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OCR for page 390
an
Substance Use and Abuse
During Pregnancy
The use of substances such as tobacco, alcohol and illicit drugs during
pregnancy has important general health implications both for the mother
and the fetus. A Food and Nutrition Board report entitled Alternative
Dietary Practices and Nutritional Abuses in Pregnancy (NRC, 1982) consid-
ered at length the adverse reproductive effects of cigarette smoking and
alcohol abuse as well as the teratogenic potential of caffeine in animals.
The present report briefly summarizes the influence of tobacco, alcohol,
caffeine, marijuana, and cocaine on the fetus and reviews the data on how
these substances may affect dietary intake and nutritional status during
pregnancy.
Marijuana use is included because of its relatively common occurrence
and because of concern about its possible adverse effect on fetal growth
and development. Cocaine is also discussed because of the recent dramatic
increase in its use and its potentially devastating effect on the health
and well-being of the mother and the fetus. Coverage of other types
of substances was considered to be beyond the scope of work of this
subcommittee, even though illicit and certain prescription drugs are known
to have detrimental effects on nutrition and pregnancy outcome. Use
of such substances should be actively assessed when counseling women
regarding nutrition and ways to promote a healthy pregnancy.
390
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SUBSTANCE USE AND ABUSE
391
CIGARETTE SMOKING
Prevalence
Although the prevalence of cigarette smoking in the general U.S.
population has declined over the past two decades, it is still a common
addiction among pregnant women. The proportion of women of child-
bearing age (20 to 44 years) who smoke has decreased from about 40%
in 1965 to 30% in 1987 (NCHS, 1989~. Smoking rates among girls aged
12 to 17 increased during the mid-1970s but subsequently declined-from
24% in 1974 to 11% in 1988 (NCHS, 1989; NIDA, 1989~. Smoking during
pregnancy also appears to have decreased. Data from the 1967 and 1980
National Natality Surveys indicate that among married pregnant women
aged 20 or older, the proportion of smokers declined from 40 to 25% for
white mothers and from 33 to 23% for black mothers (Kleinman and Kop-
stein, 1987~. This decline was limited largely to those who had completed
high school; no change was reported in the prevalence of smoking among
mothers under age 20. The 1980 National Natality Survey showed that the
overall proportion of married mothers who smoked was 25% (Prayer et
al., 1984), the highest rates occurring among white women, followed by
black and Hispanic women. Smoking was also considerably more common
among teenage mothers and those who had not completed high school
as compared with the older or more educated mothers. Data from the
26 states in the Behavioral Risk Factor Surveillance System in 1985 and
1986 indicate that the overall prevalence of smoking in pregnancy was 21%
with higher rates for unmarried (36~) as compared with married (18%)
pregnant women (Williamson et al., 1989~.
Effects on the Developing Fetus and Child
The effects of maternal smoking on pregnancy and on the developing
fetus and child have been reviewed extensively (Abel, 1980b; Berkowitz,
1988; DHEW, 1979; DHHS, 1980~. The most consistent observation is the
reduction in birth weight (on average 200 g) among infants of smokers. A
recent review of the literature on the determinants of low birth weight has,
like previous reviews, concluded that cigarette smoking is by far the single
most important modifiable factor responsible for fetal growth retardation in
developed countries (Kramer, 1987~. Other adverse effects include a mod-
erately increased risk of preterm delivery (Fedrick and Anderson, 1976;
Meyer et al., 1976; Shiono et al., 1986), perinatal mortality (DHEW, 1979;
Meyer and Fascia, 1977; Meyer et al., 1976), and, possibly, spontaneous
abortion (Alberman et al., 1976; Kline et al., 1980b; Kullander and Kallen,
1971~. A sizable proportion of perinatal deaths and preterm births appears
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392
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
to be mediated through a smoking-related increase in the incidence of
placenta previa and abruptio placentae (premature separation of the pla-
centa) (Andrews and McGarry, 1972; DHEW, 1979; Meyer and Fascia,
1977; Naeye, 1979~. In addition, children of mothers who smoke during
pregnancy may have slight but measurable deficits in long-term physical
growth, intellectual performance, and behavioral development (Butler and
Goldstein, 1973; Dunn et al., 1977; Naeye and Peters, 1984; Rantakallio,
1983~. Interpreting the long-term effects of maternal smoking is prob-
lematic, however, since it is difficult to separate the effect of in utero
exposure from postnatal passive exposure and other characteristics of the
home environment of smoking parents.
