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

Perinatal Drug Abuse and Neonatal Drug Withdrawal: Treatment & Medication

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

Treatment

Medical Care

  • 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.
  • A recent study has shown that combined use of opioid therapy and phenobarbital may reduce the overall length of hospital stay and durations of symptoms.18
  • 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.9
  • 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.

Consultations

  • 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.

Diet

  • 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.19
    • 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.20
    • 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.

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.

Medication

Opiate substitutes and phenobarbital are the mainstays of treatment. Other sedatives such as diazepam have not been shown to be effective. Many studies have compared opiates with phenobarbital alone. In general, opiates have been most effective. However, considerable data have shown that a combination treatment of opiates and phenobarbital significantly decreases hospital stay and decreases withdrawal severity. The drawback is that total duration of treatment (mostly as an outpatient on phenobarbital) is increased.

Opioids

These are the treatment of choice for neonates known to be at risk of withdrawal from opiates. Morphine elixir is gaining more support over deodorized tincture of opium as the treatment of choice for a primarily opioid withdrawal syndrome.


Opium, deodorized tincture 1:25 dilution

Use a 1:25 dilution. When ordering such a medication, be sure to emphasize that a dilute solution of the deodorized tincture is needed in a 1:25 ratio. Without this emphasis, the pharmacy may deliver undiluted DTO (used for adults) or the camphorated tincture of opium (Paregoric), which contains 45% alcohol, camphor, anise oil, and benzoic acid.

Adult

Pediatric

Starting dose: 0.05-0.1 mL/kg PO q4-6h
Maintenance dose: 0.05 mL/kg q4-6h; increase by 0.05 mL/kg at the end of every 4-h period until desired response is achieved; then, maintain dose for 3-5 d; then begin taper of 10% (of peak dose) every 2-3 d; rare to exceed 0.7 mL/dose; not to exceed 1-2 mL/kg/24h

Beware of additional respiratory depressant effects when using other CNS depressants (eg, phenobarbital)

Severe respiratory, renal, or hepatic disease

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Until weaning has begun, constantly monitor patient's vital signs and oxygen saturation; adverse effects include sedation and constipation; overdosing may cause narcosis, manifested by decreased reflexes and poor Moro reflex, sucking, grasping, and response to pain; more profound narcosis includes hypotonia, obtundation, coma, irregular shallow respirations, apnea, bradycardia, and hypothermia; if signs of opioid toxicity are observed, do not give naloxone; withdrawal seizures can occur


Morphine elixir, 2 mg/mL

Increasing data shows that, although this is similar in effect to DTO, it may be a safer alternative because the morphine elixir avoids the effects of alcohol extracts in DTO. Morphine elixir may allow for better weight gain compared with DTO, as well.

Adult

Pediatric

Starting dose: 0.04 mg/kg PO q3-4h
Increase dose by 0.02 mg/kg at the end of every 4-h period until the desired response is achieved; then maintain dose for 3-5 d; then, begin taper of 10% (of peak dose) q2-3d; doses should be administered with feedings

Beware of additional respiratory depressant effects when using other CNS depressants (eg, phenobarbital)

Severe respiratory, renal, or hepatic disease; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Until weaning has begun, constantly monitor patient's vital signs and oxygen saturation
Adverse effects include sedation and constipation; overdosing may cause narcosis, manifested by decreased reflexes and poor Moro reflex, sucking, grasping, and response to pain; more profound narcosis includes hypotonia, obtundation, coma, irregular shallow respirations, apnea, bradycardia, and hypothermia
If signs of opioid toxicity are observed, do not give naloxone; withdrawal seizures can occur

Barbiturates

Although barbiturates also are available for neonatal withdrawal syndrome, their optimal use is limited to several clinical situations, including the following:

  1. The newborn with a nonopiate withdrawal
  2. The newborn with a known polydrug withdrawal
  3. The newborn with abstinence-related seizures
  4. The newborn who has already received the maximum safe level of deodorized tincture of opium (DTO)


Phenobarbital (Luminal)

Interferes with transmission of impulses from thalamus to cortex of brain. Used as a sedative. As above, this is perhaps best used in combination with an opiate analog in reducing withdrawal severity.

Adult

Pediatric

Loading dose: 20 mg/kg PO
If continued Neonatal Abstinence Scoring System scores are >8 for 3 consecutive periods or if scores are >12 for 2 consecutive periods, then administer another 10 mg/kg q12h until a serum level of 40 mcg/mL is achieved
Maintenance dose: 2-5 mg/kg/d PO divided q8-12h, provided serum phenobarbital level is therapeutic; with good control, continue maintenance phenobarbital dose for another 72h
Weaning: The goal is to lower the serum level by 15% q24h; lower maintenance dose to 2 mg/kg/d; if serum level falls by >20% q24h, increase to 3 mg/kg/d; if serum level falls by only 10% q24h, decrease dose to 1 mg/kg/d; discontinue phenobarbital once serum level is <10 mcg/mL and the patient is clinically in good control

Beware of additional respiratory depressant effects when combining other CNS depressants (eg, morphine, tincture of opium); may decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol (contained in tincture of opium) may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase phenobarbital toxicity; rifampin may decrease phenobarbital effects

Severe respiratory disease; marked impairment of liver function; nephritic patients

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Constantly monitor vitals and oxygen saturation; draw serum phenobarbital levels daily; once discontinued from medication, observe for any abstinence for another 1-3 d
Adverse effects include sedation, poor sucking, and heightened pain sensitivity; some patients may experience a paradoxical increase in irritability with phenobarbital

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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