Use of positioning to reduce the severity of neonatal narcotic withdrawal syndrome

OBJECTIVE

This study tested the hypothesis that highly fretful, narcotic-withdrawing neonates experience less distress in a prone-lying position than comparable, supine-lying neonates.

STUDY DESIGN

Equivalent numbers of randomly assigned, narcotic-withdrawing newborns were assigned to prone-lying (n = 25) or supine-lying (n = 23) conditions. Subjects in the two groups were similar with regard to gestational age, birth weight, and clinical presentation. Peak and mean withdrawal severity, as measured by Neonatal Abstinence Scoring System (NASS) scores and daily caloric intake, were compared between supine and prone groups by Wilcoxon's two-sample test.

RESULTS

The prone-lying neonates had lower peak NASS scores (p < 0.0001), lower mean NASS scores (p < 0.0001), and lower caloric intake (p < 0.001) than supine-lying, narcotic-withdrawing newborns.

CONCLUSION

The fretfulness associated with neonatal withdrawal and other stressful conditions can be moderated by laying the affected infant prone. The pronate quieting response is a significant, endogenous source of neonatal pacification.

Opioid dependence during pregnancy. Effects and management

This article describes the complex problems associated with opioid dependence during pregnancy. Medical, obstetric, and psychosocial problems are presented. Methadone maintenance for the treatment of opioid dependence is described in this article. Specific issues of appropriate methadone dose during pregnancy, medical withdrawal, and the relationship of methadone dose and the severity of neonatal abstinence also are discussed.

MK-801 administration during ethanol withdrawal in neonatal rat pups attenuates ethanol-induced behavioral deficits

Alcohol exposure during development can produce central nervous system dysfunction, resulting in a wide range of behavioral alterations. The various mechanisms by which alcohol causes these behavioral changes, however, remain unknown. One mechanism that has been suggested is NMDA receptor-mediated excitotoxic cell death produced by ethanol withdrawal. The present study examined whether MK-801, an antagonist of the NMDA receptor that has been shown to protect against NMDA receptor-mediated excitotoxicity, could block alcohol's adverse effects on behavior. Sprague-Dawley rat pups were exposed to alcohol (6.0 g/kg) in a binge-like manner on postnatal day 6 using an artificial rearing procedure. Subjects then received an injection of MK-801 (0.1 mg/kg) or vehicle during withdrawal, 21 hr after ethanol exposure. At postnatal day 40, all subjects were tested on a serial spatial discrimination reversal task. Ethanol-exposed subjects were impaired in both discrimination and reversal learning, and committed a significantly greater number of perseverative-type errors, compared with controls. MK-801 administration during ethanol withdrawal significantly attenuated ethanol-induced deficits in reversal learning and increases in perseverative-type errors, whereas MK-801 exposure by itself had no significant effect on performance. Thus, exposure to MK-801 during ethanol withdrawal partially protected against alcohol-related disruptions in spatial reversal learning. These results support the suggestion that NMDA receptor-mediated excitotoxicity may be one mechanism by which alcohol induces behavioral teratogenicity.

Adverse reactions to the withdrawal of opioids and benzodiazepines in paediatric intensive care

The aim of this study was to examine adverse reactions to the withdrawal of opioids and benzodiazepines among critically ill children. Although withdrawal reactions have been well documented in relation to substance abusers and their newborn infants, there has been little study of this phenomenon as an iatrogenic problem. We developed a graphical case study method for examining patterns over time, and applied this to five cases referred to us by the nursing staff of a 10-bed paediatric intensive care unit. A striking pattern of behavioural distress was clearly associated with the diminution of opioids and benzodiazepines. These adverse reactions were characterized by various combinations of inconsolable crying, tremors, jitteriness, irritability, gagging, vomiting, and feeding problems. These signs appeared as early as 1 h and as late as 24 h following a significant reduction in opioid and benzodiazepine infusion rates, sometimes following very short-term therapy. We elaborate an interpretation of this distress, in light of the multiple disruptions undergone by critically ill children, and conclude by outlining our recommendations for preventing/minimizing these adverse reactions.