The adverse effects have been found to be proportional to the fre-
quengy of smoking and appear to be prevented or reduced if The mother
does not smoke during a subsequent pregnancy (Abel, 1980b; DHEW, 1979;
DHHS, 1980; Naeye, 1978~. The smoking-related effects have also been
found to be independent of other factors, such as race, parity, prepregnancy
weight, maternal weight gain, and socioeconomic status. These observa-
tions support the generally accepted conclusion that the adverse effects of
smoking represent a cause-and-effect relationship and are not a reflection
of different characteristics of smokers and nonsmokers.
Nutr~tion-Related Effects of Smoking
Cigarette smoke contains approximately 2,000 different compounds.
The exact mechanism behind the detrimental effects of smoking on the
fetus and newborn have not been established. The most widely accepted
explanation is that smoking causes intrauterine hypoxia through increased
carboxyhemoglobin levels or reduced uteroplacental blood flow (Abel,
1980b; Longo, 1982~. Other nutrition-related factors may also play a
role. Cyanide, a constituent of tobacco smoke, and thiocyanate levels in
the blood and urine of smokers and their infants are higher than those of
controls (Meberg et al., 1979; Pettigrew et al., 1977~. Since vitamin BE and
sulfur-containing amino acids are utilized in the detoxification of cyanide,
the depletion of these important nutrients may adversely affect the growth
and development of the.fetuses of smokers. Other studies show statisti-
cally significant reductions in the plasma levels of several amino acids and
carotene in pregnant women who smoke compared with levels in pregnant
nonsmokers (Crosby et al., 1977~. The maternal plasma carotene level in
smokers has, in turn, been positively associated with birth weight (Metcoff
et al., 1989~. Cigarette smoking also appears to be related to reduced
vitamin C levels. Data from the Second National Health and Nutrition
Examination Survey (NHANES II) revealed that serum vitamin C levels in
nonpregnant female smokers were lower than in nonsmokers (Woteki et al.,
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SUBSTANCE USE AND ABUSE
393
1986), and serum levels were found to be significantly reduced among smok-
ers after adjusting for vitamin C intake in a small-scale study of adolescent
females (Keith and Mossholder, 1986~. Smokers have also been reported to
have decreased plasma ascorbate levels, which in turn are associated with
increased metabolism of vitamin C rather than alterations in absorption or
urinary excretion (Kallner et al., 1981~. Nonpregnant, adult heavy smokers
(>20 cigarettes/day) may require up to twice as much vitamin C to maintain
a body pool of vitamin C similar to that in nonsmokers.
In NHANES II (1976-1980), the prevalence of low serum and ery-
throcyte folate levels was significantly higher for female smokers than for
nonsmokers (LSRO, 1984~. In addition, hemoglobin concentrations in
smokers were found to be higher than those in nonsmokers-a finding
that presumably reflects a response to the conversion of hemoglobin to
carboxyhemoglobin in smokers. This finding was not confirmed in the
data from the Collaborative Perinatal Project, but elevated hemoglobin
and hematocrit levels were found in the neonates of smokers (Garn et al.,
1978~. Because the presence of carboxyhemoglobin in the blood results in
elevated hemoglobin concentrations in smokers, the Centers for Disease
Control recently recommended higher hemoglobin and hematocrit cutoff
values for identifying the risk of anemia for smokers as compared with risk
for nonsmokers (CD C, 1989~. There is also evidence that smokers may
have decreased placental zinc-to-cadmium ratios, which in turn have been
related to reduced birth weight (Kuhnert et al., 1987, 1988~.
Caloric intake may modify the relationship between smoking and re-
duced birth weight. Smokers have generally been found to have a some-
what lower prepregnancy weight and weight gain during pregnancy than
nonsmokers (Butler et al., 1972; Garn et al., 1979; Rush, 1974~. It would
therefore be expected that smokers consume less food than nonsmokers;
however, data from the National WIC (Supplemental Food Program for
Women, Infants, and Children) Evaluation (Rush et al., 1988) and other
studies (Haworth et al., 1980a; Picone et al., 1982) have shown that dietary
intakes of smokers during pregnancy are higher than those of nonsmokers.
Since cigarette smoking has been demonstrated to increase the metabolic
rate (Perkins et al., 1989), the lower prepregnancy weight and weight gain
in smokers presumably reflect a reduced availability of calories for weight
gain. An increase in the nutritional intake of pregnant smokers may coun-
teract some of the smoking-related effects on birth weight (Garn et al.,
1979; Metcoff et al., 1985; Rush et al., 1980), but some data show that
infants of obese smokers will still weigh significantly less than infants of
obese nonsmokers (Haworth et al., 1980b). Thus, it appears that improving
the food intake of pregnant smokers does not completely compensate for
the negative effect of smoking on birth weight.
