A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome. Diluted tincture of opium (DTO) and phenobarbital versus DTO alone for neonatal opiate withdrawal in term infants. Opiate v CNS depressant therapy in neonatal drug abstinence syndrome. Comparison of methadone and slow-release morphine maintenance in pregnant addicts. Therapy of the neonatal abstinence syndrome with tincture of opium or morphine drops. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Observation and treatment of neonatal narcotic withdrawal. Neonatal abstinence syndrome, pharmacotherapy and developmental outcome. Rectally administered diclofenac (Voltaren) reduces vomiting compared with opioid (morphine) after strabismus surgery in children.
The incidence of neonatal abstinence syndrome (NAS) has increased 10-fold over the last decade in Glasgow. In the Princess Royal Maternity Hospital, it now accounts for 17% of special care baby unit (SCBU) admissions.
                To compare opiate replacement therapy (morphine sulphate) with the present standard treatment (phenobarbitone) for management of NAS. The primary study end point was duration of pharmaceutical treatment. Secondary end points were the requirement for additional drugs and the requirement for SCBU admission.
                Double blind, randomised controlled clinical trial.
                Differential diagnoses were excluded, and two consecutive Lipsitz scores > 4 defined NAS requiring treatment. Infants were randomised to receive morphine sulphate or phenobarbitone. Treatments were identical in appearance, odour, and volume. Increments, decrements, and discontinuation of treatments were protocol driven.
                Seventy five infants participated. All mothers received opiate replacement therapy (methadone) during pregnancy and most used other drugs (n = 62, 83%). No significant difference in maternal drug use patterns was observed between treatment groups. Median treatment duration was four days shorter with opiate replacement (8 v 12 days, Mann-Whitney U test, p = 0.02). Phenobarbitone treated infants tended to require second line treatment (47% v 35%, chi(2) test, p = 0.11) and SCBU admission (62% v 30%, chi(2) test, p = 0.04) more often.
                Opiate replacement therapy appears to be superior for management of symptomatic NAS when maternal opiate use is prevalent. The shorter treatment duration and lower requirement for higher intensity nursing may have significant cost implications. Tailoring NAS treatment to local maternal drug use may result in similar benefits. The purpose of this study was to test the hypothesis that treatment of neonatal opiate withdrawal (NOW) in the term infant with diluted tincture of opium (DTO) and phenobarbital was superior to treatment with DTO alone. Study design: This was a partially randomized, controlled trial in which 20 term infants exposed to methadone and/or heroin in utero were studied. The severity of NOW was assessed by using the Finnegan scoring system. Infants were assigned to either DTO and placebo (n = 10) or DTO and phenobarbital (n = 10) when medication was required. The primary outcome variable was the duration of hospitalization. Severity of withdrawal and hospital cost were secondary outcome variables.
                There were no significant differences in the gestational age, growth variables, maternal methadone dose, or age at enrollment between the 2 groups. The duration of hospitalization was reduced by 48% (79-38 days) (P <.001) and hospital cost per patient reduced by $35,856 (P <.001) for the DTO and phenobarbital group. Furthermore, these infants spent less time with severe withdrawal (P <.04), more time with mild withdrawal (P <.03), and required a lower maximum daily DTO dose (P <.009) when compared with the DTO-only group. The average duration of outpatient phenobarbital use was 3.5 months.
                The combined use of DTO and phenobarbital resulted in a shorter duration of hospitalization, less severe withdrawal, and reduced hospital cost. This combination may be a preferred regimen for the treatment of NOW. Paregoric and phenobarbital, administered randomly in 153 passively addicted neonates, initially appeared to control neonatal abstinence signs equally well. However, seven of the 62 phenobarbital-treated newborns had abstinence-associated seizures within the first month of life, while none of 49 paregoric-treated neonates had seizures. Forty-two neonates initially requiring no specific pharmacotherapy for abstinence signs were born to mothers taking less methadone hydrochloride just before delivery. Five of those 42 neonates, however, had seizures within the first 14 days of life. Seizure occurrence could not be predicted from analysis of early abstinence patterns. We consider paregoric to be the treatment of choice for the neonatal abstinence syndrome. Phenobarbital use should be monitored with serum drug levels and modification of recommended dosage regimens considered. To investigate whether the neonatal abstinence syndrome (NAS) is different in children born to women maintained on slow-release morphine, compared with those maintained on methadone, and to compare additional drug consumption in these groups of women.
