Perinatal Drug Abuse and Neonatal Drug Withdrawal Treatment & Management

  • Author: Marvin Wang, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jan 19, 2012
 

Medical Care

The following may be included in the medical treatment of perinatal drug abuse and neonatal drug withdrawal:

  • Naloxone should not be administered to any infant born to a mother who is known to be using narcotics (eg, opium, heroin, methadone, hydrocodone) because it may cause sudden symptoms of withdrawal, including seizures.
  • Treatment and medication primarily focus on opiate and cocaine withdrawal. Although understanding polydrug interactions is difficult, no specific treatment plan for amphetamine, marijuana, tobacco, or alcohol withdrawal is recognized (unless teratogenic effects are observed).
  • Controversy still remains over the proper choice of pharmacologic treatment. The mainstays of treatment include opioids (especially if specific prenatal opioid use was known) and phenobarbital. In meta-analyses, opioid therapy alone versus phenobarbital therapy alone showed no difference in treatment failure. However, those treated with opioid therapy alone had shorter lengths of stay in the hospital.
  • One study showed that combined use of opioid therapy and phenobarbital may reduce the overall length of hospital stay and durations of symptoms.[23]
  • As maternal buprenorphine use increases, the rationale for its use as a treatment for neonatal withdrawal becomes more evident. One study used buprenorphine sublingually (13.2 μ g/kg/d, divided 3 times) in withdrawing neonates. A 30% reduction in treatment time and length of stay was noted compared with standard opiate treatment.[14]
  • Recent studies have also investigated the use of clonidine with or without opiate treatment for neonatal abstinence may be a worthy alternative.[8, 24, 25]
  • Until the child has been weaned off medication, or until the symptoms have abated (as confirmed by the Neonatal Abstinence Scoring System), the patient should be constantly monitored by newborn nursery staff. Vital signs should be checked, the Neonatal Abstinence Scoring System score should be obtained, seizure precautions should be taken, and frequent weight checks should be performed.
  • All medically treated newborns should constantly be monitored for cardiovascular, respiratory, and oxygen saturation changes (see Medication).
  • In newborns with severe symptoms, intravenous fluids with electrolytes may be needed. Oral feedings may need to be withheld.
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Consultations

The following consultations may be indicated:

  • Hospital social services: A positive drug screen in a newborn of a mother without a prescription for the suspected drug warrants an investigation by the state child protection agency. The hospital social services staff can coordinate and supervise the interactions of staff, parents, and state services.
  • Occupational and physical therapy: Use of a team of therapists decreases the overall treatment time. Issues surrounding environmental stressors and patient contact can be addressed.
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Diet

The following may be indicated:

  • Breastfeeding
    • Many infants in this situation have difficulty establishing breastfeeding or bottle-feeding.
    • Although no consensus has been reached, a recent meta-analysis has demonstrated that, even when controlled for methadone or polydrug use, infants of drug-using women who were breastfed showed an overall lower need for abstinence treatment.[26]
    • Controversy has emerged regarding breastfeeding and maternal methadone use, particularly with the large dose increases seen in the last decade. In an American Academy of Pediatrics statement from 2001, breastfeeding has been encouraged, regardless of dosage. The impetus of this decision is based mostly on the minimal transfer of methadone through breast milk. Recent evidence has shown that regardless of maternal dose, methadone concentrations in breast milk were minimal, and neurobehavioral effects on the newborn were generally not seen.[27]
    • Withhold breastfeeding if other substances are suspected or if the mother is HIV positive.
  • Increased caloric intake
    • The newborn withdrawing from drugs has higher caloric demands. In addition to the catabolism resulting from withdrawal symptoms, these patients lose calories from vomiting, drooling, and diarrhea.
    • Consider provision of hypercaloric (100.42 J/oz) formula in frequent small feedings. The daily caloric goal should be 627.6-1046 J/kg/d.
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Activity

The child's comfort is paramount. Being a newborn is extremely stressful in the first few weeks of life because every external stimulus is entirely new to the infant. Add the stress of the internal stimuli from drug withdrawal, and the usefulness of environmental control can be understood. With this in mind, consider that 40% of all withdrawing newborns can be treated symptomatically (without medication). Specific methods include the following:

