Hindawi Publishing Corporation International Journal of Pediatrics Volume 2011, Article ID 935631, 5 pages doi:10.1155/2011/935631 Review Article Pharmacological Treatment of Neonatal Opiate Withdrawal: Between the Devil and the Deep Blue Sea Anthony Liu,1 Tracey Bj o¨rkman,2 Caroline Stewart,1 and Ralph Nanan1 1 Sydney Medical School-Nepean, The University of Sydney, Penrith, NSW 2751, Australia 2 Perinatal Research Centre, UQ Centre for Clinical Research, The University of Queensland, Herston, QLD 4029, Australia Correspondence should be addressed to Ralph Nanan, ralph.nanan@sydney.edu.au Received 8 September 2010; Revised 18 February 2011; Accepted 28 March 2011 Academic Editor: Chulathida Chomchai Copyright © 2011 Anthony Liu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Illicit drug use with opiates in pregnancy is a major global health issue with neonatal withdrawal being a common complication. Morphine is the main pharmacological agent administered for the treatment of neonatal withdrawal. In the past, morphine has been considered by and large inert in terms of its long-term eﬀects on the central nervous system. However, recent animal and clinical studies have demonstrated that opiates exhibit signiﬁcant eﬀects on the growing brain. This includes direct dose-dependent eﬀects on reduction in brain size and weight, protein, DNA, RNA, and neurotransmitters—possibly as a direct consequence of a number of opiate-mediated systems that inﬂuence neural cell diﬀerentiation, proliferation, and apoptosis. At this stage, we are stuck between the devil and the deep blue sea. There are no real alternatives to pharmacological treatment with opiates and other drugs for neonatal opiate withdrawal and opiate addiction in pregnant women. However, pending further rigorous studies examining the potential harmful eﬀects of opiate exposure in utero and the perinatal period, prolonged use of these agents in the neonatal period should be used judiciously, with caution, and avoided where possible. 1. Introduction Illicit drug use in pregnancy and the associated adverse eﬀects for both mother and child are important public health issues in most developed countries. Recent Australian data has shown that the prevalence of newborns with neonatal withdrawal has surged more than 30-fold over the past two decades, causing a major strain on the health system [1]. Opi- ates and to a lesser extent barbiturates are the main pharma- cological agents administered for the treatment of neonatal withdrawal. In the past, these agents have been considered by and large inert in terms of their long-term eﬀects on the central nervous system [2–5]. However, a growing body of evidence from animal studies and recent clinical studies in children suggests a more cautious approach towards uncritical use of these drugs for neonatal withdrawal. 2. Current Approaches to Opiate Treatment of Neonatal Withdrawal Undoubtedly, neonatal withdrawal is a potentially fatal condition, which requires early recognition and appropriate pharmacological treatment [6]. It is accepted that neonatal withdrawal requires treatment due to its associated mor- bidity, increased incidence of seizures [7–11], diﬃculties with weight gain [12–15], increase in infant mortality and sudden infant death syndrome (SIDS) [11, 16–21], and evidence of infant suﬀering [22]. With these potentially serious consequences, an exclusively nonpharmacological approach to neonatal abstinence cannot be recommended and widespread use of pharmacological agents for neona- tal withdrawal is the recognised and accepted practice [6, 13, 23–29]. Monitoring of babies exposed to chronic intrauterine amphetamines, cocaine, or opiates is generally recom- mended for 5–7 days after birth [30], with more than 50% of newborns developing symptoms that require treatment [31]. Treatment in the ﬁrst instance may include nonpharmaco- logical measures such as swaddling or breastfeeding. Phar- macological interventions using an opiate most commonly or alternatively a barbiturate are then frequently added [26, 29], with pharmacological management of neonatal withdrawal required in 45–80% of cases [32]. A step-up