Infants with Prenatal Substance Exposure

pregnancyEach year, an estimated 15 percent of infants are affected by prenatal alcohol or illicit drug exposure. Prenatal exposure to alcohol, tobacco, and illicit drugs has the potential to cause a wide spectrum of physical and developmental challenges for these infants. There is also potential for ongoing challenges in the stability and well-being of infants who have been prenatally exposed, and their families if substance use disorders are not addressed with appropriate treatment and long-term recovery support. The intersection of pregnancy and substance use creates a need for a collaborative approach among medical, substance use, child welfare, and early childhood providers to address the multifaceted needs of the mother, infant, and family. Coordinated services and early intervention for pregnant women with substance use disorders and their infants are critical in preparing families for optimal bonding, health, and well-being.

Contact us at ncsacw@cffutures.org or 1(866) 493-2758 to learn more about improving outcomes for substance-exposed infants and their families.

Policy and Practice Resources

  • State Level Policy Advocacy for Children Affected by Parental Substance Use
    State Policy, Advocacy and Reform Center, 2014

    This advocacy guide provides compelling data to demonstrate that substance use is a key factor in a high percentage of child welfare–involved families, outlines eight barriers to addressing parental substance use in the child welfare system, summarizes five levers for advocates aiming at going beyond pilot projects to systems change, and highlights policy and practice innovations that advocates can promote.
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  • Substance-Exposed Infants: State Responses to the Problem (PDF 1.50 MB)
    Substance Abuse Mental Health Services Administration, 2009

    This resource offers an exploration of the Five-Point Framework for addressing prenatal substance exposure and substance-exposed infants and provides state examples for each intervention point.
  • Administration for Children and Families (ACF) Child Abuse Prevention and Treatment Act (CAPTA) Program Instructions and Information Memorandums, 2016–2017

    Since April 2016, the Administration for Children and Families (ACF) has released three Program Instructions (PI) and one Information Memorandum (IM) related to CAPTA. A brief description of these Instructions and Memorandum along with links to the full documents are listed as follows.
    • Program Instruction (PI) 1 (PDF 1.41 MB)—April 13, 2016
      This PI details information to be included in the states’ June 2016, Submission of various requirements including the CAPTA State Plan update. This PI specified that states must describe “which agency or entity is responsible for developing a Plan of Safe Care, how it is monitored and how follow-up is conducted to ensure the safety of these infants.”
    • Information Memorandum (IM) 1 (PDF 238 KB)—August 26, 2016
      This IM refers states to the resources of the National Center on Substance Abuse and Child Welfare (NCSACW) for developing practice that reflects coordinated, multi-system approaches. The memo provides information on key programmatic components that have shown promising results with this population and directs states to the NCSACW resource, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders: Practice and Policy Considerations for Child Welfare, Collaborating Medical and Service Providers. (PDF 1.53 MB)
    • Program Instruction (PI) 2 (PDF 278 KB)—January 17, 2017
      This PI provides additional guidance on implementing provisions in the Comprehensive Addiction and Recovery Act (CARA) specific to the removal of “illegal” in regard to infants with prenatal exposure, the requirement that Plans of Safe Care address the needs of both infants and their families or caretakers, and the new requirements related to data collection and monitoring.
    • Program Instruction (PI) 3—April 10, 2017
      This PI provides guidance to states, territories, and insular areas on actions required to take to receive their allotments for federal fiscal year 2018. It summarizes the actions required in completion and submission of (1) the third APSR update to the 2015-2019 CFSP, (2) the CAPTA Update, and (3), the CFS-101, Parts I, II, and III.
  • NCSACW Webinar Series on Opioid Use Disorders and Treatment
    National Center on Substance Abuse and Child Welfare, 2017

    NCSACW developed a webinar series on medication-assisted treatment for families affected by substance use disorders, opioid use in pregnancy and treatment for Neonatal Abstinence Syndrome.

State and Local Examples

  • Substance Exposed Infants In-Depth Technical Assistance Project
    National Center on Substance Abuse and Child Welfare (NCSACW)

    NCSACW provides in-depth technical assistance to strengthen the capacity of states and local jurisdictions to improve the safety, health, and well-being of substance-exposed infants and the recovery of pregnant and parenting women and their families.
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  • Fetal Alcohol Spectrum Disorder Plan of Safe Care (PDF 952 KB)
    Arkansas Department of Human Services, Division of Children and Family Services, 2013

    This document provides guidance to staff requiring referrals from the Child Abuse Hotline for infants born with and affected by FASD. This one-page tool outlines this pathway for referrals to the hotline and provides a checklist of actions that inform a plan of safe care.
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  • Perinatal Screening, Risk Assessment and Referral Form (PDF 185 KB)
    State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services

    This tool embeds the 4Ps+ Screening tool into a broader perinatal risk assessment tool. The tool further includes information on service referrals, including substance use disorder assessment and treatment.
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  • Pregnancy Home Risk Screening Form (PDF 338 KB)
    Community Care of North Carolina, 2013

