TOPIC 41: Substance Use Disorder – Recognize, Evaluate, and Manage Health Issues in an Infant Born to a Mother with a Substance Use Disorder
OFFICIAL ABP TOPIC: 41
Recognize, evaluate, and manage health issues in an infant born to a mother with a substance use disorder
BACKGROUND
Substance use disorder is characterized by the persistent use of substances such as alcohol and opioids despite harmful consequences. Substance use during pregnancy can have detrimental short- and long-term effects on the fetus. Infants born to mothers with substance use disorder are at risk for neonatal abstinence syndrome, IUGR, prematurity, and microcephaly, as well as long-term cognitive and behavioral issues.
EVALUATING THE SUBSTANCE-EXPOSED NEONATE
MATERNAL AND NEONATAL RED FLAGS FOR SUBSTANCE EXPOSURE
|
CATEGORY |
MATERNAL |
NEONATAL |
|
History |
– Late/absent prenatal care – Polysubstance use |
– IUGR – Preterm delivery – Low birthweight |
|
Clinical Signs |
– Placental abruption – Acute hypertensive episodes |
– Microcephaly – Withdrawal signs (e.g., jitteriness, irritability) |
NEONATAL ABSTINENCE SYNDROME (NAS)
NAS refers to neonatal withdrawal from in utero exposure to drugs. It most commonly occurs after exposure to opioids, but it can also occur with benzodiazepines, antidepressants, nicotine, and alcohol and is often more severe in polysubstance use disorder that includes opioid use.
Clinical features of NAS include:
- Fragmented sleep cycles and difficulty staying alert
- Hypertonicity, tremors, and jitteriness
- Autonomic dysfunction (sweating, sneezing, nasal congestion, yawning, fever, tachypnea)
- Sensitivity to minimal stimuli, causing irritability and a high-pitched cry
- Vomiting, loose stools, feeding difficulties, and poor weight gain
Diagnosis of NAS is based on maternal substance use (on history or toxicology screen) and at least two of the withdrawal signs and symptoms above. A positive drug test on umbilical cord blood or the infant’s first void or meconium can help confirm the diagnosis but is not required.
The Modified Finnegan Scoring Tool should be used to quantify withdrawal severity in all substance-exposed newborns even if they are not showing signs of withdrawal.
- Scoring starts at birth and continues every 3-4 hours throughout hospitalization.
- Opioid-exposed newborns are monitored for a minimum of 96 hours before discharge.
For infants with suspected exposure to substances, history should include amount and frequency of maternal use of nicotine, alcohol, illicit drugs (e.g., cocaine, opioids, methamphetamines, marijuana, PCP), and prescription drugs (opioids, benzodiazepines, SSRIs). In addition to evaluating for signs of withdrawal, a thorough physical exam should include assessment for other sequelae of substance exposure, such as fetal alcohol spectrum disorder.
SUBSTANCE-SPECIFIC COMPLICATIONS
|
PERINATAL COMPLICATIONS |
LONG-TERM COMPLICATIONS |
|
|
Nicotine |
Low birth weight, preterm birth, SIDS |
Cognitive/behavioral issues, ADHD |
|
Alcohol |
Fetal alcohol spectrum disorder (short palpebral fissures, thin vermilion border, smooth philtrum, CNS abnormalities), IUGR |
Learning disabilities, impulsivity |
|
Opioids |
NAS (50-95% incidence), microcephaly, possible congenital malformations |
Cognitive/behavioral delays, ADHD |
|
Cocaine |
Placental abruption, IUGR |
Executive function deficits |
|
Methamphetamines |
Prematurity, IUGR |
Motor delays, behavioral problems |
In addition, other conditions that overlap with or mimic NAS should be considered.
DIFFERENTIAL DIAGNOSIS FOR NAS-LIKE PRESENTATIONS
|
CONDITION |
KEY FEATURES |
EVALUATION |
|
Sepsis |
Lethargy, poor feeding, temperature instability |
Blood cultures, CBC, CRP |
|
Hypoglycemia |
Jitteriness, hypotonia, apnea |
Blood glucose level |
|
Hypoxic-Ischemic Encephalopathy |
Altered tone, seizures, abnormal respiratory effort |
Neuroimaging (MRI/CT), EEG |
|
Genetic Syndromes |
Dysmorphic features, congenital anomalies |
Karyotyping, genetic testing |
|
NAS |
Tremors, high-pitched cry, poor feeding |
Finnegan scoring, maternal history, toxicology |
MANAGEMENT OF NAS
Non-Pharmacologic Interventions
These non-pharmacologic interventions are for all substance-exposed newborns regardless of NAS score:
- Provide a quiet, low-stimulation environment (e.g., dim lighting, minimized noise).
- Promote parent-newborn bonding with rooming-in and skin-to-skin contact.
- Breastfeed when appropriate and safe (breastfeeding is contraindicated if the mother is using cocaine, marijuana, or hallucinogens such as PCP).
Pharmacologic Treatment
- Indications: Initiate treatment if Modified Finnegan scores persistently exceed 8.
- First-Line Therapies: Use oral morphine or methadone; adjust doses based on symptom control.
- Adjunctive Therapies: Consider clonidine or phenobarbital for refractory cases.
PHARMACOLOGIC TREATMENT OVERVIEW
|
Medication |
Indication |
Dosing |
Notes |
|
Morphine |
First-line for NAS |
0.03-0.05 mg/kg every 3-4 hours |
Monitor for respiratory depression |
|
Methadone |
Alternative first-line |
Dosing varies; start at 0.05-0.1 mg/kg/day |
Long half-life; harder to titrate |
|
Clonidine |
Adjunctive for refractory NAS |
0.5-1 mcg/kg every 4-6 hours |
Monitor for hypotension |
|
Phenobarbital |
Adjunctive if benzodiazepine exposure suspected |
Loading: 10-20 mg/kg; Maintenance: 5 mg/kg/day |
Risk of sedation, neurodevelopmental delays |
ONGOING MANAGEMENT OF THE SUBSTANCE-EXPOSED INFANT
All babies born to mothers who abuse licit or illicit substances during pregnancy would likely benefit from long-term developmental follow-up and early intervention services.
- Providers should be aware of local legal requirements to report prenatal substance use in collaboration with social services providers. The U.S. Child Abuse Prevention and Treatment Act requires healthcare professionals to refer infants with prenatal substance use exposure and their caregivers to family support programs called Plans of Safe Care.
- Monitor growth, feeding, and developmental milestones during frequent office visits.
- Refer to early intervention programs for developmental support and assessments.
- Support maternal mental health and substance abuse treatment programs to optimize long-term outcomes.
REFERENCES
https://www.uptodate.com/contents/neonatal-abstinence-syndrome-nas-management-and-outcome
https://www.uptodate.com/contents/neonatal-abstinence-syndrome-nas-clinical-features-and-diagnosis