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Management of neonatal drug withdrawal
Volume 92 Number 5
Editorial correspondence
practical. The method currently used is as follows: Careful measurement of the distance to the carina is made. The patient is then cautiously intubated with an endotracheal tube Of appropriate size. The tube is inserted with the tip and concave curve of the tube directed anteriorly. When it has been ascertained that the tip of the tube is at the carina (by approximating the measured distance), the endotracheal tube is slowly turned about 30 ~ to 45 ~ tO the left and slowly advanced. An associate may also turn the patient's head about 30 ~ to the right just prior to the turning of the endotracheal tube. A radiograph is then taken to ascertain the precise Position of the tube. We then follow the same precautions and procedures in management as those suggested by Dr. Brooks and associates. Gerald L. Dickman, D.O. 7532 N.W. 11 Oklahoma City, OK 73127 REFERENCE 1.
Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~OIATR 91:648, 1977.
Reply To the Editor: I appreciate Dr. Dickman's additional technical suggestions for intubation of the left bronchus. Chest auscultation has not been helpful to us in determining tube placement below the carina, since we have used this procedure only in severely affected patients with no clinical evidence o f air entry in the hyperinflated hemithorax. John G. Brooks, M.D. Assistant Professor Department of Pediatrics (Pulmonary) University of Colorado Medical Center 4200 E. Ninth Ave. Denver, CO 80262
Management of neonatal drug withdrawal To the Editor: During the last three years of managing and following prospectively an average of 52 heroin or methadone-addicted newborn infants per year at the Jefferson Davis Hospital, Houston, Texas (average deliveries 10,000 per year; 80% indigent black and Latin American population), we have documented only one seizure which could b e attributed solely to withdrawal.
861
At our nursery, infants are evaluated carefully for any symptoms of withdrawal in the delivery suite and the transitional nursery; even those who are asymptomatic are transferred automatically to one of the intensive care nurseries where evaluations of glucose, calcium, weight, vital signs, mottling, sweating, central nervous system irritability (hyper-reflexia, highpitched cry, tremors, hyperactivity, and irritability), gastrointestinal symptoms, and poor sucking are made routinely. We do not wait for gastrointestinal symptoms, hyperpyrexia, or severe manifestations of hyperexcitability before treating with paregoric. Possibly the high incidence of seizures (7.8% in the infants withdrawing from methadone; 1.2% in the infants withdrawing from heroin) in the study of Herzlinger, Kandall, and Vaughan 1 is due to: (1) more stringent criteria for the institution o f therapy, and (2) the use of nonphysiologic therapeusis; i.e. diazepam is not specific therapy for narcotic withdrawal, although it is certainly a proven anticonvulsant. Since diazepam use was discontinued after 1972, our major concern is that withdrawal symptoms in these infants (according to the authors' criteria for treatment, "progressive vomiting or diarrhea, hyperpyrexia, moderate or severe irritability and tremors, inability to sleep between feedings, or clinically apparent convulsions,") are allowed to progress to a rather severe degree before treatment is instituted, increasing the likelihood of Seizures and of further morbidity. Janette Goddard, M.D. Fellow, Pediatric Neurology Baylor College o f Medicine Geraldine S. Wilson, M.D. Assistant Professor o f Pediatrics Baylor College of Medicine Texas Medical Center Houston, TX 77030 REFERENCE 1.
Herzlinger RA, Kandall SR, and Vaughan HG Jr: Neonatal seizures associated with narcotic withdrawal, J PEDIATR 91:638, 1977.