[Management of drug addict pregnant women and their children]

Children of substance abuse mothers have an increased risk of severe pathological disorders such as perinatal diseases (prematurity, intrauterine growth retardation, infections) with their neurological and respiratory complications and sequelae, and transmission of drug addiction related infections, ie human immunodeficiency virus, hepatitis B and C virus, syphilis. Many of these children present a drug withdrawal syndrome characterized by restlessness and jetteriness during the neonatal period. This is frequently followed by a post withdrawal period of several weeks duration with crying, excitement, sleep and feeding difficulties. Although these drug withdrawal manifestations have no incidence on the vital prognosis, it severely impairs the mother-infant interaction. Despite these disorders it appears that the outcome of these children is mainly related to their familial environment which is exposed to many risk factors: mother-child separation, violence, delinquency, precariousness, unhealthy housing, prostitution, drug dependency, parental death or imprisonment... Early medico-psycho-social intervention starting during pregnancy and a prolonged support for several years are the only way to improve their spontaneously poor outcome.

Perinatal exposure to methadone affects central cholinergic activity in the weanling rat

Pregnant rats were implanted with osmotic minipumps containing either methadone hydrochloride (initial dose, 9 mg/kg/day) or sterile water. Their offspring were cross-fostered so that they were exposed to methadone prenatally and/or postnatally. Perinatal methadone exposure disrupted cholinergic activity on postnatal day 21 as measured by the turnover rate of acetylcholine (TRACh) in both female and male rats, although there were some sexually-dimorphic responses. The most profoundly affected brain region was the striatum, where prenatal exposure to methadone increased ACh turnover, whether or not the rats continued to be exposed to methadone postnatally. It appears unlikely that neonatal withdrawal contributes to brain regional changes in ACh turnover, as continued postnatal exposure to methadone did not prevent the prenatal methadone induced changes.

Role of noradrenergic hyperactivity in neonatal opiate abstinence

Despite the existence of a well-defined abstinence syndrome in offspring of opiate-dependent mothers, the mechanisms involved in neonatal abstinence remain unclear. The goal of the present study was to determine the contribution of noradrenergic neurons in the opiate abstinence syndrome in neonatal rats (10 days old). First, the ability of the alpha 2-adrenergic agonist, clonidine to attenuate the symptoms of neonatal opiate abstinence precipitated by naloxone was determined. Secondly, the activity of noradrenergic neurons was determined by measuring postmortem levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) in the hypothalamus, hippocampus and cortex in opiate-abstinent pups. Neonatal opiate abstinence was characterized by an increased incidence of wall climbing, tremors and mouthing. Acute treatment with morphine and naloxone in chronic saline-treated pups also produced the tremor, albeit less severe than in pups treated chronically with morphine. Clonidine (0.2 mg/kg) attenuated the expression of tremor and mouthing in neonates, but increased wall climbing. Clonidine elicited wall climbing in opiate-naive neonates. Treatment with morphine followed by naltrexone increased MHPG levels in all of the brain areas examined, irrespective of the chronic treatment, but naltrexone treatment elicited a larger increase in MHPG levels in pups treated chronically with morphine. Acute morphine treatment increased MHPG levels only in the hypothalamus. The results of the present study provide behavioral and neurochemical data supporting the hypothesis that noradrenergic hyperactivity plays a role in neonatal opiate abstinence.

Ontogeny of morphine withdrawal in the rat

The present studies examined behavioral changes during precipitated morphine withdrawal in 7- to 42-day-old rat pups. One group of rats was injected with morphine sulfate (10.0 mg/kg) twice daily for 6.5 days. Another group of 7-day-old rats received a lower dose of morphine (3.0 mg/kg). Controls were saline injected or untreated litters (7-day-old pups only). On Day 7, a target pup was injected with saline or naltrexone (0.3-10.0 mg/kg). Preweaning pups were observed in a warm chamber with the litter. Forty-two-day-old rats were tested individually. Morphine-treated pups tested with naltrexone showed significant alterations in behavior that varied at different ages. For example, rolling, stretching, and head and paw moves were observed at the younger ages, whereas burrowing, diarrhea, jumps, teeth chatter, and wet dog shakes occurred in the older rats. These data indicate that morphine-abstinent rats demonstrate withdrawal signs that are within the developmental repertoire of the rat.

Biological mechanisms and perinatal exposure to abused drugs

Use of illicit and licit drugs during pregnancy is a major public health concern, as it can have adverse effects on the developing fetus. Infants born of women addicted to narcotics, cocaine, alcohol, or polydrugs often undergo a characteristic withdrawal syndrome and may have physical, behavioral, and/or neurological abnormalities. As it is not feasible to ascertain whether these functional changes in human infants are produced by abused substance(s) per se or by a combination of complex socioeconomic factors and polydrug use, researchers in recent years have developed and utilized various innovative animal models to assess drug-induced alterations and their biological mechanisms during the developmental period under a controlled environment. To promote interdisciplinary communications as well as to assess the progress and the future needs in this area, the National Institute on Drug Abuse (NIDA) held a technical review at which biomedical researchers discussed their current findings in various physiological systems. This report summarizes the major findings and the methodological and experimental issues discussed at the conference. The meeting was held in Washington, DC, on May 25 and 26, 1994.

