AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Neonatal withdrawal syndrome, generically termed neonatal abstinence syndrome (NAS), is a constellation of behavioral and physiological signs and symptoms that are remarkably similar despite marked differences in the properties of the causative agent. Two major types of NAS are recognized: NAS due to prenatal or maternal use of substances that result in withdrawal symptoms in the newborn and postnatal NAS secondary to discontinuation of medications such as fentanyl or morphine used for pain therapy in the newborn.

Maternal substance abuse, the cause of prenatal NAS, has both medical and developmental consequences for the newborn, in addition to the legal, health, and economic consequences for the mother. Postnatal NAS results when an abrupt discontinuation of opioid analgesia occurs, usually after prolonged drug exposure. NAS is more pronounced in neonates with long-term exposure to fentanyl than in those exposed to morphine.

Drug abuse in pregnancy and neonatal psychomotor behavior consistent with withdrawal from opiate and polydrug withdrawal is currently a significant clinical and social problem. Approximately 3% of the 4.1 million women of child-bearing age who abuse drugs are believed to continue drug use during pregnancy.¹

Drugs frequently associated with neonatal problems include the following:

• Opiates and narcotics
• • Codeine
  • Fentanyl
  • Heroin and methadone
  • Meperidine (Demerol)
  • Morphine
  • Pentazocine
  • Propoxyphene
  • Cocaine
  • Diazepam and lorazepam
  • Selective serotonin reuptake inhibitors (SSRIs)
• Other drugs
• • Barbiturates
  • Caffeine
  • Chlordiazepoxide
  • Diphenhydramine
  • Ethanol
  • Marijuana
  • Nicotine
  • Phencyclidine
  • Meprobamate
  • Hydroxyzine
  • Glutethimide
  • Ethchlorvynol

Pathophysiology

Most illicit drugs cause an addiction in both the mother and the infant. Addiction or tolerance in the latter is due to passage of the drugs across the placental barrier; this occurs in varying degrees, depending on the pharmacokinetic properties of the individual drugs. Disruption of this transplacental passage of drugs at birth results in the development of a withdrawal syndrome.

NAS is often a multisystem disorder that frequently involves the CNS, GI system, autonomic system, and respiratory system. Manifestations of NAS depend on various factors, including the drug used, its dose, frequency of use, and the infant's own metabolism and excretion of the active compound or compounds. In addition, prenatal NAS depends on the infant's last intrauterine drug exposure and the mother's drug metabolism and excretion. Withdrawal is generally a function of the drug's half-life; the longer the half-life, the later the onset of withdrawal. A longer half-life is also associated with a decreased likelihood of NAS in the infant.  

Opiates produce the most dramatic effects on both the mother and fetus. Aside from the withdrawal symptoms, common findings in infants exposed to opiates include low birth weight, prematurity, and intrauterine growth retardation (IUGR). Because of its short half-life, heroin withdrawal may start as early as 24 hours after birth and usually peaks within 48-72 hours in 50-80% of infants born to mothers who are dependent on heroin. Some delayed withdrawal may occur as long as 6 days after birth. Sedative-hypnotics such as benzodiazepines and barbiturates have an even longer half-life, and withdrawal may not start until after the infant has been discharged from hospital (age 2 wk).

Methadone is used to treat heroin addiction, and its effects on the fetus are similar to the effects of heroin. Methadone's half-life is longer than 24 hours, and acute withdrawal may occur within the first 48 hours after birth and as long as 7-14 days later. The withdrawal may even be delayed up as long as 4 weeks after birth, with subacute signs developing as long as 6 months after birth. Neonates face an increased risk of fetal distress and demise, impaired fetal growth, and an increased risk of sudden infant death syndrome (SIDS). Thrombocytosis occurs in the second week of life and may continue until age 4 months. The severity of methadone withdrawal (in relation to dose) is difficult to establish, but higher maternal doses are associated with more significant withdrawal symptoms in the neonate, especially if the maternal dose is higher than 20 mg/d.

