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1.    Neonates exposed in utero to opiates should be examined systematically for signs of neonatal abstinence syndrome to assess the need for intervention.   A standardized assessment tool (Finnegan et al., 1975) appears as Exhibit 2. The protocol for opiate-exposed infants is summarized in Exhibit 3, and is discussed in detail below.

2.   Paregoric has been found to decrease seizure activity, increase sucking coordination, and decrease the incidence of explosive stools Phenobarbital is also a commonly used agent, and may be especially helpful in cases of poly-drug abuse.  Other specific agents have been considered in the treatment of neonatal abstinence syndrome, but experience with morphine, methadone, chlorpromazine, and rauwolfia is much too limited to support their use.

Neonates experiencing abstinence often attempt to suck frantically on their fists or thumbs, yet their sucking reflex may be uncoordinated and ineffectual.  Infants undergoing  abstinence frequently develop mild tremors that occur only when the infant is disturbed; however, tremors can progress to a point where they occur spontaneously without stimulation.   High-pitched crying, increased muscle tone, greater irritability, decreases in cudliness, and decrements in responsitivity to visual stimulation also may develop. ( Kaplan et al. 1976, Strauss et al.1976b, 1979; Chasnoff et al. 1984; Jeremy and Hans 1985; Finnegan and Kaltenbach 1992) 

In addition, methadone -exposed infants have been observed to be in deficient in their ability to interact with the environment, with a reduced capacity for attention and less social responsiveness immediatly after birth.  (Kaltenbach and Finnegan, 1988).  >>> Deficits in interaction are present until infants are free from other with-drawal symptoms and completely detoxified.  If abstinence is appropriately recog- nized, assessed,and adequately treated, the risk of severe consequences such as dehydration, seizures, and death can be minimized. ( Martin, Payte, and Zweben 1991; Jarvis and Schnoll)    

Diazepam has been used to treat neonatal abstinence, but this agent controls seizures poorly and may lead to respiratory depression in the neonate (Finnegan and Ehrlich, 1990).

3.  Naloxone is sometimes given to newborns to reverse the perinatally acquired effects of analgesics administered to the mother during labor and delivery.

 Naloxone is contraindicated in opiate-exposed infants with respiratory depression due to its potential for precipitating a severe narcotic withdrawalNaloxone is not specifically contraindicated for infants born to cocaine-using mothers, 

Providers should be aware that such mothers may be polydrug abusers who have also used opiates and that in this circumstance, naloxone may precipitate narcotic withdrawal in the infant.

4.  Modification of the infant's environment - by placing the infant in a dimly-lit, quiet room; swaddling him or her; and using a nonoscillating waterbed if available - may be useful. However, this environmental modification does not eliminate the need for close observation of the infant. Drug-exposed infants in a prone or lateral position are generally comforted best. But caretakers should note an ongoing debate over prone versus supine positioning as possible factors in SIDS.




Drug ----------------------  Dose  -----------------------------------  Considerations ---------------------

1. Paregoric       0.2ml every 3hrs (PO) up to max of           If abstinence syndrome
(0.4mg MS/cc
)    0.4ml every 3hrs.  Gradually decrease       remains uncontrolled, add 
                         dose every other day by 0.05mgL/dose     phenobarbital.
                                                                                     Observation of infant should
                        After stabilization for 5 days, taper the      be maintained for 1-2 days
                        dose cautiously.                                      after discontinuing drugs.
Drug -----------------  Dose ------------------------------------------- Considerations ---------------------

2. Phenobarbital    Loading Dose: 5mg/kg IM,IV             After stabilization for 5 days,
                             Maintenance Dose: 3-5mg/kg/day      taper the dose cautiously.
                             (po, IM, or IV) divided into doses
        Serum phenobarbital should
                             every 8 hours.                                   be monitored when clinically
                             Increase as needed, by 1mg/kg         indicated.  Excessive pheno-
                             every other day or as clinically            barbital dose may cause poor
                             indicated.                                         feeding behavior and lethargy.

  


Exhibit 4 presents pharmacologic interventions for seizures associated with opiate withdrawal.

Diagnostic evaluation of seizures associated with opiate withdrawal should include:

1Full sepsis workup.

2Metabolic workup including tests of blood sugar, electrolytes, calcium, phosphorus, and magnesium levels and arterial blood gases.

3.  Central nervous system imaging (cranial ultrasound, coaxial tomography [CT], or magnetic resonance imaging [MRI]).

4.  An electroencephalogram (EEG). If the EEG is normal, levels of phenobarbital (Bellegral-S, Donnatal) and then paregoric should be tapered. Fifty percent of opiate-exposed infants will have an abnormal first EEG.  >  If  the EEG remains abnormal, a pediatric neurologist should be consulted for possible maintenance anticonvulsant treatment.




