Dr. Gideon Koren MD, FRCPC. Director, Motherisk Program University of Toronto. Ivey Chair in Mol. Toxicolog University of Western Ontari

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1 TREATING THE MOTHER PROTECTING THE UNBORN A MOTHERISK Educational Program : Novel Methods for Diagnosis and Follow-up Gideon Koren MD FRCPC FACMT Motherisk Program Ivey Chair in Molecular Toxicology Portrait of the Addicted Mother Unemployed (93%) Annual income < $15,000/yr (CAD) (96%) Grade 12 education or less (92%) Single/Divorced/Separated (74%) No permanent residence (23%) Multiple pregnancies (87%) Apprehended children (25%) Children living with other family members (74%) Abused by partner (60%) Depressed (78%) Suicidal thinking (25%) Maternal Interviews Validity of report fear of litigation shame guilt Bias in retrospective reporting exposures are minimized when adverse outcomes occur Inability to quantify dose recall not standardized preparations 1

2 Urinalysis Difficult collection Narrow window of detection resulting in greater likelihood of false negatives Advantages of Hair Analysis over Urinalysis Non-invasive sample collection While it is very easy to tamper with urine and evade detection, hair is difficult to tamper with Increased detection Historical information (past exposure) Safety-net testing (in case of debatable results, it is easy to obtain another hair sample, while it is impossible to obtain another urine sample from the same time period) Physiology of the Hair Shaft 2

3 Routes of Drug Entry Into Hair 1. Capillary blood supply to follicle 2. Transport via sebacious gland 3. Transport via sweat gland 4. Absorption via passive exposure Neonatal Hair Sample Neonatal Toxicology: Determining Prenatal Exposures Urinalysis Exposures within several days of delivery Hair Analysis Exposures from the 22 nd week of pregnancy Meconium Analysis Exposures from the 13 th week of pregnancy 3

4 Prevalence of In Utero Exposure to Cocaine in Toronto (1990-1) a random study of 600 cases Method of Ascertainment 37/ % positive hair test 34 positive urine test 9 positive maternal report 7 the combination of maternal history and urine test would have missed 76% of cases Why determine prenatal exposures? Drugs of abuse: cocaine, heroin, methamphetamine, etc. Confirm strong clinical suspicion if urinalysis negative Late-pregnancy use strong indicator of addiction Fetal Alcohol Spectrum Disorder Hx of in utero exposure required for most diagnosis, access to services Public Health Impact ~1/100 are affected by FASD Compare PKU 1/15,000; Congenital Hypothyroid 1/4,000 Hair Testing in Children Passive ( second-hand ) exposures Contaminated environment Crack smoke Crystal meth Cannabis Nicotine Drug administration (e.g. opiates, benzodiazepines) Acute, historical Chronic 4

5 Case Study 1 20 month-old child ER admission; heavily sedated Urine toxicology; positive for opiates MD requested hair analysis Case Study 1 8 centimetres (whole length) - Sampled August 10, 2005 Cocaine 9.00 ng/mg high Benzoylecgonine 0.43 ng/mg Opiates 0.68 ng/mg low Oxycodone 1.84 ng/mg TIME PERIOD = mid-november 2004 to mid-july 2005 Case Study 1: Repeated Sedation & Cocaine Exposure Drug concentration in hair (ng/mg) Cocaine Benzoylecgonine Opiates Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Time of Exposure 5

6 Case Study 2 Child; 2.5 years old ER Admission; unconscious, fractures, physical signs of abuse Urine toxicology: positive for cocaine SCAN team requests hair analysis Case Study 2 15 centimetres (whole length) Sampled August 9, 2005 Segmental Analysis 0-1 cm (mid-june to mid-july 2005) Cocaine 8.37 ng/mg medium Benzoylecgonine 0.47 ng/mg 1-15 cm (mid-april 2004 to mid-june 2005) Cocaine ng/mg very high Benzoylecgonine 4.43 ng/mg Case Study 2 Pattern of Cocaine Exposure; Case #2 Level of Exposure (ng/mg) Cocaine Benzoylecgonine 0 May- Jun- Jul-04 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul Time of Exposure 6

