Methadone & Pregnancy
“Is methadone safe for my baby?” is usually the first question  we hear           from women.
Pregnant women have been treated with methadone for more than  25  years          and neither methadone or other opiates have not been  shown to  directly          cause birth defects. However, your baby may  experience some side  effects          from methadone. The most common  are smaller-than-normal head  size, low          birth weight, and  withdrawal symptoms. As babies born dependent  on methadone           grow, they usually will fall in the normal range for size and   development.

Methadone is not the only thing that can cause these symptoms.   Smoking          cigarettes, drug use, your biological makeup,  nutrition, and how  well          you take care of yourself are just a  few examples of things that  can affect          the health of your  baby.
Whether or not you are pregnant, you only get the benefits of   methadone          if you are stable on your dose. There is no ‘magic  number’ of  milligrams          to stay below. If you feel any  withdrawals or cravings to use,  make sure          you talk to your  counselor about adjusting your dose. When you  feel withdrawals,           so does your baby and that can lead to complications and even   miscarriage.

Research does not necessarily show any connection between a mother’s dose and withdrawal symptoms in the baby.

It might seem that the more milligrams a mother is taking, the worse the withdrawal symptom s will be, however this is not the case. That’s why we encourage you to focus on finding a dose that works for you and not to worry about the amount of milligrams. If you are tapering, most clinics will stop your taper and keep you at your current dose. Some women ask about tapering off methadone while they are pregnant. The Government’s Center for Substance Abuse Treatment says this: “Medical withdrawal of the pregnant women from methadone is not indicated or recommended.” and here at methadoneandpregnancy.com agree with them. Remember- If you were not ready to taper before you were pregnant, you are not ready to taper because you are pregnant. Medically, pregnant women have been safely tapered off of methadone, but it’s only been done on an inpatient basis where they can monitor the fetus for any distress. You should never try to detox yourself. This can be very dangerous to you and your baby. This can also put your recovery in jeopardy. Usually when women learn more about methadone use during pregnancy and see other healthy babies at the clinic with their moms, they decide to continue methadone treatment. It’s not uncommon to need a dose increase during your pregnancy. By the third trimester the amount of blood in your body just about doubles! Because of this your dose of methadone may need to be increased to help keep you and your baby free from withdrawal symptoms. In fact, an increase in methadone (if you need it) during this time can help improve growth and reduce risk of premature delivery. We cannot stress it enough; make sure you are stable on your dose! If for some reason you aren’t able to make it to the clinic for one day make sure you call the clinic and let them know you aren’t able to make it in. Do your best to get there the next day as early as possible. If you’re having problems with transportation, talk to your counselor. They will help you to figure out how you can get to the clinic every day. Many people wonder: does methadone use during pregnancy increase the chance of my child becoming an addict? There are not many studies that have looked at long-term effects of babies born depended on methadone. The other problem is that there are so many factors influencing drug use, it would be difficult to pinpoint methadone as the ‘cause’ if a child did start using drugs. We do know that there is a genetic component to addiction, so regardless if you are in methadone treatment or not, if you or the baby’s father has had substance abuse problems, the child may be at an increased risk of being an addict or having problems with drug use. While you are pregnant some clinics require that you meet with the Nurse Practitioner (NP) or other medical staff at least once per month. The medical staff wants to check in with you to make sure your pregnancy is going smoothly and ask about your prenatal visits. This is an excellent time to ask any medical questions. If you have any questions at anytime feel free to talk to your counselor or medical staff at the clinic. Your questions are important and deserve to be answered! Clinic staff may ask you to sign a release so we can speak with your prenatal providers. The release is needed so we can talk with your prenatal provider about your treatment at the clinic. It’s also important to have a release in place so if there are any medical concerns the clinic will be able to assist you. Medications such as Suboxone, Nubain, and Stadol could cause you to have severe withdrawal symptoms if you are taking methadone. Be cautious of medications that you are prescribed or given. You should always check with your medical providers before taking any medication. You should never take anyone else’s prescription medication. And be careful about taking any medications, even if it’s offered to you from a friend or family member. Some people store more than one type of medication in a bottle and you might be given something that could harm you, your pregnancy, or cause you to have a positive drug screen. All of your providers are here to support you and want to help you to have a healthy and safe pregnancy! Let us know what you need and how we can help. 1. Methadone maintenance treatment Methadone maintenance treatment (MMT) is the treatment of choice for opioid dependant pregnant women 2. Methadone is a long-acting opioid that enables women to cease or reduce their heroin use and related behaviours, in accordance with a harm minimization philosophy. MMT throughout pregnancy is associated with improved fetal development, infant birth weight, and reduces the risk of perinatal and infant mortality in heroin dependant women (level III 2, 1). The aims of methadone maintenance treatment are to:
  • Reduce or eliminate illicit heroin and other drug use
  • Improve the health and wellbeing of those in treatment
  • Facilitate social rehabilitation
  • Reduce the spread of blood borne diseases
  • Reduce the risk of death associated with opioid use
  • Reduce the level of crime associated with opioid use 2
