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%
Download ReportTranscript 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%
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 • • Organs were small with diminished number of normal sized cells • • caused by the high rate of chorioamnionitis and infections 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 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 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 Late withdrawal can show up at 2-4 wks of age symptoms within 48-72 hours similar symptoms to heroin withdrawal but more intense 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 No increase in congenital anomalies but do have birth weights correlate with 1st trimester dose of methadone 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 Effects on the brain obstructs AA transport in the placenta 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