Infants of addicted mothers
Vandana Nayal, MD
Edited 6/2005
Abuse of drugs
•
5.5% of women use illicit drugs during
pregnancy
• Women account for 30% of addicts
• Marijuana is the most commonly used illicit
drug
• 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
Heroin
 810,000
heroin addicts in 1995
 Smoking and snorting now more
desirable due to fears of HIV with IV use
Heroin
•
•
•
•
Very potent and fast acting
Highly lipid soluble and crosses the
placenta
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
•
•
Organs were small with diminished
number of normal sized cells
•
•
caused by the high rate of chorioamnionitis
and infections
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
symptoms
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
 Difficulties
in general processing of
perception and cognition
 Lower concentration and short term
memory
 More aggressive and compulsive,
uncontrollable tempers
 Attention deficit and hyperactivity
Methadone
 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
Methadone

70-90% of infants have abstinence syndrome



Late withdrawal can show up at 2-4 wks of
age



symptoms within 48-72 hours
similar symptoms to heroin withdrawal but more
intense
voracious appetite but poor weight gain
due to strong tissue binding of methadone
Treatment


Same as for heroin
Duration of treatment is longer
Methadone

Lower incidence of IUGR than heroin


No increase in congenital anomalies but do
have






birth weights correlate with 1st trimester dose of
methadone
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
behavior
 Buprenorphine used in Europe for addiction


no increase in incidence of congenital anomalies,
lower incidence of SGA, milder abstinence
syndromes
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


Effects on the brain




obstructs AA transport in the placenta
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
deficits
Fetal alcohol syndrome

Withdrawal: tremors, irritability, apnea, sz
 IUGR/SGA



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
Marijuana

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,
distractibility
Cocaine
 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
Cocaine

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
Phencyclidine
“Angel dust”
• Stimulant and depressant, schizophrenic like
episodes
•
•
•
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
sound


May cause lethargy lasting several months
May have frequent infections and poor weight gain
LSD
 Ocular
malformations
 cataract
 retinal
dysplasia
 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
nails

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
factors


Inadequate prenatal care, STD, h/o past
substance abuse, referral to child welfare,
prostitution
Most states require report of positive tests to child
welfare