Jeffrey L. Segar, MD
Peer Review Status: Internally Peer Reviewed

It has been reported that women account for approximately 30% of the drug-addicted population and the majority of them are of childbearing age. Thus, drug abuse not only affects the mother but may harm the fetus and child.

Clinical manifestations

A. Signs of heroin withdrawal occur in 50-75% of infants born to addicted mothers and usually begin within the first 24-72 h of life.

The incidence of withdrawal depends on several factors, including dosage, duration of addiction, and time of last maternal dose.

Heroin use may be associated with delayed symptomatology up to 7 days, signs from methadone may occur even later.

B. The signs of drug withdrawal may be subtle or overt, consisting of a combination of any of the following:

  1. Gastrointestinal: Diarrhea, vomiting, ravenous appetite, poor feeding.
  2. Neurologic: Irritability, jitteriness, restlessness (rubbed knees, rubbed nose), erratic sleeping, fist-sucking, shrill cry, hypertonia, hyperreflexia, myoclonus and less often seizures. The incidence of seizures is higher in methadone-maintained mothers (10-15%) than in those abusing heroin.
  3. Urinary and/or meconium drug testing should be performed for any baby with signs consistent with neonatal withdrawal.


A. Obtain a Social Service consult

B. Swaddling - most infants can be managed in this manner 

C. Small, frequent feedings if gastrointestinal signs present 

D. Medications

Neonatal Abstinence Scoring Systems exist to assess the severity of withdrawal. However, clinical expertise, rather than a numerical score, should be used in the decision to use medications. Generally, severe irritability interfering with feeding and sleep, vomiting and diarrhea, temperature instability, severe tachypnea, and seizures are indications for treatment.

Schedule for Treatment of Infant in Withdrawal
Drug Dosage
Phenobarbital 15-20 mg/kg loading dose, then 3-6 mg/kg/d maintenance
Paragoric 3-6 drops q4-6 h PO; if no improvement, increase dose by 1-2 drops. Begin gradual wean after 4-6 days
Diazepam 0.2 - 0.5 mg/kg/day dose PO q8h
Methadone 0.1 - 0.5 mg/kg/day PO q4-12h

Duration of treatment in neonatal heroin withdrawal may vary from 4 days to 6 weeks, longer with methadone withdrawal.

Other drugs


  • Crosses the placenta, slowly metabolized by fetus
  • Higher incidence of tremors and altered visual responses in offspring of heavy users
  • No known overt withdrawal


  • Vasoconstrictive effects lead to neurologic complications (infarct, IVH, cystic lesions)
  • Higher incidence of prematurity, LBW, abruptio placenta
  • Associated with higher incidence of genitourinary tract and gastrointestinal anomalies
  • Short and/or long term neurobehavioral abnormality 


  • Acute ingestion: hyperactivity, tremors for 72h, followed by lethargy for 48h
  • Chronic ingestion: consider fetal alcohol ingestion and its spectrum of abnormalities including CNS, growth deficiency, facial features, cardiac and musculoskeletal anomalies