Neonatal Drug Withdrawal

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0 Committee

on Drugs

Neonatal

Drug Withdrawal

Symptoms of neonatal drug withdrawal consist of: W = wakefulness; I = irritability; T =

tremu-lousness, temperature variation, tachypnea; H =

hyeractivity, high-pitched persistent cry, hypera-cusia, hyperreflexia, hypertonus; D = diarrhea,

dia-phoresis, disorganized suck; R = rub marks,

respi-ratory distress, rhinorrhea; A = apneic attacks,

autonomic dysfunction; W = weight loss or failure

to gain weight; A = alkalosis (respiratory); L =

lacnimation (Fig 1); also, hiccups, vomiting, stuffy nose, sneezing, yawning, photophobia, twitching, myoclonic jerks, opisthotonos, or seizures.

When these symptoms are seen in a newborn infant, the physician should consider a diagnosis of withdrawal from maternal drugs. Narcotics re-ported to cause these symptoms in the neonate are heroin,’ methadone,2 meperidine,3 morphine,’ co-deine,4 pentazocine,5’6 and pnopoxyphene.7 A

glos-0

sary of drugs is provided in Fig. 2.

The onset of symptoms may be present at birth or may begin within four days of delivery. In some instances, symptoms may not become obvious until

10 days of age. This depends upon the drug the infant was exposed to in uteno and the pharmaco-kinetic excretion of the drug. Subacute symptoms of narcotic drug withdrawal may last for 4 to 6

months.8

Rosen and Pippenger9 have demonstrated that infants born to mothers maintained on methadone do not begin to manifest withdrawal symptoms until the plasma level is less than 0.06 g/mL. In utero exposure to multiple drugs may cause a bi-phasic pattern of withdrawal symptomatology in the neonate.’#{176} Polydrug abusers frequently use as many as two to five drugs in combination; these might include phenobarbital, diazepam, marijuana,

pentazocine, tnipelennamine, phencyclidine, and codeine.” A physician who is unaware ofa mother’s

drug ingestion may initially make an erroneous diagnosis of colic in the infant; therefore, a detailed maternal drug history should be obtained, including prescription and nonprescription drugs received,

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social habits of the parents, and whether the mother is breast-feeding. In the event a negative drug his-tory is obtained but infant symptomatology is con-sistent with drug withdrawal, a drug screen should be performed on the mother’s or infant’s blood and urine. Recently, screening of meconium for drugs has been reported to produce greater confirmation

of fetal drug exposure than screening of urine.’2

TREATMENT

OF NARCOTIC

WITHDRAWAL

FROM MATERNALLY ACQUIRED DRUGS

Treatment of the neonate should be primarily supportive, as unjustified pharmacologic adminis-tration will prolong hospitalization and subject the infant to additional exposure to drugs that are not

indicated. Supportive care includes swaddling to decrease sensory stimulation; frequent small

feed-ings of hypercalonic (24 cal/oz) formula to supply

the additional caloric requirements; and

observa-tion of sleeping habits, temperature stability, weight gain or loss, or change in symptomatology which might suggest another disease process taking

place (ie, infection). The clinical symptoms in 30%

to 50% of infants who manifest drug withdrawal

may be treated in the above manner without use of pharmacologic therapy.

Excess weight loss may represent inadequate pro-vision of calories rather than the need for phar-macologic therapy. Besides the caloric expenditure caused by increased activity, crying, and decreased sleep, calories may be lost through vomiting, drool-ing, and diarrhea. Hyde et al’3 have shown that infants withdrawing from maternal narcotics have an increased 02 consumption at the tissue level, which increases caloric need. Caloric intake should be calculated daily in order to provide the 150 to 250 cal/kg/24 h necessary for proper growth in babies suffering withdrawal from narcotics.14”5

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w = Wakefulness I = Irritability

T = Tremulousness, temperature variation,

tachy-pnea

H = Hyperactivity, high-pitched persistent cry,

hy-peracusia, hyperreflexia, hypertonus D =

Diarrhea,

diaphoresis, disorganized suck

A = Rub marks, respiratory distress, rtiinorrhea

A = Apneic

attacks, autonomic dysfunction

W =

Weight loss

or failure to gain weight

A = Alkalosis (respiratory)

L = Lacnmation

Fig 1. Symptoms of neonatal drug withdrawal.