  • Loose swaddling, as well as holding and slow rocking the infant, may be helpful.
  • Perform environmental controls emphasizing quiet zones, low lighting, and gentle handling. At Massachusetts General Hospital, a battery-operated vibrating box that clips to the bassinet is used often. The device creates a tactile "white noise" that allows the newborn withdrawing from drugs to focus away from multiple-environmental stimuli. Anecdotal evidence supports improved outcomes with its use.
  • Use a pacifier for excessive sucking.
  • Frequent diaper changes are necessary. Diaper dermatitis is common in infants who are withdrawing from narcotics and have loose stools. Proper skin care can minimize skin breakdown and associated discomfort.
  • Position the newborn to reduce aspiration. The guidelines of the American Academy of Pediatrics specifically discourage prone position sleeping for newborns. Some recent evidence suggests that placing babies in the left lateral position is more useful to decrease gastroesophageal reflux than placing babies in the right lateral or supine position.
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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.

Specialty Editor Board

David N Sheftel  MD, Assistant Professor of Pediatrics, Chicago Medical School at Rosalind Franklin University of Medicine and Science

David N Sheftel 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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP  Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Director, Neonatal Follow-up Program, 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 & Ethics, National Hospice and Palliative Care Organization, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

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.

References

  1. [Best Evidence] O'Donnell M, Nassar N, Leonard H, Hagan R, Mathews R, Patterson Y. Increasing prevalence of neonatal withdrawal syndrome: population study of maternal factors and child protection involvement. Pediatrics. Apr 2009;123(4):e614-21. [Medline].

  2. Lester BM. The Maternal Lifestyles Study. Ann N Y Acad Sci. Jun 21 1998;846:296-305. [Medline].

  3. Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol. Feb 2003;101(2):374-9. [Medline].

  4. Wilsnack SC, Beckman LJ. Drinking, sexuality, and sexual dysfunction in women. In: Alcohol Problems in Women: Antecedents, Consequences, and Intervention. New York, NY: Guilford Press; 1984:189.

  5. Hien D, Scheier J. Trauma and short-term outcome for women in detoxification. J Subst Abuse Treat. May-Jun 1996;13(3):227-31. [Medline].

  6. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. Nov 21 1990;264(19):2511-8. [Medline].

  7. Berghella V, Lim PJ, Hill MK, et al. Maternal methadone dose and neonatal withdrawal. Am J Obstet Gynecol. Aug 2003;189(2):312-7. [Medline].

  8. Esmaeili A, Keinhorst AK, Schuster T, Beske F, Schlosser R, Bastanier C. Treatment of neonatal abstinence syndrome with clonidine and chloral hydrate. Acta Paediatr. Feb 2010;99(2):209-14. [Medline].

  9. Dryden C, Young D, Hepburn M, Mactier H. Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG. Apr 2009;116(5):665-71. [Medline].

  10. Lim S, Prasad MR, Samuels P, Gardner DK, Cordero L. High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome. Am J Obstet Gynecol. Jan 2009;200(1):70.e1-5. [Medline].

  11. McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet Gynecol. Sep 2005;193(3 Pt 1):606-10. [Medline].

  12. McCarthy JJ, Leamon MH, Stenson G, Biles LA. Outcomes of neonates conceived on methadone maintenance therapy. J Subst Abuse Treat. Sep 2008;35(2):202-6. [Medline].

  13. Kacinko SL, Jones HE, Johnson RE, Choo RE, Huestis MA. Correlations of maternal buprenorphine dose, buprenorphine, and metabolite concentrations in meconium with neonatal outcomes. Clin Pharmacol Ther. Nov 2008;84(5):604-12. [Medline].

  14. Kraft WK, Gibson E, Dysart K, Damle VS, Larusso JL, Greenspan JS. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Pediatrics. Sep 2008;122(3):e601-7. [Medline].

  15. Farid WO, Dunlop SA, Tait RJ, Hulse GK. The effects of maternally administered methadone, buprenorphine and naltrexone on offspring: review of human and animal data. Curr Neuropharmacol. Jun 2008;6(2):125-50. [Medline].

  16. Jones HE, Johnson RE, Jasinski DR, et al. Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome. Drug Alcohol Depend. Jul 2005;79(1):1-10. [Medline].

  17. Stroud LR, Paster RL, Papandonatos GD, Niaura R, Salisbury AL, Battle C. Maternal smoking during pregnancy and newborn neurobehavior: effects at 10 to 27 days. J Pediatr. Jan 2009;154(1):10-6. [Medline].

  18. National Toxicology Program. NTP-CERHR monograph on the potential human reproductive and developmental effects of amphetamines. NTP CERHR MON. Jul 2005;(16):vii-III1. [Medline].