    This prenatal risk assessment tool embeds questions about substance use, domestic violence, smoking and poverty.
  • Pregnancy Medical Home Care Pathways: Management of Substance Use in Pregnancy
    Community Care of North Carolina, 2015

    This detailed pathway guidance works conjointly with the Community Care of North Carolina Pregnancy Home Risk Screening Form. The pathway provides a framework for screening pregnant women and engaging them in services based on their individual needs. The pathway provides tools for pregnant women who are in long-term recovery, recently abstinent, and in active substance use.
  • Journeys of Hope: Mommies and Babies Overcoming Neonatal Abstinence Syndrome
    Texas Department of State Health Services, 2014

    In this video, three mothers describe their experience in recovering from opioid dependency during pregnancy. Professionals from child welfare, substance use treatment, and the medical field discuss how providing care without judgment results in better outcomes for both mom and baby.
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  • The Treatment of Opioid Dependence in Pregnancy: Vermont Guidelines. (PDF 1.26 MB)
    Vermont Department of Health, Division of Alcohol and Drug Abuse and Fletcher Allen Health, 2010

    This document offers information on types of medication-assisted treatment, guidelines for Obstetric Providers, and guidelines on the management of neonatal abstinence syndrome.
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  • Children and Recovering Mothers (CHARM) Collaborative, Appendix 5 (PDF 1.53 MB)
    Substance Abuse and Mental Health Services Administration, 2016

    Appendix 5 of this document provides details about the CHARM Collaborative where a team partners with child protective services (CPS) in the 30 days before the woman’s due date to jointly, with the family and treatment providers, create a plan for the infant and family for after the baby’s birth. This proactive approach to engaging pregnant women in treatment and establishing the plan for the newborn has significantly reduced the number of emergency investigations for CPS at the time of birth. This case study includes an example of the CHARM Collaborative Universal Consent and CHARM memorandum of understanding.
  • Project LINK
    Department of Behavioral Health and Developmental Services

    This program provides intensive case management and home visiting services to pregnant and parenting women who are at risk or are currently abusing substances. Project LINK is part of Virginia’s Home Visiting Consortium, which provides online and in-person training for home visitors on parental substance use.
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  • Substance Use Disorders during Pregnancy: Guidelines for Screening & Management (PDF 1.04 MB)
    Washington State Department of Health, 2016

    This document provides steps for healthcare professionals in developing and implementing a maternal screening and assessment model as well as guidance to hospitals, healthcare providers, and affiliated professionals about maternal drug screening, laboratory testing, and reporting of drug‐exposed newborns.
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  • Guidelines for Testing and Reporting Drug Exposed Newborns in Washington State (PDF 541 KB)
    Washington State Department of Health, 2015

    This document provides guidance related to maternal and newborn screening, and reporting drug-exposed newborns to the Department of Social and Health Services. These guidelines were developed in response to calls form hospital staff and hospital legal counsel about issues related to reporting positive newborn toxicology screen and testing/consent issues.
  • Parent-Child Assistance Program (PCAP)
    University of Washington, 2017

    The Parent‐Child Assistance Program (PCAP) is an evidence‐based home visitation case‐management model for mothers who abuse alcohol or drugs during pregnancy. Its goals are to help mothers build healthy families and prevent future births of children exposed prenatally to alcohol and drugs.

Additional Resources

  • Responding to Infants Affected by Substance Exposure
    Child Welfare Information Gateway, 2011

    This webpage provides resources to states that are legislatively required to have policies and procedures for reporting substance-exposed newborns to child protective services, to assess the need for intervention, and to establish a plan of care. Resources include strategies used in the states to address prenatal substance exposure and information about the various effects of the most common drugs involved with prenatal exposure.
  • Prenatal Drug Use and Newborn Health: Federal Efforts Need Better Planning and Coordination
    U.S. Government Accountability Office (GAO), 2015

    GAO examined federal agency efforts related to prenatal opioid use and neonatal abstinence syndrome to identify gaps and determine how federal efforts are planned and coordinated. The report recommends that the U.S. Department of Health and Human Services (HHS) designate a focal point to lead departmental planning and coordination on the issues. The Office of National Drug Control Policy and HHS concurred with the GAO recommendations.
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  • Neonatal Abstinence Syndrome Fact Sheet (PDF 548 KB)
    National Association of State Alcohol and Drug Abuse Directors, 2015

    This resource offers an overview and symptoms of neonatal abstinence syndrome (NAS), promising practices, and grant initiatives that address serving infants with NAS and their families.
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  • Pregnant Women and Substance Use: Overview of Research and Policy in the United States (PDF 500 KB)
    Jacobs Institute of Women’s Health-George Washington University, 2017

    This paper examines: current research on health effects of substance use and substance use disorders on pregnant women and their children; policies and programs that help ensure that pregnant women who use substances have access to the highest quality healthcare, including prenatal care; the current barriers to accessing treatment for substance use disorders for pregnant women, including those who are incarcerated; and the impact of laws and policies regarding substance use on pregnant women and families.
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  • Substance-Exposed Newborns: New Federal Law Raises Some Old Issues (PDF 116 KB)
    National Conference of State Legislatures (NCSL) Children’s Policy Initiative, 2004

    This publication describes the federal law to protect children who are affected by prenatal exposure to illegal drugs, provides an overview of existing state reporting laws, discusses the role of child protective services, and highlights the importance of prevention.

