Neonatal Abstinence Syndrome Follow-up

  • Author: Ashraf H Hamdan, MD, MBBCh, MSc, MRCP; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Mar 3, 2010
 

Further Inpatient Care

The length of hospitalization in patients with neonatal abstinence syndrome (NAS) varies, depending on the drug, withdrawal symptoms, and social factors.

Other issues that need to be addressed include breastfeeding and infectious disease prevention. If the mother abuses intravenous drugs, screen for HIV, hepatitis B and hepatitis C, Chlamydia,syphilis, and gonorrhea.

  • Breastfeeding confers immunologic benefits to the neonate, and bonding benefits the mother. One study reported that only small amounts of methadone were detected in breast milk of women maintained on higher doses of methadone and recommended breast feeding for methadone-maintained women.[32] The benefits of breastfeeding often outweigh the effect of the small amount of methadone that enters the breast milk. The earlier recommendation of the American Academy of Pediatrics (AAP) is not to breastfeed for the mother who is receiving maintenance doses of methadone more than 20 mg/24 h.[28] Currently the AAP classifies methadone as compatible with breastfeeding.[33]
  • Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used antidepressants in postpartum mothers. In general, SSRIs are well tolerated and effective for the mothers and probably are safe for their breastfeeding infants. Sertraline and paroxetine have minimal transfer into human milk and no adverse effects on infants. In contrast, fluoxetine produces significant plasma concentrations in some breastfed infants, especially if the exposure began in utero. Infant should be monitored closely for signs such as uneasy sleep, irritability, and poor feeding or sucking.[34, 35]
  • Enrollment in a drug rehabilitation program may be a prerequisite for breast feeding. Both marijuana and alcohol exposure through breast milk result in decreased motor development at age 1 year.
  • Breastfeeding is contraindicated if the mother is still using illicit drugs or has HIV infection.
Next

Further Outpatient Care

The infant's discharge should occur after the following criteria are met:

  • The infant is taking oral feeds and gaining weight satisfactorily.
  • The infant is physiologically stable (has normal vital signs including blood pressure).
  • The infant is showing neurobehavioral recovery (can reach full alert state, responds to social stimuli, and can be consoled with appropriate measures).
  • All necessary assessments have been completed because adherence to followup schedules cannot be ensured.

Drug abuse during pregnancy is associated with medical, psychological, and economic problems that require extensive evaluation by qualified service providers. Mothers and fathers of drug-exposed infants need substance abuse treatment and a wide array of services to support them in their parenting role. Provision must be made for such services prior to an infant's discharge.

Provide follow-up care in the first few weeks to months of life to assess infant growth, behavioral characteristics, and motor ability.

Discharging otherwise healthy infants home once they are stable on treatment for neonatal abstinence syndrome can reduce hospital stay and associated costs. However, a safe discharge of the infant requires that support structures within the home and community are in place. In one study, compliance with the necessary clinic attendance was facilitated by establishment of a weekly follow-up clinic. This continuity of care was provided by staff with whom the families were familiar and which met all the families’ needs for the infants, including vaccinations, subspecialist appointments, and prescriptions.

Previous
Next

Deterrence/Prevention

Identification of substance abuse is the first step in attempting to break the cycle of reproductive morbidity or mortality. Ideally, substance use should be terminated by women and their male sexual partner before conception. Pregnant drug-using women should be counseled at the earliest opportunity to abstain completely from all injurious substances and to seek prenatal care. Adequate dietary intake and supplemental prenatal vitamins should be stressed.

Early drug screening during pregnancy reveals the need for counseling in pregnant women with a history of drug abuse.

Federal, state, and local agencies should reduce barriers to the use of family planning services and increase access to early prenatal care and other health services, including drug rehabilitation.

Health education specifically targeting consequences of drug abuse during and after pregnancy is beneficial to prevent this growing social problem.

Previous
Next

Complications

Narcotics may have a direct effect on the development of the respiratory center in the brain stem, but an adverse effect of opiates on long-term postnatal growth is not evident. In longitudinal studies, developmental sequelae have not been proven. Problems with habituation, visual and auditory responsiveness, and interactive patterns have been observed in the first months of life.

Previous
Next

Prognosis

Infants born to mothers who are chemically dependent face not only the experience of sudden withdrawal from poly intoxicants but also other medical and social challenges. Prognosis widely varies and depends on the family, socioeconomic variables, and whether either or both parents continue to use illicit drugs. A home environment with an addicted mother is a compromising variable.