7 When an adult s hair contains cocaine what % of households have cocaine in a child s hair? Positive, 93.0%, Negative 7.0% New Ways to Identify Problem Drinking Fatty Acid Ethyl Esters (FAEE) - metabolites of ethanol + fatty acids Stay in meconium Levels above 2 nm indicate problem drinking Grows into adult hair: when above 0.5ng/mg of hair = indicates excessive drinking Used in Berlin for detection of drinking drivers Used by Motherisk since Mid 2007 Meconium FAEE: FASD Outcomes Derauf et al (United States) Lower one-minute Apgar scores (p = 0.003) [ethyl oleate] assoc. w/low birth weight (p = 0.006) N = 422 Noland et al Decreased score on executive functioning task Tapping inhibition (age 4 years) Lower birth weight, length, head circumference N = 316 Peterson et al Decreased psychomotor performance (age 2 years; P < 0.04) N = 202 7

8 Meconium FAEE: FASD Outcomes Jacobson et al (South Africa) [ethyl oleate] in FAS or pfas diagnosed children (age 5 years; p < 0.005) [ethyl oleate] > maternal self-report correlates to: Recognition memory, Processing speed, Complexity of symbolic play N = 55 Brien et al (Canada) Animal study: guinea pig Meconium [FAEE] = neonatal brain weight N = 51 n = 25 ethanol-exposed n = 23 pair-fed control n = 3 water control Who orders a hair test? Neonatal testing (hair or meconium) Physician with suspicion of exposure Child protection agency with custody of newborn/child Required Documentation Signatures Hair collector must verify identity of donor Adult testing: Hair donor must sign consent Ordering physician (neonatal/child) Donor name, date of birth Sample date September 9 th, 2007: Nice, France 10 th International Congress of Therapeutic Drug Monitoring & Clinical Toxicology Workshop #10: Therapeutic Drug Monitoring of In Utero Drug Abuse Rates of Fetal Exposure to Alcohol in Ontario by Meconium FAEE Analysis Joey Gareri, MSc Motherisk Laboratory Division of Clinical Pharmacology & Toxicology Hospital for Sick Children, Toronto, Ontario, Canada Collaborators: Gideon Koren MD, Hazel Lynn MD, Chitra Rao MSc, Maureen Handley BScN 8

9 Public Health Impact May & Gossage, 2001 ~1/1000 are affected by FAS Several studies ( ) ~1/100 general population are affected by FASD (N. America) Abel, % of alcohol-exposed children have full-blown FAS 40% of alcohol-exposed have FASD Nulman et al. 1998; Stade, 2003 Economic impact = ~$14,000/year per FASD individual Public Health Challenge Intervention prior to age 6 is optimal Significant attenuation of secondary disabilities Early intervention occurs in only 11% of affected individuals Methods of early screening are needed (Chudley et al. 2005) FASD Diagnosis: Canadian Guidelines (2005) A. Presence of the 3 characteristic facial features (short palpebral fissures, smooth or flattened philtrum, thin vermilion border). B. Evidence of significant prenatal exposure to alcohol at levels known to be associated with physical or developmental effects, or both. C. Presence of 1 or more facial features with growth deficits plus known or probable significant prenatal alcohol exposure. D. Presence of 1 or more facial features with 1 or more central nervous system deficits plus known or probable significant prenatal alcohol exposure. E. Presence of 1 or more facial features with pre- or postnatal growth deficits or both (at the 10th percentile or below [1.5 SD below the mean]) and 1 or more central nervous system deficits plus known or probable significant prenatal alcohol exposure. 9

10 Detecting Alcohol Abuse One standard drink (Canadian definition) 13.6 grams of ethanol 12 oz. beer (5%) 5 oz. wine (12-15%) 1.5 oz. liquor (40%) Alcohol Elimination Rate: ~7 g per hour e.g. 5 drinks in 1 hour (i.e. binge episode) 0 BAC within 10 hours 0 UAC within 12 hours Meconium as the Ideal Matrix Meconium = baby s first bowel movements (i.e. first few stools) A matrix unique to the developing fetus that is already commonly used in neonatal drug screening Superior to blood and urine Discarded material Collection is easy and non-invasive Wide window of opportunity Accumulation from 13 th week gestation until birth Prevalence of Fetal Alcohol Exposure in Grey Bruce, Ontario 10

