Risks incurred by children of drug-addicted women: some medical and legal aspects
Effects of drug addiction on new-born infants
Infection of children by a contaminated drug
Drug poisoning of children
Depressive drug-addicted mothers
Criminal failure to report offences
Author: C. VAILLE
Pages: 149 to 156
Creation Date: 1985/01/01
A review of recent literature shows a dramatic increase in the number of drug-addicted pregnant women, which increases the number of infants susceptible to the adverse effects of such addiction. The majority of new born infants born to mothers addicted to opiates show a narcotic withdrawal syndrome. The risk of prematurity and other health disorders occurring in a new-born infant is substantially increased by the mother's abuse of narcotics during pregnancy. The microbial infection of children by a contaminated drug abused in the family, and accidental poisoning of children by drugs, have also been reported.
The treatment of drug-addicted pregnant women has raised ertain medical and legal questions, such as the breach of confidentiality of medical information and the criminal failure to report offences, as well as the failure to render assistance. The promotion of information and education about drug abuse during pregnancy, and the effects of such abuse on the pregnant women, her foetus and the future of a new-born infant is an urgent necessity.
There has recently been an increase in the number of drug-addicted women treated in the medico-social services in France. A similar increase has already been reported elsewhere [ l] - [ 3] . The question is whether the dangers to the children of drug-addicted women will also increase [ 4] . If so, preventive measures should be developed. In discussing the risks of children born to drug-addicted women, the present article focuses on certain medical and legal aspects of the problem, but does not include the dangers of tobacco smoking and alcohol poisoning [ 5] .
Over the past two decades, heroin addiction among pregnant women has increased dramatically [ 1, 2] . Solish and others [ 6] carried out an investigation on the effects of methadone on the foetus. The presence of alkaline phosphatase and oestrogens in the blood suggested that biochemical changes in the foetoplacental unit might, in the long run, affect the child. The metabolism of methadone in the foetus might explain the high incidence and severity of withdrawal symptoms in new-born infants. According to Bashore and others [ 1] , the exposure of a foetus to methadone, rather than heroin, is preferable during the pre-natal period because the exposure to heroin leads to social and legal complications, and because most of the children born to heroin-addicted mothers are taken away from them and placed with foster families, whereas women on methadone maintenance generally keep their babies.
Eriksson and others [ 7] carried out a study in Sweden of amphetamine addicted women during pregnancy. One third of the women were successfully detoxified at the beginning of pregnancy and received the same prenatal care as the average woman. Their new-born infants remained in their care when they left the maternity hospital. Among the other two thirds, there was an increase of 25 per cent in premature births and an increase of 7.5 per cent in perinatal mortality ; 74 per cent of the infants born to the amphetamine-addicted women remained in the care of their mothers.
In 1959, the Bulletinon Narcoticsfirst drew attention to the narcotic withdrawal syndrome in infants born to drug-addicted mothers [ 8] .
Bashore and others emphasized that the percentage of stillborn children of women who had undergone Complete "cold turkey" treatment for heroin addiction was alarmingly high [ 1] . During withdrawal, catecholamines increased regularly in the amniotic fluid ; the result was an increase in the psychomotor activity of the foetus, with relative oxygen-deficiency. After birth, withdrawal symptoms were reported in the majority of the new-born infants of heroin-addicted or methadone-addicted mothers.
Bloch reported in 1981 that neonatal resuscitation problems caused by narcotics were no longer exceptional in France [ 9] .
Perlmutter found prematurity in 56.5 per cent, and perinatal mortality in 17.4 per cent, of the new-born infants of drug-addicted mothers [ 10] .
At the first international conference on premature infants, Smith [ 11] , referring to the effects of narcotics on the infant, stated that codeine administered to the mother as an analgesic was less dangerous to the infant than other narcotics. Smith also stated that the side-effects of respiratory depression caused by narcotic analgesics and barbiturates were dangerous to the infant.