GENERIC NAME

amitriptyline

chlordiazepoxide chlorpromazine

clomipramine

clonidine

diazepam

diphenhydramine

ethchlorvynol hydroxyzine imipramine lithium

mependine

meprobamate

methadone

pentazocine

phenobarbital

propoxyphene theophylline

trifluoperazine

TRADE NAMES

Elavil, Endep, Enovil,

SK-Amitnptyline Librium

Thorazine

(investigative

drug)

Catapres

Valium

Benadryl Placidyl

Atarax, Orgatrax, Vistanl

Imavate, SK-Pramine, Tofranil

Eskalith, Uthane, Lithobid,

Lithonate, Lithotabs

Demerol

Equanil, Meprospan, Miltown

Dotophine

Talwin

Luminal, SK-Phenobarbital, Sedadrops, Solfoton Darvon, Dolene, SK-65 Bronkodyl, Elixophyllin,

Somophyllin-T,

Slo-Phyllin,

Theostat, Theolair, Theophyl

Stelazine

Fig 2. Glossary of drugs. Trade names are listed in accordance with the AMA Drug Evaluation, ed 5 (Chi-cago, American Medical Association), 1983.

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896 NEONATAL

DRUG WITHDRAWAL

determining when pharmacologic treatment is

nec-essary and whether a drug dose should be advanced or decreased. Supportive cane in the form of intra-venous fluids and replacement electrolytes may be

necessary to stabilize the infant’s condition in the

acute phase without the need for pharmacologic intervention.

Indications for drug treatment include vomiting and diarrhea that result in excessive weight loss or dehydration, inability of the infant to sleep, fever unrelated to infection, and seizures. It is essential that infection, hypoglycemia, hypocalcemia,

hypo-magnesemia, hyperthyroidism, CNS hemorrhage,

and anoxia be ruled out as the etiology for the symptoms. The history of a drug abuser mother should be checked for evidence of past hepatitis on

sexually transmitted disease.

o

PHARMACOLOGIC AGENTS USED TO TREAT

NARCOTIC WITHDRAWAL

Narcotics

Paregoric. Many physicians prefer paregoric for therapy of the narcotic abstinence syndrome be-cause of the ease in administration of the drug. Infants treated with paregoric for narcotic

with-drawal symptoms have a more physiologic sucking

pattern, higher nutrient consumption, higher

pen-centage of sucking time, greater sucking pressure exerted at nursing, and more weight gain than

infants treated with diazepam or phenobarbital.’9

Paregoric contains anhydrous morphine (0.4 mg/ mL). In addition, it contains opium alkaloids which

consist of isoquinoline derivatives (nancotine and

papavenine) which are antispasmodics and phen-anthrene derivatives (morphine and codeine) which are analgesics and narcotics. Paregoric contains camphor, a CNS stimulant that is eliminated from the body slowly because of its high lipid solubility and the need for glucuronic conjugation for urinary excretion. Paregoric contains a high concentration

ofalcohol (44% to 46%), which is a CNS depressant,

and anise oil, which may cause habituation. Benzoic acid (4 mg/mL), an oxidative product of benzyl alcohol, is present in paregoric. Severe acidosis,

CNS depression, respiratory distress, hypotension,

renal failure, seizures, and death have been reported

to occur in small premature infants who receive benzyl alcohol in amounts of 99 to 234 mg/kg/24

h.2022 Glycerine is another component.

