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					Infants of addicted mothers

   Vandana Nayal, MD
   Edited 6/2005
Abuse of drugs
• 5.5% of women use illicit drugs during
• Women account for 30% of addicts
• Marijuana is the most commonly used illicit
• Has been a decrease in the use of cocaine
  and crack and increase in methamphetamine,
  heroin, and alcohol abuse
Obstetric complications of
drug abuse
 Premature  labor
 Syphilis and other STDs
 TB, hepatitis, HIV
 Neonatal complications
 Effects confounded by
   Poor nutrition, poor health care, suboptimal
   child-rearing environment
 810,000  heroin addicts in 1995
 Smoking and snorting now more
  desirable due to fears of HIV with IV use
•   Very potent and fast acting
•   Highly lipid soluble and crosses the
•   Concentration in fetal brain is twice that
    in adult brain
•   Decrease in nucleic acid and protein
    synthesis in fetal brain and decreased
    density of cortical neurons
Heroin: Newborn effects
•   Low BW and SGA common
•   Increased incidence of prematurity
    •   caused by the high rate of chorioamnionitis
        and infections
•   Organs were small with diminished
    number of normal sized cells
    •   heroin may cause direct growth inhibition
•   No increase in congenital abnormalities
Heroin: Clinical manifestations
•   Neonatal abstinence syndrome in 50-75%
    •   Signs and symptoms begin within 24-48 hours
• Intensity depends on dosage, duration of
  addiction, and time of last dose.
• Symptoms
    •   Irritability, jitteriness, coarse tremors, high pitched
        cry, fist sucking, poor feeding, sneezing, stuffy
        nose, yawning, tachypnea, vomiting, diarrhea,
        hypo or hyperthermia, hypertonia, hyperreflexia,
        seizures, absence of quiet sleep
•   Lower incidence of RDS and hyperbili
Heroin: Treatment
 AAP recommends tincture of opium
 Tincture of opium (10 mg/ml as 25 fold
  dilution = 0.4 mg/ml morphine equivalent)
  0.1ml/kg or 2 drops/kg q4h with feeds
       May be increased by 2 drops q4h to control
       Continue stabilization dose for 3-5 days, then
        slowly decrease dose every 4 hours without
        changing frequency
   Naloxone contraindicated
       May precipitate severe withdrawal or seizures
Heroin: Other Treatments
   Phenobarbital
       Load with 15-20mg/kg IM or PO/24h
       Maintenance is 4-6mg/kg/day every 12h PO
       Plasma level goal is 20-30mg/ml
       After stabilization, decrease dose and then
        frequency for 4 days to 6 weeks
 Paregoric (0.4 mg/ml of morphine)
 Methadone
 Diazepam
 Tylenol
Heroin: Prognosis
             in general processing of
 Difficulties
  perception and cognition
 Lower concentration and short term
 More aggressive and compulsive,
  uncontrollable tempers
 Attention deficit and hyperactivity
 Synthetic   opiate
 Therapy of choice for heroin addiction
  since 1965
 Mothers on methadone maintenance
  seem to have better prenatal care and
  better lifestyles than those taking heroin
   But there is a high incidence of multiple
    drug abuse
   70-90% of infants have abstinence syndrome
       symptoms within 48-72 hours
       similar symptoms to heroin withdrawal but more
   Late withdrawal can show up at 2-4 wks of
       voracious appetite but poor weight gain
       due to strong tissue binding of methadone
   Treatment
       Same as for heroin
       Duration of treatment is longer
   Lower incidence of IUGR than heroin
       birth weights correlate with 1st trimester dose of
   No increase in congenital anomalies but do
       decreased OFC (<3rd percentile)
       increased T3 and T4 levels,
       thrombocytosis noted at 1-16 weeks of age
       systolic hypertension weeks 2-12
       higher incidence of seizures between 7-10 days
   Higher incidence of SIDS
Methadone: Prognosis
 High incidence of hyperactivity, learning and
  behavior disorders
 Higher incidence of infection
       especially otitis and candida
 Poor fine motor coordination and aggressive
 Buprenorphine used in Europe for addiction
       no increase in incidence of congenital anomalies,
        lower incidence of SGA, milder abstinence
       recently approved in the U.S.
Alcohol: The stats
 113   million users of alcohol in 1998
   20% are women
   18-35% were moderate to heavy drinkers
     Moderate: 2/ day, > 7/wk, or 3/occasion
     Heavy: 2-3/day or >5/occasion