Neonatal narcotic withdrawal in Hong Kong Chinese

A retrospective case controlled study was carried out to study the neonatal characteristics, outcome and narcotic withdrawal syndrome in 51 neonates exposed to narcotic antenatally. The birth weight, head circumference and body length were significantly smaller in the study group while the incidence of prematurity (41%) and small-for-gestational age babies was increased (27.5%). Narcotic withdrawal occurred in 83% of narcotic exposed neonates. About half of them had onset of withdrawal symptoms within the first 24 hours. All of these newborns were treated by either phenobarbitone (45%), chlorpromazine (9.5%) or both (40.5%). The average duration of treatment was 15.7 days. There was one neonatal death due to in utero withdrawal and hypoxia, and another post-neonatal death due to sudden infant death. Neonatal jaundice, necrotising enterocolitis, clinical sepsis and congenital syphilis were more common in the drug-addicted group.

Therapeutic handling techniques for the infant affected by cocaine

The effects of maternal cocaine abuse can be manifested in infants as physiologic, psychologic, cognitive, and developmental deficits. The effects of cocaine disrupt the sleep and wake cycles, which may cause the infant to be difficult to handle or unresponsive to parents or caregivers. Assessments of sleep/wake states and interventions to aid these infants are described. Cocaine-affected infants can also present with hypertonic or hypotonic muscle tone disorders. Interventions to improve muscle tone are included in the discussion.

[Neonatal abstinence syndrome: current and future aspects]

Pregnant heroin-addicted women constitute a major social problem that should not be ignored. Newborns may develop a neonatal abstinence syndrome (NAS). They present with behavioural troubles running a typical clinical course. The level of severity of NAS will be accurately determined, leading to definition of the most appropriate therapy. The best therapeutic formula appears to be paregoric elixir, mixed with phenobarbital if necessary. Least severe cases can be easily controlled by appropriate surrounding conditions. Pharmacological as well as physiopathological effects of opiates are described. Little is known about the long-term effects of opiate exposure; they apparently include frequent instrumental troubles. At the present time, the rapid intervention of a multidisciplinary team is recommended, taking charge of the mothers who should receive methadone in progressively tapering doses.

Cocaine-exposed newborns show an exaggerated sucking response to sucrose

The sucking responses of 16 newborn infants exposed to cocaine just prior to birth and 16 control newborns were recorded when offered a fluidless sucrose-flavored nipple and a comparable nonsweet nipple. Cocaine-exposed infants showed a significantly greater preference for sweet taste: Compared with control infants, the cocaine group sucked more frequently when offered the sweet nipple and less frequently when presented with the nonsweet nipple. This heightened response to sweet stimulation might reflect (i) a coping mechanism for the perinatal distress of intrauterine cocaine-exposure since sweet taste appears to alleviate distress via an opioid mechanism; and/or (ii) altered dopaminergic activity in a common neuronal pathway that mediates the rewarding aspects of both cocaine and sweet taste.

Differences in salivary cortisol levels in cocaine-exposed and noncocaine-exposed NICU infants

To assess whether cocaine exposure in utero affected adrenocortical responsiveness in the neonatal period, salivary cortisol levels were compared between noncocaine-exposed (n = 35) and cocaine-exposed (n = 11) healthy preterm infants just prior to hospital discharge. Cortisol levels were measured under three conditions: Basal--120 min after no disrupting event or behavioral distress; Noninvasive Stressor--30 min after a neurobehavioral examination; Invasive Stressor--30 min after a heel-stick procedure. There were no differences in Basal cortisol levels between the noncocaine-exposed and cocaine-exposed infants, but the cocaine-exposed infants had significantly lower levels in both the Noninvasive and Invasive Stressor conditions. The suppressed cortisol responding to stressful events in cocaine-exposed infants suggests that these infants may have decreased modulation capability to normally stressful events, which could underlie some of the subtle state regulation problems reported.