Cocaine and amphetamines are stimulants with potent vasoconstrictor effects that stimulate the release and block the reuptake of the neurotransmitters dopamine, epinephrine, norepinephrine, and serotonin. Cocaine is a potent CNS stimulant that alters the major neurotransmitters and rapidly crosses the placenta. Early studies suggested that neonates exposed to cocaine exhibited a hyperactive Moro reflex, jitteriness, and excessive sucking. More recent studies do not support that neonates who have been exposed to cocaine differ behaviorally from unexposed infants. The unresolved question is whether or not cocaine acts to limit head growth or disrupt brain development. A synergistic effect between cocaine and other CNS toxins is still possible.

Methylxanthine accumulates in the blood of breastfed infants whose mothers regularly consume caffeine substances. Nicotine is transferred through the placenta and may reach concentrations 15% higher than maternal levels. In utero exposure impairs neonatal habituation, orientation, autonomic regulation, and orientation to sound. Exposure also affects the infant's ability to be comforted and is associated with exaggerated startle reflex and tremor.

No evidence suggests neonatal withdrawal problems associated with maternal use of marijuana during pregnancy. Fetal exposure to marijuana has been associated with hypoglycemia, hypocalcemia, sepsis, hypoxic encephalopathy, intracranial hemorrhage, and jitteriness. Effects on the fetus depend on the dose, with evidence of IUGR noted in cases of heavier usage.

Neonates exposed to marijuana while in utero may also exhibit signs of nicotine toxicity, such as tachycardia, poor perfusion, irritability, and poor feeding. Growth inhibition is pronounced at birth and affects weight, length, and head circumference. Catch-up growth occurs within the first year in each growth category. Cognitive effects may persist to school age. However, withdrawal symptoms are generally not noted in infants in the newborn period. Extended follow-up does not show any effect in children aged 5-6 years.

Several studies have demonstrated that maternal cigarette smoking during pregnancy increases the risk of having a low birth weight infant.² Neonates born to mothers who smoke during pregnancy weigh an average of 150-250 g less at birth than neonates born to mothers who do not smoke during pregnancy. Research findings also suggest that infants of mothers who smoke during pregnancy may develop nicotine withdrawal in a pattern that is related to the magnitude of in utero exposure. Infants who have been exposed to tobacco have been found to be more excitable and hypertonic and demonstrate more stress and abstinence signs.

SSRIs (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat depression and a wide spectrum of other mood and behavioral disorders. Infants exposed to SSRIs during the last trimester of pregnancy may exhibit neonatal adaptation syndrome. This is primarily manifested as CNS (eg, irritability), motor (eg, agitation, tremors), respiratory (eg, increased respiratory rate, nasal congestion), and GI signs (eg, emesis, diarrhea). These manifestations are self-limiting and usually disappear by age 2 weeks. Symptoms are more commonly reported with fluoxetine and paroxetine exposure. A decrease in maternal SSRI use during the third trimester may lower the neonatal risk of developing withdrawal syndrome, but this needs to be balanced against the harmful effects of depression during pregnancy.

Frequency

United States

Neonatal drug withdrawal is a common problem in populations in which drugs taken for therapeutic, recreational, or addiction purposes are readily available to pregnant women. However, the incidence is difficult to determine because of unreliable histories of maternal drug abuse and limited health provider skills in eliciting drug histories and diagnosing nonopiate drug exposure in the newborn period. In addition, maternal use of more than one drug makes ascribing a given effect on the neonate to a specific drug difficult.

The National Household Survey on Drug Abuse in the United States found that 3.7% of pregnant women aged 15-44 years reported using illicit drugs, compared with 8.3% of nonpregnant women.¹ The rate of illicit drug use among pregnant women aged 15-17 years was 15.1%, nearly equal to the rate for nonpregnant women of the same age. A more recent study, primarily evaluating methamphetamine use in a nonselected population, reported that 10.7% of mothers had used illicit drugs during pregnancy.

