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Narcotic addiction in a newborn infant
NARCOTIC ADDICTION IN A NEWBORN INFANT
LI'~VANAG P. ROI~IAN, M.D.,* AND J. NEAL ST. Louis, Me. DDICTION, as defined by the Drug Addiction Committee of the National Research Council, 1 is a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated administration of a drug; its characteristics are a compulsion to continue to take the drug" and to increase the dose, with the development of psychic and sometimes physical dependence on the drug, so that the development of means to continue the administration of the drug becomes an important motive in the addict's existence. Infants born of nareotie-addicted mothers are said to show a more or less characteristic syndrome. Recel~tly, we have had a premature infant, born of a mother who was an addict to heroin, who developed this syndrome.
A
CASE
REPORT
Baby R. S., a 4-pound i21/~-ounce premature male infant, was born at the Homer G. Phillips Hospital on March 15, 1957, of a heroin-addicted mother who had apparently given herself heroin intravenously four hours before coming to the hospital for admittance. The physical examination of the infant after delivery was entirely negative for any abnormal findings except for slight subcostal retractions. He was immediately placed in a preheated incubator. F r o m t h e D e p a r t m e n t of P e d i a t r i c s , H o m e r G. P h i l l i p s H o s p i t a l . * C h i e f R e s i d e n t in P e d i a t r i c s , H o m e r G. Phillips Hospital. * * S u p e r v i s o r , H o m e r G. P h i l l i p s H o s p i t a l ; Assistant Professor, Department of Pediatrics, W a s h i n g t o n U n i v e r s i t y S c h o o l of M e d i c i n e .
231
~[IDDELKAMP,
M.D.**
Eight hours later, the infant developed a temperature elevation of 101.4 ~ F. axillary. He was observed to be hyperactive and crying very frequently. At this time, the patient's mother was also reported to be having withdrawal symptoms f o r which she was give~ Sparine. Since there were no other symptoms found in the infant, no treatment was given. Sixteen hours after birth he developed excessive irritability manifested by twitchings of all extremities, but without actual convulsions, and a very shrill cry. The irritability was such that a mere tap on the patient's incubator would produce twitchings of all the extremities accompanied by a shrill cry as if in pain. The p a t i e n t was placed immediately on ~6 grain of sodium phenobarbital and 4 drops of paregoric every 6 and 4 hours, respectively, for 24 hours. He remained asymptomatie and the dosage was decreased to 88 grain of sodium phenobarbital every 12 hours, and paregoric, 2 drops every 4 hours, for the next 24 hours. The third day after medications were started he received paregoric, 2 drops every 8 hours, and sodium phenobarbital, 1/16 grain once. All medication was then discontinued, and he remained asymptomatic thereafter. Being" premature, this infant was given artificial feedings. He gained weight after the usual initial loss. At 15 days of age, the patient developed mild diarrhea. He was placed on antibiotics, and his formula was altered, with improvement of the diarrhea within 24 hours. Two days later he developed vomiting, but this was promptly controlled. The patient then gained weight steadily, and he was discharged asymptomatie weighing 5 pounds.