The dose of paregoric administered to a full-term

infant for treatment of neonatal narcotic

with-drawal is from 0.2 mL (0.08 mg morphine

equiva-lent) to 0.5 mL (0.2 mg morphine equivalent) per dose every 3 to 4 hours until the symptoms of withdrawal are controlled. A neonatal abstinence

score is helpful in determining the need for

increas-ing or decreasing the dose. The dose of paregoric should be tapered after symptomatology has been

stabilized for three to five days.

Tincture of Opium. The United States

Pharma-copeia preparation of tincture of opium also

con-tains opiate alkaloids and morphine (10 mg/mL)

but in a weaker alcohol preparation (17% to 21%). There is concern about stocking tincture of opium

in hospital pharmacies because doctors and nurses may inadvertently mistake this preparation for

par-egonic and thus administer an excess dose of opium. A 25-fold dilution of tincture of opium contains the

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

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same concentration of morphine equivalent as par-egoric (0.4 mg/mL morphine equivalent) without the additives (camphor, anise oil, benzoic acid, or

0

glycerine) found in paregoric. A recent study has shown that the diluted solution remains stable for at least 2 weeks (S. Segal, unpublished data, 1983). Because of the danger of mistaking tincture of opium for paregoric, tincture of opium should be dispensed to the nursery only in a dilution that contains a concentration of morphine equivalent to the concentration in paregoric. A suggested name for the preparation is “neonatal opium solution.” Diluted tincture of opium should be administered according to the same morphine equivalent dosage schedule used for paregoric.

Morphine. In the past, parenteral morphine has

been used to treat the severe vasomotor collapse

observed in infants with heroin withdrawal.’5

The parenteral form of morphine contains

so-dium bisulfite (1 mg/mL), which has been reported to produce an anaphylactic reaction consisting of prunitus, flushing, and acute wheezing in older

pa-tients.24 The parenteral form of morphine also

con-tains phenol (5 mg/mL). Absorption of phenol via the skin has been associated with jaundice in small infants.25 The dose of phenol that produces hyper-bilirubinemia is not known. The 8-mg/mL ampul of morphine also contains 7 mg/mL (0.12 mEiJ

mL) of sodium chloride. Because morphine is used

in such small doses, these additives may not have a significant effect on the infant.

An oral preparation of morphine (2 and 4 mg/

mL), which contains no additives and less alcohol

than paregoric (10%), is now available. Oral mor-phine has less analgesic effect than the same par-enteral dose. To date there have been no studies in which morphine preparations with morphine

equiv-alents similar to paregoric have been used to treat neonatal narcotic withdrawal. Oral morphine doses should be calculated to deliver to the full-term infant the same quantity of morphine equivalent usually supplied in paregoric.

There is some concern regarding safety in use of opiate preparations in neonates due to their marked respiratory depressant effect. This concern is ac-centuated in the report by Mitchell et al26 of life-threatening reactions in infants less than 3 months of age who were premedicated with morphine. They found that morphine doses of 0.1 mg/kg may cause respiratory cessation in non-narcotic-habituated

infants. Infants manifesting narcotic withdrawal will be more refractory to this dose.

Methadone. The neonatal abstinence syndrome

has been treated with methadone. The prolonged

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plasma half-life of methadone (t,. = 26 hours)

makes difficult the adjustment of the dose of

meth-adone in the infant during decreasing require-ments.9 The multiple-dose vial of methadone con-tains chlorobutanol (0.5 mg/mL), which is a

seda-tive, and 8% ethyl alcohol in the oral form.

Neuroleptics

Diazepam. Rapid suppression of narcotic

with-drawal symptoms has been observed in infants treated with diazepam (1.0 to 2 mg every 8 hours).

