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Heroin withdrawal syndrome
March, 1970 T h e Journal o/ P E D I A T R I C S
483
Letters to the Editor
Heroin ~vithdra~val syndrome To the Editor: It was with great interest that I read the article, "The course of the heroin withdrawal syndrome in n e w b o r n infants treated with phenobarbital or chlorpromazine," by Drs. Kahn, Newmann, and Polk (J. PEDIAT. 75: 495, 1969). At Metropolitan Hospital, we have had the opportunity in the past 9 years of observing and caring for 371 infants born of drug-addicted mothers. Sixty-six per cent of these manifested symptoms suggestive of withdrawal; only 70 per cent of these (47 per cent of our total series) eventually required treatment. We do not feel that in a research program the observation of mild, moderate, or severe tremors and irritability is sufficient indication for the initiation of treatment. We believe that symptoms must be progressive and increasing in intensity before treatment should be started, especially if one is to judge the effect of a routine of treatment, or to compare the effects of various drugs. We agree with Drs. Kahn, Newmann and Polk that these infants should be treated adequately to relieve the distress and discomfort that is evident. We also feel that unless these infants are in a study program, it is conceivable that all infants of drug-addicted mothers, even those with mild or moderate symptoms, may be treated early, rather than to wait for progressive symptoms to develop; and that treatment should be continued for as long as necessary, especially since the treatment is so simple and harmless. On the basis of our observations (to be published in the near future), it seems unlikely that the symptoms would stop after a period of only 4 days of treatment in infants manifesting extreme withdrawal. We have had the experience of symptoms coming under control in less than 10 days of treatment, but we have felt that these infants would have recovered without treatment. Approximately 50 per cent of our treated patients required between 10 and 21 days of treatment before recovery; another 27 per cent required up to 40 days of treatment before coming under control. We have seen the recurrence of symptoms in
a number of infants who were treated for periods of less than 7 days, several of whom were patients who had been signed out against advice while under treatment. Chlorpromazine has been our drug of choice. The infants as a rule respond within 24 hours and remain in quiet sleep from feeding to feeding. No evidence of drug toxicity has been observed in any of our patients. We have had little experience with phenobarbital. Since some of our infants present with evidence of respiratory distress at or shortly after birth, phenobarbital, because of its possible effect on the central nervous system, certainly would not be the drug of choice. The movie produced by Dr. Marvin Green and myself (available through Smith, Kline, French & Co.) presents clearly the typical symptoms of a patient with severe withdrawal, and should be the type of patient studied for the effects of any course of treatment. On the basis of some studies done at our institution, we believe that the intrauterine exposure to the drug-addicted mother does produce some subtle detrimental withdrawal effects that are not clinically evident. We do not believe that it is justifiable to exclude from mortality statistics those infants who die in the neonatal period for seemingly unrelated conditions. Our mortality rate is just under 4 per cent; included are all deaths that occur in the neonatal period of babies born to drug-addicted mothers for whatever reason.
Carl Zelson, M.D. Professor of Pediatrics Director Newborn Nursery New York Medical College--Metropolitan Hospital 1901 First Ave. New York, N. Y. 10029
Reply To the Editor: We appreciate Dr. Zelson's letter describing his experience in yet another of New York's municipal hospitals. It is difficult to evaluate his comments without the opportunity to study the basic data from which his conclusions are
Vol. 76, No. 3, pp. 483-486
483
Letters to the Editor
Heroin ~vithdra~val syndrome To the Editor: It was with great interest that I read the article, "The course of the heroin withdrawal syndrome in n e w b o r n infants treated with phenobarbital or chlorpromazine," by Drs. Kahn, Newmann, and Polk (J. PEDIAT. 75: 495, 1969). At Metropolitan Hospital, we have had the opportunity in the past 9 years of observing and caring for 371 infants born of drug-addicted mothers. Sixty-six per cent of these manifested symptoms suggestive of withdrawal; only 70 per cent of these (47 per cent of our total series) eventually required treatment. We do not feel that in a research program the observation of mild, moderate, or severe tremors and irritability is sufficient indication for the initiation of treatment. We believe that symptoms must be progressive and increasing in intensity before treatment should be started, especially if one is to judge the effect of a routine of treatment, or to compare the effects of various drugs. We agree with Drs. Kahn, Newmann and Polk that these infants should be treated adequately to relieve the distress and discomfort that is evident. We also feel that unless these infants are in a study program, it is conceivable that all infants of drug-addicted mothers, even those with mild or moderate symptoms, may be treated early, rather than to wait for progressive symptoms to develop; and that treatment should be continued for as long as necessary, especially since the treatment is so simple and harmless. On the basis of our observations (to be published in the near future), it seems unlikely that the symptoms would stop after a period of only 4 days of treatment in infants manifesting extreme withdrawal. We have had the experience of symptoms coming under control in less than 10 days of treatment, but we have felt that these infants would have recovered without treatment. Approximately 50 per cent of our treated patients required between 10 and 21 days of treatment before recovery; another 27 per cent required up to 40 days of treatment before coming under control. We have seen the recurrence of symptoms in
a number of infants who were treated for periods of less than 7 days, several of whom were patients who had been signed out against advice while under treatment. Chlorpromazine has been our drug of choice. The infants as a rule respond within 24 hours and remain in quiet sleep from feeding to feeding. No evidence of drug toxicity has been observed in any of our patients. We have had little experience with phenobarbital. Since some of our infants present with evidence of respiratory distress at or shortly after birth, phenobarbital, because of its possible effect on the central nervous system, certainly would not be the drug of choice. The movie produced by Dr. Marvin Green and myself (available through Smith, Kline, French & Co.) presents clearly the typical symptoms of a patient with severe withdrawal, and should be the type of patient studied for the effects of any course of treatment. On the basis of some studies done at our institution, we believe that the intrauterine exposure to the drug-addicted mother does produce some subtle detrimental withdrawal effects that are not clinically evident. We do not believe that it is justifiable to exclude from mortality statistics those infants who die in the neonatal period for seemingly unrelated conditions. Our mortality rate is just under 4 per cent; included are all deaths that occur in the neonatal period of babies born to drug-addicted mothers for whatever reason.
Carl Zelson, M.D. Professor of Pediatrics Director Newborn Nursery New York Medical College--Metropolitan Hospital 1901 First Ave. New York, N. Y. 10029
Reply To the Editor: We appreciate Dr. Zelson's letter describing his experience in yet another of New York's municipal hospitals. It is difficult to evaluate his comments without the opportunity to study the basic data from which his conclusions are
Vol. 76, No. 3, pp. 483-486