1. Newnam, Katherine M. PhD, RN, CPNP, NNP-BC, IBCLE

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Nurses who provide patient care for patients in labor and delivery, nurseries, and neonatal intensive care units (NICUs) are not surprised to hear the escalation of marijuana use in the pregnant females, as the widespread legalization of cannabis continues. Marijuana is "the most commonly used illicit drug during pregnancy" according to a recent publication of the Journal of the American Medical Association (JAMA).1 The drug is detectable approximately 30 days from last use.2 Self-report of pregnant females in California from 2009 to 2016 showed an increased use of marijuana during the month prior to delivery from 2.4% to 3.9%. This global increase of all pregnant females is especially alarming in light of 14.6% of pregnant adolescents reported use within the past month, which is likely an underestimate.2 According to data from the United States from the years 2002 to 2014; 22% of pregnant adolescents and 19% of pregnant 18- to 24-year-olds tested positive for marijuana on screening tests during labor.1 Evidence also suggests that the use of prenatal marijuana impairs fetal growth and neurodevelopment.3


The American College of Obstetricians and Gynecologists recommends we "discourage pregnant and breast-feeding women from using marijuana" according to a committee opinion.4 Updated and specific recommendations for providers to discuss with patients include:


* "Obtain a history: ask women trying to conceive or in early pregnancy about their use of tobacco, alcohol, drugs (including marijuana), and other nonmedical use of medications.


* Counsel women who report marijuana use about potential adverse health consequences associated with continued marijuana use during pregnancy.


* Encourage pregnant women and those considering pregnancy to discontinue marijuana use.


* Encourage pregnant women and those considering pregnancy to discontinue using medicinal marijuana and use another therapy that has better pregnancy-specific data.


* Because the data are insufficient to evaluate the effects of marijuana use on infants during lactation and breast-feeding, discourage lactating and breast-feeding women from using marijuana"4


In a recently published retrospective cohort study, data from the US National Inpatient Sample (1999-2013) were reviewed to determine obstetrical and neonatal outcome differences in mothers (n = 66,925) who were abusing or using cannabis during pregnancy compared with unexposed mothers. Using unconditional logistic regression, the findings were significant for higher risk of a preterm infant (odds ratio, 1.40; 95% confidence interval, 1.36-1.43) and/or growth restricted (odds ratio, 1.35; 95% confidence interval, 1.30-1.41) in those women reporting cannabis use.5 In addition, there was a significant difference reported in cannabis use from 0.28% in 1999 to 0.95% using in 2013 (P < .05).5 These findings mirror the California study described earlier.2


We understand from this growing body of evidence that cannabis use is increasing especially among our youth. Adolescent and young mothers are at the greatest risk for preterm labor and/or delivery, have the poorest socioeconomic status with few resources to care for an at-risk infant.2 Many may not understand the ramifications of using marijuana during pregnancy including the risk to infant outcomes and possible requirements for reporting positive drug tests to authorities.4 Clearly, we have a problem that will likely increase, as cannabis legalization continues across the United States.


1. Brown QL, Sarvet AL, Shmulewitz D, Martin SS, Wall MM, Hasin DS. Trends in marijuana use among pregnant and nonpregnant reproductive-aged women, 2002-201R4. JAMA. 2017;317(2):207-209. [Context Link]


2. Young-Wolff KC, Tucker LY, Alexeeff S, et al Trends in self-reported and biochemically tested marijuana use among pregnant females in California from 2009-2016. JAMA. 2017;318(24):2490-2491. [Context Link]


3. Volkow ND, Compton WM, Wargo EM. The risks of marijuana use during pregnancy. JAMA. 2017;317(2):120-130. [Context Link]


4. Committee Opinion No. 722 Summary: Marijuana Use During Pregnancy and Lactation. Obste Gynecol. 2017;130(4):931-932. doi: 10.1097/AOG.0000000000002349. [Context Link]


5. Petrangelo A, Czuzoj-Shulman N, Abenhaim HA. Obstetrical and neonatal outcomes in pregnancies affected by cannabis abuse or dependence. Obste Gynecol. 2018;131:62S. doi:10.1097/01.AOG.0000533055.36599.04. [Context Link]



We have all encountered the preterm infant ready for discharge who cannot pass a car seat oximetry test. Repeat testing is conducted with continued desaturations and/or bradycardia ... parents are frustrated; insurance companies are requesting documentation supporting the need for continued monitored care and the infant's hospitalization is extended while everyone waits. Families verbalize frustration, as infants remain stable during sleep, oral feedings, and other physical activities and seem ready for discharge.1 However, a subset of neonatal intensive care unit (NICU) patients exhibits frequent desaturations while positioned in a rear-facing semireclined car safety seat. The etiology of the desaturations during sitting is likely multifactorial. Reportedly, these are infants who have intermittent cardiorespiratory instability, neurodevelopmental immaturity, or cannot maintain adequate oxygen saturations when additional metabolic expenditures are required to sit, stabilize the neck, and protect the airway.2,3 These situations are sometimes remedied through the use of a car bed.3