Overall the incidence of drug-exposed newborns has been reported to be from 3% to 50%, depending on the specific patient population, with urban centers tending to report higher rates. Among offspring exposed to opioids or heroin in utero, withdrawal signs develop in 55-94%.

International

No accurate data are available concerning worldwide incidence. Data from the UK Advisory Council on the Misuse of Drugs suggests 6,000 babies are born to mothers who abuse drugs each year (1% of all UK deliveries).^{3, 4} In the past, heroin was the most commonly abused drug. Women are now more likely to use cocaine, methadone, or more than one illicit drug.

Mortality/Morbidity

Death is rarely associated with withdrawal alone but occurs as a consequence of prematurity, infection, and severe perinatal asphyxia.

Long-term mortality rate is likely to be extremely low, although the risk for SIDS is significantly higher among infants who are exposed to opiates. Infants exposed to methadone have a 3.7-fold higher risk of SIDS compared with controls. Infants exposed to cocaine have a 2.3-fold higher risk for SIDS compared with infants with no exposure. This increased risk is related to a complex interplay of factors; the compromised home environment associated with a mother who is drug addicted is an important variable.

Race

Rates of illicit drug use have been reported to be similar among white (4%), black (3.7%), and Hispanic (3.3%) pregnant women.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• The most reliable method of determining the extent of drug use in pregnancy is maternal history as part of routine antenatal assessment, with a structured interview providing a greater yield than an informal interview.
• The amount of information obtained from the mother about prenatal drug exposure widely varies and may not be reliable. How the mother is questioned and the specificity of the questions are the most important factors.
• The Committee on Substance Abuse of the American Academy of Pediatrics recommends obtaining a comprehensive medical and psychological history that includes specific information regarding maternal drug use as part of every newborn evaluation.⁵
• The relationship between maternal cocaine use and placental abruption is well established. Therefore, a perinatal history of abruption should alert the medical caretaker that prenatal exposure to cocaine is a possibilty.

Physical

Infants are suspected of having neonatal abstinence syndrome (NAS) if they exhibit any of the following signs: 

• CNS dysfunction
• • High-pitched cry
  • Restlessness, with sleep duration less than 1-3 hours after feeding
  • Hyperactive reflexes
  • Jitteriness
  • Tremors
  • Hypertonia
  • Myoclonic jerks
  • Generalized convulsions
• Metabolic, vasomotor, and respiratory disturbances
• • Sweating
  • Fever
  • Mottling
  • Frequent yawning
  • Sneezing (>3 times per interval)
  • Nasal flaring
  • Respiratory rate greater than 60 breaths per minute without retractions
  • Apnea
• GI dysfunction
• • Excessive (frantic) sucking or rooting
  • Poor feeding
  • Hyperphagia, usually associated with poor weight gain
  • Regurgitation or projectile vomiting
  • Loose or watery stools
• Alcohol-specific symptoms
• • Withdrawal that presents within the first 24 hours of life is reported among infants with the dysmorphic features of fetal alcohol syndrome.
  • Neonates also exhibit irritability, tremors, seizures, opisthotonus, and abdominal distention.
• Lysergic acid (LSD) symptoms
• • The effect of LSD on the fetus is clouded by the high incidence of polydrug abuse.
  • Withdrawal symptoms manifest as hypertonia, tremors, poor feeding, and abnormal feeding patterns.
• Other symptoms
• • Nicotine may produce withdrawal symptoms in infants, including increased excitability and hypertonicity.
  • Caffeine withdrawal includes feeding difficulties, vomiting, excessive crying, irritability, and poor sleep patterns. Onset of symptoms may occur as long as 5 days after birth and persist for weeks or months.

The timing of onset of the symptoms gives an indication of the maternal drug abuse. Withdrawal from high levels of maternal alcohol can occur within a day or 2 of birth. Heroin has a short half-life and withdrawal also occurs within 48–72 h of birth, whereas methadone withdrawal occurs at 7–14 days.

