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 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 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  symptoms within 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 1 st 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 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 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