                An open, randomized trial was conducted in an established clinic. Forty-eight pregnant women who presented to the clinic as opiate or polysubstance abusers were enrolled and maintained on either methadone (24 women) or slow-release morphine (24 women) up to and following delivery. The programme included psychosocial therapy and support for their opiate-addicted partners.
                Standard urinalysis methods were used to measure consumption of cocaine and benzodiazepines during pregnancy. Injection sites were monitored to indicate additional opiate use. NAS was measured according to Finnegan score and the amount of phenobarbiturates prescribed to alleviate the symptoms.
                No difference was found in the number of days that NAS was experienced by neonates born to methadone or morphine maintained mothers (mean = 16 and 21 days, respectively). All children were born healthy and no serious complications arose. Fewer benzodiazepines (p < 0.05) and fewer additional opiates (p < 0.05) were consumed by the morphine-maintained women compared with those who took methadone, but no difference was seen in cocaine consumption. Nicotine consumption was reduced significantly in both groups during pregnancy (p < 0.02).
                Both methadone and morphine are suitable maintenance agents for pregnant opiate addicts. Maintenance agents that result in a less prolonged NAS should be studied in further trials. Treating opioid-addicted women with methadone in pregnancy increased the number of newborns suffering from neonatal abstinence syndrome (NAS). High-pitch crying, insomnia, tremor, myoclonic jerks, vomiting, diarrhoea and poor weight gain were reported symptoms, which were evaluated using the Finnegan (F)-score. Earlier phenobarbital or paregoric had been used to suppress symptoms. We surveyed the administration of pure mu-agonist morphine (MO) in comparison to the alcoholic opioid mixture in tincture of opium (TO). Thirty-three newborns were included in the survey, after informed consent by their parents.
                NAS started 3-5 days after delivery and lasted for 27 or 30 days (mean) in the TO and MO groups, respectively. In either of the tested parameters, we found no significant differences between the two groups (2P < 0.05). The maximum F-score was similar in both groups, but the dose to suppress NAS was higher in the MO group (0.6-0.5 mg/day; total dose 61.6-42.7 mg of morphine). The duration of the therapy was longer in the MO than in the TO group (37.5-32.4 days). On the other hand the weight gain was better in the MO group than in the TO group (25-19 g/day), but was reduced in both groups compared with healthy newborns.
                Morphine is suitable to treat NAS in a similar manner as tincture of opium, but avoids unwanted effects of the alcoholic extracts with various alkaloids in the tincture of opium and allows better weight gain of the newborns. In utero exposure to drugs of abuse can lead to neonatal abstinence syndrome, a condition that is associated with prolonged hospitalization. Buprenorphine is a partial mu-opioid agonist used for treatment of adult detoxification and maintenance but has never been administered to neonates with opioid abstinence syndrome. The primary objective of this study was to demonstrate the feasibility and, to the extent possible in this size of study, the safety of sublingual buprenorphine in the treatment of neonatal abstinence syndrome. Secondary goals were to evaluate efficacy relative to standard therapy and to characterize buprenorphine pharmacokinetics when sublingually administered.
                We conducted a randomized, open-label, active-control study of sublingual buprenorphine for the treatment of opiate withdrawal. Thirteen term infants were allocated to receive sublingual buprenorphine 13.2 to 39.0 mug/kg per day administered in 3 divided doses and 13 to receive standard-of-care oral neonatal opium solution. Dose decisions were made by using a modified Finnegan scoring system.
                Sublingual buprenorphine was largely effective in controlling neonatal abstinence syndrome. Greater than 98% of plasma concentrations ranged from undetectable to approximately 0.60 ng/mL, which is less than needed to control abstinence symptoms in adults. The ratio of buprenorphine to norbuprenorphine was larger than that seen in adults, suggesting a relative impairment of N-dealkylation. Three infants who received buprenorphine and 1 infant who received standard of care reached protocol-specified maximum doses and required adjuvant therapy with phenobarbital. The mean length of treatment for those in the neonatal-opium-solution group was 32 compared with 22 days for the buprenorphine group. The mean length of stay for the neonatal-opium-solution group was 38 days compared with 27 days for those in the buprenorphine group. Treatment with buprenorphine was well tolerated.