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394
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
In summary, cigarette smoking may affect maternal nutrition (and con-
sequently, fetal nutrition) in two important ways: the increased metabolic
rate in smokers can lead to the lower availability of calories, and exposure
to tobacco may increase iron requirements and decrease the availability of
certain nutrients such as vitamin Bit, amino acids, vitamin C, folate, and
zinc. In addition, the hypothesized reduction in uteroplacental blood flow
in smokers could restrict nutrient and oxygen flow to the fetus.
As a result, mothers who smoke may need special counseling regarding
dietary intake and may benefit from multiv~tamin-mineral supplementation,
but this has not been investigated. Furthermore, compensatory intakes
should not replace strategies for persuading women to give up smoking.
Some smoking cessation programs during pregnancy have been found to
be effective in increasing infant birth weight (Sexton and Hebel, 1984), and
pregnancy may be a particularly opportune time to introduce antismoking
assistance (Sexton and Hebel, 1984; Windsor et al., 1985~.
ALCOHOL
Effects on the Developing Fetus and Child
Although the fetal alcohol syndrome (FAS) was not described until
1973 (Jones and Smith, 1973), alcohol is now recognized as a potent terato-
gen. FAS is estimated to affect approximately one to two infants per 1,000
live births in the United States (Abel and Sokol, 1987) and is characterized
by prenatal or postnatal growth retardation, distinct facial anomalies, and
mental deficiency (Rosett, 1980~. Other potential alcohol-related birth de-
fects include cardiac and genitourinary abnormalities (Ernhart et al., 1985;
Hanson et al., 1976), but it is difficult to attribute isolated anomalies to
alcohol exposure. In addition to FAS, alcohol has been associated with a
spectrum of adverse effects that range from spontaneous abortion (Harlap
and Shiono, 1980; Kline et al., 1980a) to subtle behavioral effects in the
absence of physical anomalies (Aronson et al., 1985; Shaywitz et al., 1980~.
The effect of alcohol on central nervous system dysfunction is of partic-
ular concern, since some degree of intellectual impairment is frequently
reported for children with FAS, especially those having the most severe
dysmorphogenesis (Streissguth et al., 1983~.
Definitions and Prevalence of Alcohol Use and Abuse
According to national surveys of women aged 18 or older, the propor-
tion who drink alcohol at least occasionally has decreased slightly between
1971 (58%) and 1985 (55%), and the proportion who consume 30 cc (1
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SUBSTANCE USE AND ABUSE
395
oz) or more of pure alcohol per day has dropped from 5 to 3% during the
same period (NCHS, 1989~. Among women aged 18 to 25, the proportion
who reported that they consumed alcohol in the preceding month increased
from 58% in 1976 to 68% in 1979 and then declined to 57% in 1988 (NCHS,
1989; NIDA, 1989~.
Precise estimates of alcohol abuse cannot easily be obtained because of
underreporting of alcohol intake and the difficulty of accurately quantifying
alcohol exposure. Nor has any consistent criterion been used for defining
alcohol abuse. In the 1980 National Natality Survey, it was found that
among 4,405 married women who delivered live infants, 39% consumed
some alcohol during the pregnancy and 3% drank three or more servings
of alcoholic beverages per week (Prayer et al., 1984~. Alcohol consumption
was highest among white mothers, followed by Hispanic and black mothers.
Age and education were both positively related to drinking; i.e., drinking
was most prevalent among older and better educated mothers. Other
studies have estimated that anywhere from 0.8% (Streissguth et al., 1983)
to 9% (Ouellette et al., 1977) of pregnant women are heavy drinkers; most
studies report a range of 2 to 3%. Although the definition of heavy use
has varied, consumption of two or more drinks per day has commonly
been used for identifying heavy alcohol intake. It is not known whether
alcohol consumption during pregnancy has declined since the 1977 and 1981
Surgeon General's reports on alcohol and pregnancy, but at least one study
found no significant decrease in the relative proportion of heavy drinkers
among Pregnant women in Seattle. Washington, between 1974-1975 and
~~= r--c~--~ ---,
1980-1981 (Streissguth et al., 1983~.