  • Withdrawal from heroin, without MMT is associated with risks to the fetus and a high risk of relapse2. Women should be informed of these risks, and if it is to be attempted it should ideally be done in the 2nd trimester, supervised in a specialist unit (Consensus,1). While inpatient supervision of withdrawal is not available at the Women's, WADS clinicians are able to provide outreach services to pregnant women undergoing withdrawal in specialist detoxification units.
2. Methadone stabilisation program Heroin dependant women should have priority access to methadone treatment, which includes admission to an inpatient obstetric unit for stabilization and rapid dose titration, with respite from the external environment (Consensus,1). This service is offered at the Women's, under the supervision of WADS care coordination team inpatient stabilisation brochure, at any gestation. Admission is for 5 days (Monday to Friday). Inpatient admission is necessary as rapid induction onto methadone is required. Legislative requirements must be met, including obtaining a permit for prescribing methadone from DHS before commencing, as per the Women's CPG: Methadone and Buprenorphine Dosing Procedures. Care in pregnancy should be provided as per CPG: Care of Women with Alcohol and Drug Issues in Pregnancy. 2.1 Criteria for methadone stabilisation program Women will be assessed as being
  • dependent on opioids
  • motivated to undertake induction onto MMT
  • willing to comply with the whole program and methadone regime.
Women not suitable for treatment with methadone3:
  • Severe hepatic impairment
  • Hypersensitivity to methadone
  • Unable to give informed consent (eg. Major psychiatric illness) or age under 18, consider jurisdictional requirements for obtaining legal consent
Specialist advice should be sought for clients with severe respiratory depression, acute asthma, acute alcoholism, head injury and raised intracranial pressure, ulcerative colitis, biliary and renal tract spasm, patients receiving monoamine oxidase inhibitors. 3. Methadone induction procedure Women should commence on a dose of methadone that should be titrated to the woman's symptoms with rapid increases1. The starting dose should be 20mg, and is reviewed at 4 hourly intervals or earlier if required. At each review, if the woman has objective signs of withdrawal (eg. Pupils dilated, restless, see short opiate withdrawal scale in appendix of National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn), then give an additional 5-10mg. If there are no signs of withdrawal no extra dose is given until the next scheduled review. The maximum dose in the first 24 hours should not exceed 50mg. Extreme caution should be exercised when assessing the woman's requirements on subsequent days if a dose of over 30mg is used on day 1, in order to prevent accumulation and possible toxicity from methadone. The same process should be repeated on day 2 (when the woman will almost certainly require less methadone), commencing again with 20mg and giving additional doses of 2.5 to 10mg as required, with a maximum dose increase of 50mg. If at any time the woman becomes sedated (small pupils, drowsiness), increase frequency of observation and ensure no further methadone is administered until sedation is reversed. Women should be encouraged to remain on the ward for 30-60 minutes post dose, for observation. Women should be cautioned regarding the use of other drugs whilst on methadone. Urine drug screening is not routine, but may sometimes be requested if there are concerns about harmful concurrent drug use. 3.1 Vomiting Vomiting is a serious concern in pregnant women on methadone. Vomiting of a methadone dose may lead to withdrawal in both mother and fetus (consensus,1). If a methadone dose is vomited (consensus,1):
  • Within 10 minutes of dosing - consider giving a repeat dose
  • Within 10-60 minutes of dosing - consider giving half a repeat dose
  • More than 60 minutes after dosing - consider half a repeat dose if withdrawal occurs
Prevention of vomiting (consensus,1):
  • Women should be discouraged from ingesting methadone on an empty stomach
  • Women should be encouraged to sip their dose slowly
  • If the dose consistently causes vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before dosing
  • If woman vomits constantly not in relation to dose, assess and treat according to the Women's CPG: Hyperemesis Gravidarum.
sources: http://www.thewomens.org.au/Methadon...ioninPregnancy Health Conditions of Drug-exposed Infants Birth weight Birth weight is an important factor associated with children’s overall health and development. Children who weigh under five-and-one-half pounds at birth are more likely to have serious medical problems and to exhibit developmental delays. Drug-exposed infants often do not exhibit normal development. Prematurity The risk of prematurity (birth at less than thirty-seven weeks) is higher in drug-exposed infants. Other complications can include an increase in acute medical problems following birth, and extended periods of hospitalization. Birth weight under three pounds has been associated with poor physical growth and poor general health status at school age. Low Birth weight infants also have an increased risk of neurosensory deficits, behavioral and attention deficits, psychiatric problems, and poor school performance. Premature infants may have experienced bleeding of the brain tissue, hydrocephalus, bronchial problems, eye disease, and interferences with the normal ability to feed. Small for Gestational Age (SGA) This term is used to describe infants whose Birth weight is below the third percentile for their gestational age (i.e., 97% of infants the same age are heavier than the SGA infant). It is common for women who abuse cocaine to experience decreased appetite and provide inadequate nutrition for themselves and their baby. Failure to Thrive (FTT) Infants who were exposed to alcohol and/or drugs may exhibit this disorder, which is characterized by a loss of weight, or slowing of weight gain, and a failure to reach developmental milestones. This can be due to medical and/or environmental factors. The infant’s behavior includes poor sucking, difficulty in swallowing, and distractibility. Many of these children live in chronically dysfunctional families which places them at greater risk of parental neglect. Neurobehavioral symptoms Within seventy-two hours after birth, many infants who were exposed prenatally to drugs experience withdrawal symptoms, including tremors and irritability. Their skin may be red and dry; they may have a fever, sweating, diarrhea, excessive