When taken during pregnancy, analgesics and barbiturates may have a dangerous effect on the respiration of the new-born infant. The use of phenobarbitone during pregnancy may lead to haemorrhage in the newborn infant [ 11] . Finnegan and others found pulmonary distress in the newborn infants of drug-addicted mothers. Infants displaying tachypnoea at birth seemed, in general, to be able to compensate their respiratory anomalies by the third day of life, when the pulmonary rate returned to normal levels [ 3] .
Tenner and others [ 12] found that the children of drug-addicted mothers showed hypertrophic ventricles of the heart.
Rubenstein and others identified acquired immunodeficiency syndrome (AIDS) in seven infants [ 13] .
Taylor and others [ 14] found in a study of salmonellosis epidemic in Michigan that 76 per cent of the patients, compared with 21 per cent in the control group, admitted having used cannabis. The samples of cannabis obtained from patients were contaminated by Salmonella muenchen.Analysis showed that some cases of salmonellosis observed in different states were interrelated, and an analysis of the strains showed that cases associated with cannabis could be found in other states. The median age of affected children in two states was 10 years ; among patients aged less than one year, the median was five months. The affected children may have had direct contact with particles of contaminated cannabis or with persons who had abused a contaminated drug [ 14] .
Moody and others [ 15] carried out an investigation to see whether the transmission of pathogenic fungi from contaminated cannabis could be prevented through the use of a water pipe, with negative results.
Karp and others [ 16] described 31 episodes of phencyclidine poisoning in children under five. The presence of phencyclidine was proved by an analysis of the children's urine. In 10 cases, the poisoning was due to oral ingestion of the drug left lying around by the parents; in 10 other cases, the children had been in a room in which phencyclidine had been smoked.
As clinical diagnosis is difficult, it is probable that many cases of intoxication among children escape the notice of physicians.
Drug-addicted mothers are very often depressive, which may make it more difficult to take an infant being treated in an intensive care unit for neonatal withdrawal syndrome away from its mother. The drug-addicted mother usually feels guilty about having abused drugs during pregnancy, and may display a bereavement syndrome when her child is taken away from her. The mother feels that the child's drug-induced illness casts blame on her and this may also lead her to feel irritable towards the child. The mother's depression may have disastrous effects on her relationship with the child, and serious adverse consequences on the child's development.
In France and many other countries, the treatment of a drug-addicted pregnant woman raises some medico-legal problems.
The law of 31 December 1970 substantially modified the provisions concerning narcotics in the Penal Code and Health Code. The following paragraphs describe difficulties encountered in its implementation that may have a bearing on the consequences of drug addiction for the foetus and newborn infant.
The treatment of a drug-addicted pregnant women is complicated by the need to decide whether a doctor is bound to guarantee confidentiality even though it may threaten the life of the foetus and the future of the new-born infant. It is thus difficult to ensure the confidentiality of medical information, which is a necessary factor in persuading the pregnant woman to undergo treatment.
The problem of medical confidentiality was discussed by a working group of the Inter-ministerial Narcotics Committee, which concluded that the system of reporting established in compliance with the law of 1970 did not operate sufficiently in a way to safeguard patients anonymity. The working group's proposal that the reporting system should be discontinued was endorsed by the Committee.
With regard to a possible breach of medical confidentiality, lawyers argue that professional privilege is not jeopardized, since the law concerns addicts who have committed an offence and are therefore "in the hands of the law" [ 17] .
Some judges have criticized the flow of information between the public prosecutor's office and departments of health. Health authorities do not fully comply with all the provisions of the Public Health Code relating to the treatment of drug addicts that specify, in particular, that : "If the treatment is discontinued, the management of the centre or the physician in charge of the treatment shall immediately notify the health authorities, who shall inform the public prosecutor's office". The law does not lay down any time limit for notification to the health authorities, and there are often practical difficulties resulting from delays between the decision to make a court order and the issue by the health authorities of a summons to appear for treatment. The treatment centres, particularly psychiatric hospitals, designated for treatment of drug addicts by health authorities, are often repellent to addicts. In some departments there is no appropriate follow-up of detoxication treatment.
With respect to the law of 1970 and its implementation, a symposium held at Menton [ 18] reached the following conclusions:
". . . without the law, insurmountable difficulties may be encountered in the treatment of some drug addicts. However, it cannot provide a remedy for all the problems resulting from drug addiction itself. . .
