Cleofe J. Chavez

A study of factors that influence the severity of neonatal narcotic withdrawal

1. History is unreliable in assessing maternal drug habit. Morphine was detected in significant amounts in maternal and fetal urine regardless of whether the mother was on a methadone program or whether she denied any use of heroin during the last trimester of pregnancy. 2. Infants born to drug-addicted mothers were, in general, of birthweight normal and appropriate for gestational age (i.e., greater that 10th percentile). The infants born to mothers on a methadone clinic program had a higher birthweight compared to those whose mothers were not on any methadone program. 3. In order of frequency, the signs and symptoms of withdrawal were: central nervous system manifestations-fist sucking, irritability, tremors, sneezing, high-pitch cry, hypertonia; vasomotor in the form of stuffy nose; and gastrointestinal in the form of sweating, diarrhea, vomiting and yawning. Convulsions were not noted. No death occurred. 4. The severity of neonatal narcotic withdrawal did not correlate with the infants gestational age, APGAR, sex or race; nor with maternal age, parity, duration of heroin addiction or duration of methadone intake. Also, it did not correlate with the total morphine level measured either in infants or mothers urine or in cord blood. The serum levels of calcium and glucose were normal and identical in either mild or severe withdrawal. 5. The severity of neonatal withdrawal correlated significantly with the methadone dose per day of the mother (in initial, final or average dose). A maternal methadone dose of more than 20 mg per day was associated with a higher incidence of moderate to severe withdrawal in their babies. As a corollary, it was also noted that infants whose mothers were on a high methadone dose (i.e., greater than 20 mg per day) had a greater postnatal weight loss despite a significantly higher birthweight initially, and stayed in the hospital longer. 6. Finally, the modification of the environment to reduce external stimuli to the infant born to a drug-dependent mother, does not prevent or diminish the severity of neonatal narcotic withdrawal. Thus, there is no need to manage these infants in a special nursery.

Sudden infant death syndrome among infants of drug-dependent mothers

F E W R E P O R T S describe an associat ion be tween sudden infant death and maternal prenatal addiction?, 2 Recognition of this association is essential for two reasons: (1) there is an increase in the incidence of drug abuse among women of childbearing age; and (2) methadone, the drug currently in use to treat opiate addiction, is also a narcotic. A combined maternal methadone and infant follow-up clinic provided the authors with the opportunity to follow infants born to drug-dependent mothers. The durgs principally Used by the women were heroin and methadone; the use of other drugs, however, namely diazepam. barbiturates, cocaine, amphetamines, and alcohol, was common. The reports of sudden infant death, as related by the addicted mothers, prompted us to investigate this problem.

Perinatal problems (excluding neonatal withdrawal) in maternal drug addiction: A study of 830 cases

However, not every child with ambiguous genitalia needs a bone marrow karyotype. Determination of the chromosomal sex is only one factor in the evaluation of such an infant, and the sex of rearing may depend on the prospect for functional repair, rather than the genetic sex. Bone marrow karyotyping on the first day of life, before a complete evaluation of the external and internal genitalia and the metabolic status have been carried out, could lead the parents to over-value this one piece of information and might interfere with their ability to make a rational decision in choosing the most appropriate gender for their child. We recommend that bone marrow chromosome analysis in newborn infants should be utilized only when the following three criteria have been met: (1) There is a strong clinical suspicion of a chromosomal syndrome known to be associated with a severe defect in brain development. (2) Immediate surgical treatment or assisted ventilation or both are required to sustain life. (3) The parents and physicians are prepared to take action depending on the outcome of the procedure.

235 SUDDEN INFANT DEATH SYNDROME (SIDS) AMONG INFANTS OF DRUG DEPENDENT MOTHERS (IDDM)

Sudden unexpected death among IDDM is a major medical problem. Our experience at Hutzel Hospital shows a very high incidence of SIDS among the IDDM (17/1000). A retrospective study of IDDM was performed to determine if any neonatal factors exist which may predispose to sudden unexpected infant death.RESULTS: From 9/74 to 9/77 a total of 637 fullterm IDDM weighing at least 2268 g were delivered. Using the criteria previously reported, the severity of neonatal drug withdrawal was assessed: 89% (564/637) had minor to mild (MM) and 12% (73/637) moderate to severe (MS) withdrawal. Two percent (14/637) were later reported to have died of SIDS. A significantly higher number of infants with MS (6/73) died of SIDS compared to those with MM withdrawal (8/564), x2=9.060, p<0.01. Those who died had no significant medical problems during the neonatal period. All died between 4-16 weeks of age: 57% in Winter, 21% in Summer and 21% in the Fall.CONCLUSION: 1) The frequency of SIDS is higher among IDDM compared to the general population. 2) A significantly higher incidence of infants with MS withdrawal died from SIDS compared to those who had lesser degrees of withdrawal. 3) Since there is a correlation between maternal methadone dose and severity of neonatal withdrawal (J Pediat, April/76), the use of low methadone dosage during pregnancy is strongly recommended.