  19. Smith LM, LaGasse LL, Derauf C, et al. The infant development, environment, and lifestyle study: effects of prenatal methamphetamine exposure, polydrug exposure, and poverty on intrauterine growth. Pediatrics. Sep 2006;118(3):1149-56. [Medline].

  20. Sanz EJ, De-las-Cuevas C, Kiuru A, et al. Selective serotonin reuptake inhibitors in pregnant women and neonatal withdrawalsyndrome: a database analysis. Lancet. Feb 5-11 2005;365(9458):482-7. [Medline].

  21. Ryan RM, Wagner CL, Schultz JM, et al. Meconium analysis for improved identification of infants exposed to cocaine in utero. J Pediatr. Sep 1994;125(3):435-40. [Medline].

  22. Finnegan LP. Neonatal abstinence syndrome: Assessment and pharmacotherapy. In: In Neonatal Therapy: An Update. 1986:122-46.

  23. Coyle MG, Ferguson A, Lagasse L, et al. Diluted tincture of opium (DTO) and phenobarbital versus DTO alone for neonatalopiate withdrawal in term infants. J Pediatr. May 2002;140(5):561-4. [Medline].

  24. Leikin JB, Mackendrick WP, Maloney GE, et al. Use of clonidine in the prevention and management of neonatal abstinence syndrome. Clin Toxicol (Phila). Jul 2009;47(6):551-5. [Medline].

  25. Agthe AG, Kim GR, Mathias KB, Hendrix CW, Chavez-Valdez R, Jansson L. Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics. May 2009;123(5):e849-56. [Medline].

  26. Abdel-Latif ME, Pinner J, Clews S, Cooke F, Lui K, Oei J. Effects of breast milk on the severity and outcome of neonatal abstinence syndrome among infants of drug-dependent mothers. Pediatrics. Jun 2006;117(6):e1163-9. [Medline].

  27. Jansson LM, Choo R, Velez ML, Harrow C, Schroeder JR, Shakleya DM. Methadone maintenance and breastfeeding in the neonatal period. Pediatrics. Jan 2008;121(1):106-14. [Medline].

  28. Wouldes TA, Woodward LJ. Maternal methadone dose during pregnancy and infant clinical outcome. Neurotoxicol Teratol. Jan 25 2010;[Medline].

  29. Mansoor E, Morrow CE, Accornero VH, Xue L, Johnson AL, Anthony JC, et al. Longitudinal effects of prenatal cocaine use on mother-child interactions at ages 3 and 5 years. J Dev Behav Pediatr. Jan 2012;33(1):32-41. [Medline]. [Full Text].

  30. Levine TP, Liu J, Das A, Lester B, Lagasse L, Shankaran S. Effects of prenatal cocaine exposure on special education in school-aged children. Pediatrics. Jul 2008;122(1):e83-91. [Medline].

  31. Lim S, Prasad MR, Samuels P, Gardner DK, Cordero L. High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome. Am J Obstet Gynecol. Jan 2009;200(1):70.e1-5. [Medline].

  32. Seligman NS, Salva N, Hayes EJ, Dysart KC, Pequignot EC, Baxter JK. Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates. Am J Obstet Gynecol. Oct 2008;199(4):396.e1-7. [Medline].

  33. Ebner N, Rohrmeister K, Winklbaur B, et al. Management of neonatal abstinence syndrome in neonates born to opioid maintained women. Drug Alcohol Depend. Mar 16 2007;87(2-3):131-8. [Medline].

  34. [Guideline] AAP. Neonatal drug withdrawal. American Academy of Pediatrics Committee on Drugs [published erratum appears in Pediatrics 1998 Sep;102(3 Pt 1):660]. Pediatrics. Jun 1998;101(6):1079-88. [Medline]. [Full Text].

  35. Bauer CR. Perinatal effects of prenatal drug exposure. Neonatal aspects. Clin Perinatol. Mar 1999;26(1):87-106. [Medline].

  36. Behnke M, Eyler FD, Warner TD, Garvan CW, Hou W, Wobie K. Outcome from a prospective, longitudinal study of prenatal cocaine use: preschool development at 3 years of age. J Pediatr Psychol. Jan-Feb 2006;31(1):41-9. [Medline].

  37. Bishai R, Koren G. Maternal and obstetric effects of prenatal drug exposure. Clin Perinatol. Mar 1999;26(1):75-86, vii. [Medline].

