
interviewed twice. The study was done at two local hospital systems in Northeast Tennessee
.Information about whether the mother was using any substances was evaluated by a USD test
and self-report. The study came to a conclusion that smoking has twice the impact on birthweight
compared to illicit drug use. The risk of having a lower birth weight, brain alterations, Sudden
Infant Death Syndrome, infections, and cognitive/academic defects can be associated with a
lower birth weight due to choosing to use substances, especially smoking. It was also found in
this study that women who used illicit drugs during pregnancy also smoked and were poly-drug
users, along with psychosocial and other medical risk factors (Bailey, McCook, Hodge,
the U.S neonatal ICU, Neonatal abstinence syndrome is a drug-withdrawal syndrome that most
commonly occurs after in utero contact with opioids. The frequency is known to have increased
during the past decade. Data was evaluated from infants with the neonatal abstinence syndrome
from 2004 through 2013 in 299 neonatal intensive care units across the United States. Among
674,845 infants admitted to NICUs, 10,327 were identified with the neonatal abstinence
syndrome. From 2004 through 2013 neonatal abstinence syndrome was responsible for a
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 9
substantial and growing portion of resources dedicated to critically ill neonates in NICUs
The article Maternal and Paternal Recreational Drug Use and Sudden Death, focuses on
the results of a study that tried to determine how the effects of drugs used in the mother and
father affected the conception, pregnancy, and postnatal process during the infants first year of
life and how it affected the child. This was a study done in California with 239 infants that died
of SIDS and 239 infants that matched on all health levels with the care of their parents. It was a
case control study. The conclusion of this study was there was no association with SIDS and
recreational drug use with the parents but marijuana use was associated with SIDS in both the
mother and father. Maternal substance abuse affected the children way more than paternal
substance use. However paternal substance use was still a factor in SIDS of the child. The most
apparent substance abuse in mothers that caused SIDS were opiates, stimulants, and
tranquilizers. Substance abuse is the third leading cause of death in infants from 1 month to 1
The article Mortality Risk Associated with Paternal Drug and Alcohol Use in California,
focused in on the maternal use of substances during pregnancy. It did not include paternal use.
The study showed the relationship between maternal use of drugs and alcohol and how it could
have affected fetal, neonatal, and post neonatal mortality. This study was done in California with
birth and death certificate data were used to identify drug/alcohol-diagnosed births. There was no
number identified as to how many certificates they looked at exactly, however, they did estimate
to look at approximately 4,500,000 death certificates. The results of this study showed
association with maternal use and mortality rate of infants was greatly increased when the
mother used specifically cocaine as the drug but alcohol and other recreational drugs played a
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 10
key role in the increase of infant mortality. The article states that increased collaboration with
drug treatment programs and closer follow-up for drug-using women and their children may
improve mortality outcomes. This study was done with children in the ages between the first
month and second year. Doctors conducted this study (Wolfe, 2015. 93-100).
The article of Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes
and Practice Implications, focused in only on drug use in the mother during pregnancy and how
it affected the developing fetus and child’s overall outcome. The drugs studied were tobacco,
marijuana, stimulants, and opiates. The study not only considered how the child was born but the
timing of the drug use with the mother, any other mixtures of drugs, and health/environmental
factors. The study focused on women of child bearing age. The study is a comprehensive study
of looking individually at tobacco, marijuana, and opiates across many different areas in the
USA. The study does not specify specifically the number that each individual study looked at.
The conclusion of this study was substance use during pregnancy can affect the developing fetus
both directly, through passage of the drug through the placenta, and indirectly, through poor
maternal health habits and environmental conditions. Each child must be individually assessed
for his or her risk factors, developmental difficulty, and their caregiving environment.
Developmental outcomes may be saved by interventions that occur early in life, are tailored for
the alcohol or drug specific problems, and target the mother’s level of stress and continued
Although this journal was not published to focus on drug use while pregnant, the journal
The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected
Topics, spotlights the effects on the transfer of a small amount of certain drugs through breast
milk during and post pregnancy, in mothers producing and lactating milk. Recommending the
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 11
termination of drug and alcohol use while pregnant is increasing over the years and can be
accomplished but remaining that short-term sobriety while breastfeeding is often overlooked and
not fully thought about by parents (Sachs, 2013, p.799). Meaning, that mothers may not know
that they are indirectly harming their infant while using these even though they are not pregnant.
