eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Perinatal Drug Abuse and Neonatal Drug Withdrawal: Follow-up

Author: Marvin Wang, MD, Clinical Instructor, Department of Pediatrics, Harvard Medical School; Co-director of Newborn Nurseries, Attending Physician, Department of Pediatrics, Massachusetts General Hospital,
Contributor Information and Disclosures

Updated: Sep 28, 2009

Follow-up

Further Outpatient Care

  • Early intervention and developmental pediatrics: Any newborn who has been exposed to drugs is considered at risk for developmental and cognitive compromises. These children should have regular follow-up care with a team of child development specialists to quickly identify potential deficits.
  • State child protective services: In the event of court-imposed custody, children should be monitored through the foster family and adoption process.
  • General pediatrics: As with any newborn, perform regular follow-up care for immunizations, anticipatory guidance, and physical examinations.

Inpatient & Outpatient Medications

  • Administer paregoric and phenobarbital for withdrawal of opiates and barbiturates, respectively (see Medication).

Complications

  • Perinatal complications include the following:
    • Incidence of medical and obstetric complications increases with in utero drug exposure. In particular, the incidence of premature delivery, abruptio placentae, breech presentation, and intrauterine growth retardation are significantly increased in mothers who are dependent on drugs. The doses of analgesia are typically higher to match the tolerance to drugs already being used.
    • In particular, cocaine use, with its vasoconstrictive properties, has been associated with an increase in vaginal bleeding, abruptio placentae, placenta previa, premature rupture of membranes, abortion, pneumothorax, pneumonia, malnutrition, and seizures.
    • Amphetamine use presents similarly to cocaine use and is related to an increased rate of abruptio placentae, maternal hypertension, and renal disease. Hypertension can often be confused with preeclampsia, leading to an increased cesarean delivery rate.
    • Opioid use has been shown to increase the rate of premature labor, premature rupture of membranes, breech presentation, antepartum hemorrhage, toxemia, anemia, uterine irritability, and infection (eg, HIV, hepatitis, syphilis).
    • Alcohol use has been associated with an increased rate of abruptio placentae. Complications for mothers who drink alcohol heavily can include increased spontaneous abortions and premature placental separation.
    • Cannabinoid use has been associated with an increased serum carboxyhemoglobin level. A slightly elevated incidence of precipitate labor, meconium staining, and dysfunctional labor occurs in mothers who use cannabinoids.
  • Prematurity is accompanied by a host of medical complications including asphyxia, neonatorum, intracranial hemorrhage, respiratory distress syndrome, hypoglycemia, hypocalcemia, septicemia, and hyperbilirubinemia.
  • Although gross generalizations, the following growth characteristics may occur as a result of exposure to drugs:
    • Tobacco is described as perhaps the most common cause of low birth weight deliveries. Symmetric decreases are observed in all growth parameters, but these children exhibit appropriate catch-up growth.
    • Alcohol may cause symmetric decreases in all growth parameters. Data supports a synergistic effect in growth retardation with concomitant cocaine abuse.
    • Amphetamines and cocaine may cause symmetric decrease in all growth parameters. However, the growth-restricting effect of cocaine is more likely a result of maternal malnutrition. Likewise, growth retardation resulting from cocaine use tends to resolve with catch-up growth within 2 years after birth.
    • Opiate use may result in normal growth parameters. In particular, newborns exposed to methadone tend to have higher-than-expected growth parameters.

