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Neonatal Abstinence Syndrome Follow-up

  • Author: Ashraf H Hamdan, MD, MBBCh, MSc, MRCP; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Jan 02, 2016
 

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.

For patient education resources, see the Children's Health Center, Pregnancy Center, and Women's Health Center, as well as Drug Dependence and Abuse, Narcotic Abuse, Substance Abuse, and Sudden Infant Death Syndrome (SIDS).

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Further Inpatient Care

The length of hospitalization in patients with 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.[59] The benefits of breastfeeding often outweigh the effect of the small amount of methadone that enters the breast milk.

The previous recommendation of the AAP was for mothers receiving maintenance doses of methadone more than 20 mg/24 h not to breastfeed.[55] However, the AAP now classifies methadone as compatible with breastfeeding.[60] The ACOG recommends that breastfeeding should be encouraged in patients without HIV who are not using additional drugs and who have no other contraindications.[50]

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.[61, 62]

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.

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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.

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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.

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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.

Irner et al in a recent study showed that children of mothers ceasing or decreasing their use of substances up to time of the birth delivered healthier babies than the mothers who continued to use substances. In addition, their results indicated that early intervention, including treatment of addiction during pregnancy, prenatal care, and psychosocial support, can help to prevent some developmental defects of newborn children of substance-using mothers.[63]

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.[64] Another study showed increased hyperactivity, impulsivity, inattention symptoms, and delinquency has been associated with prenatal marijuana use.[65]

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.

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Contributor Information and Disclosures
Author

Ashraf H Hamdan, MD, MBBCh, MSc, MRCP Clinical Associate Professor of Pediatrics, Vanderbilt University Medical Center; Neonatologist, Pediatrix Medical Group of 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

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, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

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 Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

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 Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Scott S MacGilvray, MD Clinical 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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases, gratefully acknowledge the contributions of previous authors Jaques Belik, MD, and Judy Hawes, RN, MN, to the writing and development of this article.

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