Infants of addicted mothers

1. Infants of addicted mothers Vandana Nayal, MD Edited 6/2005

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. LSD • Ocular malformations • cataract • retinal dysplasia • primary persistent hyperplastic vitreous

25. 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

26. 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