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Iowa Neonatology Handbook: Pharmacology
Infants of Drug-Abusing Mothers
Jeffrey L. Segar, MD
Peer Review Status: Internally Peer Reviewed
It has been reported that women account for approximately 30% of
the drug-addicted population and the majority of them are of
childbearing age. Thus, drug abuse not only affects the mother but
may harm the fetus and child.
I. Clinical Manifestations
A. Signs of heroin withdrawal occur in 50-75% of infants born to
addicted mothers and usually begin within the first 24-72 h of life.
The incidence of withdrawal depends on several factors, including
dosage, duration of addiction, and time of last maternal dose. Heroin
use may be associated with delayed symptomatology up to 7 days, signs
from methadone may occur even later.
B. The signs of drug withdrawal may be subtle or overt, consisting
of a combination of any of the following:
- 1. Gastrointestinal: Diarrhea, vomiting, ravenous appetite,
poor feeding.
- 2. Neurologic: Irritability, jitteriness, restlessness (rubbed
knees, rubbed nose), erratic sleeping, fist-sucking, shrill cry,
hypertonia, hyperreflexia, myoclonus and less often seizures. The
incidence of seizures is higher in methadone-maintained mothers
(10-15%) than in those abusing heroin.
- 3. Urinary and/or meconium drug testing should be performed
for any baby with signs consistent with neonatal withdrawal.
II. Treatment
A. Obtain a Social Service consult
B. Swaddling - most infants can be managed in this manner
C. Small, frequent feedings if gastrointestinal signs
present
D. Medications: Neonatal Abstinence Scoring Systems exist to
assess the severity of withdrawal. However, clinical expertise,
rather than a numerical score, should be used in the decision to use
medications. Generally, severe irritability interfering with feeding
and sleep, vomiting and diarrhea, temperature instability, severe
tachypnea, and seizures are indications for treatment.
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Schedule for Treatment of Infant in Withdrawal
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Drug
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Dosage
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Phenobarbital
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15-20 mg/kg loading dose, then 3-6 mg/kg/d maintenance
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Paragoric
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3-6 drops q4-6 h PO; if no improvement, increase dose by
1-2 drops. Begin gradual wean after 4-6 days
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Diazepam
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0.2 - 0.5 mg/kg/day dose PO q8h
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Methadone
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0.1 - 0.5 mg/kg/day PO q4-12h
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Duration of treatment in neonatal heroin withdrawal may vary from
4 days to 6 weeks, longer with methadone withdrawal.
III. Other Drugs
A. Marijuana:
- Crosses the placenta, slowly metabolized by fetus
- Higher incidence of tremors and altered visual responses in
offspring of heavy users
- No known overt withdrawal
B. Cocaine:
- Vasoconstrictive effects lead to neurologic complications
(infarct, IVH, cystic lesions)
- Higher incidence of prematurity, LBW, abruptio placenta
- Associated with higher incidence of genitourinary tract and
gastrointestinal anomalies
- Short and/or long term neurobehavioral abnormality
C. Alcohol:
- Acute ingestion: hyperactivity, tremors for 72h, followed by
lethargy for 48h
- Chronic ingestion: consider fetal alcohol ingestion and its
spectrum of abnormalities including CNS, growth deficiency, facial
features, cardiac and musculoskeletal anomalies
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