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 abusePremature laborSyphilis and other STDsTB, hepatitis, HIVNeonatal complicationsEffects confounded by

Poor nutrition, poor health care, suboptimal child-rearing environment

Heroin810,000 heroin addicts in 1995Smoking 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

• 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

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: PrognosisDifficulties in general processing of

perception and cognitionLower concentration and short term

memoryMore aggressive and compulsive,

uncontrollable tempersAttention deficit and hyperactivity

MethadoneSynthetic opiateTherapy of choice for heroin addiction

since 1965Mothers 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

symptoms within 48-72 hours similar symptoms to heroin withdrawal but more

intense Late withdrawal can show up at 2-4 wks of age

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

birth weights correlate with 1st trimester dose of methadone

No increase in congenital anomalies but do have 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 stats113 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 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

CocaineUses

local anesthetic, powerful stimulantPharmacology

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 methMood elevating, highly addictiveVery popular in the West and MidwestWell 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

LSDOcular 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