Medical Care
Perhaps the most important aspect of medical care for the potentially withdrawing infant should be that all nurseries caring for such infants develop a care protocol addressing screening and treatment. Such plans minimize care variance and have the potential to prevent unnecessary withdrawal from occurring. [1]
Administer paregoric and phenobarbital for withdrawal of opiates and barbiturates, respectively (see Medication). The following may be included in the medical treatment of perinatal drug abuse and neonatal drug withdrawal:
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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.
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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).
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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.
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One study showed that combined use of opioid therapy and phenobarbital may reduce the overall length of hospital stay and durations of symptoms. [40]
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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 μg/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. [30]
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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.
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All medically treated newborns should constantly be monitored for cardiovascular, respiratory, and oxygen saturation changes (see Medication).
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In newborns with severe symptoms, intravenous fluids with electrolytes may be needed. Oral feedings may need to be withheld.
Consultations
The following consultations may be indicated:
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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.
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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 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. [43]
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. [44]
In addition, women who are adhering to buprenorphine maintenance treatment should be encouraged to breastfeed, as the amount of this medication being excreted in human milk is small. [45]
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:
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Loose swaddling, as well as holding and slow rocking the infant, may be helpful.
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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.
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Use a pacifier for excessive sucking.
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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.
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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.
Long-Term Monitoring
The following is indicated as part of further outpatient care in perinatal drug abuse and neonatal drug withdrawal:
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Early intervention and developmental pediatrics: Any newborn who has been exposed to drugs is considered at risk for developmental and cognitive compromises. These children should have regular follow-up care with a team of child development specialists to quickly identify potential deficits.
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State child protective services: In the event of court-imposed custody, children should be monitored through the foster family and adoption process.
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General pediatrics: As with any newborn, perform regular follow-up care for immunizations, anticipatory guidance, and physical examinations.
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Perinatal Drug Abuse and Neonatal Drug Withdrawal. Neonatal abstinence scoring form.