Rep To the Editor: We thank Drs. Goddard and Wilson for their comments. Although our observed incidence of withdrawal-associated seizures conforms closely to published series, we recognize that other groups have observed lower incidences of such seizures. This may be related to a number of factors, such as exclusion of my oclonic jerks from the seizure group, nonrecognition of subtle seizures due to technique of care (e.g., swaddling of the infant in a darkened room), and geographic variations in maternal drug patterns. We cannot tell from the above letter whether any of these considerations apply. We agree that early institution of specific therapy might reduce the incidence of seizures. Since not all infants undergoing withdrawal will require treatment, however, and since treatment
Editorial correspondence
practical. The method currently used is as follows: Careful measurement of the distance to the carina is made. The patient is then cautiously intubated with an endotracheal tube Of appropriate size. The tube is inserted with the tip and concave curve of the tube directed anteriorly. When it has been ascertained that the tip of the tube is at the carina (by approximating the measured distance), the endotracheal tube is slowly turned about 30 ~ to 45 ~ tO the left and slowly advanced. An associate may also turn the patient's head about 30 ~ to the right just prior to the turning of the endotracheal tube. A radiograph is then taken to ascertain the precise Position of the tube. We then follow the same precautions and procedures in management as those suggested by Dr. Brooks and associates. Gerald L. Dickman, D.O. 7532 N.W. 11 Oklahoma City, OK 73127 REFERENCE 1.
Brooks JG, Bustamante SA, Koops BL, Hilton S, Cooper D, Wesenberg RL, and Simmons MA: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants, J P~OIATR 91:648, 1977.
Reply To the Editor: I appreciate Dr. Dickman's additional technical suggestions for intubation of the left bronchus. Chest auscultation has not been helpful to us in determining tube placement below the carina, since we have used this procedure only in severely affected patients with no clinical evidence o f air entry in the hyperinflated hemithorax. John G. Brooks, M.D. Assistant Professor Department of Pediatrics (Pulmonary) University of Colorado Medical Center 4200 E. Ninth Ave. Denver, CO 80262
Management of neonatal drug withdrawal To the Editor: During the last three years of managing and following prospectively an average of 52 heroin or methadone-addicted newborn infants per year at the Jefferson Davis Hospital, Houston, Texas (average deliveries 10,000 per year; 80% indigent black and Latin American population), we have documented only one seizure which could b e attributed solely to withdrawal.
861
At our nursery, infants are evaluated carefully for any symptoms of withdrawal in the delivery suite and the transitional nursery; even those who are asymptomatic are transferred automatically to one of the intensive care nurseries where evaluations of glucose, calcium, weight, vital signs, mottling, sweating, central nervous system irritability (hyper-reflexia, highpitched cry, tremors, hyperactivity, and irritability), gastrointestinal symptoms, and poor sucking are made routinely. We do not wait for gastrointestinal symptoms, hyperpyrexia, or severe manifestations of hyperexcitability before treating with paregoric. Possibly the high incidence of seizures (7.8% in the infants withdrawing from methadone; 1.2% in the infants withdrawing from heroin) in the study of Herzlinger, Kandall, and Vaughan 1 is due to: (1) more stringent criteria for the institution o f therapy, and (2) the use of nonphysiologic therapeusis; i.e. diazepam is not specific therapy for narcotic withdrawal, although it is certainly a proven anticonvulsant. Since diazepam use was discontinued after 1972, our major concern is that withdrawal symptoms in these infants (according to the authors' criteria for treatment, "progressive vomiting or diarrhea, hyperpyrexia, moderate or severe irritability and tremors, inability to sleep between feedings, or clinically apparent convulsions,") are allowed to progress to a rather severe degree before treatment is instituted, increasing the likelihood of Seizures and of further morbidity. Janette Goddard, M.D. Fellow, Pediatric Neurology Baylor College o f Medicine Geraldine S. Wilson, M.D. Assistant Professor o f Pediatrics Baylor College of Medicine Texas Medical Center Houston, TX 77030 REFERENCE 1.
Herzlinger RA, Kandall SR, and Vaughan HG Jr: Neonatal seizures associated with narcotic withdrawal, J PEDIATR 91:638, 1977.
Rep To the Editor: We thank Drs. Goddard and Wilson for their comments. Although our observed incidence of withdrawal-associated seizures conforms closely to published series, we recognize that other groups have observed lower incidences of such seizures. This may be related to a number of factors, such as exclusion of my oclonic jerks from the seizure group, nonrecognition of subtle seizures due to technique of care (e.g., swaddling of the infant in a darkened room), and geographic variations in maternal drug patterns. We cannot tell from the above letter whether any of these considerations apply. We agree that early institution of specific therapy might reduce the incidence of seizures. Since not all infants undergoing withdrawal will require treatment, however, and since treatment