vomiting, and even seizures. Such infants may require medication for calming. Other infants exposed to stimulants show a pattern of lethargy during the first few days after birth, are easily overstimulated, and may go from sleep to loud crying within seconds. These behaviors usually decrease over time and subside in toddlerhood. Infectious diseases Infants with prenatal drug exposure may be exposed prenatally or postnatally to infectious and/or sexually transmitted diseases contracted by their mothers. The most common infectious diseases seen in infants are chlamydia, syphilis, gonorrhea, hepatitis B, HIV, and AIDS. Sudden Infant Death Syndrome (SIDS) Children who have been exposed prenatally to alcohol and/or drugs have an increased risk of dying from sudden infant death syndrome. The causes of SIDS are unknown and its occurrence is almost impossible to predict. Apnea/cardiac monitoring is recommended for these infants. Fetal Alcohol Syndrome Mothers who consume large quantities of alcohol during pregnancy may have babies who are born with Fetal Alcohol Syndrome (or FAS). A diagnosis of FAS is based on three factors: 1) prenatal and postnatal growth retardation; 2) central nervous system abnormalities, and, 3) abnormalities of the face. Many of these children display significant disabilities, learning disorders, and emotional problems as they mature. Each of the above conditions associated with prematurity or drug exposure has programmatic implications for caregivers; the children who exhibit these conditions are often referred to as "medically fragile". Developmental Outcomes There are many unknowns involved in trying to predict the outcomes of infants and children exposed to drugs. While we know that there are certain physical problems that may remain with the child, in a structured and nurturing environment, many of these children are able to grow and develop quite normally. A small percentage of children have been found to have moderate to severe developmental problems. But regardless of their health status, all children who have a history of prenatal substance exposure should receive developmental evaluations on a regular basis: at least once during the first six months; at twelve months; and at least every year thereafter until school age. Early identification of social, language, cognitive, and motor development problems is essential. Developmental Patterns in Children Exposed Prenatally to Drugs Birth to fifteen months
  • Unpredictable sleeping patterns
  • Feeding difficulties
  • Irritability
  • Atypical social interactions
  • Delayed language development
  • Poor fine motor development
Toddlers from sixteen months to thirty-six months
  • Atypical social interactions
  • Minimal play strategies
Preschool children from age three to five While average preschoolers are beginning to share and take turns, demonstrate language skills, and increase their attention spans in a group setting, the drug-exposed toddler may be hyperactive, have a short attention span, lose control easily, have mood swings and problems moving from one activity to another. These children may also experience difficulties processing auditory or visual information/instructions. School and teenage years There has not been sufficient research into the long-term biological effects of drug exposure on older children and teenagers, however, we do know that children with the behaviors described above are at greater risk of abuse and neglect, learning disabilities, and behavioral problems. Obviously, it becomes imperative to identify these problems at a very early age, access the necessary resources for the child, and build a team of professionals who regularly monitor the progress of each child. Supporting a drug-exposed child in the course of his life may require advocating vigorously for specialized educational services; providing recreational and employment opportunities that allow a measure of success; educating parents; and providing counseling. Techniques in Working with Drug-exposed Infants and Young Children Respite and crisis care programs working with drug-exposed infants and children may not know the exact drugs to which each child was exposed. A combination of substances, including alcohol and tobacco, may be involved. There are a few techniques, however, which can be used in a general plan of care that may be individualized to meet the specific problems of each child:
  1. Provide a calm environment: low lighting; soft voices; slow transition from one activity to another.
  2. Be aware of signs of escalated behavior and frantic distress states before they occur, e.g., increased yawns, hiccoughs, sneezes, increased muscle tone and flailing, irritability, disorganized sucking, and crying.
  3. Use calming and special care techniques on a regular basis, such as
    • swaddling blankets tightly around the infant
    • using a pacifier even when the infant is not organized enough to maintain a regular suck
    • rocking, holding, or placing the infant in a swing, or Snuggly™ carrier
    • massaging the child
    • bathing in a warm bath, followed by a soothing application of lotion
    • rubbing ointment on diaper area to prevent skin breakdown
  4. Encourage developmental abilities when the infant is calm and receptive using only one stimulus at a time. Look for signs of infant distress and discontinue the activity if this occurs.
  5. Gradually increase the amount and time of daily developmental activities; encourage the child to develop self-calming behaviors and self control of his own body movements.
Behavior Descriptions and Suggested Strategies Feeding problems Feed the baby more often; feed smaller amounts at one time; allow the infant to rest frequently during feeding. Place the infant upright for feeding; after feeding, place the child on his side or stomach to prevent choking; if vomiting occurs, clean the skin immediately to prevent irritation. Irritability/unresponsive to caregiver Reduce noise in the environment; turn down lights; swaddle the infant: wrap snugly in a blanket with arms bound close to the body. Hold the infant closely; put the infant in a bunting-type wrapper and carry it close to your body. Rock the infant slowly and rhythmically, either horizontally or with its head supported vertically, whichever soothes. Place the child in a front-pack carrier; walk with the infant; offer the infant a pacifier or place it in an infant swing. Goes from one adult to another, showing no preference for a particular adult Respond to specific needs of child with predictability and regularity.

