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PEDIATRICS (ISSN 0031 4005). Copyright © 1983 by the
American Academy of Pediatrics.
0 Committee on Drugs
AMERICAN ACADEMY OF PEDIATRICS 895
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 failureto 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,
0
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 WITHDRAWALFROM 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
Each nursery should adapt one of the abstinence
scoring methods to judge the need for drug therapy
as nurses and doctors often become sympathetic
with the jittery and frantic behavior observed in
the infant and are prone to begin drug therapy for
subjective reasons.’6’8 An abstinence scoring sheet
results in the use of more objective criteria for
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w = WakefulnessI = Irritability
T = Tremulousness, temperature variation, tachy-pnea
H = Hyperactivity, high-pitched persistent cry, hy-peracusia, hyperreflexia, hypertonus
D = Diarrhea, diaphoresis, disorganized suckA = Rub marks, respiratory distress, rtiinorrheaA = Apneic attacks, autonomic dysfunctionW = Weight loss or failure to gain weightA = Alkalosis (respiratory)L = Lacnmation
Fig 1. Symptoms of neonatal drug withdrawal.
GENERIC NAME
amitriptyline
chlordiazepoxidechlorpromazineclomipramineclonidinediazepamdiphenhydramineethchlorvynolhydroxyzineimipraminelithium
mependinemeprobamatemethadonepentazocinephenobarbital
propoxyphenetheophylline
trifluoperazine
TRADE NAMES
Elavil, Endep, Enovil,SK-Amitnptyline
Librium
Thorazine(investigative drug)CatapresValiumBenadrylPlacidylAtarax, Orgatrax, VistanlImavate, SK-Pramine, TofranilEskalith, Uthane, Lithobid,
Lithonate, LithotabsDemerolEquanil, Meprospan, MiltownDotophineTalwinLuminal, SK-Phenobarbital,
Sedadrops, SolfotonDarvon, Dolene, SK-65Bronkodyl, Elixophyllin,
Somophyllin-T, Slo-Phyllin,Theostat, Theolair,Theophyl
Stelazine
Fig 2. Glossary of drugs. Trade names are listed inaccordance with the AMA Drug Evaluation, ed 5 (Chi-cago, American Medical Association), 1983.
0
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896 NEONATAL DRUG WITHDRAWAL
determining when pharmacologic treatment is nec-essary and whether a drug dose should be advancedor decreased. Supportive cane in the form of intra-
venous fluids and replacement electrolytes may benecessary to stabilize the infant’s condition in the
acute phase without the need for pharmacologicintervention.
Indications for drug treatment include vomitingand diarrhea that result in excessive weight loss or
dehydration, inability of the infant to sleep, feverunrelated to infection, and seizures. It is essentialthat 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. oPHARMACOLOGIC 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 pressureexerted at nursing, and more weight gain thaninfants treated with diazepam or phenobarbital.’9
Paregoric contains anhydrous morphine (0.4 mg/mL). In addition, it contains opium alkaloids whichconsist of isoquinoline derivatives (nancotine and
papavenine) which are antispasmodics and phen-
anthrene derivatives (morphine and codeine) whichare analgesics and narcotics. Paregoric containscamphor, a CNS stimulant that is eliminated from
the body slowly because of its high lipid solubilityand the need for glucuronic conjugation for urinaryexcretion. Paregoric contains a high concentration
ofalcohol (44% to 46%), which is a CNS depressant,
and anise oil, which may cause habituation. Benzoicacid (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 opiumin 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
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AMERICAN ACADEMY OF PEDIATRICS 897
same concentration of morphine equivalent as par-
egoric (0.4 mg/mL morphine equivalent) without
the additives (camphor, anise oil, benzoic acid, or0 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 hasbeen 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 usedin 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 syndromehas been treated with methadone. The prolonged
0 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 gastrointestinalsymptoms 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
reflex, and may delay the bonding between motherand infant. Elixirs of phenobanbital contain 14% to25% alcohol. The parentenal forms contain pnopyl-
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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 totalcare 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 infa�itafter 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 andwith 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 forsubacute 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 thedrug for a longer period of time than is indicated
or they may use the drug to supply their own needfor 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 thephysical and mental development of any infant whois withdrawing from maternal drugs.