Prognosis

  • Growth deficiency
    • Children with prenatal nicotine exposure exhibit appropriate catch-up growth but are known to have smaller lungs and, possibly, decreased ventilatory drive in response to carbon dioxide.
    • Children with prenatal amphetamine and cocaine exposure exhibit catch-up growth within 2 years of life.
    • Children with prenatal opiate exposure typically do not exhibit changes in growth parameters.
    • Infants exposed to buprenorphine have not exhibited significant differences in growth parameters compared to infants who have not been exposed.
  • Cognitive and developmental defects
    • Infants exposed to nicotine tend to score higher on auditory habituation but lower on the orientation cluster of the Brazelton Newborn Behavioral Assessment Scale (NBAS).
    • Infants exposed to alcohol may develop mental retardation, which is one of the hallmarks of FAS. An apparent dose-dependent relationship is present, and FAS now accounts for approximately 33% of all mental retardation. Milder cognitive effects include prolonged language delays and sleep dysfunction. Newborns exposed to alcohol also tend to be hypotonic.
    • Infants exposed to cocaine may exhibit fetal brain malformation resulting from changes in the homeostatic neurochemistry.
      • Serious debate surrounds the actual deleterious effects of in utero cocaine exposure. Consequences previously described include altered behavior on NBAS scores (eg, poor state regulation, decreases in alertness and orientation, abnormal reflexes, tone and motor maturity), increased tone (described as hypertonic tetraparesis), electroencephalogram (EEG) changes, abnormal auditory brainstem responses, and prolonged behavioral and language delays. However, data are inconsistent to prove that cocaine is solely responsible for these problems.
      • Research on this topic has been difficult, as confounding variables (such as postnatal psychosocial issues and polydrug use in pregnancy) are difficult to control. Prior conventional wisdom dictated that neurological morbidity was associated with cumulative postnatal risks preventing proper development. Recent prospective studies have shown no direct effect of cocaine exposure on development at age 3 years after correcting for race, parity, and socioeconomic status.
    • Infants exposed to opioids may have increased overall activity on NBAS testing. They tend to have difficulty being consoled.
  • Treatment length
    • Although length of treatment cannot always be correlated as a dose-dependent relationship with maternal use, recent data have suggested that, in mothers using high doses of methadone, for every daily dosage increase of 5.5 mg, an extra day in length of treatment time was added. Gestational age was not seen as significant.21 However, recent data have also shown that infants born to mothers using methadone had increased length of treatment when concomitant benzodiazepine use or increased gestational age were associated. These findings were noted even when controlling for maternal methadone dose, concomitant use of tobacco or antidepressants, and trimester timing of initial dose.22
    • Several studies have compared the withdrawal effects of buprenorphine exposure with that of methadone exposure. In most cases, buprenorphine exposure was associated with decreased overall neonatal withdrawal treatment time and lower neonatal length of stay. Data on whether infants exposed to buprenorphine were more likely to require withdrawal treatment compared with infants exposed to methadone are conflicting.23,11,10

Patient Education

 


More on Perinatal Drug Abuse and Neonatal Drug Withdrawal

Overview: Perinatal Drug Abuse and Neonatal Drug Withdrawal
Differential Diagnoses & Workup: Perinatal Drug Abuse and Neonatal Drug Withdrawal
Treatment & Medication: Perinatal Drug Abuse and Neonatal Drug Withdrawal
Follow-up: Perinatal Drug Abuse and Neonatal Drug Withdrawal
Multimedia: Perinatal Drug Abuse and Neonatal Drug Withdrawal
References
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Further Reading

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Keywords

perinatal drug abuse, neonatal drug withdrawal, neonatal abstinence syndrome, neonatal withdrawal syndrome, substance abuse during pregnancy, maternal drug abuse, opiates, cocaine, nicotine, alcohol, maternal drug abuse, newborn withdrawal syndrome, prematurity, heroin, codeine, methadone, meperidine, fetal alcohol syndrome, poor feeding, attention deficit hyperactivity disorder, ADHD, hyperphagia, diaphoresis, hyperacusis, apnea, tachycardia, alcohol-related neurodevelopmental disorder, ARND, low birth weight, fetal hypoxia

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Contributor Information and Disclosures

Author

Marvin Wang, MD, Clinical Instructor, Department of Pediatrics, Harvard Medical School; Co-director of Newborn Nurseries, Attending Physician, Department of Pediatrics, Massachusetts General Hospital,
Disclosure: Nothing to disclose.

Medical Editor

David N Sheftel, MD, Director, Division of Neonatology, Clinical Associate Professor, Department of Pediatrics, Lutheran General Children's Hospital of Park Ridge, Chicago Medical School
David N Sheftel, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, National Hospice and Palliative Care Organization, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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