Perinatal problems (excluding neonatal withdrawal) associated with maternal drug addiction: a review of 830 cases

This study shows that besides neonatal withdrawal, there are other important complications during pregnancy and postnatal period that we should be aware of when dealing with the pregnant drug addict. This study is based on a review or 830 cases covering the period from 1972-76.Among the maternal problems, a high incidence of the following conditions were noted: maternal age <20 yrs (17%), meconium stained amniotic fluid (13%), anemia (13%), PROM (12%) and infection (10%). As for infection, venereal disease (57%) urinary tract infection (15%) and hepatitis (6%) were the most common. There was a uniform 3-5% incidence of abruptio placenta, hypertension and toxemia. The Apgar score was <6 at 1 minute in 20% of the infants. Birth weight <2.5 kg occurred in 31%. Of the total infants 19% were premature and 16% were SGA.The postnatal problems that occurred (excluding withdrawal) were: jaundice (14%), infection (11%), aspiration (including meconium) pneumonia (9%), transient tachypnea (7%) and HMD (5%). Congenital malformations were noted in 4% of the infants with the major anomalies involving principally the genitourinary system. A total of 22 (2.6%) infants died. Thirteen (13) were premature with severe HMD and 9 were fullterm (5 with meconium aspiration and 4 with major congenital anomalies).SUMMARY: (1) The lifestyle of the pregnant addict predisposes her and her infant to a nigh incidence of infection, particularly venereal disease, (2) the high incidence of meconium stained fluid and low Apgar score in the infant indicate that fetal withdrawal leading to asphyxia is a serious and not an uncommon complication during the prenatal period, (3) postnatally, despite the high incidence of low birth weight and prematurity, the aspiration syndromes, particularly meconium aspiration, constitute the major pulmonary problem and a leading cause of death in the infant.

A STUDY OF FACTORS THAT INFLUENCE THE SEVERITY OF NEONATAL NARCOTIC WITHDRAWAL

A prospective study of 198 infants of drug dependent mothers included: (1) history of maternal drue habit, (2) measurement in infants urine of total morphine & qualitative detection of other drugs by gas chromatograph, (3) evaluation of severity of neonatal withdrawal by a scoring system & (4) study of the effect of a modified environment (quiet, warm, dimly lit & frequent feeding) on withdrawal.RESULTS: (1) history is unreliable in assessing maternal drug habit. Mean morphine levels of 1.02 & 0.99mg% were found in the urine of infants whose mothers claim non-usage of heroin for 1-3 months before delivery, respectively. (2) severity of neonatal withdrawal did not correlate with infants urine morphine level range 0-9.4 mg%, P<0.35), but correlated significantly to maternal methadone dose (P<0.005). None to mild withdrawl was seen in mean maternal methadone dose of 21.9 mg/day vs. 31 mg/day in moderate to severe withdrawl. The duration of methadone intake did not correlate with severity of withdrawl. (3) in order of decreasing frequency the S & S of withdrawal were: fist-sucking, irritability, tremors, sneezing, shrill cry, hypertonia, stuffy nose, sweating, diarrhea, vomiting and yawning. Convulsion was not noted. No death occurred. Mean birthweight = 2885 ± 454 g & gest. age = 39 ± 1.1 wks. (> 10th percentile). Mean weight loss = 160.5 g (4)the control (C) & experimental (E) groups for modified environment study were matched for weight, sex, gest. age and maternal methadone dose. The incidence of mild withdrawal was 68% (C) vs. 71% (E); of moderate withdrawal, 27% (C) vs. 26% (E): of severe withdrawal, 5% (C) vs. 3% (E). The difference between the 2 groups was not significant. (5) the qualitative detection of other drugs in the infants urine will be presented.

EVALUATION OF A NEONATAL RECOVERY ROOM UNIT |[lpar]|NRRU|[rpar]|

A number of hospitals still exist with their neonatal ICU not within the vicinity of the delivery rooms. This means transporting compromised & unstable infants some distance to reach the ICU. At Hutzel Hosp. this problem was solved by the use of a NRRU in the delivery suite. This report evaluates our experience. The NRRU was designed as a miniature ICU & can accomodate 2 infants. High-risk infants with problems during delivery and those born with low APGAR scores were admitted to the NRRU for observation, stabilization of vital signs and/or further treatment. A nurse from the neonatal ICU was called to the NRRU if a patient was anticipated. The infants were transferred out of the NRRU only after vital signs had stabilized & skin temp. was at least 97 F.RESULTS: During a 10-month period, 54 newborns were admitted to the NRRU: (1) transfusion for severe Rh (9%), (2) tracheal lavage due to meconium aspiration (6%), (3) APGAR (1 min) less than 5 (67%) & (4) normal APGAR but high-risk newborn (18%). The mean 1 min. APGAR = 3.6 ± 2.7 with 89% requiring resuscitation. Mean birthweight = 2183 ± 954 g. Mean duration of stay = 48.3 min. 43% of those admitted subsequently died but this group had a significantly lower gestational age, weight & APGAR score compared to those who survived (P<0.005). It cannot be concluded whether the NRRU has improved survival but the 58% survival of infants with mean APGAR of 3.6 is encouraging. One factor for this might be the better temp. of the babies upon arrival at the ICU (97.1±0.9). In contrast, skin temp. on admission to the NRRU = 95.8 1.2F. It was also noted that working in the NRRU was more convenient because a pediatric nurse assisted & necessary equipment was on hand. The NRRU also prevented the holding up of a delivery room (mean = 48.3min.) because of an infant. This allowed more time for the infant to stabilize completely before being transported. It is felt that a NRRU can be used for optimal care to infants.