Although FAS is believed to be limited to chronic alcohol abusers,
growth retardation has been observed at lower levels of alcohol consumption
(approximately 30 to 60 cc, or 1 to 2 oz. of absolute alcohol daily) (Hanson
et al., 1978; Little, 1977; Wright et al., 1983~. Another study showed
a significantly increased risk of delivering a growth-retarded infant for
women who consumed one to two drinks per day (Mills et al., 1984~. Still
other studies have demonstrated no or inconsistent associations between
moderate levels of alcohol consumption and fetal growth (Brooke et al.,
1989; Kline et al., 1987; Marbury et al., 1983; Rosett et al., 1983; Tennes
and Blackard, 1980~. Thus, the evidence concerning the effects of low levels
of alcohol consumption is both limited and inconsistent. The possibility
that maternal binge drinking may adversely affect the fetus has also been
suggested by data on both humans and animals (Clarren et al., 1978, 1988~.
Nutrition-Related Effects of Alcohol Use
The exact mechanism by which alcohol adversely affects fetal growth
and morphogenesis has not been established. Animal studies have docu
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396
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
mented direct dose-response effects of alcohol on fetal growth and devel
opment and have shown that these effects were not attributable to other
factors such as malnutrition (Randall et al., 1981~. Alcohol may also affect
the fetus indirectly through its effect on maternal nutrition. Since ethanol
is a source of energy, chronic alcoholics may have a relatively low intake
of proteins, essential fats, vitamins, and minerals. In a prospective study of
alcohol use during pregnancy and neonatal outcome in Cleveland, Ohio,
investigators compared 24-hour dietary intake histories of patients with
positive and negative scores on the Michigan Alcoholism Screening Test
(Sokol et al., 1981~. Those with positive scores had significantly lower
intakes of meat and vegetable protein, dairy foods, cereal and bread,
calcium, certain B vitamins, and vitamin D. However, dietary intake was
not significantly different among rare, moderate, and heavy drinkers in
another study (Ouellette et al., 1977~.
There are few data on the effect of alcohol on maternal nutrition.
In one study maternal and umbilical cord blood zinc levels were found
to be lower in alcoholic than in nonalcoholic pregnant women (Flynn et
al., 1981), although the importance of these findings has been questioned
(Kiely, 1981~. Other studies suggest that alcohol may impair placental
transport of amino acids, which in turn may adversely affect fetal nutrition
(Fisher et al., 1981~. Animal studies have similarly shown that ethanol
inhibits placental transport of certain amino acids (Henderson et al., 1981;
Lin, 1981) and zinc (Ghishan et al., 1982~.
Ethanol can also interfere with the intestinal transport of several es-
sential nutrients including calcium, amino acids, and some vitamins (Wilson
and Hoyumpa, 1979~. The adverse effects of ethanol on liver function may
lead to abnormalities in metabolism and nutrient utilization (Lieber, 1985~.
However, evidence concerning the adverse effects of alcohol on specific
nutritional indices comes largely from studies of nonpregnant hospitalized
alcoholics, many of whom had hepatic damage. Specifically, chronic alcohol
abuse has been linked to increased urinary zinc excretion and low serum
zinc concentrations (Fredricks et al., 1960; McClain and Su, 1983; Vallee
et al., 1957), decreased levels of hepatic vitamin A (Leo and Lieber, 1982),
impaired uptake and utilization of folate (Halsted et al., 1971), and possibly
thiamin malabsorption (Camilo et al., 1981; Hoyumpa, 1983~. Thus, zinc,
vitamin A, folate, and thiamin deficiencies may occur with chronic alcohol
consumption. However, supplementation with fat-soluble vitamins, partic-
ularly vitamin A, may not be advisable, partly because of general concerns
regarding toxicities, but also because data on animals suggest that vitamin A
supplementation combined with ethanol consumption may enhance hepatic
toxicity (Leo and Lieber, 1983~.
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SUBSTANCE USE AND ABUSE
397
There is evidence from experiments in animals that nutritional factors
may act synergistically with alcohol exposure in producing adverse effects.
For example, low protein and caloric intakes have been hypothesized to
interact with alcohol exposure, leading to higher blood alcohol levels and
more severe growth retardation in rats (Wiener et al., 1981~. However,
inconsistent results have been obtained when the protein content of the
diet was increased (Weinberg, 1985; Wiener et al., 1981~. Zinc deficiency
has also been postulated to be a coteratogen with alcohol. Studies in rats
have shown that low zinc intake plus alcohol had more severe effects on
the fetus than did either alcohol or low zinc intake alone (Keppen et al.,
1985; Ruth and Goldsmith, 1981~. Plasma zinc levels and increased urinary
zinc excretion were significantly lower in six infants with FAS as compared
with levels in controls (Assad) and Ziai, 1986~. Zinc supplementation
has been suggested as a way to prevent or lessen adverse alcohol-related
effects; however, a study in rats produced no evidence that supplementation
of a high-ethanol diet with zinc increased the placental transport of zinc
(Ghishan and Greene, 1983~.