Long-term problems of children exposed to illicit drugs in utero include adverse neurodevelopmental outcomes. Lower intelligence quotient scores have been reported in children with in utero exposure to cocaine or methadone. Speech, perceptual, and cognitive disturbances have been reported in toddlers who were exposed to opiates. Difficulties with expressive language articulation have been reported in children of mothers who abused cocaine. Behavioral problems are also reported in children of mothers who have taken illicit substances in pregnancy. These include lower levels of learning and adapting to new situations; higher sensitivity to their environment resulting in irritability, agitation, aggression, poor social skills; and a lack of imitative play and late emergence of symbolic play.

Prenatal exposure to marijuana has been associated with increased levels of depression during childhood.[36] Another study showed increased hyperactivity, impulsivity, inattention symptoms, and delinquency has been associated with prenatal marijuana use.[37]

The severity of withdrawal signs, including seizures, has not been proven to be associated with differences in long-term outcome after intrauterine drug exposure. Furthermore, treatment of drug withdrawal may not alter the long-term outcome.

Previous
Next

Patient Education

For excellent patient education resources, visit eMedicine's Substance Abuse Center and Children's Health Center. Also, see eMedicine's patient education articles Drug Dependence and Abuse, Narcotic Abuse, Substance Abuse, and Sudden Infant Death Syndrome (SIDS).

Previous
 
Contributor Information and Disclosures
Author

Ashraf H Hamdan, MD, MBBCh, MSc, MRCP  Clinical Assistant Professor of Pediatrics, Vanderbilt University Medical Center; Neonatologist, Pediatrix Medical group Nashville

Ashraf H Hamdan, MD, MBBCh, MSc, MRCP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Scott S MacGilvray, MD  Clinical Associate Professor, Department of Pediatrics, Division of Neonatology, The Brody School of Medicine at East Carolina University

Scott S MacGilvray, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

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, 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. Chana S, Anand K. Can we use methadone for Analgesia in neonates?. Arch Dis Child Fetal Neonatal Ed. 2001;85:79–81. [Medline]. [Full Text].

  2. Franck LS, Vilardi J, Durand D, Powers R. Opioid withdrawal in neonates after continuous infusions of morphine or fentanyl during extracorporeal membrane oxygenation. Am J Crit Care. Sep 1998;7(5):364-9. [Medline].

  3. Substance Abuse and Mental Health Services Administration Office of Applied Studies. 2003 National Survey on Drug Use & Health: Results. US Department of Health and Human Services. Available at http://www.drugabusestatistics.samhsa.gov/NHSDA/2k3NSDUH/2k3results.htm. Accessed December, 2007.

  4. Hytinantti T, Kahila H, Renlund M, Jarvenpaa AL, Halmesmaki E, Kivitie-Kallio S. Neonatal outcome of 58 infants exposed to maternal buprenorphine in utero. Acta Paediatr. Aug 2008;97(8):1040-4. [Medline].

  5. 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].

  6. 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].

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

  8. Law KL, Stroud LR, LaGasse LL, et al. Smoking during pregnancy and newborn neurobehavior. Pediatrics. Jun 2003;111(6 Pt 1):1318-23. [Medline]. [Full Text].

  9. Substance Use During Pregnancy: 2002 and 2003 Update. National survey on drug use and health; June 2, 2005. [Full Text].

  10. SAMHSA. Substance Use among Women During Pregnancy and Following Childbirth. Rockville, MD: Substance Abuse and Mental Health Services Administration; May 21, 2009. [Full Text].

  11. Cairns PA. Drug misuse: Conception into childhood. Current Paediatrics. December 2001;11(6):475-9.

  12. Prentice S. Substance misuse in pregnancy. Obstetrics, Gynaecology & Reproductive Med. September 2007;17:272-7.

  13. Gyarmathy VA, Giraudon I, Hedrich D, Montanari L, Guarita B, Wiessing L. Drug use and pregnancy - challenges for public health. Euro Surveill. Mar 5 2009;14(9):33-6. [Medline]. [Full Text].

  14. SAMHSA. Special issues during pregnancy. Rockford, MD: DHHS; May 21, 2009. [Full Text].

  15. Lester BM, ElSohly M, Wright LL, Smeriglio VL, Verter J, Bauer CR. The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics. Feb 2001;107(2):309-17. [Medline].

  16. [Guideline] American Academy of Pediatrics Committee on Substance Abuse. Drug-exposed infants. Pediatr. Aug 1995;96(2 Pt 1):364-7. [Medline].