AGENTS PRODUCING SYMPTOMS SIMILARTO 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 observedin 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 pharmacologicagents 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 pharma-
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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 mineEthchlorvynol
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
and the natural course of the symptoms may have been shortened.
899
Alcohol Hyperactivity, crying, irritability; poor suck,
tremors, convulsions, onset of symptoms atbirth, 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 at10-14 d of age
Bromide Lethargy, dilated pupils, hypotonia, hyper-tonus, high-pitched cry, feeding difficulty, �reflexes
Chlordiazepox- Irritability, tremors; symptoms may start at 21ide d
Chlorpromazine Extrapyramidal dysfunction, intention tremor,opisthotonos, mask-like facies; onset 1st 24-36 h
Clomipramine Hypothermia, cyanosis, tremors; onset 12 h ofage
Breathelessness, cyanosis, � ilR, I RR, diapho-resis, irritability, feeding difficulty, weightloss
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 receivingmultiple-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 ofabdomen before voiding
Lithium Respiratory distress, lethargy, cyanosis, poorsuck, 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
9 mo, 2-3 d-Rx I 53,57
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TABLE 2. Pharmacologically Active Excipients inProducts Used to Treat Neonatal Withdrawal*
* Abbreviations used are: P, parenteral; po, per os (by
mouth).
0
0
0
REFERENCES
1. Cobrinik RW, Hood RT Jr, Chusid E: The effect of maternalnarcotic addiction on the newborn infant. Review of theliterature and report of 22 cases. Pediatrics 1959;24:288
2. Blatman S, Lipsitz PJ: Children of women maintained onmethadone: Accidental methadone poisoning of children, inFourth National Conference on Methadone Treatment, San
Francisco, Jan 8-10, 1972. New York, National Associationfor the Prevention of Addiction to Narcotics, Publisher,
1972, p 1753. Fisch GR, Henley WL: Symptoms of narcotic withdrawal in
a newborn infant secondary to medical therapy of themother. Pediatrics 1961;28:852
4. Mangurten HH, Benawra R: Neonatal codeine withdrawalin infants of nonaddicted mothers. Pediatrics 1980;65:159
5. Goetz RL, Bain RV: Neonatal withdrawal symptoms asso-
ciated with maternal use of pentazocine. J Pediatr1974;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 withmaternal use of propoxyphene hydrochloride (Darvon). JPediatr 1974;85:684
8. Wilson GS, Desmond MM, Verniaud WM: Early develop-
ment of infants of heroin-addicted mothers. Am J Dis Child1973;126:457
9. Rosen TS, Pippenger CE: Disposition of methadone and its
relationship to severity ofwithdrawal in the newborn. AddictDis 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 phenothiazineagent.4’
Infants who are withdrawing from maternally
acquired barbiturates should be administeredphenobarbital if pharmacologic treatment is nec-
essary. The therapeutic plasma level necessary to
treat barbiturate withdrawal is not known. Thecalculated loading dose (10 to 15 mg/kg/24 h) ofphenobarbital should be given in divided doses over
a 24-hour period and followed by a maintenancedose of 3 to 5 mg/kg/24 h. Blood levels should be
monitored to prevent intoxication. Infants rarelyrequire phenobarbital administration for longerthan 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 andthen 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, MDHoward 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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AMERICAN ACADEMY OF PEDIATRICS 901
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 drugabusers, 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;2:33315. Hill RM, Desmond MM: Management of the narcotic with-
drawal syndrome in the neonate. Pediatr Clin N Am1963;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
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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 thethreads of their previous life. Specifically, when Lucy began to repaper their
new house, some of the volunteers acted shocked and even hostile. The reactionwounded 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.
0
0
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