Infants of addicted mothers

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Infants of addicted mothers

• Vandana Nayal, MD
• Edited 6/2005

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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

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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

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Heroin

• 810,000 heroin addicts in 1995
• Smoking and snorting now more desirable due to
  fears of HIV with IV use

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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

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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

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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

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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

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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

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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

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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

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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

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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 (
• 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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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LSD

• Ocular malformations
• cataract
• retinal dysplasia
• primary persistent hyperplastic vitreous

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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

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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