  17. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacolotherapy. In: Neonatal therapy: An update. New York, NY: Excerpta Medica; 1986:122-46.

  18. Ostrea EM, Ostrea AR, Simpson PM. Mortality within the first 2 years in infants exposed to cocaine, opiate, or cannabinoid during gestation. Pediatrics. Jul 1997;100(1):79-83. [Medline]. [Full Text].

  19. Lester BM, Tronick EZ. History and description of the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. Mar 2004;113(3 Pt 2):634-40. [Medline].

  20. Chasnoff IJ. Prenatal substance exposure: maternal screening and neonatal identification and management. Neoreviews. 2003;4(9):e228-e235.

  21. Gray T, Huestis M. Bioanalytical procedures for monitoring in utero drug exposure. Anal Bioanal Chem. Aug 2007;388(7):1455-65. [Medline].

  22. van Huis M, van Kempen AA, Peelen M, Timmers M, Boer K, Smit BJ. Brain ultrasonography findings in neonates with exposure to cocaine during pregnancy. Pediatr Radiol. Mar 2009;39(3):232-8. [Medline].

  23. Kassima Z, Greenough A. Neonatal abstinence syndrome: Identification and management. Current Paediatrics. June 2006;16:172-5.

  24. Lainwala S, Brown ER, Weinschenk NP, Blackwell MT, Hagadorn JI. A retrospective study of length of hospital stay in infants treated for neonatal abstinence syndrome with methadone versus oral morphine preparations. Adv Neonatal Care. Oct 2005;5(5):265-72. [Medline].

  25. Kraft WK, Gibson E, Dysart K, et al. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Pediatrics. Sep 2008;122(3):e601-7. [Medline].

  26. [Best Evidence] Agthe AG, Kim GR, Mathias KB, et al. Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics. May 2009;123(5):e849-56. [Medline].

  27. Sarkar S, Donn SM. Management of neonatal abstinence syndrome in neonatal intensive care units: a national survey. J Perinatol. Jan 1 2006;26(1):15-7. [Medline].

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

  29. Mazurier E, Cambonie G, Barbotte E, Grare A, Pinzani V, Picaud JC. Comparison of chlorpromazine versus morphine hydrochloride for treatment of neonatal abstinence syndrome. Acta Paediatr. Oct 2008;97(10):1358-61. [Medline].

  30. SAMHSA. The Drug Addiction Treatment Act of 2000 (DATA 2000). DHHS; 2000. [Full Text].

  31. 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].

  32. [Guideline] 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].

  33. [Guideline] AAP. Transfer of drugs and other chemicals into human milk. Pediatrics. Sep 2001;108(3):776-89. [Medline].

  34. Anthony BE, Bryan BL. Neonatal Abstinence Syndrome. NeoReviews. 2009;10(5):e222.

  35. Hale TW. Pharmacology review: drug therapy and breastfeeding: antidepressants, antipsychotics, antimanics, and sedatives. NeoReviews. May 2004;e451 –e456.

  36. Gray KA, Day NL, Leech S, Richardson GA. Prenatal marijuana exposure: effect on child depressive symptoms at ten years of age. Neurotoxicol Teratol. May-Jun 2005;27(3):439-48. [Medline].

  37. Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. May-Jun 2000;22(3):325-36. [Medline].

  38. Maternal Resource Center. Prenatal Substance Exposure. April 2008;Available from: National Abandoned Infants Assistance Resource Center. Accessed 2/20/2010. Available at http://aia.berkeley.edu/media/pdf/2008_perinatal_se.pdf.

  39. Jaudes PK, Ekwo E, Van Voorhis J. Association of drug abuse and child abuse. Child Abuse Negl. Sep 1995;19(9):1065-75. [Medline].

  40. Smith DK, Johnson AB, Pears KC, Fisher PA, DeGarmo DS. Child maltreatment and foster care: unpacking the effects of prenatal and postnatal parental substance use. Child Maltreat. May 2007;12(2):150-60. [Medline].

  41. American Academy of Pediatrics. Pickering LK. The Red Book: 2006 Report of the Committee on Infectious Diseases. 27th. 2006.

  42. [Guideline] American Academy of Pediatrics Committee on Fetus and Newborn. The initiation or withdrawal of treatment for high-risk newborns. Pediatrics. Aug 1995;96(2 Pt 1):362-3. [Medline].

  43. Bahwere P, Haumont D, Delange F. Congenital hypothyroidism and neonatal withdrawal syndrome. Eur J Pediatr. Nov 1996;155(11):937-8. [Medline].

