Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus (see Table: Some Drugs With Adverse Effects During Pregnancy Some Drugs With Adverse Effects During Pregnancy Drugs are used in over half of all pregnancies, and prevalence of use is increasing. The most commonly used drugs include antiemetics, antacids, antihistamines, analgesics, antimicrobials, diuretics... read more ). Fetal alcohol syndrome Fetal Alcohol Syndrome Alcohol exposure in utero increases the risk of spontaneous abortion, decreases birth weight, and can cause fetal alcohol syndrome, a constellation of variable physical and cognitive abnormalities... read more and the effects of cigarette smoking on the fetus Social and Illicit Drugs During Pregnancy Drugs are used in over half of all pregnancies, and prevalence of use is increasing. The most commonly used drugs include antiemetics, antacids, antihistamines, analgesics, antimicrobials, diuretics... read more are discussed elsewhere.
A fetus that has been exposed to drugs in utero (termed fetuses exposed to noxious substances [FENS]) can become dependent on the drug during gestation. Although some toxic substances used by the mother are not illegal, many are. In any case, the home situation should be evaluated to determine whether the infant will be safely cared for after discharge. Understanding local jurisdictions and laws is important because many countries and localities have mandatory reporting guidelines. With the supportive help of relatives, friends, and visiting nurses, the mother may be able to care for her infant. If not, foster home care or an alternative care plan may be best.
Prenatal exposure to amphetamines Amphetamines Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more has lasting subtle effects on neonatal brain structure and function. Some studies have shown decreased volume of the caudate, putamen, and globus pallidus (anatomic components of brain) in methamphetamine-exposed children, whereas other studies have not uniformly confirmed these findings. Other studies indicate that prenatal methamphetamine exposure may be associated with abnormal neurobehavioral patterns or fetal growth restriction, but these findings are not yet fully established.
Prolonged maternal abuse of barbiturates Anxiolytics and Sedatives Anxiolytics and sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause stupor and respiratory depression, which is managed with intubation and mechanical ventilation... read more may cause neonatal drug withdrawal with jitteriness, irritability, and fussiness that often do not develop until 7 to 10 days postpartum, after the neonate has been discharged home. Sedation with phenobarbital 0.75 to 1.5 mg/kg orally or IM every 6 hours may be required and then tapered over a few days or weeks, depending on the duration of symptoms.
Cocaine Cocaine Cocaine is a sympathomimetic drug with central nervous system stimulant and euphoriant properties. High doses can cause panic, schizophrenic-like symptoms, seizures, hyperthermia, hypertension... read more inhibits reuptake of the neurotransmitters norepinephrine and epinephrine; it crosses the placenta and causes vasoconstriction and hypertension in the fetus. Cocaine abuse in pregnancy is associated with a higher rate of placental abruption Abruptio Placentae Abruptio placentae is premature separation of a normally implanted placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include vaginal... read more and spontaneous abortion Spontaneous Abortion Spontaneous abortion is noninduced embryonic or fetal death or passage of products of conception before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation... read more , perhaps caused by reduced maternal blood flow to the placental vascular bed; abruption may also lead to intrauterine fetal death or to neurologic damage if the infant survives.
Neonates born to addicted mothers have low birth weight, reduced body length and head circumference, and lower Apgar scores Apgar score Extensive physiologic changes accompany the birth process, sometimes unmasking conditions that posed no problem during intrauterine life. For that reason, a person with neonatal resuscitation... read more . Cerebral infarcts may occur, and rare anomalies associated with prenatal cocaine use include limb amputations Limb deficiencies Congenital limb defects involve missing, incomplete, supernumerary, or abnormally developed limbs present at birth. (See also Introduction to Congenital Craniofacial and Musculoskeletal Disorders... read more , genitourinary malformations Overview of Congenital Genitourinary Anomalies Congenital anatomic anomalies of the genitourinary tract are more common than those of any other organ system. Urinary tract anomalies predispose patients to many complications, including urinary... read more , including prune-belly syndrome Prune-Belly Syndrome Prune-belly syndrome consists of abdominal muscle deficiency, urinary tract abnormalities, and intra-abdominal undescended testes. The name prune-belly syndrome derives from the characteristic... read more , and intestinal atresia or necrosis. All are caused by vascular disruption, presumably secondary to local ischemia caused by the intense vasoconstriction of fetal arteries caused by cocaine. In addition, a pattern of mild neurobehavioral effects has also been observed, including decreases in attention and alertness, lower IQ, and impaired gross and fine motor skills.