     Abusive: more than 5/day
Alcohol: The effects
   Alcohol crosses the placenta readily
       obstructs AA transport in the placenta
   Effects on the brain
       decreased brain weight
       neuron size and morphology abnormal
       may impair several neurotransmitter systems or
        their receptors
   Long term outcomes
       effects range from gross morphologic and CNS
        impairments to subtle cognitive and behavioral
Fetal alcohol syndrome
 Withdrawal: tremors, irritability, apnea, sz
       prenatal continuing to postnatal growth failure
       microcephaly is common
 Facial features: short palpebral fissures,
  hypoplastic philtrum, thin upper lip,
  micrognathia, retrognathia
 Heart defects: VSD, Tetrology
 Other effects: hypoplasia of labia,
  hypospadias, skin hemangioma, joint defects
 Long term cognitive deficits: mild to mod MR
 Crosses the placenta
 Pregnancy effects: shortened gestation,
  prolonged labor, meconium staining
 Neonatal effects
       decreased birth wt, higher incidence of tremors,
        altered visual responses, disturbed sleep cycling
 At 6, 12, and 24 m there were no differences
  in physical and developmental evaluations
 In older kids
       Delays in visual system maturation, more conduct
        problems, poorer language comprehension,
 Uses
   local   anesthetic, powerful stimulant
 Pharmacology
   blocks presynaptic uptake of NE and
    dopamine: tachycardia, HTN, euphoria
   Disrupts metabolism of serotonin leading to
    increased wakefulness in sleep-wake cycle
   Pregnancy effects:
       born 1-2 weeks earlier
       increased placental abruption, previa
       strong association with STDs
   Infant effects
       low BW, growth retardation
       smaller OFC
            predictive of poor developmental outcome
       higher incidence of IVH, hemorrhagic infarcts,
        early onset NEC, genito-urinary abnormalities
       readily enters breast milk: tremors, irritability, sz
       higher incidence of SIDS
• “Angel dust”
• Stimulant and depressant, schizophrenic like
    •   Affects coordination, speech, drunkenness, violent
        and bizarre behavior
• Highly lipid soluble so crosses placenta
• Causes degeneration of cortical neurons and
  has inhibitory effects on potassium channels
• At 3 months infants were within normal limits
Amphetamines and meth
 Mood  elevating, highly addictive
 Very popular in the West and Midwest
 Well absorbed and localize to tissues
  such as CNS very quickly
Amphetamines and meth
   Infant effects
       High perinatal mortality and morbidity
       High rates of prematurity
       SGA
       Higher rates of IVH
       Withdrawal presents acutely as drowsiness,
        respiratory distress, jitteriness, hypersensitivity to
            May cause lethargy lasting several months
       May have frequent infections and poor weight gain
 Ocular   malformations
   cataract

   retinal

   primary persistent hyperplastic vitreous
Drug screening
   Screening tests done with rapid, inexpensive,
    sensitive method
       Confirmation of positive results is done with a
        more specific method (gas chromatography and
        mass spectrophotometry)
       Some meds can cross-react under the screening
        test (i.e. morphine and codeine)
   Gas chromatography and mass
    spectrophotometry can be applied to urine,
    meconium, amniotic fluid, vernix, hair and
       Drugs in meconium and hair reflect long term use
Drug screening
   A positive newborn urine test only implies
    drug use in the last 3-4 days prior to delivery
       Mothers who test positive at delivery are usually
        heavy users
   Best choice is to screen infants based on risk
       Inadequate prenatal care, STD, h/o past
        substance abuse, referral to child welfare,
       Most states require report of positive tests to child