Drug----------------------------Dose-----------------------------------------Comments----------------

Phenobarbital               Loading Dose:  10mg IV push;      Maintain therapeutic range
                                    repeat with another 10mg/kg           by following levels.
                                    in 10 minutes.
                                    Maintenance:  24 hrs after

                                    loading dose, start 3-5mg/kg
                                    divided in q12h doses.
  
Dilantin                       Loading Dose:  10mg/kg IV;           Maintain therapeutic range.
                                   repeat with another 10mg/kg            by following levels.
                                   twenty minutes.
                                   Maintenance:  12  hrs after
                                   loading  dose, start 5-7mg/kg/d
                                  divided in doses every 12 hr.


Note: If patient is not on paregoric, paregoric treatment regimen should be implemented.


Hospitals can promote positive interaction between parents and infants by adopting liberal visiting policies and mother-infant interaction time for newborn nurseries. Two other areas of concern are breastfeeding and instruction of mothers in handling drug-exposed infants.


Breastfeeding is a key area of concern, especially among substance-using women. The advantages of breastfeeding are many, and are well documented. Benefits include the fact that breastfeeding strengthens the bond between the mother and the infant - an advantage that is of vital importance.

Despite the instances described below, when breastfeeding is contraindicated, the decision on the part of service providers to advise women against breast-feeding should not be made without careful thought and training, taking into account the particular circumstances of the individual woman. Service providers must often become active breastfeeding advocates, encouraging the mother to breastfeed despite initial resistance to do so and educating her on breastfeeding advantages to both herself and the newborn.

Nonetheless, there are instances when breastfeeding of drug-exposed infants is contraindicated.  Since most drugs are secreted in breast milk, it has often been the practice to advise drug-using mothers not to breastfeed.  Women who have been actively using drugs through the pregnancy and after the delivery have been discouraged from breastfeeding because of a number of factors including possible drug toxicity from diverse agents in varying levels, including the risk of exposure to drugs used intravenously, and the mother's medical and nutritional problems associated with continued drug use.

Cocaine readily passes into breast milk and may lead to neonatal neurotoxicity, including irritability, tremors, brisk reflexes, mood lability, and even seizures. In addition, breastfeeding is contraindicated if the mother is HIV positive. (It should be noted, however, that the HIV status of the mother may not be known to the care provider or the mother.)

Despite these warnings, the well-known advantages of breastfeeding have led to a reconsideration of breastfeeding in selected substance-using women. There are two kinds of situations, highlighted below, in which care providers might wish to recommend that substance-using women breastfeed their babies: when the woman is on methadone or abstinent.

In many instances, women who are methadone-maintained should be encouraged to breastfeed, particularly if the woman is known to be HIV-negative and free of other drug use. 
The fact that breast-feeding is not contraindicated among methadone-maintained patients is an advantage to methadone that is sometimes underemphasized, yet is of crucial importance.

The recovering user of other substances (including cocaine), who has complied with rehabilitation and been documented to be AOD-free for a suitable period of time before delivery, may be able to breastfeed the infant, provided she continues to abstain from AODs and consents to frequent, random toxicology screens.

» » » In sum, the recommendation regarding whether a substance-using woman should breastfeed her newborn should be made on an individual basis, taking a variety of factors into account.   Service providers should receive ongoing training on the issue to keep up with the latest developments in the field.


Parents and other providers of primary care should be taught (Gardner et al., 1989):

Þ  To assess the baby, interpret his or her cues for more or less interaction, and synchronize one's behavior with that of the infant.

Þ  To organize care and handling so that the baby is not bombarded by multiple stimuli that overwhelm her or his limited ability to habituate.

Þ  To utilize graduated interventions in quieting the fussy, irritable baby.

Þ  To appreciate the infant's unique competencies: The baby's ability to see, hear, and interact with the environment.


It is often quite difficult to follow an AOD-using mother and her newborn after release from the hospital, and thus it is vital that the infant and the mother not be discharged too early.   According to the Newborn Assessment Score, most babies (96 percent) are symptom - free of withdrawal seizures by the third or fourth day after birth and might otherwise be ready to be discharged from the hospital. However, a small but significant percentage of babies present with withdrawal seizures within 7 to 10 days after birth.

 For this reason, it is important to closely monitor the drug-exposed infant to determine if he or she needs to remain in the hospital after 4 days.  Other medical, social, or environmental issues may further prolong the need for hospitalization (Doberczak et al., 1988). 

