What are the postpartum care guidelines for a neonate exposed to methamphetamine (meth) use during pregnancy?

From the Guidelines

Neonates born to mothers who used methamphetamine during pregnancy should be observed for at least 72 hours after birth for signs of neonatal abstinence syndrome (NAS) and managed with a supportive treatment approach, including swaddling, minimizing stimulation, frequent small feedings, and skin-to-skin contact, with pharmacologic therapy considered if symptoms are severe, as recommended by the most recent guidelines 1.

Key Considerations

• Methamphetamine exposure in utero can lead to neonatal abstinence syndrome (NAS), characterized by irritability, excessive crying, tremors, feeding difficulties, respiratory distress, and sleep disturbances.
• Initial management of NAS is primarily supportive, focusing on minimizing environmental stimuli and providing comfort measures such as swaddling and skin-to-skin contact.
• Pharmacologic therapy, including morphine or methadone, may be necessary for severe withdrawal symptoms, with doses adjusted based on symptom control and gradually weaned as symptoms improve 1.
• Comprehensive follow-up care, including developmental assessments, is crucial for infants exposed to methamphetamine in utero, as it may impact neurological development.
• Breastfeeding is not recommended if the mother continues to use methamphetamine due to drug excretion in breast milk, but should be encouraged if the mother is in recovery and abstinent.

Recent Advances

• A 2024 review highlights advances in the care of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome, including the use of the Eat, Sleep, and Console approach for assessment and symptom-triggered dosing for pharmacologic treatment 1.
• Emerging research emphasizes the importance of addressing racial/ethnic disparities in perinatal toxicology testing and the need for clear guidelines on substance use screening and testing in hospitals.

Clinical Recommendations

• Clinicians should be aware of the risks and benefits of screening and testing for substance use in pregnant individuals and obtain consent before obtaining biologic samples for toxicology testing.
• Hospitals should establish clear guidelines on actions following a positive verbal screen or aberrant test result, including communication of risks and benefits to birth parents and obtaining consent for testing.
• The American Academy of Pediatrics recommends a supportive treatment approach for NAS, with pharmacologic therapy considered if symptoms are severe, and emphasizes the importance of comprehensive follow-up care for infants exposed to methamphetamine in utero 1.

From the FDA Drug Label

Pregnancy Teratogenic Effects Methamphetamine has been shown to have teratogenic and embryocidal effects in mammals given high multiples of the human dose. There are no adequate and well-controlled studies in pregnant women Methamphetamine hydrochloride tablets should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus. Nonteratogenic Effects Infants born to mothers dependent on amphetamines have an increased risk of premature delivery and low birth weight Also, these infants may experience symptoms of withdrawal as demonstrated by dysphoria, including agitation and significant lassitude.

Methamphetamine use in pregnancy is associated with teratogenic and embryocidal effects. Infants born to mothers dependent on amphetamines are at risk of premature delivery, low birth weight, and withdrawal symptoms.

• Postpartum care for the neonate should include monitoring for signs of withdrawal and premature delivery.
• The decision to use methamphetamine during pregnancy should be made with caution, considering the potential risk to the fetus versus the potential benefit to the mother 2.

From the Research

Methamphetamine Use in Pregnancy

• Methamphetamine use during pregnancy is associated with worse pregnancy outcomes and significantly higher rates of co-existing health and psychosocial problems 3
• Newborn infants exposed to methamphetamine are at increased risk of perinatal complications, present differently at birth to infants exposed to other drugs of dependency such as opioids, and have poorer neurological adaptation and feeding difficulties 3

Postpartum Care for Neonate

• There is limited data on the outcomes of pregnant methamphetamine users, and current clinical practice guidelines for the care of substance-exposed pregnant women are opioid-centric with little attention paid to the consequences of prenatal methamphetamine exposure 3
• Methamphetamine-exposed infants may experience growth restriction and withdrawal symptoms, although the incidence of withdrawal symptoms requiring pharmacologic intervention is relatively low (4% in one study) 4

Treatment of Neonatal Abstinence Syndrome

• Clonidine and phenobarbital are sometimes used as adjunctive therapy for neonatal abstinence syndrome (NAS), although phenobarbital may be associated with shorter duration of morphine therapy, inpatient adjunctive days, and length of stay compared with clonidine 5
• A study comparing clonidine and chloral hydrate with morphine and phenobarbital for NAS found that the clonidine/chloral hydrate group had a shorter duration of treatment and hospitalization, as well as reduced withdrawal symptoms 6