The newborn infant has a limited capacity to

me-tabolize and excrete diazepam. Total elimination of diazepam and its metabolites may take 1 month or more.2’ The infant’s suck reflex may also be de-pressed, and late-onset seizures have been observed in infants treated with diazepam.28 Panentenal

di-azepam contains benzyl alcohol (1.5%) and sodium benzoate (5%), which may displace bilirubin for conjugation and excretion; therefore, use of diaze-pam is contraindicated in a jaundiced infant or a premature infant.29 Nathenson et al3#{176}measured albumin binding capacities of addicted infants treated with diazepam and found some decrease in albumin binding capacity.

In addition, parenteral diazepam contains ethyl

alcohol (10%) and significant quantities of propyl-ene glycol (40%). Cerebral and hepatic dysfunction and hyperosmolality with an osmolar gap have been

reported in infants receiving large quantities (10

mL/24 h) of parenteral multivitamins which con-tam 30% propylene glycol.31’32

Chlorpromazine. The CNS and gastrointestinal

symptoms produced by narcotic withdrawal are controlled by chlorpromazine. A dosage of 2.2 to 3 mg/kg/24 h in divided doses every 6 hours intra-muscularly or orally has been used in infants. Oc-casionally, hypothermia may develop. The abnon-malities in rapid eye movement (REM) sleep ob-served during withdrawal are not alleviated by chlorpromazine. Some chlorpromazine metabolites are eliminated slowly oven an 18-month period in adults; therefore, a prolonged excretion time may be anticipated in the neonate.” Chlorpromazine contains sodium chloride (6 mg/mL), sodium bis-ulfite, and sulfite (2 mg/mL). The multidose vial contains henzyl alcohol (2%).

Sedatives

Phenobarbital. Hyperactive behavior in the

in-fant who manifests narcotic withdrawal is modified

by administration of phenobarbital, but the drug

does not relieve the gastrointestinal symptoms. Large doses of phenobanbital may significantly sup-press the CNS of the infant, may impair the suck

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pnopyl-0

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898 NEONATAL DRUG WITHDRAWAL

ene glycol (67.8%), ethyl alcohol 10%, and benzyl alcohol 1.5%. The therapeutic blood level of pheno-barbital necessary for control of narcotic with-drawal symptoms is not known. Finnegan et al34 used a neonatal loading dosage of 16 mg/kg/24 h of phenobarbital that produced blood levels of 20 to 30 sg/mL, which effectively controlled symptoms of narcotic withdrawal.34 A blood level should be obtained 24 to 28 hours later and the maintenance dose adjusted according to the infant’s symptoma-tology as determined by the abstinence score and the phenobarbital plasma level. Finnegan et al34 reported that maintenance doses of 2 to 8 mg/kg/ 24 h were required to control withdrawal symptom-atology and maintain phenobarbital plasma levels. After the infant’s condition has stabilized, the maintenance dose should be decreased to allow the drug level to decrease by 10% to 20% per day.

Antihypertensive

Agent

Clonidine has been shown to reduce withdrawal symptoms in adult opiate addicts. It has been ad-ministered to two neonates withdrawing from ma-ternal methadone.3 More data are required to de-fine the role of clonidine in the treatment of neo-natal withdrawal.

GENERAL

CARE

OF THE

NEONATE

Medications should be administered at the time of feeding in order to limit the number of times the infant is disturbed. When vomiting is a problem, oral drugs may be administered 30 minutes before

a feeding. After a stabilizing dose is attained, the drug dose should be maintained so that the infant sleeps well, eats effectively, and gains weight for a period of three to five days; then the dose may be

tapered. The physician may be hesitant to taper the dose of medication; this hesitancy may result in prolonging the infant’s hospitalization and drug therapy. The abstinence scoring sheet and changes in weight may be used to determine objectively the rapidity with which drug therapy should be tapered. Irritability and tremors should not be used as a criteria for continued drug administration as sub-acute symptoms of irritability, tremors, and poor sleeping patterns may last until age 6 months.8

FOLLOW-UP CARE

Optimal treatment of the infant requires a team approach by a physician who is knowledgeable of the symptoms and therapy of neonatal withdrawal and who communicates with the parents; a nursing staff willing to tolerate the symptoms of the infant

and willing to incorporate the parents into the total

care of the infant; and a social service worker who

can win the confidence of the parents and thus

determine the parents’ ability to care for the infait

after discharge from the hospital.