"In fact, however good a law may be, it does not, of itself, provide a solution to a problem as difficult as the treatment of drug addiction. Judges and health services must consider the problem jointly and pool their experience. The discussions at the symposium showed that the attitudes were beginning to Converge to some extent; it was generally recognized than an interdisciplinary solution to the problem must be found."
With the aim of protecting children at risk, the law of 15 June 1971 supplemented and amended article 62 of the Penal Code on the reporting of crimes, and article 378 of the same Code regarding privileged communication. Some passages of the commentary by M. Couderc [ 19] are quoted below :
" . . . articles 62 1 and 63 of the Penal Code do not derogate from article 378 2 and do not authorize persons bound to observe the confidentiality of privileged communications to report an abuse to which they are witnesses. Two reasons have been mentioned. One argument is drawn from the rule of interpretation that special laws derogate from general laws, article 62 being in the latter and article 378 in the former category. The second argument is. provided by the very existence of a series of absolutely unambiguous legislative exceptions . . . In addition, article 225 of the Family and Social Welfare Code (order of 5 January 1959), which rules out the application of article 378 to social welfare workers or auxiliaries who inform the authorities when the health, safety, morals or education of minors are endangered, is negative confirmation that no comparable exception exists under the law to cover other persons bound to observe the confidentiality of privileged communications".
In the United States of America all states have promulgated laws compelling physicians to report cases of child abuse (or neglect). In some states, particularly New York and Michigan, new-born infants of drug addicted mothers are automatically reported if they display withdrawal symptoms. The reason is that the child has been subject to physical aggression through an act of the mother and that, consequently, the rules on child abuse (or neglect) apply. It is generally the hospital that reports the case.
The Consultative Assembly of the Council of Europe (document 2628 and recommendation 561) has recommended that physicians must without delay inform the competent administrative authority, only, in writing, of cases that they detect, for the purpose of promoting the welfare of such children.
Any increase in the number of drug-addicted women will no doubt be accompanied by an increase in the birth of children suffering from drug intoxication.
1Article 62: "Any person who, having knowledge of the abuse or neglect of a person under 15, does not in the circumstances defined in the preceding subparagraph notify the administrative or judicial authorities shall be punished with a period of imprisonment lasting from two months to four years and a fine of 2,000 to 20,000 francs, or with either one of these two penalties."
2Article 378: " . . . persons shall not be subject to the penalties . . . when they inform the medical or administrative authorities responsible for health and social welfare of the abuse or neglect of persons under 15 of which they have knowledge through the exercise of their profession : if called as witnesses in a case of abuse or neglect of such minors, they shall be at liberty to give evidence without incurring any penalty."
The degree of risk incurred by the child of a drug-addicted mother depends on the effect of a drug or drugs taken during pregnancy and on the family environment of the child. The treatment of pregnant women with narcotics presents a serious risk to the foetus.
"Cold turkey" treatment of a mother addicted to heroin often leads to the death of the foetus. After birth, withdrawal syndrome appears in a very high percentage of infants born to drug-dependent mothers and the bodyweight of these new-born infants is lower; this backwardness persists for several months.
Microbial infection of children has been found in families using contaminated drugs such as cannabis. The poisoning of children by drugs that have been used in the family has also been reported. Depression is often observed in drug-addicted mothers that may adversely affect the development of the child.
As said earlier, one of the problems of treating drug-addicted women and their children is the difficulty of ensuring the confidentiality of medical information.
The question arises as to how a physician can avoid being cited for nonobservance of articles 62 and 63 of the French Penal Code, on grounds of criminal failure to render assistance, or for breach of confidentiality covered by article 378 of the Penal Code.
Further research is needed to provide appropriate prevention of the consequences of drug addiction during pregnancy. In the medical field, an attempt should be made to discover a method of detoxication of pregnant opiate-addicted women that would cause less serious damage to the foetus than "cold turkey" treatment; clonidine and other alpha-2 adrenergic agonists may deserve further research. In the legal field, instructions should be prepared to safeguard the interests of drug-addicted women during pregnancy and their children. Finally, the promotion of information and education about drug abuse of pregnant women and the adverse effects of such abuse is most needed at present.
