Hee Kim

DRUG USE IN PREGNANT ADOLESCENTS: A COMPARISON BETWEEN SELF-REPORT AND TOXICOLOGY SCREENING. 13

DRUG USE IN PREGNANT ADOLESCENTS: A COMPARISON BETWEEN SELF-REPORT AND TOXICOLOGY SCREENING. 13

No Increase in Developmental Delay in Very Low Birth Weight Cocaine Exposed Infants: A Two Year Follow-Up † 1306

Objective: Published studies reveal conflicting data on the effect of in-utero cocaine exposure on infant development, with little data on VLBW infants. The aim of this study was to measure the effect of cocaine and other variables on the VLBW infant.

Cocaine Attenuates Neonatal Withdrawal in Methadone-Maintained Mothers† 1226

There is conflicting data about the effect of cocaine on the withdrawal of newborns from methadone. We reviewed 85 consecutive cases of newborns born at Bronx Lebanon Hospital Center from January 1993 till February 1996 to mothers in methadone maintenance programs. The age range of the mothers was 18-41 years (mean 30.4± 5.1) with 75% Latino and 22% African-American. Sixty-four women (91%) had prenatal care during the pregnancy and 7% had extramural deliveries. The overall prevalence of illicit drug use within one month prior to delivery was 55%. This was determined by history or a positive infant urine toxicology screen. The mothers were divided into 4 groups: 1. methadone alone (methadone) 38 mothers (45%), 2. cocaine + methadone (cocaine) 13 (15%), 3. opiates + methadone (opiates) 13 (15%), 4. methadone +cocaine+opiates (poly-drug) 21 (25%). There were no significant differences between the groups in birth weight, gestational age, length, head circumference, neonatal morbidity, blood pressure, and exposure to smoking or alcohol. There were several important differences between the groups. The daily dose of methadone was significantly higher in the cocaine group than in the methadone group (76 vs 56 mg, p=0.0036) or the opiate group (55mg, p=0.0050). In addition, mothers using cocaine were enrolled in a methadone program significantly longer than the methadone users (60 vs 25 months, p=0.0015) or opiate users (13 months, p=0.0011). However, the peak total withdrawal score(modified Finnegan 1975) was significantly lower in the cocaine-exposed group than the methadone-exposed group (12 vs 16, p=0.0111) or the opiate-exposed group (16, p=0.0220). The number of hospital days spent withdrawing was also significantly lower with cocaine than methadone (22 vs 34, p=0.0235) or opiate(39, p=0.042). Despite the use of illicit drugs, 44% (20/45) of these newborns were discharged home to their mothers. We conclude that while methadone maintenance programs are hailed as an effective method of preventing illicit drug use, concomitant drug use is still very high and continues to place the newborn at risk both in the immediate neonatal period as well upon discharge home. Cocaine use attenuates the neonatal withdrawal syndrome from methadone, whereas opiate use does not.

Psychiatric Symptoms In Postpartum Adolescent and Adult Women 68

The object of this study was to evaluate post-partum women for psychiatric symptomatology, including cognitive disturbances, anxiety, depression, and anger in order to better meet their needs for support and involve them in the care of their infants. We interviewed 52 post-partum women at The Bronx Lebanon Hospital Center, 17 adolescents (age≤19 yrs, mean age 17.5 yrs.) and 35 adults (mean age 26.6 yrs.). The presence of psychiatric symptoms were measured by using the 29-item Psychiatric Symptom Index (Ilfeld 1976) on mothers within 5 days of delivery. There were no significant differences between the adolescents and the adults for maternal race, prenatal complications, type of delivery, cigarette smoking, drug use, current employment status, or infant health. Adults were more likely to have planned the pregnancy(41.2% vs. 11.8%, p=.003), received prenatal care (100% vs. 87.5%, p=.033), and report feeling happy upon learning they were pregnant(71.4% vs 29.4%, p=.010). Despite the fact that adult mothers were less likely to be worried about the health of their babies (25.7% vs. 52.9%, p=.003) and more likely to report that they would be better off a year from now (90.0% vs. 62.5%, p=.025), they demonstrated higher depressive symptomatology, higher amounts of anger, and greater overall psychiatric symptomatology than adolescent mothers. Physicians need to be aware of the high levels of depression and anger among adult mothers to provide appropriate support. Adolescent mothers may not realize the gravity of their situation and may not seek adequate intervention. Table

Adolescent Pregnancy Correlates with Educational Underachievement in an Urban Setting 27

