METHADONE AND CHILDREN

Saul Blatman
Pediatrics 1971;48;173-175

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Copyright © 1971 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
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VOLUME 48 AUGUST 1971 NUMBER 2

COMMENTARIES

METHADONE AND CHILDREN

T HE increasing use of methadone main- tablets. Both of these are readily ingested
tenance (substitution) programs13 in by children. A small child who ingests a full
the treatment of adult heroin addiction has adult dose of methadone or even residual
created situations for children which re- amounts of liquid containing the drug, can
quire the attention of pediatricians. Metha- progress from a drowsy state to coma in as
done is an analgesic drug. In urban areas, brief a period as one-half hour, and may die
thousands of heroin addicts are now receiv- of respiratory failure within a few hours if
ing high dosage of methadone, usually 80 to he is untreated. Recognition of this form of
120 mg daily. This approach to heroin ad- poisoning can be made by history primar-
diction has met with greater success than ily, when it is known that a parent or other
any other form of treatment. It is expected adult is being treated with methadone, and
that increasing numbers of heroin addicts when a methadone container is discovered.
will be treated in the near future by this The treatment of choice appears to be
method throughout the United States and naloxone hydrochloride, (Narcan ) 0.01
Canada. mg/kg intravenously, which Endo Labora-
Pediatricians should focus on three as- tories is about to make commercially avail-
pects of the problem as follows: (1) acci- able, although its safe and effective use in
dental poisoning of children by methadone, children has not been fully established. It is
(2) the infants born to women who are suggested that the package insert be stud-
treated with methadone during pregnancy, ied before administration of Narcan. If
and (3) the question of including adoles- Narcan is not used, intravenous nalorphine
cent heroin users in methadone mainte- hydrochloride (Nalline), 0.1 mg/kg, or
nance treatment programs. levallorphan tartrate (Lorfan), 0.02 mg/kg,
Accidental methadone poisoning of are effective for this form of narcotic poison-
young children is increasing in incidence in ing. Nalline and Lorfan may increase respi-
urban centers.5’6 In recent months New ratory depression if the diagnosis of narcotic
York City alone has experienced many of poisoning is incorrect; this is especially true
these poisonings resulting in coma and in at if respiration is impaired as a result of barbi-
least four deaths. Boston, Detroit, and turate poisoning. Because Narcan is free of
Washington, D.C. have likewise reported this problem, it is the antidote of choice
accidental poisoning by methadone in chil- when the precise diagnosis is in question.
dren. Childproofing and labeling of con- The first injection of antidote will usually
tainers holding methadone should be produce marked, rapid improvement in the
embarked upon. Methadone is usually dis- comatose child. If the diagnosis is in ques-
pensed in liquid form in fruit juice or in tion, and there is no dramatic response to

PERIAmIcs, Vol. 48, No, 2, August 1971

173

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174 METHADONE AND CHILDREN

the first dose of antidote, it is safe to repeat apparently not increased in babies born to
the injection of Narcan, whereas continued women maintained on high dosage of meth-
administration of Nalline or Lorfan should adone. While withdrawal symptoms in in-
be held in abeyance. Careful, continuous fants need to be studied at greater length,
observation of the child is essential even preliminary indications are that those born
though initial response to the narcotic an- to women who took methadone during
tagonist occurs, since the depressant action pregnancy do not experience more severe
of methadone may last for from 24 to 48 symptoms than infants born to women on
hours, or even longer, while the antidotal heroin. Studies of the relationship and tim-
action of the narcotic antagonist lasts only ing of the last dose of methadone or heroin,
for 2 to 3 hours. It is, therefore, possible to as well as the sedatives and analgesics ad-
effect successful resuscitation in a child ministered before delivery, are necessary.
who later lapses into fatal coma if adminis- Follow-up of babies born to mothers main-
tration of the narcotic antagonist is not re- tained on methadone indicates that up to
peated. Immediate emptying of the stomach age 4 years the offspring show normal phys-
of the child who ingests methadone may be ical and mental development.8 This study is
helpful, but if delayed an hour or more, Ia- being continued. There is no evidence to
vage or emesis may only serve to interfere justify the stigma of “addict” which has at
with respiration. Dialysis is not indicated, times been applied to babies born to
because the amount of methadone in the women maintained on methadone during
blood is minute. Central nervous system pregnancy. Such babies are usually asymp-
stimulants are likewise not indicated, since tomatic and normal by age 10 days and
they demonstrate no effect against the de- thereafter.
pressant manifestations of methadone and The continuing abuse of drugs by school
may only augment its stimulant effects. Hos- age children, particularly by adolescents,
pital emergency rooms and pediatric ser- and the failure of therapeutic approaches to
vices should be made aware of the problem adolescent heroin users draws attention of
of accidental methadone poisoning in chil- the pediatrician to this problem. In addi-
dren and should post a protocol for the treat- tion, heroin-related deaths in large numbers
ment of this form of poisoning. of adolescents call for an evaluation of
Infants born to women who are treated methadone treatment of teen-age heroin
with large amounts of methadone daily dur- users. Recent studies9”#{176} indicate that further
ing pregnancy are under study by several work is needed before specific recommen-
groups. From the point of view of the dations can be made. Perhaps it would be
child’s well-being, preliminary results8 indi- advisable to treat adolescent heroin users in
cate that there are decided advantages in slow detoxification programs; it may be pos-
bringing pregnant women into methadone sible to withdraw both heroin and metha-
treatment programs as opposed to allowing done in this way and not commit the ado-
them to remain on heroin. Advantages in- lescent to indefinite methadone treatment.
clude the more frequent participation in Because of the special rehabilitation needs
prenatal care by the pregnant addict, of adolescent addicts, it may be advisable
shorter hospital stay for infants in the neona- to assemble special treatment units for
tal period, and improved attention to child them. Properly evaluated programs estab-
health care by the mother who is participat- lished for this purpose could supply an-
ing in a methadone maintenance program. swers, and such programs are now under
These advantages for the children can be way.9
attributed to a more stable social environ- SAUL BLATMAN, M.D.
ment of methadone-treated mothers com- Department of Pediatrics
pared with those who are on heroin. The Beth Israel Medical Center
incidence of congenital malformations has New York, New York 10003