In summary, alcohol may be related to decreased dietary intake, im-
paired metabolism and absorption of nutrients, and altered nutrient activa-
tion and utilization. Interactions between alcohol and deficiencies of such
nutrients as protein and zinc may also play a role in the etiology of alcohol-
related effects in the fetus. Although there is no convincing evidence that
nutritional supplementation will counteract the adverse effects of alcohol,
multivitamin-mineral supplementation (excluding vitamin A) may be indi-
cated for women who are known or suspected alcohol abusers. However,
since alcohol abuse has clearly been shown to be detrimental to the fetus,
nutritional supplementation should not replace efforts to encourage women
to limit or eliminate alcohol intake during pregnancy.
CAFFEINE
Caffeine along with theophylline and theobromine are methylxanthines
found in coffee, tea, cola, and cocoa beverages. Caffeine is also a common
additive in many non-prescription preparations, especially mild analgesics
(Graham, 1978~. The Food and Nutrition Board's GRAS (Generally Rec-
ognized as Safe) Survey Committee estimated in 1977 that 74% of pregnant
females consumed some caffeine and that the mean intake for the entire
group was 144 mg/day (approximately 1.5 cups of coffee) (NRC, 1977~. In
a more recent study of pregnant women in Connecticut, the average daily
caffeine intake was found to be slightly lower (102 ma) (Bracken et al.,
1982~.
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DIETARY INTAKE; AND NUTRIENT SUPPLEMENTS
Pharmacologic Effects of Caffeine and Other Methylxanthines
The three xanthines share several pharmacologic properties; namely,
they stimulate the central nervous system and the cardiac muscle, act on the
kidney to produce diuresis, and relax smooth muscle (Rail, 1985~. Of the
three xanthines, caffeine is believed to be the most active central nervous
system stimulant and the most extensively studied. Caffeine passes readily
to the fetus, but the fetus cannot metabolize caffeine effectively, nor can
the infant do so until several months after birth (Aldridge et al., 1979~.
Maternal consumption of two cups of coffee significantly increases maternal
epinephrine concentrations and decreases intervillous placental blood flow
(Kirkinen et al., 1983~.
Possible Effects on the Developing Fetus
Although there is substantial evidence that caffeine is teratogenic in
animals (Bertrand et al., 1965; Collins et al., 1982), there is no convinc-
ing evidence that it is associated with birth defects in humans (Heinonen
et al., 1977; Kurppa et al., 1982; Linn et al., 1982; Nelson and Forfar,
1971; Rosenberg et al., 1982~. Coffee and caffeine consumption have been
associated with a reduction in birth weight and an increased risk of low-
birth-weight infants, especially among full-term deliveries (Hogue, 1981;
Martin and Bracken, 1987; Man and Netter, 1974; Munoz et al., 1988; van
den Berg, 1977; Watkinson and Fried, 1985), but it is not clear in some
of these studies whether the effects were due to caffeine, some other con-
stituent of coffee, or other characteristics of coffee drinkers. Furthermore,
most of the studies only assessed coffee consumption (Heinonen et al.,
1977; Hogue, 1981; Kurppa et al., 1982; Linn et al., 1982; Mau and Netter,
1974; van den Berg, 1977), while others included additional sources of
caffeine (Martin and Bracken, 1987; Nelson and Forfar, 1971; Rosenberg
et al., 1982; Watkinson and Fried, 1985~. In addition, the level at which
adverse effects have been reported ranges from a total daily caffeine intake
greater than 150 mg (equivalent to 1.5 or more cups of coffee) (Martin and
Bracken, 1987) to seven or more cups of coffee per day (Hogue, 1981~. An
increased risk of late first- and second-trimester spontaneous abortions in
women consuming more than 150 mg of caffeine daily after adjustment for
other risk factors has also been reported (Srisuphan and Bracken, 1986~.
In contrast, other studies have found no significant association between
maternal caffeine or coffee consumption and reduced birth weight (Brooke
et al., 1989; Hingson et al., 1982; Linn et al., 1982; Tennes and Blackard,
1980) or preterm delivery (Berkowitz et al'., 1982; Linn et al., 1982~.
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SUBSTANCE USE AND ABUSE
Nutr~tion-Related Effects of Caffeine or Coffee
399
Little is known about the nutritional status of pregnant women who
consume caffeine. One study noted that women who consumed more than
300 mg of caffeine daily during pregnancy had lower weight for height
and lower average intakes of calories, protein, calcium, vitamin A, thiamin,
riboflavin, and vitamin C than those of women who consumed less than
or equal to 300 mg daily (Watkinson and Fried, 1985~. The differences,
however, were based on a small number of heavy caffeine users and
were not statistically significant. Coffee and caffeine intakes have been
reported to affect the status of some nutrients in nonpregnant populations.