May have poor inner controls/frequent temper tantrums


Use  books,  pictures, doll play, and conversation to help the child explore  and express a range of feelings.

Ignores  verbal/gestural  limit setting
Talk  the child  through to the consequence of the action.

Shows decreased   compliance with simple, routine commands
Provide  the child  with explicitly consistent limits of behavior.

Exhibits tremors  when  stacking or reaching
Observe  the child  and note the onset of tremors, their duration, and how the  child compensates for them; provide a variety of materials to enhance  development and refinement of small motor skills, e.g., blocks, stacking  toys, large Leggos™, and puzzles with large pieces. Sand and water play  are soothing and appropriate.

Unable to end or let  go  of preferred object or activity
Provide  attention  and time to children who are behaving appropriately; provide  child with an opportunity to take turns with peers and adults.

Delayed receptive  and  expressive language
Create  a stable  environment where the child feels safe to express feelings,  wants, and needs; use stories/records/songs; use hands-on activities to  reinforce the child’s language abilities.

Expresses wants,  needs,  and fears by having frequent temper tantrums
Remove  and help  calm the child; redirect the child’s attention; verbalize the  expected behavior; reflect the child’s feelings. Praise attempts toward  adaptive behavior. Set consistent limits.

Difficulty with  gross  motor skills (e.g. swinging, climbing, throwing, catching,  jumping, running, and balancing)
Provide  appropriate  motor activities through play, songs, and equipment. Offer  guidance, modeling, and verbal cues as needed.

Over-reacts to  separation  of primary caregiver
Offer  verbal  reassurance; be consistent, and help the child learn to trust  adults.

