Changing drug withdrawal patterns in newborns mean new therapies needed, says UF pediatrician

Opioid pain relievers prescribed to pregnant women have been linked to increasing rates of drug withdrawal among newborns, and that means new diagnosis and treatment approaches are needed, a UF pediatrics expert says.

Those higher rates have led to the first comprehensive update and review of the issue by the American Academy of Pediatrics in a decade. The new report, co-authored by Mark L. Hudak, M.D., a professor and associate chairman of pediatrics at the UF College of Medicine-Jacksonville, was published in the February edition of the journal Pediatrics.

“The more we study the signs of opioid withdrawal and the possible treatments, the more we’ll be able to help these babies,” Hudak said.

Exposure to drugs while in the womb can cause abnormalities in body structure, impair development of the brain and central nervous system and result in drug withdrawal symptoms in newborns.

Diagnoses of neonatal drug withdrawal in Florida are 10 times higher than they were in 1995, according to the Florida Department of Health. Nationally, diagnoses have nearly doubled over the same period, according to the federal Agency for Healthcare Research and Quality. Pockets of the country — such as Florida, with its proliferation of “pill mills” that provided relatively easy and clandestine access to prescription opioids — witnessed higher surges in neonatal drug withdrawal than other locales.

In addition to addressing the consequences to and treatment of babies exposed prenatally to maternal opioids, the updated pediatrics report discussed how to treat babies who develop drug dependency after receiving needed medication for pain and sedation because of prolonged critical illnesses.

The study tells physicians what to look for and steps to take if they see signs of withdrawal. Doctors can test a baby’s urine and stool for trace amounts of drugs to determine if the baby is at risk for withdrawal. Treatment includes preventing overstimulation by keeping the baby in a dark, quiet environment, rocking or swaying the child for comfort, and providing frequent small feedings to replenish excess calories burned or lost through vomiting, regurgitation or loose stools. Occasionally, intravenous fluids need to be given. Drug therapy is used to relieve signs of moderate or severe withdrawal.

Additional studies are needed to identify the optimal treatment for babies, said Hudak, chief of neonatology at the UF College of Medicine-Jacksonville. Hudak was a member of the American Academy of Pediatrics committee on drugs when he co-authored the paper.

The increase in rates of neonatal drug withdrawal is partly because physicians have become more aware of the problem and look for it more. But the main cause is more widespread use of opioids by expectant mothers. What is interesting is a dramatic shift in the types of drugs that show up most often among newborns according to the report.

A decade ago, the most common cause for withdrawal in newborns was maternal abuse of “street” opioids such as heroin, or supervised treatment with methadone to prevent drug withdrawal symptoms and craving for illicit drugs. Today, prescription pain medications that contain opioids such as oxycodone and hydrocodone are increasingly responsible for the withdrawal syndrome seen in babies.

“There is definitely an increase in the number of babies with signs of withdrawal where the mother was legitimately treated for pain by a primary care physician or other medical specialist,” Hudak said.

The challenge for physicians who treat mothers with chronic pain is to prescribe the minimum effective dose of opioid needed or find alternative classes of medication that will not cause infants to have withdrawal. In some cases, interventions such as physical therapy might reduce reliance on drug therapy.

The rapid shift in the causes of neonatal drug withdrawal is one of the reasons the treatment policy was updated, said Daniel Frattarelli, M.D., chairman of pediatrics at Oakwood Hospital in Dearborn, Mich., and chairman of the American Academy of Pediatrics committee on drugs. “The pattern among babies born with signs of withdrawal has changed quite a bit,” he said. “Even five years ago, it was all street drugs.”