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although they do not have typical neonatal withdrawal symptoms. If present, the
intensity and duration of symptoms are much shorter than in opioid-exposed
infants. Most importantly, these infants should be evaluated for additional
substance exposure, as many pregnant women using cocaine may also
demonstrate polysubstance use.
Amphetamines
The effects of amphetamine and methamphetamine use are similar to cocaine,
acting as a CNS stimulant, but with a longer duration of action. There is a
similarly increased risk of miscarriage, prematurity, growth restriction, and
placental abruption. Infants may present with disturbances in state regulation and
sleep, as well as feeding disturbances, hypertonia, and tremors.
Marijuana
The effects of marijuana, and specifically tetrahydrocannabinol (THC) are dose
dependent. Infants with higher intrauterine exposure are more likely to present
with lethargy, hypotonia, and decreased responses to stimuli. Infants may exhibit
increased startle reflexes or tremors. Infants rarely present with typical symptoms
of NAS, although long-term studies are lacking.
Selective Serotonin Reuptake Inhibitors
There has been increased use of antidepressants in pregnancy over the last
decade, particularly the use of selective serotonin reuptake inhibitors. Emerging
literature suggests prenatal SSRI exposure may result in infant withdrawal
symptoms of altered state regulation and autonomic reactivity. There have been
reports of more serious reactions, such as tachycardia and cyanosis. Symptoms
appear to be self-limited, and current therapy is largely supportive, although longterm studies regarding the safety of SSRI use in pregnancy are still warranted.

Abnormal Tone
Hypotonia in the neonate can interfere with adequate oral intake, and in
progressive or severe forms, may impede normal respiratory function. These
infants may present with failure to thrive, respiratory distress and impending
respiratory failure, aspiration pneumonia, apnea, including sleep apnea, or
apparent life-threatening events (ALTEs). The goals of treatment are to stabilize

the infant with supportive care, including intubation and assisted ventilation when
appropriate, and then initiating the diagnostic evaluation for the low tone (see
Table 96.5 ). The differential for hypotonia is quite broad and extends beyond
neurologic disorders. Systemic illness, including infections, endocrine disorders,