Neurobehavioral syndromes in cocaine-exposed newborn infants

The effects of fetal cocaine exposure on newborn cry characteristics were studied in 80 cocaine-exposed and 80 control infants. The groups were stratified to be similar on maternal demographic characteristics and maternal use of other illegal substances and alcohol during pregnancy. The hypothesis was that excitable cry characteristics were related to the direct effects of cocaine, while depressed cry characteristics were related to the indirect effects of cocaine secondary to low birthweight. Structural equation modeling (EQS) showed direct effects of cocaine on cries with a longer duration, higher fundamental frequency, and a higher and more variable first formant frequency. Indirect effects of cocaine secondary to low birthweight resulted in cries with a longer latency, fewer utterances, lower amplitude, and more dysphonation. Cocaine-exposed infants had a lower birthweight, shorter length, and smaller head circumference than the unexposed controls. Findings were consistent with the notion that 2 neurobehavioral syndromes, excitable and depressed, can be described in cocaine-exposed infants, and that these 2 syndromes are due, respectively, to direct neurotoxic effects and indirect effects secondary to intrauterine growth retardation.

Neonatal opiate abstinence syndrome in term and preterm infants

Data on 178 term and 34 preterm infants born to methadone-maintained mothers were analyzed to assess the effects of neonatal opiate abstinence in infants of varying gestational ages. More mothers in the term group (79%) than in the preterm group (53%) had abused other drugs during pregnancy (p less than 0.001). Mean (+/- SD) gestational age was 39.5 weeks +/- 1.4 for term infants and 34.3 weeks +/- 2.6 for preterm infants. On the basis of a semiobjective symptom scoring scale, term infants had more severe abstinence symptoms and more prominent central nervous system manifestations than preterm infants. The severity of abstinence symptoms correlated with maternal methadone dosage in both term and preterm infants. Maternal multiple drug abuse (e.g., heroin, cocaine) did not influence severity of abstinence symptoms in either group. More term infants (145/178) than preterm infants (20/34) required treatment for these symptoms (p less than 0.005). In 13 of 178 term infants, compared with 1 of 34 preterm infants, abstinence-related seizures developed. Peak severity occurred 1 to 2 days earlier in term than in preterm infants. A less severe abstinence syndrome in preterm infants may be due to (1) developmental immaturity of either dendritic ramifications, specific opiate receptors, or neurotransmitter function, or (2) reduced total drug exposure during the intrauterine period.

Prenatal cocaine use: impact on infants and mothers

Prenatal cocaine use does not allow a mother to provide an environment that promotes her infant's normal development. Pediatric nurses and other health care professionals need to support and assist the mother in the recovery process for the benefit of the child's health and development.

A comparison of the effects of single- and split-dose methadone administration on the fetus: ultrasound evaluation

A prospective study was conducted to evaluate the effects of oral methadone on fetal activity (body movements, breathing, longest inactive period) for drug-dependent pregnant women on methadone maintenance. Seven consenting drug-dependent pregnant women between 26 and 37 weeks gestation were enrolled in the study. Pairs of ultrasound observation studies were conducted, before and after single-dose methadone (SDM) treatment and split-dose methadone treatment. There were significant decreases in both body movements (p less than 0.001) and breathing episodes (p less than 0.01), and a significant increase in the longest period of inactivity (p less than 0.001) following SDM. A similar but not significant trend was noted before and after split-dose methadone. The results of the single-dose studies differed significantly from normal controls. However, the results of the split-dose studies were similar to controls. It is recommended that women on methadone maintenance should be offered a split-dose treatment protocol.

Management of the pregnant opiate user

Increasing numbers of women are seeking help for drug misuse. In addition to problems associated with drug dependence, there are also problems concerning child care, pregnancy and women's health. In this paper we discuss the management of the pregnant opiate user, effects of opiate use in utero and postpartum and ways in which non-drug services can assist in the early identification and treatment of these women.

The care of infants menaced by cocaine abuse

The newborn's symptoms of prenatal drug exposure threaten attachment. Consequently, psychosocial progress is impeded. Early intervention provides hope for these infants.

Auditory brainstem-evoked potentials in term infants born to mothers addicted to opiates

A series of 20 normal newborn term infants and 12 infants born to mothers who had abused opiates during pregnancy were studied. Auditory brainstem-evoked potentials were used to describe neurophysiologic dysfunction in a group of drug-addicted term infants. Significant differences in the auditory brainstem-evoked potentials were found between the two groups. Specifically, a decrease in the central conduction times was noted for the I-III interpeak interval, suggesting neurophysiologic dysfunction in the area of the pons and cerebellum.