Dr. Williams of the Medical University of South Carolina has no relevant financial relationships to disclose.)
Dr. Ward of the Medical University of South Carolina has no relevant financial relationships to disclose.)
Dr. Ross of the Medical University of South Carolina has no relevant financial relationships to disclose.)
Dr. Johnston of Johns Hopkins University School of Medicine and Chief Medical Officer at Kennedy Krieger Institute has no relevant financial relationships to disclose.)
This article includes discussion of congenital opioid syndrome, and congenital syndromes: narcotics. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Neonatal abstinence syndrome (NAS) is a clinical diagnosis that describes the constellation of symptoms that result from the abrupt discontinuation of chronic fetal exposure to opioids used in pregnancy. Neonatal abstinence syndrome occurs in over 50% of infants exposed to opioids in utero. In this article, the authors provide a historical background, as well as information on the pathophysiology, clinical spectrum, and management of neonatal abstinence syndrome. The clinical or consulting neurologist will find this information useful in formulating a differential diagnosis when faced with a neonate with signs and symptoms pertaining to CNS/autonomic dysfunction.
• The incidence of neonatal abstinence syndrome following in utero exposure to opioids has increased over the last decade and is related to the increased use and abuse of prescription opioids. Prescriptions for opioids in pregnancy have increased with up to 1 in 5 pregnant women receiving a prescription opioid during pregnancy (Desai et al 2014).
• Management of neonatal abstinence syndrome involves appropriately identifying infants at risk for withdrawal, along with assessment of symptoms with objective assessment tools and management of symptoms with supportive measures and with pharmacologic therapy where appropriate.
• Standardization of care, which includes standardization of scoring, use of nonpharmacologic therapy and pharmacologic therapy as well as strict adherence to treatment protocols, have all been shown to decrease the duration of pharmacologic therapy and length of hospital stay.
Historical note and terminology
Medical use of opium dates back 6000 to 7000 years to Mesopotamian and Egyptian cultures. The word opium in Greek means "poppy juice." Opium has more than 20 alkaloids. Morphine, which was named after Morpheus, the Greek god of dreams, was isolated from opium in 1806 and was followed by the isolation of codeine. In 1822, Thomas De Quincey, in a book titled Confessions of an Opium Eater, first reported narcotic addiction in scientific literature. However, it was not until the end of the century that the concerns regarding adverse effects of maternal narcotic addiction on the fetus were addressed. Congenital morphinism was first described in Germany in 1875. The first report of successful treatment in an infant was in 1903 (Perlstein 1947).
Heroin, a semisynthetic narcotic, was manufactured by Bayer Company in 1874 for the treatment of cough and morphine dependency. By 1903, the passage of Pure Food and Drug Act resulted in regulation of narcotics; however, opiates remained available over the counter in some forms such as paregoric until the 1960s. Methadone was synthesized in Germany and then introduced in the United States in 1947. It was Dole and Nyswander who first reported the use of methadone for the management of heroin addiction (Hoegerman and Schnoll 1991). In 1998, a National Institute of Health consensus panel recommended methadone maintenance for the management of addiction in pregnant patients (Anonymous 1998a).
Opioid narcotics can be divided into natural, semisynthetic and synthetic opioids. Opium, morphine, and codeine are examples of natural opiates derived from the opium-producing poppy, Papaver somniferum. Semisynthetic opioids are derived from opium, and examples of these are heroine, hydromorphine, oxycodone, and buprenorphine. Examples of synthetic opioids are meperidine, fentanyl, methadone, and propoxyphene (Hoegerman and Schnoll 1991).
A method for standardized assessment and treatment of infants with narcotic withdrawal was first developed and published by Dr. Loretta Finnegan in 1975 (Finnegan et al 1975).
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