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The following guidelines pertain to three substances that have a great impact on the health of infants -- heroin, methadone, and cocaine.   Rapid recognition, careful assessment, and appropriate treatment of abstinence symptoms in infants exposed in utero to one or more of these substances will contribute to a satisfactory initial and long-term outcome for these neonates.

Programs dealing directly with drug-exposed neonates will find more detailed information on assessment and treatment in a protocol being developed by the Center for Substance Abuse Treatment. This detailed guideline is titled Drug-Exposed Infants Treatment Improvement Protocol (TIP)  5


Neonatal Effects of HeroinThe effects of heroin on the neonate may include the following:

1     Low birth weight. The low birth weight is due primarily to symmetric intrauterine growth retardation. In addition, low birth weight may be secondary to prematurity.

2     Meconium aspiration.  Meconium aspiration may be caused by hypoxia in association with antepartum or intrapartum passage of meconium secondary to fetal stress.

3    Sexually transmitted diseases.  Maternal lifestyle issues predispose the infant to congenital syphilis, gonorrhea, hepatitis B, and HIV infection.

4    Neonatal abstinence syndrome.  Neonatal abstinence syndrome occurs in about 60 to 80 percent of heroin-exposed infants. Its onset is usually within 72 hours of birth, with a high mortality if the syndrome is severe and untreated.  Premature infants have been reported to show a less severe abstinence syndrome following opiate exposure.

»»»The syndrome involves the central and autonomic nervous systems, gastrointestinal system, and pulmonary system. Central nervous system (CNS) signs include irritability, hypertonia, hyperreflexia, abnormal suck, and poor feeding. Seizures are seen in 1 to 3 percent of infants. Gastrointestinal signs include diarrhea and vomiting. »»» Respiratory signs include tachypnea, hyperpnea, and respiratory alkalosis. Autonomic signs include sneezing, yawning, lacrimation, sweating, and hyperpyrexia.    §§§§§    If the infant is hypermetabolic,  the postnatal weight loss may be excessive and subsequent weight gain suboptimal.

5    Delayed effects.  Delayed effects include subacute withdrawal with symptoms such as restlessness, agitation, irritability, and poor socialization that may persist for four to six months. There is an increased incidence of Sudden Infant Death Syndrome (SIDS). Behavioral and developmental consequences, such as hyperactivity and poor school -performance, have been inconsistently reported.   §§§  Studies on these behavioral and developmental consequences are difficult to interpret because of poor long-term followup and inability to control for postnatal environmental influences.

6    No effect.   It is important to understand that many infants will show no adverse effects from maternal use of heroin. Many women will know this, based on their own experience or that of other women. Providers should acknowledge this reality so that women will not use this knowledge to discount their advice.


Neonatal abstinence syndrome is best treated with a substitute opioid such as paregoric or with a Central Nervous System depressant such as phenobarbital.



The neonatal effects of methadone may include:

1      Abstinence Syndrome.  The neonate suffers an abstinence syndrome similar to that seen with heroin. The abstinence syndrome for methadone usually starts later and lasts longer (due to longer half life) than for heroin.  Central nervous system signs are prominent.   Electroencephalograms (EEGs) are abnormal in about 50 percent of the infants. Seizures occur in about 7 percent of the infants, tend to occur between days 7 and 14, and are primarily myoclonic. Abstinence is more variable in onset and course than with heroin.   Exposure to both heroin and methadone may produce a biphasic or atypical pattern of withdrawal.

2     Fetal growth and reduced perinatal mortality.         Multiple risk factors may contribute to poor fetal growth in methadone-exposed children.  Although birth weight and head size may be reduced, fetal growth is generally more normal than with heroin, and may be related to the first trimester dosage of methadone.  Reduced perinatal mortality compared with heroin use may be due to positive changes in lifestyle including increased prenatal care.

3     Postnatal effects.      The postnatal weight change pattern may be suboptimal if the infant is hypermetabolic. A thrombocytosis may develop during the second week of life and peak at about the eighth week before returning to normal. There is biochemical evidence of hyperthyroidism in some infants.