Specifically, caffeine intake has been observed to increase urinary calcium
excretion (Massey and Hollingbery, 198%a,b) and coffee consumption has
been related to decreased urinary thiamin excretion (Lewis and Inoue,
1981) and depressed zinc and iron absorption (Morck et al., 1983; Pecoud
et al., 1975~. In a prospective study of pregnant women in Costa Rica,
investigators found that consumption of three or more cups of coffee a day
was associated with significantly lower maternal and neonatal hemoglobin
and hematocrit levels (Munoz et al., 1988~. Since all the women in that
study reportedly took prenatal supplements containing iron, supplemental
iron did not appear to prevent the hematologic deficits among the coffee
consumers. However, coffee consumption may facilitate calcium intake,
particularly for Hispanic populations, who tend to dilute the coffee with a
substantial amount of milk.
Thus, although there is no convincing evidence that coffee or caffeine
causes birth defects in humans, there is some limited evidence that moderate
to heavy use of coffee and caffeine may lower infant birth weight. The latter
finding has not been reported in all studies and needs to be confirmed by
additional investigations. In 1980, the U.S. Food and Drug Administration
recommended that the most prudent action for pregnant women and those
who may become pregnant was to avoid caffeine-containing products or
to use them sparingly (FDA, 1980~. Although it appears sensible to limit
coffee and caffeine intake during pregnancy, the subcommittee concluded
that the data are not sufficient for making a specific recommendation.
Information regarding the influence of coffee and caffeine on maternal
nutrition is very limited, and it is not known whether nutrient supplements
would be necessary or beneficial for those who continue to consume caffeine
ounng pregnancy.
MARIJUANA
Prevalence of Marijuana Use
National surveys estimate that the proportion of women between the
ages of 18 and 25 who had used marijuana in the previous month increased
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DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
from 19% in 1976 to 26% in 1979 and subsequently declined to 11%
in 1988 (NCHS, 1989; NIDA, 1989~. According to the 1988 survey, the
proportions were lower for teenage girls (7%) and for women aged 26 to
34 (7%~. In the 1985 survey, usage among the 18 to 25 year aids was
substantially higher for whites (18%) and blacks (17%) compared with that
for Hispanics (9%) (NIDA, 1987~. Although there are no national data on
the prevalence of marijuana use during pregnancy, estimates from hospital-
based studies have ranged from approximately 10% (Hatch and Bracken,
1986; Linn et al., 1983) to 27% (Zuckerman et al., 1989~. Variations in
population characteristics as well as differences in methods of ascertaining
marijuana use are likely explanations for the wide range. For example,
a recent study showed that self-reported maternal marijuana use is lower
than the estimate obtained from a combination of interviews and urine
assays (Zuckerman et al., 1989~. Underreporting was also more common
for self-reported marijuana use than for self-reported cigarette or alcohol
use during pregnancy (Hingson et al., 1986~.
Pharmacologic Effects of Marijuana
The main active ingredient of marijuana, /~9-tetrahydrocannabinol,
crosses the placenta (Indanpaan-Heikkila et al., 1969~. Because marijuana
is fat-soluble and is excreted at a slow rate (Jones, 1980), the exposure of
the fetus to the drug may be prolonged. Marijuana smoking, like tobacco
smoking, is also associated with increased carboxyhemoglobin levels (Wu
et al., 1988), which in turn may impair fetal oxygenation and, consequently,
fetal growth. Indeed, the increase in carboxyhemoglobin levels has been
found to be substantially higher for marijuana smoking than for tobacco
smoking (Wu et al., 1988~. Furthermore, marijuana use tends to increase
the heart rate and blood pressure (Foltin et al., 1987), which may lead to
reduced uteroplacental blood flow to the fetus.