The period of treatment in the hospital is the

time when both parents learn to help care for their infant. The infant who is withdrawing from a drug

is a very difficult infant with whom to bond and

with whom to live on a 24-hour basis; the caretakers should be provided constant emotional support. Participation of the parents in the care of their infant in the hospital assists them in gaining con-fidence in interpreting the infant’s symptoms and

decreases the demands for medication sought for

subacute symptoms of withdrawal once the infant is discharged from the hospital. No infant born to a known drug abuser should be discharged home on

drugs as the parents may sympathetically use the

drug for a longer period of time than is indicated

or they may use the drug to supply their own need

for drug replacement. Parents of infants who are

withdrawing from drugs prescribed to the mother

for medical purposes have strong guilt feelings and

tend to overreact to the symptoms demonstrated

by the infant.

Recurrence of withdrawal symptoms in the infant

may develop after discharge from the hospital. It is essential that the hospital staff establish rapport with the parents so that they will return the infant

to the hospital for treatment in this event. Sudden

infant death syndrome (SIDS) and acquired

im-munodeficiency syndrome (AIDS) have been

ob-served in infants born to methadone and heroin

users.bl9 In one study, the incidence of SIDS was

correlated with the severity of the infants’ with-drawal symptoms while in the nursery.4#{176}

There should be a long-term follow-up of the physical and mental development of any infant who

is withdrawing from maternal drugs.

AGENTS PRODUCING SYMPTOMS SIMILAR

TO THOSE OF NARCOTIC WITHDRAWAL

Other maternal medications may produce in the

infant a symptom complex similar to that of

nan-cotic withdrawal (Table 1). The symptoms observed in the infant may represent withdrawal or

intoxi-cation and may last for variable periods of time (days to months).

In general, infants who demonstrate intoxication from maternal drugs require mostly supportive care

during the period of excretion of the drug rather

than administration of additional pharmacologic agents that the infant must metabolize and excrete.

In cases of severe symptomatology, drug therapy

may be indicated for patient comfort.

Infants who manifest adverse reaction to

mater-nal psychotropic agents and who require

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TABLE 1. Nonnarcotic Maternal Drugs That Cause Neonatal Psychomotor Behavior Consistent with That Produced

by Withdrawal (W) or Intoxication (I)*

Drug Symptoms Duration of Symptoms W/I Reference

Barbiturates

2#{189}mo, 5 d-Rx I 50,51

0

Desmethylim-ipramine

Diazepam

Diphenhydra-0 mine

Ethchlorvynol

Glutethimide

Hydroxyzine

Imipramine

52

Phencyclidine

Theophylline

0

45

* Abbreviations used are: HR, heart rate; RR, respiratory rate; Rx, refers to infant treated with pharmacologic agents

Alcohol Hyperactivity, crying, irritability; poor suck,

tremors, convulsions, onset of symptoms at birth, poor sleeping pattern, hyperphagia,

diaphoresis

Amitniptyline Tremors, poor sleeping patterns, feeding diffi-culty, abdominal pain

Irritability, severe tremors, hyperacusis,

exces-sive crying, vasomotor instability, diarrhea,

restlessness, tone, hyperphagia, vomiting, disturbed sleep; onset 1st 24 h of life or at

10-14 d of age

Bromide Lethargy, dilated pupils, hypotonia, hyper-tonus, high-pitched cry, feeding difficulty, reflexes

Chlordiazepox- Irritability, tremors; symptoms may start at 21

ide d

Chlorpromazine Extrapyramidal dysfunction, intention tremor, opisthotonos, mask-like facies; onset 1st 24-36 h