Different scoring systems have been developed for assessing the severity of NAS, such as those by Finnegan, Ostrea, Lipsitz, and Rivers.^{6, 7} These are based on opiate withdrawal and may not be entirely appropriate for the infant exposed to cocaine or other drugs.

The most widely used system is the Finnegan scoring system, in both its original and modified forms. Despite the number of items that can be scored, it is nevertheless a relatively easy and reliable system to use once staff have been adequately trained. However, the potential for bias and subjectivity may affect the scores, and the thresholds for treatment reported in the literature vary. This scale can also be used to assess the resolution of signs and symptoms after initiating treatment. To obtain a daily average score, measurements are performed every 4 hours until the patient is stable. If 3 consecutive scores are equal to or greater than 8, treatment for withdrawal is started. The decision to commence treatment can depend on factors other than this score alone, including the reported exposure, the age of the infant, consideration of comorbidities that might influence the score, whether an inpatient or outpatient strategy is used, and the experience of the clinician making treatment decisions.

The infant is best cared for in a unit with experienced personnel who can recognize problems, perform constant evaluations, and institute the necessary interventions.

Causes

Current resurgence in heroin use is associated with the introduction of a cheap, smokeable form that is comparable to crack cocaine, only more potent. Cocaine's current popularity is related to increased availability and the presence of newer, cheaper forms.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Hyperviscosity and intracranial hemorrhage should also be considered. Drug withdrawal should be considered as a diagnosis in infants in whom compatible signs develop. Physicians should be aware of other potential diagnoses that should be evaluated and treated, if confirmed.

Infants with signs and symptoms of neonatal abstinence syndrome (NAS) may have other conditions that result in abnormal behavior. The nonspecific nature of the clinical features of NAS mean that some drug-exposed infants may have exaggerated scores when they are hungry or may have other conditions such as neonatal sepsis, hypoglycemia, hypocalcemia, hyperthyroidism, or subarachnoid hemorrhage. On the other hand, congenital hypothyroidism has been reported to mask the symptoms of NAS. For that reason, assess the infant and consider whether symptoms are solely due to NAS and whether other investigations are warranted.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

Early drug screening during pregnancy reveals the need for maternal counseling for mothers with a history of drug abuse.

• Radioimmunoassay and enzyme immunoassay
• • These are the most commonly used drug screens. Both are semiquantitative and highly sensitive, but enzyme immunoassay takes less time to perform and is less expensive.
  • These tests inform the clinician about the presence or absence of substance abuse, rather than quantifying the drug level, as in toxicology screens.
• Blood tests: The usefulness of neonatal blood samples varies. Blood samples are of limited value because the window of detection is narrow because of the rapid effects of metabolism and the low concentrations of drugs present in blood.
• Urine toxicology assays
• • Urine toxicology screening is useful for clinical and research purposes. Urinary excretion of metabolites may be detectable only for a few days (eg, benzoylecgonine) to a few weeks (eg, cannabinoids). One cannot expect to ascertain early pregnancy use or even relatively recent use if the metabolite concentration does not reach the detection threshold.
  • Urine is relatively easy to obtain, requires minimal preparation (provided samples are not contaminated by meconium or feces), and can be analyzed using numerous laboratory techniques. Although urine samples generally contain a higher drug concentration than serum samples, the detection of compounds depends on obtaining an appropriate sample as close as possible to birth and also depends on the timing of maternal drug ingestion prior to delivery.
  • These tests detect recent use of cocaine and its metabolites, amphetamines, marijuana, barbiturates, and opiates. Cocaine can be detected in urine 6-8 hours after use in the mother and as long as 48-72 hours after use in the newborn.
  • Detection of drugs depends on many variables, including individual drug metabolism, hydration status of the subject, route of administration, and frequency of ingestion.
  • No drugs are known to crossreact with the immunoassays for cocaine and marijuana. Several over-the-counter remedies and herbal preparations may contain ephedrine and phenylpropanolamine (recalled from US market), which can produce false-positive enzyme immunoassay test results for amphetamines. Therefore, confirmatory testing is required.
  • Immunoassay for opiates does not distinguish between codeine, morphine, or their glucuronide conjugates.
• Meconium analysis
• • Meconium analysis is currently considered the best method for detecting drug exposure in pregnancy. It provides a wider window of detection of gestational exposure, presumably as remote as the second trimester, when drugs begin to accumulate in meconium (by direct deposition from the biliary tree or when the fetus ingests amniotic fluid).
  • Meconium analysis is reliable for detecting opioid and cocaine exposure after the first trimester and can be used to detect a range of other illicit and prescribed medications.
• Hair analysis
• • This method is useful in detecting narcotics, marijuana, cocaine, and cocaine-alcohol metabolites, but the technique is expensive, not widely available, and limited by the procedures required to quantify the very small amounts of drug present. Obtaining an adequate sample may be difficult, and recent exposure might not be detected because hair growth is slow. 
  • Analysis of 1.5 cm of maternal hair reveals the maternal drug use pattern during the previous 3 months. Drug metabolites can be detected in infant hair for 2-3 months after birth.