This journal was not a carried out study performed by the author but rather was an update on new
evidence the journal wanted to publish. As we know specific drugs are organized in groups and
may have a large impact on pregnancy, thus the restriction warnings on many drug
classifications and substances. Some of these factors that affect the infant include minor effects
such as decreased sleep and vomiting caused by alcohol (Koren, 2002) compared to major
effects such as preterm infant, which can be caused by benzodiazepines (Jain, 2005), infant
intoxication from the use of cocaine (Winecker, 2001) and death due to using methamphetamine,
which has a 48-hour duration in the breast milk (Bartu, 2009). In conclusion, after reviewing the
material provided not all therapeutics or drugs aren’t as severe as others, but some have the
potential to do serious damage physically and cognitively. More research is needed to determine
about how much of a drug is secreted into the milk and which ones are more strenuous to
According to the study, Maternal use of Marijuana During Pregnancy and Lactation:
implications for Infant and Child Development and Their Well-Being Cannabis is one of the most
widely used drugs in the USA among women who are of reproductive age. During their study
they had a sample size of 17,934 females of child bearing age. Marijuana use during pregnancy
and breastfeeding can have adverse effects with infant child development neurologically and
cognitively. With animal and human studies of fetal brain tissue has been documented. This
research has shown that there is a positive association between parental drug use and child
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 12
development. Parenting skills can be altered when using marijuana and along with abuse and
child endangerment. In 2013 daily use of marijuana was reported by 16.2 % of pregnant users in
the study and of that 16.2%, 18.1% of them meet the criteria for abuse and dependence. Out of
movement, memory, appetite, thermoregulation, pain, and immunity in the body. This plays a
big role in the beginning or early pregnancy and over stimulation with the CB1 receptors with
these drugs in the placenta can impair fetal growth by inhibiting cytorophoblastic proliferation
which is vital in embryo survival and brain development. The lipophilic characteristics of
cannabinoids allow them to cross blood brain barriers and placental membranes. Cannabis can
affect neurotransmitters like dopaminergic neurons that see early on in brain development. When
dopamine is disturbed there is an increase with neuropsychiatric disorders. THC is another type
of drug that was found in human infant feces which shows that it can be absorbed and
metabolized in infants and fetuses. It goes to the brain and can be stored in fat tissues for weeks-
months. Use of cannabis in studies can have an association with stillbirths, preterm labor.
Intrauterine growth restriction, and increase in birth defects. The National Institute of Child
Health and Human Development Stillbirth and Collaborative research Network reported that
cannabis use with stillbirth odds ratio is 2.34:95R confidence interval on a scale of 1.13-4.811. In
this study after the control of smoking, alcohol, and use of other drugs it was also found that a
lower birth weight was associated with cannabis use. Infants that receive secondhand smoke
have a greater rate of respiratory problems such as, childhood asthma, bronchitis, and
pneumonia. Public Health Authorities has not resolved the issue of to what degree does parenting
skills become affected with marijuana use. Prenatal substance exposure is associated with 2-3
times more likely increased risk of child maltreatment. A telephone survey was done with 3,203
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 13
people in mid-size cities in California about abuse and neglectful parents. Marijuana users self-
identified with an increase in frequency of child physical abuse, but did not report the abuse.
Another problem with marijuana is that it can be edible now and children can get into it because
of the new colors and fancy packaging. In this study it was proven that many who used
marijuana also abused other substances (Merritt, Wilkinson, & Chervenak, 2016.001-008).
In the review we nursing students found various limitations throughout the studies that
were researched. Most articles had a smaller sample size, focusing on the United States. The lack
of quality of literature found for the specifications of the topic. Self-report of drug use is not
During our literature review we have found that there is not a proven relationship
between the effects of substances and infant mortality. What was found was there is a
relationship between drugs and the effects of body functions such as low birth weight,
disabilities in infants, and SIDS/NAS. As future nurses we need to advocate for more in depth
research to see if there is a correlation between infant mortality and substance use. Also, we need
to familiarize women of child bearing age about the risk of using opioids while trying to
conceive. Mothers who are using substances or prescribed opioids also need to learn that many
medicines can be in there breast milk when they breast feed. Being informative and upfront
about this subject with our patients is the best way to achieve better outcomes.
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 14
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