Medication Summary

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.

Class Summary

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 tincture

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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.

Morphine

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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.

Class Summary

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)

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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.

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Media Gallery

Perinatal Drug Abuse and Neonatal Drug Withdrawal. Neonatal abstinence scoring form.

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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: Received research grant from: New England Pediatric Device Consortium.

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

Dharmendra J Nimavat, MD, FAAP Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine; Staff Neonatologist, Clinical Director, NICU Regional Perinatal Center, HSHS St John's Children's Hospital

Dharmendra J Nimavat, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Additional Contributors

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

David N Sheftel, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics

Disclosure: Nothing to disclose.

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.