Other Tests

• A recent report has suggested that detecting drug exposure from umbilical cord tissue has similar sensitivity and specificity to meconium samples and may have some advantages over collection of meconium.⁸
• Additional assessment of mothers who abuse drugs and their infants includes screening for hepatitis B and C and sexually transmitted diseases, including human immunodeficiency virus (HIV) infection.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• The large number of infants who suffer from neonatal abstinence syndrome (NAS) and the associated long-term morbidity mandate that affected infants be accurately identified and their treatment and support should be optimized.
• The assessment and management of NAS pose difficulties for staff and families and have been hampered by a lack of prospective studies and by few research studies that specifically assess the merits of one management approach over another.
• Vomiting and diarrhea leading to dehydration and poor weight gain, in the absence of other diagnoses, are indications for treatment, even in the absence of a high drug-withdrawal score.
• In the delivery room, naloxone use is contraindicated in infants whose mothers are known to be dependent on opioids because of the risk of neonatal seizures from abrupt drug withdrawal. However, in the absence of a specific history of opioid abuse, naloxone treatment remains a reasonable option in the delivery room management of a depressed infant whose mother recently received a narcotic.
• Primary treatment of neonatal symptoms related to prenatal substance exposure should be supportive because pharmacologic therapy can prolong hospitalization and exposes the infant to additional agents that are often not necessary. Approximately 30-91% of infants who exhibit signs of NAS receive pharmacological treatment.
• Nonpharmacologic approaches include the following:
• • Assess daily for signs of withdrawal, including sleeping habits, feeding patterns, and weight gain.
  • Reduce the degree of ambient light exposure, minimize excessive noise, avoid unnecessary handling, and provide swaddling for settling.
  • Provide frequent small feeds of hypercaloric formula.

Diet

• Frequent small feedings are preferable and should provide 150-250 kcal/kg per 24 hours for proper growth of the infant undergoing significant withdrawal.

Activity

• Swaddling, pacifiers, low lighting, oscillating cribs, and avoidance of abrupt changes in the infant’s environment can be helpful.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medications should be considered when supportive measures fail to ameliorate the infant's withdrawal. This may be manifested early on as difficulty with feeding, extreme irritability, and poor sleeping. If a scoring system is used, pharmacological treatment is commonly started when the average of 3 scores is 8 or more on the Finnegan scale⁶ or 4 or more on the Lipsitz scale.

Many pharmacological agents have been used to treat neonatal abstinence syndrome (NAS). However, few randomized trials have compared the efficacy of the various pharmacological treatments. A recent US survey reported that opioid medications are the most commonly used medications for the treatment of both opioid and polydrug withdrawal.⁹ Diluted tincture of opium (DTO) is recommended by the American Academy of Pediatrics for the treatment of NAS due to opioid withdrawal.¹⁰ Many neonatal units use proprietary oral or intravenous morphine solutions, and methadone is also used.