  38. Choo RE, Huestis MA, Schroeder JR, et al. Neonatal abstinence syndrome in methadone-exposed infants is altered by levelof prenatal tobacco exposure. Drug Alcohol Depend. Sep 6 2004;75(3):253-60. [Medline].

  39. Coyle MG, Ferguson A, Lagasse L, et al. Neurobehavioral effects of treatment for opiate withdrawal. Arch Dis Child Fetal Neonatal Ed. Jan 2005;90(1):F73-4. [Medline].

  40. Eyler FD, Behnke M. Early development of infants exposed to drugs prenatally. Clin Perinatol. Mar 1999;26(1):107-50, vii. [Medline].

  41. Flanagan P, Kokotailo P. Adolescent pregnancy and substance use. Clin Perinatol. Mar 1999;26(1):185-200. [Medline].

  42. Gewolb IH, Fishman D, Qureshi MA, Vice FL. Coordination of suck-swallow-respiration in infants born to mothers with drug-abuseproblems. Dev Med Child Neurol. Oct 2004;46(10):700-5. [Medline].

  43. Hans SL. Demographic and psychosocial characteristics of substance-abusing pregnant women. Clin Perinatol. Mar 1999;26(1):55-74. [Medline].

  44. Hoyme HE, May PA, Kalberg WO, et al. A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 institute of medicine criteria. Pediatrics. Jan 2005;115(1):39-47. [Medline].

  45. Jackson L, Ting A, McKay S, et al. A randomised controlled trial of morphine versus phenobarbitone for neonatalabstinence syndrome. Arch Dis Child Fetal Neonatal Ed. Jul 2004;89(4):F300-4. [Medline].

  46. Jackson L, Ting A, McKay S, Galea P, Skeoch C. A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome. Arch Dis Child Fetal Neonatal Ed. Jul 2004;89(4):F300-4. [Medline].

  47. Johnson K, Gerada C, Greenough A. Treatment of neonatal abstinence syndrome. Arch Dis Child Fetal Neonatal Ed. Jan 2003;88(1):F2-5. [Medline].

  48. Kosofsky BE. Cocaine-Induced Alterations in Neuro-Development. Seminars in Speech and language. 1998;19(2):109-121. [Medline].

  49. Kuschel CA, Austerberry L, Cornwell M, et al. Can methadone concentrations predict the severity of withdrawal in infantsat risk of neonatal abstinence syndrome?. Arch Dis Child Fetal Neonatal Ed. Sep 2004;89(5):F390-3. [Medline].

  50. Langenfeld S, Birkenfeld L, Herkenrath P, et al. Therapy of the neonatal abstinence syndrome with tincture of opium or morphinedrops. Drug Alcohol Depend. Jan 7 2005;77(1):31-6. [Medline].

  51. Messinger DS, Bauer CR, Das A, et al. The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics. Jun 2004;113(6):1677-85. [Medline].

  52. [Best Evidence] Osborn DA, Jeffery HE, Cole M. Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database Syst Rev. 2005;(3):CD002059. [Medline].

  53. Philipp BL, Merewood A, O'Brien S. Methadone and breastfeeding: new horizons. Pediatrics. Jun 2003;111(6 Pt 1):1429-30. [Medline]. [Full Text].

  54. Shephard R, Greenough A, Johnson K, Gerada C. Hyperphagia, weight gain and neonatal drug withdrawal. Acta Paediatr. 2002;91(9):951-3. [Medline].

  55. Smeriglio VL. Prenatal Drug Exposure and Child Outcome. Clinics in Perinatology. 1999;26(1):1-15. [Medline].

  56. Tan-Laxa MA, Sison-Switala C, Rintelman W, Ostrea EM Jr. Abnormal auditory brainstem response among infants with prenatal cocaine exposure. Pediatrics. Feb 2004;113(2):357-60. [Medline].

  57. Tronick EZ, Beeghly M. Prenatal cocaine exposure, child development, and the compromising effects of cumulative risk. Clin Perinatol. Mar 1999;26(1):151-71. [Medline].

  58. Vinner E, Vignau J, Thibault D, et al. Neonatal hair analysis contribution to establishing a gestational drug exposureprofile and predicting a withdrawal syndrome. Ther Drug Monit. Aug 2003;25(4):421-32. [Medline].

 
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Neonatal abstinence scoring form.
 
 
 
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