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

  45. Boukydis CF, Lester BM. The NICU Network Neurobehavioral Scale. Clinical use with drug exposed infants and their mothers. Clin Perinatol. Mar 1999;26(1):213-30. [Medline].

  46. Buchi KF. The drug-exposed infant in the well-baby nursery. Clin Perinatol. Jun 1998;25(2):335-50. [Medline].

  47. Connolly WB Jr, Marshall AB. Drug addiction, pregnancy, and childbirth: legal issues for the medical and social services communities. Clin Perinatol. Mar 1991;18(1):147-86. [Medline].

  48. Frank L. Assessment and management of opioid withdrawal in ill neonates. Neonatal Network. 1995;14:39-48. [Medline].

  49. Heier LA, Carpanzano CR, Mast J, Brill PW, Winchester P, Deck MD. Maternal cocaine abuse: the spectrum of radiologic abnormalities in the neonatal CNS. AJNR Am J Neuroradiol. Sep-Oct 1991;12(5):951-6. [Medline].

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

  51. Kallen B. Neonate characteristics after maternal use of antidepressants in late pregnancy. Arch Pediatr Adolesc Med. Apr 2004;158(4):312-6. [Medline]. [Full Text].

  52. Kaltenbach K, Berghella V, Finnegan L. Opioid dependence during pregnancy. Effects and management. Obstet Gynecol Clin North Am. Mar 1998;25(1):139-51. [Medline].

  53. Kandall RS. Improving Treatment for Drug-Exposed Infants Treatment Improvement Protocol (TIP) Series 5. Available at http://ncadi.samhsa.gov/govpubs/bkd110/default.aspx. Accessed February, 14 2010.

  54. Kandall SR. Treatment strategies for drug-exposed neonates. Clin Perinatol. Mar 1999;26(1):231-43. [Medline].

  55. Kuschel C. Managing drug withdrawal in the newborn infant. Semin Fetal Neonatal Med. Apr 2007;12(2):127-33. [Medline].

  56. McKim EM. Caffeine and its effects on pregnancy and the neonate. J Nurse Midwifery. Jul-Aug 1991;36(4):226-31. [Medline].

  57. [Best Evidence] Moses-Kolko EL, Bogen D, Perel J, Bregar A, Uhl K, Levin B. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA. May 18 2005;293(19):2372-83. [Medline].

  58. Oei J, Lui K. Management of the newborn infant affected by maternal opiates and other drugs of dependency. J Paediatr Child Health. Jan-Feb 2007;43(1-2):9-18. [Medline].

  59. Pierog S, Chandavasu O, Wexler I. Withdrawal symptoms in infants with the fetal alcohol syndrome. J Pediatr. Apr 1977;90(4):630-3. [Medline].

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

  61. Ter Horst PG, Jansman FG, van Lingen RA, Smit JP, de Jong-van den Berg LT, Brouwers JR. Pharmacological aspects of neonatal antidepressant withdrawal. Obstet Gynecol Surv. Apr 2008;63(4):267-79. [Medline].

  62. Theis JG, Selby P, Ikizler Y, Koren G. Current management of the neonatal abstinence syndrome: a critical analysis of the evidence. Biol Neonate. 1997;71(6):345-56. [Medline].

  63. Umans JG, Szeto HH. Precipitated opiate abstinence in utero. Am J Obstet Gynecol. Feb 15 1985;151(4):441-4. [Medline].

  64. Vance JC, Chant DC, Tudehope DI, et al. Infants born to narcotic dependent mothers: physical growth patterns in the first 12 months of life. J Paediatr Child Health. Dec 1997;33(6):504-8. [Medline].

  65. Wagner CL, Katikaneni LD, Cox TH, Ryan RM. The impact of prenatal drug exposure on the neonate. Obstet Gynecol Clin North Am. Mar 1998;25(1):169-94. [Medline].

  66. Young T E, Mangum B. CNS Drugs. In: Thomson Reuters clinical editorial staff. Neofax: A manual of drugs used in neonatal care. 22nd ed. Montvale, New Jersey: Thomson Reuters healthcare; 2009:187-214.

  67. Zeskind PS, Stephens LE. Maternal selective serotonin reuptake inhibitor use during pregnancy and newborn neurobehavior. Pediatrics. Feb 2004;113(2):368-75. [Medline].

 
Previous
Next
 
Neonatal abstinence syndrome scoring form.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.