232
THE JOURNAL OF PEDIATRICS
The child was followed in our Prem a t u r e Clinic. The last visit was Dec. 3, 1957, at 9 months of age, when he weighed 18 pounds 121/~ ounces. He was doing well in a foster home on regu l a r baby foods, formula, and vitamins. DISCUSSION
The early recognition b y obstetricians and pediatricians of narcotic withdrawal symptoms in infants is extremely i m p o r t a n t for survival. Goodfriend ~ emphasized this when he reported the over-all m o r t a l i t y in infants showing withdrawal s y m p t o m s as 33.8 per cent, with a 93.2 per cent mortality when this condition was unrecognized and no t r e a t m e n t was given. Diacetylmorphine (heroin), a synthetic morphine derivative made by aeety]ation of both O H groups with a formula of CHsC0.0.Cl~H170N.O. OCCHa and a molecular weight of less t h a n 400, readily passes through the placenta and appears in the fetal blood and tissues within an hour or so a f t e r administration to the mother. I t is transplacental t r a n s f e r t h a t produces reaction in the fetus. Terwilliger and H a t c h e r ,~ were able to demonstrate only a trace of morphine in the breast milk of an addict taking 128 rag. of morphine daily and concluded that v e r y little narcotic could be t r a n s f e r r e d in this manner. The onset of symptoms in the inf a n t will frequently coincide with the onset of withdrawal symptoms in the mother, if the mother did not i'eceive narcotics after her delivery. The s y m p t o m s manifested by these infants are progressive irritability, restlessness, crying, yawning', and diaphoresis. Some authors report diarrhea, which, when associated with vomiting, has led to inanition. Also, convulsions and collapse have been observed. How-
ever, not all infants delivered of addicts manifest these symptoms, nor do they all require treatment. Goodfriend 2 reported ten patients, four of which manifested withdrawal symptoms and were treated. Steg 6 reported three eases, none of which required treatment. H a p p e P reported twelve eases, all of which were treated with paregoric. Barbiturates, morphine, and paregoric are the drugs most commonly used in the t r e a t m e n t of these infants. To and Oh 4 of J a p a n reported twentynine eases in which the mother treated the infants by blowing opium smoke in their faces. Our patient developed s y m p t o m s a f t e r delivery which we felt were severe enough to require treatment. He responded very well to t r e a t m e n t with barbiturates and paregoric. W e believe that the diarrhea which developed at 15 days of age in our i n f a n t was not related to the narcotic addiction. CONCLUSION
1. I n f a n t s delivered of narcotic-addicted mothers m a y present typical withdrawal symptoms, as our p a t i e n t did. 2. E a r l y diagnosis and institution of p r o p e r treatment, if s y m p t o m s are severe enough, are important. REFERENCES 1. Goodman, L. S., and Gillman, A.: The Pharmacological Basis of Therapeutics, ed. 2, New York, 1955, The Macmillan Co., pp. 134-135. 2. Goodfriend, M. J., Shey, I. S., and Klein, M.D.: Am. J. Obst. & Gynec. 71" 35, 1956. 3. Happel, J. J.: Tr. In. Soe. Tennessee, p. 162, 1892; Med. & Surg. Reporter, Phila. 67: 402, ]892. 4. To, S., and Oh, J . : Jap. J. M. Se. Tr., IV, Pharmacol. 8" 93, 1934. 5. Terwilliger, W. G., and Hatcher, R. A. : Surg., Gynee. & Obs~;. 58: 823, ]934. 6. Steg, N.: A. M. A. J. Dis. Child. 94: 286, 1957.
LI'~VANAG P. ROI~IAN, M.D.,* AND J. NEAL ST. Louis, Me. DDICTION, as defined by the Drug Addiction Committee of the National Research Council, 1 is a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated administration of a drug; its characteristics are a compulsion to continue to take the drug" and to increase the dose, with the development of psychic and sometimes physical dependence on the drug, so that the development of means to continue the administration of the drug becomes an important motive in the addict's existence. Infants born of nareotie-addicted mothers are said to show a more or less characteristic syndrome. Recel~tly, we have had a premature infant, born of a mother who was an addict to heroin, who developed this syndrome.
A
CASE
REPORT
Baby R. S., a 4-pound i21/~-ounce premature male infant, was born at the Homer G. Phillips Hospital on March 15, 1957, of a heroin-addicted mother who had apparently given herself heroin intravenously four hours before coming to the hospital for admittance. The physical examination of the infant after delivery was entirely negative for any abnormal findings except for slight subcostal retractions. He was immediately placed in a preheated incubator. F r o m t h e D e p a r t m e n t of P e d i a t r i c s , H o m e r G. P h i l l i p s H o s p i t a l . * C h i e f R e s i d e n t in P e d i a t r i c s , H o m e r G. Phillips Hospital. * * S u p e r v i s o r , H o m e r G. P h i l l i p s H o s p i t a l ; Assistant Professor, Department of Pediatrics, W a s h i n g t o n U n i v e r s i t y S c h o o l of M e d i c i n e .
