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acute intoxication, and to assess the safety of the infant’s current home
environment. First-line treatment for infants with abstinence syndrome is
supportive care and decreased stimulation. Available pharmacotherapy is
dependent on the class of drug the infant was exposed to in utero. Infants that
present with seizures respond well to anticonvulsant therapy, however, these
infants should have a broad diagnostic evaluation for seizure etiology, including
infection, metabolic derangements, and CNS hemorrhage.
CLINICAL PEARLS AND PITFALLS
The age of presentation for infants with NAS can vary from several
hours to several weeks after birth, depending on the exposed
substance.
Naloxone administration to chronically opioid-exposed neonates is
contraindicated as it may precipitate severe withdrawal and/or seizures.
Opioids
Infants with opiate withdrawal may present with sleep–wake abnormalities,
feeding difficulties, irritability, or weight loss. In extreme cases, up to 10% of
infants will also present with seizures. Common opioid exposures during
pregnancy may include morphine (and its derivatives), heroin, methadone, and
buprenorphine. Sixty percent to 80% of infants exposed to heroin or methadone
will develop signs of NAS. Higher doses of maternal methadone are more likely
to result in NAS. The onset of withdrawal is most often in the first 2 to 3 days
after birth, although can present as late as 4 weeks of age. Pharmacotherapy for
opioid withdrawal includes opiates (oral or intravenous morphine), barbiturates
(phenobarbital), and benzodiazepines (diazepam). Opiate treatment can decrease
the incidence of seizure, reduce time to regain birth weight, and decrease the
incidence of treatment failure. More recent reports using clonidine have been
promising in the treatment of opioid withdrawal, although larger, more detailed
pharmacokinetic studies are warranted.
Cocaine
Cocaine use in pregnancy increases the risk of intrauterine demise, placental
abruption, hypoxia–ischemia, and growth restriction of the developing fetus.

Early exposure may also be associated with congenital anomalies, though a
distinct syndrome has not been described. These children may have abnormalities
in state regulation, autonomic regulation, and reflexes at 2 to 4 weeks postpartum,