                  

DISCHARGE

CRITERIA

The infant's discharge should occur after the following criteria are met:

1.  The infant is taking oral feeds and gaining weight satisfactorily.

2The infant is physiologically stable (has normal vital signs including blood pressure).

3.  The infant is showing neurobehavioral recovery  (can reach full alert state, responds to social stimuli, and can be consoled with appropriate measures).

4.  All necessary assessments have been completed, since adherence to followup schedules cannot be ensured.


1.  The parent(s) or alternate primary care provider should receive anticipatory guidance (oral and written) regarding late and subacute withdrawal, seizures, behavioral interventions, and medications (side effects, route of administration, dose, etc.).

2.  A home evaluation should be performed on all drug-exposed infants or those with multiple risks by a public health nurse or a protective social service worker within 7 days of discharge, when feasible.

3.  A follow-up appointment for pediatric care should be scheduled within 2 to 4 weeks.

4.  Mothers and fathers who are not already enrolled in drug abuse treatment and need to be should be referred to an accessible and suitable treatment program prior to the infant's discharge.

5Facilitation of mother's postpartum gynecologic care and family planning should be incorporated into discharge planning of the infant. To promote quality improvement, discharge planning instructions should be documented in medical records, and a discharge summary of the hospital course should be given to parents or alternate primary caregiver.

Þ      Drug abuse during pregnancy is associated with medical, psychological, and economic problems that require extensive evaluation by qualified service providers. Mothers and fathers of drug-exposed infants need substance abuse treatment and a wide array of services to support them in their parenting role. Provision must be made for such services prior to an infant's discharge.

End Notes

1  The research documents aspects of neurobehavioral development in 36- and 48-month-old children.    At 48 months, significantly lower scores in verbal and memory domains were associated with maternal marijuana use after adjusting for confounding variables.   This negative relationship is the first reported association beyond the neonatal stage, and may represent a long-term effect of the drug upon com-plex behavior that, at a younger age, had not developed and/or could not be assessed.

2   Information in this section is based on data from Pietrantoni and Knappel, 1991.

Reference:  Improving Treatment For Drug-Exposed Infants  TIP 5 Chapter 2 Reference:  Methadone Treatment For Opioid Dependence, Strain & Stitzer 


Jessica Carr      20 August 2005                Kent Daily Times

Chase was born with neonatal abuse syndrome.  __ With high hopes of recovery from her addiction to opiates, Veronica signed up at a clinic that could assist her in her recovery efforts.   ____  The clinic put her on buphenorphine, a legal but controlled substance that would help to wean her off the drugs.  

When Veronica learned she was pregnant, her clinical doctor informed her that the buprenorphine was much too dangerous, now that she was pregnant and her only hope was to change her treatment to methadone.

"When they first told me I had to switch to the methadone, I was kind of in shock because I really didn’t know much about it," Veronica said.

"The only thing that my doctor had told me was that if I didn’t stop taking the buprenorphine that my baby would die.  He didn’t really explain anything, he basically just told me that this was what I had to do and that was that."

That’s when Sharon Dembinski, the pediatric nurse practitioner in the neonatal special care nursery at Kent, came into the picture.

"My OBGYN referred me to Sharon and I am so glad that she did," Veronica said. "Sharon explained to my boyfriend and I what would happen when our baby was born.  *** She talked with us about how we would care for his withdrawal symptoms and how they would monitor him.  She was always there to answer our questions and explained for me what I would and wouldn’t be able to do."

"For one thing, I really wanted to breastfeed the baby and I really didn’t think I would be able to, but Sharon explained to me that I could," Veronica said. "Then, she let us know ahead of time that we weren’t going to be able to take him home because they were going to have to medicate him for the first 24 hours and that was really hard especially because when people find out that it’s because the baby’s mother is on
methadone.   I guess that’s because there is such a stigma attached to it, but the people at Kent weren’t like that at all, they were all so compassionate with us."

Veronica said that she, as a result of her encounter with Sharon Dembinski and her experience with the new program at Kent, was able to give birth. She is now raising a healthy baby boy, nine months old and doing well.

"My boyfriend, Eddy and I would have been scared to death had Sharon not been there to help us through it all and even still to this day, we have stayed in touch -- we talk almost every day and have really become good friends," Veronica said."I just can’t say enough about the program."

Veronica and Chase’s progress is not something that’s too far out of the ordinary, according to Dembinski.

"What I have seen in patients that I have worked with before their delivery and then followed up with afterwards is that they are doing well and have maintained their recovery," Dembinski said.

"For a lot of moms in the early recovery stages, pregnancy can turn out to be her way and, with the appropriate education and support, recovery can be successful and the result in far reaching positive consequences for the family affected as well as the community at large."

©Kent County Daily Times 2005

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

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