Currently, many infants are exposed to polydrug abuse. Unfortunately, evidence from randomized studies is insufficient to determine the best management for these patients. In 2 randomized trials, phenobarbital, rather than diazepam or paregoric, was best at controlling symptoms in infants exposed to polydrugs. The results of another study suggested that the combination of phenobarbital with DTO may be more effective than DTO alone because the combination was associated with a shorter hospital stay.⁸

Drug Category: Antiepileptic agents

These drugs have a long half-life and can be orally administered, allowing for the neonate to be discharged and treated as an outpatient.

Disadvantages include lack of effect on GI symptoms and ineffectiveness in treating seizures secondary to withdrawal. In addition, antiepileptics contain 14-25% alcohol, and larger doses are required to achieve the desired effect.

Drug Category: Opiates

These agents are the mainstay of treatment for opiate withdrawal, either alone or in combination with other medications. These agents are CNS depressants with advantages that include oral administration, mild sedation that improves the effectiveness of sucking, and effectiveness in treating seizures secondary to opiate withdrawal.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• The length of hospitalization 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 C, Chlamydia, syphilis, and gonorrhea.
• Breastfeeding confers immunologic benefits to the neonate, and bonding benefits the mother. Advise breastfeeding for the mother who is receiving maintenance doses of methadone if she receives no more than 20 mg of methadone per 24 hours and is not abusing other drugs. Only small amounts of methadone are detected in breast milk.
• Breastfeeding is contraindicated if the mother is still using illicit drugs or has infections such as HIV or hepatitis. 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.

Further Outpatient Care

• 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 (NAS) 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.

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

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.

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.
• 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.

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).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to screen
• • The medicolegal implications of screening the infant who has been exposed to drugs for the purpose of providing clinical care are complex. Screening creates a conflict between maternal, fetal, and neonatal interests. Although the state courts have granted unborn children some rights in other contexts, any attempt to grant unborn children greater protection against actions taken by their mothers during pregnancy is subject to strict scrutiny.
  • Screening neonates for illicit drugs without maternal consent is not recommended. In addition, performing these tests without maternal approval may be illegal in certain areas.
• Failure to protect an infant at risk
• • Evidence of maternal substance abuse should alert the infant's medical caretaker that the mother may have medical, psychological, or behavioral problems that could have an impact on the infant's long-term health and welfare.
  • Testing the mother, infant, or both, with informed consent, is useful in some clinical situations, even when drug use is not suspected.
  • Some infants may be ill served if the physician relies solely on urine toxicology testing for screening. These test findings may be negative if drugs were used early in pregnancy or during the immediate 48 hours prior to delivery. Results also depend on laboratory variability.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. 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.
2. 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].
3. Cairns PA. Drug misuse: Conception into childhood. Current Paediatrics. December 2001;11(6):475-9.
4. Prentice S. Substance misuse in pregnancy. Obstetrics, Gynaecology & Reproductive Med. September 2007;17:272-7.
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6. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacolotherapy. In: Neonatal therapy: An update. New York, NY: Excerpta Medica; 1986:122-46.
7. 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].
8. Kassima Z, Greenough A. Neonatal abstinence syndrome: Identification and management. Current Paediatrics. June 2006;16:172-5.
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13. Bahwere P, Haumont D, Delange F. Congenital hypothyroidism and neonatal withdrawal syndrome. Eur J Pediatr. Nov 1996;155(11):937-8. [Medline].
14. Bauer CR. Perinatal effects of prenatal drug exposure. Neonatal aspects. Clin Perinatol. Mar 1999;26(1):87-106. [Medline].
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16. Buchi KF. The drug-exposed infant in the well-baby nursery. Clin Perinatol. Jun 1998;25(2):335-50. [Medline].
17. Chasnoff IJ. Prenatal substance exposure: maternal screening and neonatal identification and management. Neoreviews. 2003;4(9):e228-e235.
18. 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].
19. Frank L. Assessment and management of opioid withdrawal in ill neonates. Neonatal Network. 1995;14:39-48. [Medline].
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21. 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].
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Article Last Updated: Aug 6, 2008