Effects on the Developing Fetus and Child
Animal experiments indicate that marijuana may have a fetotoxic
potential, including increased fetal resorption and reduced birth weight
(Harclerode, 1980), but some of these effects may have been related to
reductions in food and water consumption (Abel, 1980a). Data on the
influence of marijuana on pregnancy outcomes in humans are both limited
and inconsistent. Adverse effects that have been reported include decreased
birth weight (Hingson et al., 1982; Zuckerman et al., 1989) and body length
(Zuckerman et al., 1989), increased frequency of preterm delivery (Gibson
et al., 1983), shortened length of gestation (Fried et al., 1984), higher
rates of precipitate labor and meconium passage (Greenland et al., 1982),
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SUBSTANCE USE AND ABUSE
401
increased risk of infant features compatible with the fetal alcohol syndrome
(Hingson et al., 1982), and altered neurobehavioral responses in neonates
(Fried, 1980; Scher et al., 1988~. Other studies, however, have reported
no effect on either birth weight or length of gestation (Linn et al., 1983;
Rosett et al., 1983) or produced inconsistent results. For example, one
study found that white, but not nonwhite, women who used marijuana
at least two to three times monthly during the pregnancy were at an
increased risk of delivering a low-birth- weight, small-for-gestational-age,
and preterm infant (Hatch and Bracken, 1986~. Another investigation,
which was based on two pregnancy cohorts followed over different periods,
found a reduction in birth weight with increasing frequency of marijuana use
during the second, but not the first phase of the study (Kline et al., 1987~.
Furthermore, a recent study found no association between marijuana use
during pregnancy and features compatible with fetal alcohol effects at age
4 (Graham et al., 1988~. Possible explanations for the inconsistent findings
include differences in the ascertainment and classification of marijuana use,
variations in the underreporting of marijuana or other illicit drug use, and
the difficulty of controlling for highly interrelated factors such as abuse of
other substances.
Possible Nutrition-Related Effects of Marijuana Use
There are few data on the nutritional status of pregnant marijuana
users, nor is it known what effect marijuana exposure may have on specific
nutrients. Although marijuana reportedly stimulates the appetite (Abel,
1971), studies of women who have consumed marijuana during pregnancy
have provided conflicting results regarding their nutritional status. One
study found that marijuana users consumed significantly more calories
and protein and gained slightly more weight during the pregnancy than
did their controls (O'Connell and Fried, 1984~. Another study reported
that women who had a positive assay for marijuana use weighed slightly
less before the pregnancy and gained significantly less weight during the
pregnancy as compared with those who had a negative assay (Zuckerman
et al., 1989~. A third investigation found no consistent relationship between
obesity (ponderal index >30) and the frequency of marijuana usage during
pregnancy (Linn et al., 1983~. Since it appears that prepregnancy weight
and maternal weight gain were not controlled for in all investigations (Hatch
and Bracken, 1986), it is unclear to what extent nutritional factors may have
contributed to some of the reported effects of marijuana.
Despite the relatively high prevalence of marijuana use during preg-
nancy, no conclusive data are available on the effect of marijuana on the
developing fetus. There is, however, suggestive evidence that marijuana
use during pregnancy may impair fetal growth.
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DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
COCAINE
Prevalence of Cocaine Use
Cocaine use has grown to epidemic proportions during the past decade
in the United States. Although cocaine was previously believed to be a
relatively safe, nonaddictive euphoriant agent, it is now recognized that
cocaine use is associated with substantial morbidity and mortality (Cregler
and Mark, 1986; Gawin and Ellinwood, 19884. The National Household
Survey on Drug Abuse in 1988 estimated that more than 20 million people
in the United States had tried cocaine, including 20% of those between
the ages of 18 and 25 (NIDA, 1989~. The proportion of women aged
18 to 25 years who had used cocaine in the past month increased from
4.7% in 1982 to 6.3% in 1985 but declined to 3% in 1988 (NCHS, 1989;
NIDA, 1989~. Among teenage girls, however, the proportion has remained
constant between 1985 and 1988 (NIDA, 1987; NIDA, 1989~. While earlier
surveys have indicated that cocaine usage was more common among whites
than nonwhites, rates of recent usage in the 1988 survey were higher
for Hispanic and black women as compared with white women (Abelson
and Miller, 1985; NIDA, 1989~. The subcommittee was unable to find
any representative data on the prevalence of cocaine use among pregnant
women, but a recent prospective study of consecutive prenatal patients from
a poor inner-city population reported that 18% had used cocaine at least
once during the pregnancy (Zuckerman et al., 1989~. Cocaine addiction Is
believed to be five times more common than heroin addiction (Gawin and
Ellinwood, 1988~.
Cocaine is an alkaloid prepared from the plant Erythroxylon coca.
When used in the free-base form (i.e., crack), it is more potent because it
is almost pure cocaine. Cocaine acts as a central nervous system stimulant,
causing increased heart rate, hypertension, and vasoconstriction (Cregler
and Mark, 1986; Woods et al., 1987~. Because of its low molecular weight
and high solubility In water and lipids, cocaine readily crosses the placenta
(Anonymous, 1988~; however, the vasoconstrictive effect of cocaine may
reduce placental transport (Fantel and MacPhail, 1982~.