11 Grey Bruce, Ontario Population ~153,000 Diverse populous Urban centre (Owen Sound) Rural/farming communities Aboriginal communities (Cape Croker & Saugeen Reserves) Amish communities Proactive Public Health Unit Primary Objectives To measure meconium FAEE concentrations in a regional neonatal population to assess the prevalence of fetal ethanol exposure To characterize discernable expression patterns of the spectrum of FAEE that can be recovered from meconium Study Design Anonymous diaper collection No supplemental information collected Maximal participation most accurate prevalence value No consent required Notification of population health study supporting healthy child development via posters on the wards Assurance of anonymity Right of refusal to provide a sample Supplemental information (pamphlets) available upon request 11

12 Study Design Duration: January 1, 2004 February 5, regional birthing centres + Grey-Simcoe midwives Wiarton, Owen Sound, Markdale, Walkerton, Hanover METHODS: FAEE Extraction/Analysis Liquid-Liquid extraction (hexane:acetone) followed by Solid Phase extraction of FAEE from meconium (adapted by Chan et al.) FAEE Analysis by Gas Chromatography with Flame Ionization Detection LOD/LOQ: nmol/g (~ 25 50ng/g) Confirmation of all positive and random negative samples via Mass Spectrometry METHODS: FAEE Analysis: Chromatogram NEGATIVE POSITIVE 12

13 RESULTS: Rate of Fetal Alcohol Exposure GC-FID + GCMS confirmation (N=682) 17 positive + 7 unconfirmed positive 17-24/682 positive 2.5%-3.5% rate of Fetal Alcohol Exposure Results vs. Current Practice FAEE meconium analysis will provide a more reliable measure of the prevalence of in utero ethanol exposure than maternal self-reports. FAEE analysis 682 samples successfully analyzed 17 positive Fetal alcohol exposure rate: 2.5% Reported Alcohol Use in Pregnancy (Grey Bruce data) Personal Interview by nurse (Parkyn Questionnaire: Healthy Babies, Healthy Children) Yes/No question to diagnosed drug/alcohol abuse in pregnancy Prevalence of drug/alcohol use in pregnancy is 0.5% (5/1019) >5-fold higher than reported values Results vs. Anonymous Survey FAEE meconium analysis will provide a more reliable measure of the prevalence of in utero ethanol exposure than maternal self-reports. FAEE analysis 682 samples successfully analyzed 17 positive Fetal alcohol exposure rate: 2.5% Reported Alcohol Use in Pregnancy (U.S. statistics) Anonymous telephone survey (CDC 2002) Prevalence of heavy drinking in pregnancy (>14 drinks/ week) is about 0.1% to 0.3% >8-fold higher than reported values 13

14 Results vs. Anonymous Survey FAEE analysis Reported Alcohol Use in Pregnancy 682 samples successfully (Canadian statistics 2003) analyzed Anonymous telephone survey 17 positive 0.84%: 2-3 times per month Fetal alcohol exposure 1.96%: once per month rate: 2.5% Prevalence of drinking in pregnancy (>1 drink/ week) is 1.26% No significant difference Prevention by Intervention NEONATAL INTERVENTION CANNOT PREVENT PRIMARY ALCOHOL-INDUCED DAMAGE Mothers of alcohol-affected children are significantly more likely to produce subsequent alcohol affected children Substance-addicted women have an 85% incidence of multiple pregnancies (average = 4) and 25% incidence of child apprehension by social services EARLY MATERNAL INTERVENTION (e.g. 1 st pregnancy) can potentially prevent future cases of FASD Prevention by Intervention In FASD 50-70% incidence of substance addiction 50% incidence of inappropriate or promiscuous sexual behaviour FASD INTERVENTION is capable of alleviating secondary disabilities which perpetuate FASD. 14