In order to better understand the factors leading to teenage pregnancy in our high risk population, we interviewed 119 adolescent females ≤ age 21; 102 postpartum mothers and 17 hospitalized control adolescents (mostly PID and asthma). In addition to direct questioning, the WRAT for reading and Gillmore Reading Comprehension Test were administered to assess educational level. The two groups did not differ for race, citizenship, economic situation or employment. When those sexually active were asked about contraception method, 70% reported using condoms, 7% oral contraceptives, 6% other methods and 17% no method. Of the teens who used some form of contraception, 17% use it every time, 23% most of the time, 45% sporatically and 15% rarely. Information about contraception was obtained primarily from health clinics (45%), with only 14% from schools and 11% from parents. Male partners rarely play a primary role in the decision to use contraception, with only 15% raising the issue first vs 49% of the females. 70% of the pregnancies were unplanned and 30% of the mothers were using contraception at the time of conception. The postpartum group were older when they first had sexual intercourse (15±2 vs 11±6, p=0.0000). Educational underachievement was based on the difference between the expected grade level based upon age and the grade level performed on the reading tests. Teen mothers were academic underachievers, both on the WRAT (4.5±2.8 vs 1.8±2.5, p=0.0006) and on the Gillmore (4.8±2.6 vs 2.4±2.5, p=0.0008). In addition, teen mothers were in a significantly lower percentile on the WRAT than the control teens (12.3±17.6 vs 26.8±29.6, p=0.0060). We conclude that adolescents who are pregnant score lower in academic tests. These findings suggest that better intervention in terms of general education as well as education geared to preventing teenage pregnancy needs to be targeted towards this high risk population.

COCAINE AND WITHDRAWAL. 447

There continues to be controversy about whether cocaine causes withdrawal symptoms in newborn infants. Some of the controversy arises because many of these mothers abuse multiple drugs. We prospectively studied 444 consecutive mother-infant pairs. Detailed histories, including drug use were obtained by structured interviews on the post-partum floor. Concurrently, maternal and infant urine and meconium samples were obtained, numerically coded and matched to interview data to insure anonymity. Symptoms of withdrawal were obtained by researchers blinded to the toxicology data. 148 of the 444 (32%) were proven to have abused drugs during the pregnancy by history or toxicology data. 82 were proven to abusing cocaine alone (18%). 131 of our newborns had symptoms of withdrawal (29.5%). 40 of the cocaine group (49%) had withdrawal symptoms which was statistically greater than the number in the drug-free group (26%, p=.000). The symptoms among the cocaine using group were consistent with withdrawal as they started within the first few days of life and resolved within a few days. Most of the withdrawal cases were mild, with the most common symptoms being decreased sleep, tremors, increased tone, high pitched cry, hyperactive Moro, and sneezing. 2 of the babies (5%) had withdrawal severe enough to require treatment. In conclusion, cocaine does produce withdrawal which is usually mild, but occasionally requires therapy.

FACTORS INFLUENCING INITIATION OF BREAST FEEDING AMONG URBAN WOMEN. † 641

The objective of our study was to identify factors associated with the initiation of breast-feeding in a poor urban area. One hundred postpartum, nonadolescent, non-drug using mothers, 50 breast-feeding and 50 formula feeding, were consecutively interviewed. Breast-feeding women were more likely to be born outside of the United States (42 versus 14%, p = 0.002), have more years of education (12.1 +/- 1.9 versus 10.9 +/- 1.7, p = 0.002), be employed either prior to or during pregnancy (38 versus 16%, p = 0.000), be married (46 versus 26%, p = 0.037), be a nonsmoker (86 versus 64%, p = 0.011), have more prenatal visits (8.4 +/- 7.3 versus 5.0 +/- 5.9, p = 0.010), or have a breast-feeding mother (48 versus 26%, p = 0.023). There were no differences in age or ethnicity. The father of the breast-feeding baby was more likely to be better educated (12.0 +/- 2.8 versus 10.5 +/- 3.6 years, p = 0.022) and to work full-time (68 versus 40%, p = 0.005). Eighty-four percent of formula feeders knew that breast milk was better for their babies but decided not to breast-feed due to concerns of pain, smoking, and work. Sixty-three percent of women made the choice to breast-feed prior to the pregnancy, 26% during the pregnancy, and 11% after delivery. Significantly more multiparas decided prior to the pregnancy compared with primaparas. We recommend that breast-feeding education should be started prior to the first pregnancy and tailored to the concerns of the women.