                Buprenorphine administered via the sublingual route is feasible and apparently safe and may represent a novel treatment for neonatal abstinence syndrome. A total of 110 infants born to mothers who were either in a methadone maintenance program, using heroin, or recently detoxified, were studied during the neonatal period. Of these infants, 93.6 per cent developed withdrawal symptoms. No significant differences were determined in therapeutic response among those infants treated with methadone, phenobarbital, and diazepam. There was a significant reduction in the frequency of withdrawal symptoms among infants born to mothers whose methadone dose at time of delivery was less than 20 mg (17.9 per cent). It is suggested that reduction of methadone dosage in late pregnancy results in reduced incidence of withdrawal but must be carefully carried out. The majority of infants born to drug-dependent women undergo neonatal abstinence syndrome (NAS) and often require pharmacotherapy for the treatment of withdrawal symptoms. Phenobarbital, paregoric, and diazepam have been recommended for the treatment of the syndrome. While some investigators have examined the efficacy of these agents in treating NAS, there are no data regarding the use of specific pharmacologic agents and developmental outcome. This study evaluated 85 infants born to drug-dependent women who were maintained on methadone during pregnancy. Severity of infant withdrawal was assessed with the neonatal abstinence scoring system. Infants who required pharmacotherapy were randomly assigned to one of four treatment regimens: paragoric, phenobarbital (titration), phenobarbital (loading), and diazepam. When treatment was not successful with the assigned agent, one of the other agent(s) was used. At 6 months of age, the developmental status of infants was assessed with the Bayley Scales of Mental Development. Based on NAS treatment, four groups were defined: paregoric (n = 21); phenobarbital (n = 17); more than one agent (n = 31); and no treatment (n = 16). Data for the phenobarbital loading and titration groups were combined since analysis revealed no differences between groups. All infants who initially received diazepam were included in group III since diazepam as a single agent was not successful. Results of one way analysis of variance revealed no differences in developmental status between groups (p greater than 0.10, F = 0.25). Scores for all groups were well within the normal range of development.(ABSTRACT TRUNCATED AT 250 WORDS) Nausea, vomiting and pain are common complications after strabismus surgery in children. Diclofenac, a non-steroid anti-inflammatory drug, is widely used to treat acute and chronic pain but there are few reports of its use given rectally in children undergoing strabismus surgery. This open randomised study was designed to investigate the analgesic and anti-emetic properties of rectally administered diclofenac compared with opioid (morphine) given i.v. in connection with strabismus surgery in children.
                After obtaining approval from the local ethics committee and written informed consent from the parents, 50 ASA class I-II children, 4-16 years of age, were randomised to receive either rectally administered diclofenac (Voltaren) 1 mg/kg or i.v. opioid (morphine) 0.05 mg/kg perioperatively. The children were consecutively operated upon from May 1999 to January 2001. Anaesthesia was induced with fentanyl and propofol and maintained with propofol. Nitrous oxide was omitted. The postoperative pain was assessed after arrival at the post anaesthesia care unit (PACU) by using the validated Wong and Baker scale (FACES) Pain Rating Scale. Postoperative nausea and vomiting (PONV) was assessed by measuring the frequency of vomiting and the degree of nausea.
                In the diclofenac group the incidence of PONV during the first 24 h was 12% (of which one child had severe vomiting). The incidence of PONV was much higher, 72% (P = 0.0000), in the morphine group, where 56% of the children also had severe vomiting. There were no difference in pain score between the two groups. Recovery time at the PACU was longer (P < 0.002) and the postoperative analgesic requirement higher in the morphine group (10 vs. 5 children). No children needed overnight admission to the hospital.
                Diclofenac given rectally is an effective analgesic for this kind of surgery and gives less postoperative nausea than i.v. morphine. No serious adverse events were observed.
Opiates compared to supportive care may reduce time to regain birth weight and duration of supportive care but increase duration of hospital stay. When compared to phenobarbitone, opiates may reduce the incidence of seizures but there is no evidence of effect on treatment failure. One study reported a reduction in duration of treatment and nursery admission for infants on morphine. Compared to diazepam, opiates reduce the incidence of treatment failure. A post-hoc analysis generates the hypothesis that initial opiate treatment may be restricted to infants of mothers who used opiates only. In view of the methodologic limitations of the included studies the conclusions of this review should be treated with caution.