1. New Data on Common Substance Exposures in Pregnancy & Lactation
Christina Chambers, PhD, MPH
Co-Director of the Center for Better Beginnings
Professor of Pediatrics
Department of Pediatrics
Department of Family Medicine and Public Health
University of California, San Diego
First5 SD Oct. 8, 2018

2. Alcohol

3. Fetal Alcohol Spectrum Disorders
A child with Fetal Alcohol Syndrome (FAS; a), an alcohol-affected fetal mouse (b), and a comparably-staged normal fetal mouse (c) are shown. Modified from Sulik et al
Del Campo M and Jones KL.
Glass and Mattson. Pediatric Neurotoxicology. 2016;13-49

4. Fetal Alcohol Spectrum Disorders
Includes alcohol-related neurodevelopmental disorders
- children without facial features but have characteristic
cognitive and/or behavioral problems
- thought to be at least 10 times more common than FAS
- BUT there is very limited information on the true number
of children affected in the U.S.
Children with an FASD are highly likely to go undiagnosed
- If an FASD is recognized, it is most often upon reaching
school age, when years of potential intervention
opportunities have been lost
Chasnoff et al. Pediatrics. 2015;135(2):264-70
Lange et al. Pediatrics. 2013;132(4):e980-95
May, Chambers, et al. JAMA Feb 6;319(5):474-82

5. Collaboration on Fetal Alcohol Spectrum Disorders Prevalence (CoFASP)
To establish regionally-based prevalence estimates of FASD including FAS, pFAS, and ARND
Funded by NIH-NIAAA:

7. Study Design Cross-sectional Children in normal first grade classes
Comprehensive evaluation of children and maternal interviews
Four communities in the U.S. 1) Rocky Mountain, 2) Midwest, 3) Southeast, and 4) Pacific Southwest (San Diego)
Two academic years at each site comprising a study eligible population of ~13,000 children

8. San Diego Site

9. Study Design Sample consisted of 27 schools in two academic years
- Represented diversity in socioeconomic status (percent
school free lunch program) and race/ethnicity
4,409 first-grade children eligible
926 children received a full evaluation
- examination by a study geneticist for physical features and growth
- a neuropsychological testing battery
- mothers completed an interview

10. Minimum Prevalence Rate/1000 Weighted Prevalence Rate/1000
FASD Cases
Category
Number Classified
Minimum Prevalence Rate/1000
(95% CI)
Weighted Prevalence Rate/1000
FAS 1
0.4
( )
2.0
( )
pFAS 19
8.5
( )
38.8
( )
ARND 22
9.8
( )
49.2
( )
Total FASD 42
18.8
( )
90.0
( )

11. Minimum Prevalence Rate/1000
FASD Cases
Category
Number Classified
Minimum Prevalence Rate/1000
(95% CI)
Weighted
Prevalence
Rate/1000
FAS 3
1.4
( )
4.9
( )
pFAS 24
11.1
( )
41.4
( )
ARND 22
10.1
( )
38.2
( )
Total FASD 49
22.6
( )
84.4
( )

12. Summary San Diego School Sample
In this large urban setting, prevalence estimates are at least % using the most conservative estimates; likely higher
In combination with other 3 CoFASP sites across the U.S., overall conservative estimates range from %
<1% of children identified across 4 sites had a previous FASD diagnosis
These data support the premise that FASD is a major public health issue in the U.S. and is currently under-recognized

13. Cannabis

14. From the Canadian Centre on Substance Use and Addiction

15. Maternal Marijuana Use During Lactation & Infant Development – 1 Year
Examined infant exposure to marijuana via breast milk and infant motor and mental development at 1 year of age
Marijuana exposure via breast milk during the 1st month post-partum was associated with a decrease in infant motor development at 1 year of age
Correlation between maternal pre- and postpartum marijuana use that could not be effectively reduced by matching

16. Mommy’s Milk Human Milk Research Biorepository at University of California

17. Cannabinoids in Breastmilk
54 human milk samples with known maternal marijuana exposure in previous 14 days were collected from consented volunteers
Analyzed at Skaggs School of Pharmacy at University of California San Diego
Measured levels of THC, 11-OH-THC, CBD, and CBN
Bertrand K et al, Pediatrics, 2018

18. Cannabinoids in Breastmilk
Methods and Frequency of Marijuana Use in Breastfeeding Women
Characteristic
N= 50 mothers, No. (%)
N=4 mothers who gave a repeat sample, No. (%)
Route of Marijuana Exposurea
Inhalation Only
32 (64)
2 (50)
Other Only
7 (14)
0 (0)
Both
11 (22)
Frequency of Marijuana Use
<1 use/day
6 (12)
1 (25)
1 use/day
23 (46)
3 (75)
>1 use/day
21 (42)
a Inhalation Only was defined as a dose unit of joints, puffs, or grams. Other Only was defined as a dose unit of drops, milligrams or servings. Both was defined as a dose unit from both the Inhalation Only and the Other Only groups
Bertrand K et al, Pediatrics, 2018

19. Cannabinoids in Breastmilk
THC, 11-OH-THC, and CBD Levels Detected in Breast Milk
Min.
1st Qu.
Median
3rd Qu.
Max.
AQL*
BQL*
∆9-THC (ng/mL)
1.01
2.29
9.47
46.78
323.00 34 20
11-OH-THC (ng/mL)
1.33
1.35
2.38
5.45
12.80 5 49
CBD
(ng/mL)
1.32
2.92
4.99
5.97
8.56
*AQL (above quantification limits) was defined as ≥1ng/ mL and BQL (below quantification limits) was defined as <1 ng/mL
** The concentration of CBN was BQL in all 54 samples
∆9-THC was detectable in 34 of 54 samples (63%); among these, the median concentration of ∆9-THC was 9.47 ng/mL of breast milk (range: 1.01, )
Bertrand K et al, Pediatrics, 2018

20. Cannabinoids in Breastmilk
Scatterplot and Fitted Regression Last Use of Marijuana, N=34
Bertrand K et al, Pediatrics, 2018

21. Recommendations from Professional Societies

22. Committee Opinion No. 722: https://www. acog

23. Ryan SA, Ammerman Sd, O’Connor ME, AAP Committee on Substance Use and Prevention, Section on Breastfeeding. Pediatrics 2018;142:e

24. TAKE-HOME MESSAGE Do not drink if you are planning pregnancy
Do not get pregnant if you are continuing to drink
If you determine you are pregnant, stop drinking entirely through the remainder of pregnancy
Avoid cannabis during pregnancy and while breastfeeding

25. For More Information

26. Questions?