Clomipramine Hypothermia, cyanosis, tremors; onset 12 h of age

Breathelessness, cyanosis, ilR,

I

RR, diapho-resis, irritability, feeding difficulty, weight loss

Hypotonia, poor suck, hypothermia, apnea, ?hypertonia, hyperreflexia, tremors,

vomit-ing, hyperactivity, tachypnea, (mother mul-tiple drug therapy)

Tremulousness, diarrhea. Onset 5 d of age

??Lethargy, jitteriness, hyperphagia,

irritabil-ity, poor suck, hypotonia, (mother receiving

multiple-drug therapy)

I

tone, tremors, opisthotonos, high-pitched cry, hyperactive, irritable, “colic”

Tremors, irritability, hyperactivity, jitteriness, shrill cry, myoclonic jerks, hypotonia,

I

RR,

I

HR, feeding problem, clonic movements

(Mother receiving multiple therapy)

Cyanosis, respiratory distress, vasomotor insta-bility, irritability, hypokinesia, convulsions, jerky movements, RR, autonomic dysfunc-tion, hypoactivity, belly dance movements of abdomen before voiding

Lithium Respiratory distress, lethargy, cyanosis, poor suck, hypotonia

Local anesthe- Acidosis, convulsions, BR, opisthotonos,

neu-sia rologic depression, apnea, spontaneous

movement, responsiveness,

I

reflexes, ab-normal oculomotor reflexes, death, hypo-tonia, fixed pupils

Magnesium sul- Respiratory depression, hypotonia,

convul-fate sions, death

Meprobamate Irritability, tremors, poor sleep patterns, ab-dominal pain

Jitteriness, hypertonia, vomiting, lethargy, yen-tical nystagmus

I

HR, gagging, vomiting, jitteriness,

opistho-tonos

Trifluoperazine ? Late-onset, extrapyramidal dysfunction

18 mo

w

42-44

9mo I 45

4-6 mo-Rx W 46-49

9 mo, 1#{189}mo-Rx W

9 mo, 12 wk-Rx I 41,53

4d-Rx W 54

10-30d I 55

8 mo, 10-66 d-Rx I 56,57

9d-Rx I 58

? lOd-Rx IandW 59

6mo W 60

Swk-Rx W 61

?6d I 62

lOd I 63,64

Related to Rx, excreted I 65-69

1st 24 h

Depends on Rx I 70,71

9 mo, 3 mo-Rx W

18 d + Rx, 8 da + Rx I 72,73

2d I 74

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TABLE 2. Pharmacologically Active Excipients in Products Used to Treat Neonatal Withdrawal*

* Abbreviations used are: P, parenteral; po, per os (by mouth).

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REFERENCES

1. Cobrinik RW, Hood RT Jr, Chusid E: The effect of maternal narcotic addiction on the newborn infant. Review of the literature and report of 22 cases. Pediatrics 1959;24:288 2. Blatman S, Lipsitz PJ: Children of women maintained on

methadone: Accidental methadone poisoning of children, in

Fourth National Conference on Methadone Treatment, San Francisco, Jan 8-10, 1972. New York, National Association for the Prevention of Addiction to Narcotics, Publisher,

1972, p 175

3. Fisch GR, Henley WL: Symptoms of narcotic withdrawal in

a newborn infant secondary to medical therapy of the mother. Pediatrics 1961;28:852

4. Mangurten HH, Benawra R: Neonatal codeine withdrawal in infants of nonaddicted mothers. Pediatrics 1980;65:159

5. Goetz RL, Bain RV: Neonatal withdrawal symptoms

asso-ciated with maternal use of pentazocine. J Pediatr

1974;84:887

6. Dunn DW, Reynolds J: Neonatal withdrawal symptoms

associated with “T’s and blues” (pentazocine and tripelen-namine). Am J Dis Child 1982;136:644