Some neonates may show withdrawal symptoms if the mother used cocaine shortly before delivery, but symptoms are less common and less severe than for opioid withdrawal, and signs and treatment are the same.
Marijuana Marijuana (Cannabis) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent... read more does not consistently increase risk of congenital malformations, fetal growth restriction, or postnatal neurobehavioral abnormalities. However, women who use marijuana during pregnancy often also use alcohol, cigarettes, or both, which can cause fetal problems.
Opioid exposure in utero can cause withdrawal on delivery. The neonate of a woman who used opioids Opioid Use Disorder and Rehabilitation “Opioid” is a term for a number of natural substances (originally derived from the opium poppy) and their semisynthetic and synthetic analogues that bind to specific opioid receptors. Opioids... read more chronically during pregnancy should be observed for withdrawal symptoms (narcotic abstinence syndrome [NAS]). NAS usually occurs within 72 hours after delivery, although many neonatal units observe infants for 4 or 5 days to be sure there are no significant signs of withdrawal.
Characteristic signs of withdrawal include
Prenatal benzodiazepine exposure may cause similar effects.
There are many scoring systems to help quantify the severity of withdrawal (see The Opioid Exposed Newborn: Assessment and Pharmacologic Management). Mild withdrawal symptoms are treated by a few days of swaddling and soothing care to alleviate the physical overarousal and by giving frequent feedings to reduce restlessness. With patience, some problems resolve in no more than a week.
The Eat, Sleep, Console (ESC) approach for NAS assessment (1 Opioids references Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more , 2 Opioids references Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more ) and care is a promising new development that is more family centered. This approach is focused on comfort care and family involvement, and in many centers includes rooming-in with the mother. Some studies have shown that the ESC approach decreases length of stay and results in less opioid exposure for the infant. However, a significant number of infants with NAS require drug treatment, typically using an opioid, sometimes with the addition of clonidine. Phenobarbital (0.75 to 1.5 mg/kg orally every 6 hours) may help but is now considered 2nd-line treatment. Treatment is tapered and stopped over several days or weeks as symptoms subside; many infants require up to 5 weeks of therapy.
There is no consensus on the best drug, but most experts use methadone, morphine, or sometimes tincture of opium. Dosing is based on the weight of the infant and the severity of the symptoms. Typically, a starting dose is given and increased until symptoms are controlled and then slowly tapered (see Table: One Drug Regimen for Neonatal Opioid Withdrawal One Drug Regimen for Neonatal Opioid Withdrawal Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more ).
One Drug Regimen for Neonatal Opioid Withdrawal
0.04 mg/kg orally every 3–4 hours
10–20% every 2–3 days
0.05–0.1 mg/kg orally every 6 hours
10–20% every week
Adapted from Hudak ML, Tan RC, The Committee on Drugs, The Committee on Fetus and Newborn: Neonatal drug withdrawal. Pediatrics 129:E540–E560, 2012. doi: 10.1542/peds.2011-3212
The addition of clonidine 1 mcg/kg orally every 4 hours may reduce the duration of drug treatment needed in full-term infants. However, clonidine should not be given to premature infants because of the risk of bradycardia. If clonidine is used, blood pressure should be monitored as the clonidine dose is tapered because there can be rebound hypertension.
The incidence of SIDS Sudden Infant Death Syndrome (SIDS) Sudden infant death syndrome is the sudden and unexpected death of an infant or young child between 2 weeks and 1 year of age in which an examination of the death scene, thorough postmortem... read more is greater among infants born to women addicted to opioids but still is < 10/1000 infants, so routine use of home cardiorespiratory monitors is not recommended for these infants.
1. Grisham LM, Stephen MM, Coykendall MR, et al: Eat, sleep, console approach: A family-centered model for the treatment of neonatal abstinence syndrome. Adv Neonatal Care 19(2):138–144, 2019. doi: 10.1097/ANC.0000000000000581
2. Dodds D, Koch K, Buitrago-Mogollon T, Horstmann S: Successful implementation of the eat sleep console model of care for infants with NAS in a community hospital. Hosp Pediatr 9(8):632–638, 2019. doi: 10.1542/hpeds.2019-0086
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
The Opioid Exposed Newborn: Assessment and Pharmacologic Management: Scoring systems to help quantify the severity of withdrawal