Behnke, M., & Smith, V., C. (2013). Technical Report—Prenatal substance abuse: Short- and long-term effects on the exposed fetus. American Academy of Pediatrics, 131(3), e1009.

Brown, Q. L., Sarvet, A. L., & Shmulewitz, D. (2017). Trends in marijuana use among pregnant and nonpregnant reproductive-aged women, 2002-2014. JAMA, 317(2), 207-209.

Centers for Disease Control and Prevention. (2016). Incidence of neonatal abstinence syndrome – 28 states, 1999-2013. Morbidity and Mortality Weekly Report (MMWR), 65(31), 799-802. From https://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm (accessed August 17, 2017).

Centers for Disease Control and Prevention. (2016). Vital signs: Alcohol-exposed pregnancies—United States, 2011–2013. Morbidity and Mortality Weekly Report (MMWR), 65(4), 91-97. From https://www.cdc.gov/mmwr/volumes/65/wr/mm6504a6.htm (accessed August 17, 2017).

Chasnoff, I., & Gardner, S. (2015). Neonatal abstinence syndrome: A policy perspective. Journal of Perinatology, 35, 539-541. doi:10.1038/jp.2015.53

Fodor, A., Timar, J., & Zelena, D. (2014). Behavioral effects of perinatal opioid exposure. Life Sciences, 104(1), 1-8.

Gunn, J. K. L., Rosales, C. B., Center, K. E., Nuñez, A., Gibson, S. J., Christ, C., & Ehin, J. E. (2016). Prenatal exposure to cannabis and maternal and child health outcomes: A systematic review and meta-analysis. BMJ Open, 6(4), e009986

Haug, N. A., Duffy, M., & McCaul, M. E. (2014). Substance abuse treatment services for pregnant women: Psychosocial and behavioral approaches. Obstetrics and Gynecology Clinics of North America, 41(2), 267-296.

House, S. J., Coker, J. L., & Stowe, Z. N. (2016). Perinatal substance abuse: At the clinical crossroads of policy and practice. American Journal of Psychiatry, 173(11), 1077-1080.

Hooks, C. (2015). Paranoid or persecuted? The stigmatization of pregnant drug users: A literature review. Pract Midwife, 18(1), 14-8.

Hoyme, H. E., Kalberg, W. O., Elliott, A. J., Blankenship, J., Buckley, D., Marais, A. S.,… & May, P. A. (2016). Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders. Pediatrics, 138(2), e20154256.

Jarlenski, M., Hogan, C., Bogen, D. L., Chang, J. C., Bodnar, L. M., & Nostrand, E. V. (2017). Characterization of U.S. state laws requiring health care provider reporting of perinatal substance use. Women’s Health Issues, pii: S1049-3867(16), 30174-30178. doi:10.1016/j.whi.2016.12.008

Jones, H. E., Fischer, G., Heil, S. H., Kaltenbach, K., Martin, P. R., Coyle, M. G.,… & Arria, A. M. (2012). Maternal opioid treatment: Human experimental research (MOTHER)— Approach, issues and lessons learned. Addiction, 107(supplement 1), 25-35.

Ko, J. Y., Wolicki, S., Barfield, W. D., Patrick, S. W., Broussard, C. S., Yonkers, K. A.,… Iskander, J. (2017). CDC Grand Rounds: Public health strategies to prevent neonatal abstinence syndrome. Morbidity and Mortality Weekly Report, 66(9), 242-245.

Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics, 134(2), e547-e561. doi:10.1542/peds.2013-3524

Patrick, S. W., & Schiff, D. A. M. (2017). A public health response to opioid use in pregnancy. Pediatrics, 139(3), 1-7. From http://pediatrics.aappublications.org/content/early/2017/02/16/peds.2016-4070 (accessed August 17, 2017).

Terplan, M., Kennedy-Hendricks, A., & Chisolm, M. S. (2015). Prenatal substance use: Exploring assumptions of maternal unfitness. Substance Abuse: Research and Treatment, 9(S2), 1-4

Terplan, M., & Minkoff, H. (2017). Neonatal abstinence syndrome and ethical approaches to the identification of pregnant women who use drugs. Obstetrics & Gynecology, 129(1), 164.

Tsang, T. W., Lucas, B. R., Olson, H. C., Pinto, R. Z., & Elliott, E. J. (2016). Prenatal Alcohol Exposure, FASD, and Child Behavior: A Meta-analysis. Pediatrics, 137(3), e20152542.

Smith, L. M., & Santos, L. S. (2016). Prenatal exposure: The effects of prenatal cocaine and methamphetamine exposure on the developing child. Birth Defects Research Part C: Embryo Today: Reviews, 108(2), 142-146.

Wright, T. E., Terplan, M., Ondersma, S. J., Boyce, C., Yonkers, K., Chang, G., & Creanga, A. A. (2016). The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics and Gynecology, 215(5), 539-547.

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