7. Tyson HK: Neonatal withdrawal symptoms associated with maternal use of propoxyphene hydrochloride (Darvon). J

Pediatr 1974;85:684

8. Wilson GS, Desmond MM, Verniaud WM: Early

develop-ment of infants of heroin-addicted mothers. Am J Dis Child

1973;126:457

9. Rosen TS, Pippenger CE: Disposition of methadone and its

relationship to severity ofwithdrawal in the newborn. Addict Dis 1975;2:169

900 NEONATAL

DRUG

WITHDRAWAL

Excipients Generic Name

Anise oil Tincture of paregoric (po)

Benzoic acid and sodium Diazepam (P)

benzoate Tincture of paregoric (po)

Benzyl alcohol Chlorpromazine (P)

Diazepam (P) Phenobarbital (P)

Camphor Tincture of paregoric (po)

Chlorobutanol Methadone (P)

Ethyl alcohol Diazepam (P)

Methadone (po)

Morphine (P and po)

Opium tincture (po) Phenobarbital (P and po) Tincture of paregoric (po) Opium alkaloids Opiate tincture (po)

Tincture of paregoric (po) Propylene glycol Diazepam (P)

Phenobarbital (P)

Sodium bisulfite and Chlorpromazine (P)

sulfite Morphine (P)

cologic therapy are best treated with phenobarbital as it produces fewer adverse effects than the use of

neuroleptic agents in the neonate.

Diphenhydra-mine has been used in one infant thought to be

having an adverse reaction to a phenothiazine agent.4’

Infants who are withdrawing from maternally

acquired barbiturates should be administered phenobarbital if pharmacologic treatment is

nec-essary. The therapeutic plasma level necessary to

treat barbiturate withdrawal is not known. The calculated loading dose (10 to 15 mg/kg/24 h) of phenobarbital should be given in divided doses over a 24-hour period and followed by a maintenance

dose of 3 to 5 mg/kg/24 h. Blood levels should be

monitored to prevent intoxication. Infants rarely require phenobarbital administration for longer than 6 to 8 weeks.

SUMMARY

The Committee on Drugs of the American

Acad-emy of Pediatrics recommends that thoughtful

con-sideration be given to the need for administration of pharmacologic agents to newborn infants who have symptoms of drug withdrawal. Supportive care should be the first line of therapy, and objective methods such as an abstinence scoring sheet should

be used to determine the need for instituting and

then discontinuing pharmacologic treatment.

When appropriate, specific drug therapy should be used for treatment of withdrawal symptoms (ie,

phenobarbital for phenobarbital withdrawal and

opiate for opiate withdrawal). Attention should be given to potential adverse effects in the infant

resulting from excipients present in many of the drugs (Table 2).

The information provided herein should serve as

a guide for the physician in providing supportive

care and pharmacologic treatment of the infant suffering from drug withdrawal.

COMMITTEE ON DRUGS, 1982-1983 Albert W. Pruitt, MD, Chairman Walter R. Anyan, Jr, MD Reba M. Hill, MD

Ralph E. Kauffman, MD

Howard C. Mofenson, MD Harvey S. Singer, MD Stephen Spielberg, MD, PhD

Liaison Representatives John C. Ballin, PhD Martha M. Freeman, MD

Jennifer Niebyl, MD Dorothy L. Smith, PharmD

Sam A. Licata, MD Godfrey Oakley, MD Steven Sawchuk, MD

Louis Farchione, MD

AAP Section Liaisons

Earl J. Brewer, MD John A. Leer, MD

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10. Desmond MM, Wilson GS: Neonatal abstinence syndrome: Recognition and diagnosis. Addict Dis 1975;2:113

11. Chasnoff IJ, Hatcher R, Burns WJ: Polydrug- and

metha-done-addicted newborns: A continuum of impairment.