Withdraws and seems  to  daydream or not be there
Provide   opportunities for contact; move close to the child, make eye contact,  use verbal reassurance; allow, identify, and react to the child’s  expressions of emotions.

Frequent temper  tantrums
Understand  that a  tantrum is usually a healthy release of rage and frustration;  protect the child from harm; remove objects from the child’s path if he  is rolling on floor. Some children do not want to be held during a  tantrum and doing so can cause more frustration. Remain calm, using a  soothing voice; anger will only escalate the child’s frustration. Do not  shout or threaten to spank the child–the adult needs to be in control.  Help the child to use words to describe emotions. Read stories about  feelings. Help the child gain control by making eye contact, sitting  next to the child, giving verbal reassurance, and offering physical  comfort (rubbing back, etc.). Note the circumstances that provoked the  tantrum, and try to avoid such confrontations when possible. Provide a  neutral area for the child to work through the tantrum, (e.g., a large  cushion or bean bag chair). Some children want to work through a tantrum  alone; keep the child in sight, but do not interact until he is calm.

Parent  Involvement
It is critical to the  success  of the drug-exposed infant that the eventual caregiver (parent,  relative, foster parent, respite provider, adoptive parent) learn the  care routine, control techniques, and background of the children for  whom they will be providing care. Understanding the etiology of  drug-exposure, the types of medical problems that arise, the  developmental patterns, and the techniques for handling drug-exposed  infants and toddlers is imperative.

Program social workers,  case  managers, child care staff, and nursing staff must all work  together with the caregiver to offer parent education ("hands-on"  opportunities to provide care under the guidance of professionals), and  encouragement for families who undertake the care of a drug-exposed  infant. The caregiver’s understanding of the child’s behavior, physical  "cues," and developmental problems, goes a long way in helping the  drug-exposed infant, toddler, and teen succeed. It also assists the  caregiver in setting realistic expectations for children who enter the  world battling the the effects of their parent’s addiction.

Many children who were   prenatally exposed to drugs will grow and develop without unusual  problems. However, for those infants who have physical indicators, the  respite and crisis care provider can make a difference by providing,  perhaps, the first stable, nurturing environment. Here, the child can be  observed, positive routines for care can be established, and parents  can receive the critically necessary education and support to enable  them to care for an alcohol or drug-exposed child.

Summary
Staff training, caregiver   training, and parent education are all critical elements of any program  that will be successful with these children. Physical elements of the  environment (lighting, noise, and space) may need to be adjusted to  accommodate their care. The inclusion of medical support, i.e., nurses  and physicians who are familiar with the problems of these children, is  essential. In summary, the care of alcohol and drug-exposed children is a  team effort that requires coordination, case management, special care  techniques, and education to be successful in any respite or crisis care  situation. With these components in place, agencies and families can  witness the positive growth and development of children who have been  greatly at risk.

About the Author: Jeanne Landdeck-Sisco, MSW, is the Executive Director of Casa de los  Niños  in Tucson, Arizona, which was the first crisis nursery in the  U.S., established in 1973. Ms. Landdeck-Sisco served as the first  President of the ARCH National Advisory Committee for Respite and Crisis  Care Programs from 1991-93 and remained on the committee until 1996.
Resources
Center for Substance Abuse   Prevention National Resource Center for the Prevention of Perinatal  Abuse of Alcohol and Other Drugs, 9302 Lee Highway, Fairfax, VA 22031,  (800) 354-8824.
National Organization on  Fetal  Alcohol Syndrome, 1815 H Street, N.W., Suite 710, Washington, DC  20006, (202) 785-4585.
References
Besharov, Douglas J. When   Drug Addicts Have Children. Washington, DC: Child Welfare League  of America, 1994.
Hargrove, Elisabeth, et  al. Resources Related  to Children and Their Families Affected by  Alcohol and Other Drugs. Chapel Hill, NC: NEC*TAS, 1995.

Special acknowledgment is  given to Rosemarie Dyer, R.N., Nursing Supervisor at Casa  de los Niños, who has developed the agency’s program for drug- and  alcohol-exposed infants and from whose training material many of the  techniques and caregiver responses have been drawn; and to Anna  Binkiewicz, M.D., Casa de los Niños Board Member and Medical  Director, who has provided on-site medical treatment of Casa’s medically  fragile children.