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 COMMENTARIES 175

REFERENCES 7. Dole, V. P., Foldes, F. F., Trigg, H., Robinson,

1.Dole, V. P., Nyswander, M. E., and Kreek, J. W., Blatman, S.: Methadone poisoning.
M. J.: Narcotic blockade. Arch. Intern. Med., N.Y. State J. Med., 71:541, 1971.
118:304, 1936. 8. Blatxnan, S., and Lipsitz, P.: Infants born to
2. Dole, V. P., Nyswander, M. E., and Warner, heroin addicts maintained on methadone:
A.: Successful treatment of 750 criminal ad- Neonatal observations and follow-up. Pro-
dicts. J.A.M.A., 206:2708, 1968. ceedings of the third National Con-
3. Dole, V. P., and Warner, A.: Evaluation of ference on Methadone Treatment, 1970
narcotics treatment programs. Amer J. Pub- (N.I.M.H.).
lic Health, 57:2000, 1967. 9. Milln’ian, R. B., and Nyswander, M. E.: Slow
4. Dole, V. P.: Methadone maintenance treatment detoxification of adolescent heroin addicts in
for 25,000 heroin addicts. J.A.MA., 215: New York City. Proceedings of the third Na-
1131, 1971. tional Conference on Methadone Treatment,
5. McCurley, W. S., and Tunnessen, W. W., Jr.: 1970 (N.I.M.H.).
Methadone toxicity in a child. Pnwriucs, 10. Nightingale, S. L., Wurmser, L., Platt, P. C.,
43:90, 1969. and Michaux, W. W.: Adolescents on meth-
6. Sey, M. J., Rubenstein, D., and Smith, D. S.: adone: Preliminary observations. Proceed-
Accidental methadone intoxication in a child. ings of the third National Conference on
PEDIAmIc5, 48:294, 1971. Methadone Treatment, 1970 (N.I.M.H.).

POSITIVE TRANSPULMONARY AIRWAY PRESSURE

T HERE is now good evidence unpub- ing the inspired oxygen concentration and
lished and published1’2 that neonatal when this fails, the use of ventilatory sup-
intensive care is associated with increased port.5-8 Groups using respirator care have
survival. The major cause of neonatal mor- uniformly reported improvement in oxy-
tality is the idiopathic respiratory distress genation. Survival has probably been im-
syndrome (IRDS); hence the decrease in proved as well although no controlled
neonatal mortality can be ascribed, in part studies have been reported.
at least, to improvement in the management Respirator therapy requires intensive
of infants with this syndrome. The arterial care of the highest order and for this reason
oxygen tension while breathing 100% oxy- is not widely applicable. Furthermore its
gen has been shown to be the most valuable use combined with high concentrations of
prognosticator for outcome in this disease;’ oxygen (or perhaps the latter alone) has
an oxygen tension less than 100 mm Hg led to evidence of pulmonary toxicity,#{176}’1
(in 100% oxygen) during the first 24 hours and hence to what Clements and Fisher12
is associated with a markedly increased have labeled the oxygen dilemma.
mortality. Thus central in the management For many years it has been appreciated
scheme is adequate oxygenation. In the that infants with IRDS have an expiratory
past this has been accomplished by increas- grunt. Only recently has it been recognized

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 METHADONE AND CHILDREN
Saul Blatman
Pediatrics 1971;48;173-175
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