The car bed is a specialized travel restraint device that accommodates infants in a fully reclined position.4 The infant is secured to the bed through the use of an internal harness, and the car bed is placed perpendicular to the direction of travel in the back seat using the vehicular seat belt devices.3 Car beds are typically used for 4 to 8 weeks postdischarge. As the infant grows and ages, maturation of both neurological and muscular systems allows a successful transition to the rear-facing infant car seat. The American Academy of Pediatrics (AAP) reports no current data is available, which establishes a specific age or neurodevelopmental status in which the NICU graduate can safely transition from the car bed to the semireclined rear-facing car safety seat.3 A repeat car seat challenge or test is conducted in the outpatient setting. The infant is secured in a size-appropriate rear-facing infant safety seat and tested using oximetry and/or heart rate monitoring to confirm adequate oxygen saturation without bradycardia is maintained while in the sitting position. Testing is usually conducted by the primary care provider, occupational, or physical therapist.4


The most common car bed used for neonatal discharge is the Angel Ride Infant Car Bed, manufactured by Angel Guard.5 In a recent letter to customers, the company has suspended manufacturing of this product citing reasons that include "low volume sales" and a "growing cost of quality product liability insurance for specialty infant products."5 Unfortunately, we in the NICU have come to depend on this product with few acceptable options to provide our parents a car bed for discharge. Although a few of these beds remain available through secondary markets, it will not be long before this model is gone forever.


Optional car beds on the market are the "HOPE Car Bed" by Merritt Manufacturing Inc6 and the "Dream Ride LATCH Infant Car Bed" by Cosco. The HOPE car bed provides a safe travel solution for the child with specialized health needs. This larger bed fits infants from 4.5 to 35 lb and is typically used for those children who are not able to use a typical car safety seat. This bed is large and takes up most of the space on the back seat but is ideal for those children discharged with a giant omphalocele, Pavlik harness, spica cast, osteogenesis imperfecta, or other conditions. The infant is restrained by a series of harness and a cummerbund, which can be adjusted and individualized to meet the needs of the specialized infant/child.6 The Dream Ride Car Bed is manufactured with support and safety features to provide rear seat support in a lying position. This car bed is designed for infants weighing between 5 and 20 lb and between 19" and 26" (48.3-66 cm) in length.


To best meet this growing population of preterm infants, manufacturers of traditional rear-facing semireclined infant car seats report increased production of products that are safety tested for infants 4 lb and above. This may provide more options for the smallest patient who demonstrates cardiorespiratory stability during the car seat oximetry safety test offered in most NICUs prior to discharge. Ultimately, we have a charge for car seat safety upon hospital discharge from the AAP.3 The recommendations specific for preterm and low birth-weight infants include "Rear-facing car safety seats provide the best protection in a frontal crash because the forces are transferred from the back of the restraint to the infant's back, the strongest part of an infant's body. The restraint also supports the infant's head. Severe tensile forces on the neck in flexion are also prevented by use of rear-facing car safety seats."3 Whether you are a car bed fan or not, when they are no longer available, we will be forced to offer clear explanations, patience, and assurance to parents whose discharge is delayed until car seat testing is successful. Perhaps the time to examine our lack of standardized practice surrounding oximetry car seat safety checks for infant discharge has come.


1. Davis NL. Car seat screening for low birth weight term neonates. Pediatrics. 2015;136(1):89-96. [Context Link]


2. Shah MD, Dookeran KA, Khan JY. Clinical outcomes associated with a failed infant car seat challenge. Jour Pediatr. 2017;180:130-134. [Context Link]


3. Bull MJ, Engle WA; The Committee on Injury, Violence, and Poison Prevention and Committee on Fetus and Newborn, American Academy of Pediatrics. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics. 2009;123(5):1424-1429. [Context Link]


4. Davis NL, Zenchenko Y, Lever A, Rhein L. Car seat safety for preterm neonates: implementation and testing parameters of the infant car seat challenge. Acad Pediatr. 2013;13(3):272-277. [Context Link]


5. Angel Guard. Angel Guard Premature Infant bed. Accessed May 2, 2018. [Context Link]


6. Merritt Manufacturing home page. Accessed May 1, 2018. [Context Link]