Pe-O

diatrics 1982;70:210

12. Ostrea EM Jr, Kroll DW: Meconium-The ideal specimen

for drug screen in infants born to known or suspected drug

abusers, abstracted. Pediatr Res 1983;17:153A

13. Hyde WH, Scharnberg JT, Rudolph AJ: Oxygen

consump-tion in infants of narcotic addicts, abstracted. Pediatr Res

1980;14:467

14. Wilson GS: Somatic growth effects of perinatal addiction.

Addict Dis 1975;2:333

15. Hill RM, Desmond MM: Management of the narcotic

with-drawal syndrome in the neonate. Pediatr Clin N Am

1963;10:67

16. Finnegan LP, Kron RE, Connaughton JF, et al: Assessment

and treatment of abstinence in the infant of the drug-dependent mother.

mt

Clin Pharmacol 1975;12:19

17. Lipsitz PJ, Blatman 5: Newborn infants of mothers on

methadone maintenance. NY State J Med 1974;74:994

18. Ostrea EM, Chavez CJ, Stryker JC: The care of the drug

dependent woman and her infant. Lansing, MI, Michigan Dept of Public Health, Publisher, 1978

19. Kron RE, Litt M, Phoenix MD, et al: Neonatal narcotic

abstinence: Effects of pharmacotherapeutic agents and

ma-ternal drug usage on nutritive sucking behavior. J Pediatr

1976;88:637

20. Gershanik J, Boecler B, Ensley H, et al: The gasping

syn-drome and benzyl alcohol poisoning. N Engi J Med

1982;307:1384

21. Brown WJ, Buist NRM, Gipson HTC, et a!: Fatal benzyl

alcohol poisoning in a neonatal intensive care unit. Lancet

1982;1:1250

22. American Academy of Pediatrics, Committee on Fetus and

Newborn and Committee on Drugs: Benzyl alcohol: Toxic

agent in neonatal units. Pediatrics 1983;72:356 23. Deleted in proof

24. Twarog FJ, Leung DYM: Anaphylaxis to a component of

0

isoetharine (sodium bisulfite) JAMA 1982;248:2030

25. Wysowski DK, Flynt JW Jr, Goldfield M, et al: Epidemic

neonatal hyperbilirubinemia and use of a phenolic disin-fectant detergent. Pediatrics 1978;61:165

26. Mitchell AA, Louik C, Lacouture P, et al: Risks to children

from computed tomographic scan premedication. JAMA

1982;247:2385

27. Morselli PL, Principi N, Tognoni G, et al: Diazepam

elimi-nation in premature and full term infants, and children. J

Perinat Med 1973;1:133

28. Kandall SR: Late complications in passively addicted

in-fants, in Rementeria JL (ed): Drug Abuse in Pregnancy and

the Neonate. St Louis, CV Mosby, 1977, p 116

29. Schiff D, Chan G, Stern L: Fixed drug combinations and

the displacement of bilirubin from albumin. Pediatrics

1971;48:139

30. Nathenson G, Cohen MI, Litt IF, et al: The effect of

mater-nal heroin addiction on neonatal jaundice. J Pediatr

1972;81:899

31. Bekeris L, Baker C, Fenton J, et al: Propylene glycol as a

cause of an elevated serum osmolality. Am J Clin Pathol

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A DIFFERENCE IN THE FAMILY

Sometimes outsiders accept [a disabled] child but expect unreasonable sac-nifices of his parents. Lucy Forrest described . . . the ways that neighbors and strangers helped her and her husband implement a demanding treatment plan for Christopher. Volunteers came in daily to ‘pattern’ the little boy; contnibu-tions helped the family finance bimonthly trips to a distant clinic. But this support given freely during the early months when the Forrests devoted every

minute to their baby, almost evaporated when they started to pick up the

threads of their previous life. Specifically, when Lucy began to repaper their

new house, some of the volunteers acted shocked and even hostile. The reaction wounded the young couple; they felt the world exacted a heavy price for its

sympathy, asking that they devote their entire lives to their hurt son and give

up the pleasures others take for granted.

Submitted by Student

From Featherstone H: A Difference in the Family. New York, Basic Books, 1980.

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