231
~[IDDELKAMP,
M.D.**
Eight hours later, the infant developed a temperature elevation of 101.4 ~ F. axillary. He was observed to be hyperactive and crying very frequently. At this time, the patient's mother was also reported to be having withdrawal symptoms f o r which she was give~ Sparine. Since there were no other symptoms found in the infant, no treatment was given. Sixteen hours after birth he developed excessive irritability manifested by twitchings of all extremities, but without actual convulsions, and a very shrill cry. The irritability was such that a mere tap on the patient's incubator would produce twitchings of all the extremities accompanied by a shrill cry as if in pain. The p a t i e n t was placed immediately on ~6 grain of sodium phenobarbital and 4 drops of paregoric every 6 and 4 hours, respectively, for 24 hours. He remained asymptomatie and the dosage was decreased to 88 grain of sodium phenobarbital every 12 hours, and paregoric, 2 drops every 4 hours, for the next 24 hours. The third day after medications were started he received paregoric, 2 drops every 8 hours, and sodium phenobarbital, 1/16 grain once. All medication was then discontinued, and he remained asymptomatic thereafter. Being" premature, this infant was given artificial feedings. He gained weight after the usual initial loss. At 15 days of age, the patient developed mild diarrhea. He was placed on antibiotics, and his formula was altered, with improvement of the diarrhea within 24 hours. Two days later he developed vomiting, but this was promptly controlled. The patient then gained weight steadily, and he was discharged asymptomatie weighing 5 pounds.
232
THE JOURNAL OF PEDIATRICS
The child was followed in our Prem a t u r e Clinic. The last visit was Dec. 3, 1957, at 9 months of age, when he weighed 18 pounds 121/~ ounces. He was doing well in a foster home on regu l a r baby foods, formula, and vitamins. DISCUSSION
The early recognition b y obstetricians and pediatricians of narcotic withdrawal symptoms in infants is extremely i m p o r t a n t for survival. Goodfriend ~ emphasized this when he reported the over-all m o r t a l i t y in infants showing withdrawal s y m p t o m s as 33.8 per cent, with a 93.2 per cent mortality when this condition was unrecognized and no t r e a t m e n t was given. Diacetylmorphine (heroin), a synthetic morphine derivative made by aeety]ation of both O H groups with a formula of CHsC0.0.Cl~H170N.O. OCCHa and a molecular weight of less t h a n 400, readily passes through the placenta and appears in the fetal blood and tissues within an hour or so a f t e r administration to the mother. I t is transplacental t r a n s f e r t h a t produces reaction in the fetus. Terwilliger and H a t c h e r ,~ were able to demonstrate only a trace of morphine in the breast milk of an addict taking 128 rag. of morphine daily and concluded that v e r y little narcotic could be t r a n s f e r r e d in this manner. The onset of symptoms in the inf a n t will frequently coincide with the onset of withdrawal symptoms in the mother, if the mother did not i'eceive narcotics after her delivery. The s y m p t o m s manifested by these infants are progressive irritability, restlessness, crying, yawning', and diaphoresis. Some authors report diarrhea, which, when associated with vomiting, has led to inanition. Also, convulsions and collapse have been observed. How-
ever, not all infants delivered of addicts manifest these symptoms, nor do they all require treatment. Goodfriend 2 reported ten patients, four of which manifested withdrawal symptoms and were treated. Steg 6 reported three eases, none of which required treatment. H a p p e P reported twelve eases, all of which were treated with paregoric. Barbiturates, morphine, and paregoric are the drugs most commonly used in the t r e a t m e n t of these infants. To and Oh 4 of J a p a n reported twentynine eases in which the mother treated the infants by blowing opium smoke in their faces. Our patient developed s y m p t o m s a f t e r delivery which we felt were severe enough to require treatment. He responded very well to t r e a t m e n t with barbiturates and paregoric. W e believe that the diarrhea which developed at 15 days of age in our i n f a n t was not related to the narcotic addiction. CONCLUSION
1. I n f a n t s delivered of narcotic-addicted mothers m a y present typical withdrawal symptoms, as our p a t i e n t did. 2. E a r l y diagnosis and institution of p r o p e r treatment, if s y m p t o m s are severe enough, are important. REFERENCES 1. Goodman, L. S., and Gillman, A.: The Pharmacological Basis of Therapeutics, ed. 2, New York, 1955, The Macmillan Co., pp. 134-135. 2. Goodfriend, M. J., Shey, I. S., and Klein, M.D.: Am. J. Obst. & Gynec. 71" 35, 1956. 3. Happel, J. J.: Tr. In. Soe. Tennessee, p. 162, 1892; Med. & Surg. Reporter, Phila. 67: 402, ]892. 4. To, S., and Oh, J . : Jap. J. M. Se. Tr., IV, Pharmacol. 8" 93, 1934. 5. Terwilliger, W. G., and Hatcher, R. A. : Surg., Gynee. & Obs~;. 58: 823, ]934. 6. Steg, N.: A. M. A. J. Dis. Child. 94: 286, 1957.