4     Breastfeeding.      Breastfeeding is encouraged if the woman is HIV-seronegative and not abusing other drugs.

5     Delayed effects.      Delayed effects may include an increased incidence of SIDS. Long-term followup studies are incomplete and difficult to interpret. Generally, infants have performed within the normal range and no major neurologic or developmental disabilities have been reported.

6     No effect.


Treatment with either paregoric or phenobarbital is effective.


The effects of cocaine on the neonate may include the following:

1    Effects at birth. Generally, lower birth weights, head circumferences, and increased rates of prematurity have been reported compared to controls.

2    No abstinence syndrome. There is no clinically documented neonatal abstinence syndrome for cocaine as is seen with the opioids.

3     Neonatal dysfunction.  Neonatal CNS dysfunction includes transient irritability, abnormal sleeping patterns, tremors, hypertonia, and lability of state. One study has reported that about 50 percent of the infants have abnormal EEGs in the neonatal period with reversion to normal within the first few months of life. Infrequent cerebral infarctions and seizures have been reported.  Electroencephalographic abnormalities have been reported inconsistently . In addition, information on congenital malformation has been inconclusive.

4   Breastfeeding.    Most drugs pass through breast milk. The amount of cocaine that passes to the infant in the breast milk reinforces the neurotoxic syndrome.

5  Delayed effects.  Only preliminary long-term followup studies have been reported. A number of studies have suggested that incidence of SIDS is increased.

6  No effect.  It is important to understand that many infants will show no adverse effects from maternal use of cocaine. Many women will know this based on their own experience or that of other women. Providers should acknowledge this reality so that women will not use this knowledge to discount their advice.


±±±±       If treatment is indicated, a short course of phenobarbital is recommended. Use of the Brazelton Neonatal Behavioral Assessment Scale twenty-six is encouraged.

crack cocaine

Reference: Pregnant, Substance -Using Women Tip 2 Chapter 2 Guideline 14


Treating heroin-addicted pregnant women with the most effective dose of methadone does not increase their infants' symptoms of withdrawal after they are born, new study findings suggest.

Instead, methadone appears to reduce risks to both mother and infant by preventing illicit drug use.

Methadone is often substituted for heroin and other opiates when patients are treated for their addiction. When the methadone dose is high enough, it blocks the effects of heroin and reduces addicts' craving for the drug.

Many physicians believe that methadone doses should be kept no higher than 20 milligrams per day when women are pregnant, lead investigator Dr. Vincenzo Berghella told Reuters Health. But effective doses for pregnant women range from 50 to 200 mg daily.

Therefore, his research group, based at Jefferson Medical College of Thomas Jefferson University in Philadelphia, examined the records of 100 mother-newborn pairs treated in their comprehensive program for drug-addicted pregnant women. Methadone doses ranged from 20 to 200 mg per day,  they note in their article in the American Journal of Obstetrics and Gynecology.

Their study differed from previous research, they point out, because it examines higher average doses and the last dose prior to delivery. They also scored the newborns' withdrawal problems using an objective measure of clinical signs and symptoms, called the Newborn Abstinence Score (NAS).

Birth weight, highest NAS, presence of neonatal withdrawal, and average duration of treatment for withdrawal did not differ significantly between the higher doses and lower doses of methadone.

'I was happily surprised when our data confirmed that using an effective dose is best for both the women and their babies,' Berghella said.

He added that prior research demonstrated that methadone has no long-term effects on the fetus, 'just short-term withdrawal,' which occurred in 60 percent of the babies.

'Effective maintenance prevents drug hunger and craving and blocks the euphoric effect of illicit drugs,' he noted. As a result, the fetus is not exposed to erratic maternal opioid levels, protecting it from repeated episodes of withdrawal.

Furthermore, he said, 'by preventing drug-seeking behavior, women are less likely to engage in prostitution or other behaviors that increase their risk of HIV, hepatitis infection, and other sexually transmitted diseases.'

He advises heroin-addicted women to check into a program that not only helps them with their symptoms of withdrawal, but also addresses psychological and social issues. The program at Jefferson Medical College 'even helps women find housing, stay away from an abusive partner, and provides basic preventive medical care.

'That way, people can become clean and can stay clean,' Berghella concluded.

SOURCE:   American Journal of Obstetrics and Gynecology, August 2007.

Compiled & Edited By:  Deborah Shrira-Publisher       Updated:  April 2008

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