KNOWLEDGE OF MANAGED CARE AMONG URBAN WOMEN. 810

Over the past year, managed care companies, have been attempting to attract more inner city clients. In order to study whether these decisions are informed, we interviewed 100 postpartum, non-adolescent, non-drug using mothers. Mean age of these mothers was 26±7 years and the mothers had an average education of 11.6±1.9 years. 94% of the mothers were U.S. citizens or permanent residents. 99% of them lived in their own house or apartment. 25% of the mothers were employed and 61% of the babies fathers were employed. 95% of the mothers had medical insurance, 73% Medicaid. 97% of the mothers had received prenatal care. In response to direct questions about knowledge of managed care, only 21% of mothers knew what managed care was. The mothers who were knowledgeable of managed care did not differ from those were not by age, race, education, birth in the US, US citizenship, marital status, employment, smoking or drinking during pregnancy, prenatal care, number of prenatal visits, fathers age, education or employment. In conclusion, the overwhelming majority of inner city postpartum mothers have no knowledge of managed care. These mothers must be educated before attempts are made to sign them up.

ARE NURSES HOME VISITS A SOLUTION TO THE PROBLEM OF EARLY DISCHARGES AMONG INNER CITY DELIVERIES? † 642

In order to contain medical costs many insurance companies have advocated 24 hour discharges of postpartum mothers and newborn infants followed by a nurses home visit within 48 hours of discharge. We hypothesized that such an approach would not work in our inner city population because many of the addresses given by our mothers are false and therefore, these mothers and babies may not be found. We were also concerned about the safety of such visits. In order to test that hypothesis we reviewed the records of all Maternal Child Health Referrals in 1995 to the Visiting Nurse Service of New York for Bronx, N.Y. A total of 8,419 patients were referred and 7,035 visits were successful (84%). Of the 1,384 unsuccessful visits, 480 (35%) were because the patient could not be found, 265 (19%) were because the patient/family refused care, 80 (6%) because the family moved, 3 were because the visit was thought not to be safe and 628 (45%) were because of other technical problems. To evaluate a poor inner city population we reviewed the records for Bronx Lebanon Hospital. Among 1958 patients referred, 1644 were successful (84%) and 314 unsuccessful. 160 (33%) could not be found, 71 (23%) were because of refusal of care, 14 (4%) because the family moved, and 2 because of safety. We conclude that nursing home visits are successful in at least 84% of newborn infants and therefore, early discharges may be possible in the majority of deliveries even in an inner city population. We hypothesize that a single antenatal nursing home visit would help to identify those families who could have a successful post-discharge home visit.

EFFECTS OF ETHNICITY AND CULTURAL DIFFERENCES ON MATERNAL PRACTICES AND ATTITUDES. 1587

In order to better understand the role cultural differences play in regards to maternal attitudes towards their newborns, one hundred women who had delivered normal healthy newborns with birth weights over 2.2 kg were interviewed. Mothers were classified into three groups dependent upon place of birth; U.S. (60%), Puerto Rico (12%), and other locations outside the U.S. and P.R.(28%). Mothers born outside the U.S. and P.R. were predominantly from the Caribbean (54%), Africa (21%) or South America (14%). Mothers born outside the U.S. and P.R. were more likely to be married (50% v. 25%, p=.02), and to have completed high school (75% v. 20%, p=.038) than those born in the U.S. A similar relationship held for paternal education; of the non U.S./P.R. born cohort, 89% completed high school vs. 55% of the U.S. born cohort (p=.0002). There was no significant difference for maternal (MA) or paternal age (PA) although those born outside the U.S./P.R. tended to be older: MA 28.1±6.2 vs. 25.8±6.4 and PA 31.3±6.8 vs. 27.8±8.5, than U.S. born. Mothers born in P.R. lived in larger households than those born in the U.S. with an average of 4.42 additional family members v. 2.65 of U.S. born (p=.014). There were no significant differences between groups for income, insurance, employment, smoking, alcohol use, drug use, HIV status, prenatal care, maternal infection, attendance of child birth classes, and mode of delivery. There was a significant difference in feeding methods with 75% of those mothers born outside the U.S. and P.R. preferring to breast feed over formula feed whereas only 41% of U.S. born and 33% of P.R. born had decided to breast feed (p=.0035). Mothers born outside the U.S./P.R. were also significantly more likely to have been breast fed by their mothers (92%) than those born in the U.S.(28%) or P.R.(33%), (p=.0000). In our inner city population, the only distinguishing characteristics between cultural groups are marital status, educational levels and willingness to breast feed. We speculate that these differences may play a significant role in the eventual outcome of these newborns and their families.