Effects on the Developing Fetus and Infant
An association between cocaine exposure and abruptio placentae is
fairly well established (Acker et al., 1983' Bingol et al., 1987; Chasnoff and
MacGregor, 1987; Chasnoff et al., 1985; Landy and Hinson, 1988; Livesay
et al., 1987; Oro and Dixon, 1987~. There is also growing evidence that co-
caine abuse may be associated with premature labor and intrauterine growth
retardation (Chasnoff and MacGregor, 1987; Chouteau et al., 1988; Dixon
and Oro, 1987; LeBlanc et al., 1987; Oro and Dixon, 1987; Zuckerman et
OCR for page 403
SUBSTANCE USE AND ABUSE
4~)3
al., 1989) as well as spontaneous abortion (Chasnoff et al., 1985; Livesay
et al., 1987~. The teratogenic potential of cocaine is less clear, although
there are reports suggesting an increase in congenital anomalies (Bingol et
al., 1987; Chasnoffetal., 1988; Koborietal., 1989~. A mild withdrawal
syndrome (Chasnoff et al., 1985; Doberczak et al., 1988; Oro and Dixon,
1987) and transient electroencephalogram abnormalities (Doberczak et al.,
1988) have been described in some infants born to cocaine-abusing mothers.
Of great concern are recent case reports of cerebral infarction in neonates
who had been exposed to cocaine in utero (Chasnoff et al., 1986; Ferriero
et al., 1988~.
Possible Nutr~tion-Related Effects of Cocaine Use
As is true for marijuana, little is known about the nutrition-related
effects of cocaine use. Cocaine's vasoconstrictive ability may lead to fetal
hypoxia (Woods et al., 1987) and reduced nutritional supply to the fetus.
Since cocaine, like amphetamines, acts as an appetite suppressant (Cregler
and Mark, 1986; Gawin and Ellinwood, 1988; Resnick et al., 1977), an
inadequate maternal diet may play a role in the growth retardation seen
in fetuses of cocaine abusers. In one study, pregnant women with urine
assays positive for cocaine weighed significantly less before the pregnancy,
had lower hematocrit levels at the time of prenatal registration, and gained
slightly less weight during the gestation than did those with negative assays
(Frank et al., 1988; Zuckerman et al., 1989~. Although the deficit in birth
weight did not achieve significance when prepregnancy weight and maternal
weight gain were controlled for in the analysis, significant decreases in birth
length and head circumference remained (Zuckerman et al., 1989~. Thus,
these data suggest that the association between cocaine use and growth
retardation may be partially but not completely mediated by nutritional
factors. Other factors, such as cigarette smoking, alcohol consumption, and
other drug abuse, which were not controlled for in all the studies, may also
have confounded some of the reported adverse effects.
Since the origin of the current cocaine epidemic is recent, further stud-
ies should be conducted to provide more definitive evidence on the effects
of cocaine on the course of pregnancy and neonatal outcome. Isolating the
influence of cocaine from other factors will nevertheless be difficult, since
cocaine use is often accompanied by abuse of other substances as well as
other life-style patterns that may be detrimental to the fetus.
SUMMARY AND RECOMMENDATIONS FOR FUTURE RESEARCH
Although the adverse reproductive effects of tobacco, alcohol, and
many illicit drugs are well established and there is some, albeit limited and
conflicting, evidence that moderate to heavy use of coffee and caffeine may
OCR for page 404
404
DIETARY INTAKE AND NUTRIENT SUPPLEMENTS
decrease birth weight, the underlying mechanisms responsible for these
effects are generally not well understood. Much also remains to be learned
concerning critical periods of exposure, dose-response thresholds, factors
that modify susceptibility to the adverse effects, and influences of substance
abuse on maternal and fetal nutrition. Similarly, little is known about the
effects of specific patterns of substance abuse such as binge, as opposed
to chronic, alcohol consumption. Furthermore, the factors underlying or
associated with substance abuse, including the role of genetic predisposition,
need to be delineated.
CLINICAL IMPLICATIONS
· Highest priority should be given to efforts to prevent or stop
substance abuse by pregnant women since there is clear evidence that
cigarette smoking and alcohol and drug abuse adversely affect the health
of the mother and the fetus.
Since nutritional deficiencies can be expected, especially among
heavy substance abusers, diet counseling and other efforts (e.g., referral to
a social worker) to improve food intake are recommended.
· Because heavy substance abusers may have difficulty in taking the
steps needed to improve their dietary intake, the subcommittee recom-
mends the use of multivitamin-mineral supplements of the type outlined in
Chapter 1.
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___ 7
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Representative terms from entire chapter:
pregnant women