R. Bashore and others, "Heroin addiction and pregnancy", Western Journal of Medicine, vol.134, 1981, pp. 506 - 51402
K. J. Besteman, Drug Dependence in Pregnancy: Clinical Management of Mother and Child, Maryland Services research monograph series (Rockville, NIDA, 1978), p.11703
L. P. Finnegan and others, "The effects of perinatal addiction on pulmonary function in the newborn", NIDA Research monograph 41 - Problem of Drug Dependence 1981 (Rockville, Maryland, US Department of Health and Human Services, 1981), pp.319 - 32604
Child Abuse Prevention and Treatment Act, United States Code, vol. 42, sec. 5103 [Pub.L. 93 -247, United States Statutes at Large 88 : 5 (1974)].05
H. Tuchmann-Duplessis, "Retentissement de l'alcoolisme maternel sur la descendance"?, Bulletin de l'Académie nationale de médicine, vol. 164, 1980, pp. 129 - 133.06
G. Solish, R. Harper and E. Feingold, Prenatal Studies of Infants in Methadone Maintenance Women (Tissue Responses to Addictive Drugs, Spectrum Publications, 1976), pp. 653 - 665.07
M. Eriksson, G. Larsson and R. Zetterström, "Amphetamine addiction and pregnancy: 11. pregnancy, delivery and the neonatal period. Socio-medical aspects", Acta obstetricia et gynecologica Scandinavica, vol. 60, 1981, pp. 253 - 259.08
R. H. Kunstadter, "Narcotic withdrawal in newborn infants", Bulletin on Narcotics (United Nations publication), vol. l l, No. 2 (1959), p. 15.09
F. Bloch, "Réanimation néonatale: les problèmes toxicomaniaques ne sont pas exceptionnels en France", Le Quotidien du médecin, No. 2552, 1981, p. 13.10
J. F. Perlmutter, "Drug addiction in pregnant women", International Pharmaceutical Abstracts, vol. 5, No. 2 (1968), p. 109 (Citation) in Bulletin on Narcotics (United Nations publication), vol. 20, No. 3 (1968), p. 17.11
B. E. Smith, "Narcotics and the premature infant", Bulletin on Narcotics (United Nations publication), vol. 20, No. 4 (1968), p. 7.12
M. Tenner, G. Wodraska and C. Montesinos, Ultrasonic Evaluation of the Lateral Ventricles in Addicts, their Children and Neonates: Preliminary Findings (Tissue Responses to Addictive Drugs, Spectrum Publications, 1976, pp. 641 -651.13
A. Rubinstein and others, "Acquired immuno deficiency with reversed T4/T8 ratios in infants born to promiscuous and drug-addicted mothers", Journal of the American Medical Association, vol. 249, No. 17 (1983), pp. 2350 - 2356.14
D. Taylor and others, "Salmonellosis associated with marijuana", New England Journal of Medicine, vol. 306, No. 21 (1982), pp. 1249 - 1253.15
M. Moody and others, "Do water pipes prevent transmission of fungi from contaminated marijuana?", New England Journal of Medicine, vol. 306, No. 24 (1982), pp. 1492 - 1493.16
H. N. Karp, N. D. Kaufman and S. K. Anand, "Brief clinical and laboratory observations", Journal of Pediatrics, vol. 97, No. 6, (1980), pp. 1006 - 1009.17
P. J. Doll, "Les médecins et la loi du 31. 12. 1970 sur la lutte contre la toxicomanie", La Presse médicale, vol. 29, 1971, pp. 877-879.18
C. Vaille, "Traitement des toxicomanes - Responsabilité et rôle de la loi", Bulletin de l'ordre des pharmaciens, No. 213, juillet - août 1978, pp. 961 - 970.19
M. Couderc, Dispositions nouvelles pour la protection de l'enfance en danger: abstention délictueuse et secret professionel - Commentaire de la loi no 71-446 du 15 juin 1971 (Recueil Dalloz-Sirey, 13 October 1971), p. 396.