NEONATAL WITHDRAWAL SYNDROME FOLLOWING IN UTERO EXPOSURE TO SELECTIVE SEROTONIN REUPTAKE INHIBITOR
Sunil Taneja**, Rakhi Jain*, Yashwant K Rao*, Ruchi Puri**, Shailendra Rathore**
*Department of Pediatrics, GSVM Medical College, Kanpur and **Madhuraj Hospitals Pvt Ltd, Kanpur.
Keywords
Fluoxetine, in utero, withdrawal
Address for Correspondence
Dr Rakhi Jain, Department of Pediatrics, GSVM Medical College, Kanpur, India. Email: drrakhi09@gmail.com
A term male child was delivered by cesarean section to a 30year-old mother who had obsessive-compulsive disorder and was being treated with chlordiazepoxide (25 mg) and fluoxetine (20 mg) daily throughout pregnancy. The infant's Apgar scores were 5 at 1 minute and 9 at 5 minutes. The birth weight, length and head circumference were 2.19 kg, 42 cm and 31 cm respectively. At day three of life baby presented with jitteriness, decreased activity and feeding difficulty. On physical examination, activity was decreased, tone was increased in all four limbs with marked jitteriness. Total leucocyte count (TLC) was 4900 cells/cumm, absolute neutrophil count (ANC) was 1400 cells/cumm, band cell were 2% and CRP was 0.01mg/dl. Blood culture was sterile. Serum calcium, blood glucose, cerebrospinal fluid, electroencephalogram (EEG), neurosonogram and magnetic resonance imaging of brain were normal. He was treated with intravenous cefotaxime and amikacin for 7 days after which feeding improved but jitteriness persisted. Repeat TLC was 6100 cells/cumm while ANC was 1850 cells/cumm, band cells were 2%. Thus jitteriness was considered to be due to fluoxetine withdrawal however, the serum concentrations of fluoxetine of both the child and the mother could not be measured. The patient was discharged at 2 weeks with jitteriness but was feeding well. Follow up at four weeks did not reveal any further changes.

Fluoxetine, a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression, panic disorder and obsessive-compulsive disorder, is not contraindicated in pregnancy. (1) Prematurity, poor neonatal adaptation, jitteriness, hypoglycemia, hypothermia, poor muscle tone, respiratory distress, weak crying, and desaturation on feeding have been reported in such neonates. (2) There is an increased risk of neonatal complications for neonates born to mothers taking fluoxetine during the third trimester. (3) Plasma drug concentrations of SSRIs in neonates may help determine whether the symptoms are due to toxicity or withdrawal but differentiation can still be difficult since serotonergic toxicity may occur even at low therapeutic concentrations. (4) In our patient, we attributed the signs to fluoxetine withdrawal rather than to toxicity owing to the absence of hyperpyrexia, which is frequently seen in latter. Our patient was exposed to chlordiazepoxide in the first trimester and throughout pregnancy but no apparent gross anomaly was present. The symptoms presented at day 3 of life while neonatal withdrawal presents late in case of benzodiazepines which may be upto day 21 for chlordiazepoxide (5), hence the features were attributed to fluoxetine withdrawal. Whether the two drugs have any additive effect is not known due to lack of any such reports. In summary, an infant born to a mother who has taken an SSRI prior to delivery could develop significant neonatal complications that necessitate prolonged hospitalization hence a detailed maternal history and observation for few days may lead to diagnosis and apt management.
Funding
None
Conflict of Interest
None
References :
  1. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 6th edn. Philadelphia, PA. Lippincott Williams and Wilkins. 2002.  [Google Scholar]  [CrossRef]
  2. Nordeng H, Lindemann R, Perminov KV, Reikvam A. Neonatal withdrawal syndrome after in utero exposure to selective serotonin reuptake inhibitors. Acta Paediatr 2001; 90:288-291.  [Google Scholar]  [Pubmed]  [CrossRef]
  3. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996;335:1010-1015.  [Google Scholar]  [Pubmed]  [CrossRef]
  4. Hegerl U, Bottlender R, Gallinat J, Kuss HJ, Ackenheil M, Moller HJ, The serotonin syndrome scale: First results on validity. Eur Arch Psychiatry Clin Neurosci 1998;248:96-103.  [Google Scholar]  [Pubmed]  [CrossRef]
  5. Athinarayanan P, Pierog SH, Nigam SK, Glass L. Chlordiazepoxide withdrawal in the neonate. Am J Obstet Gynecol.1976;124:212-213.  [Google Scholar]  [Pubmed]
Last Updated : Wednesday, January 01, 2014 Vol 11 Issue 1 Art #7
DOI: 10.7199/ped.oncall.2014.7
How to Cite URL :
Taneja S, Jain R, Rao K Y, Puri R, Rathore S. NEONATAL WITHDRAWAL SYNDROME FOLLOWING IN UTERO EXPOSURE TO SELECTIVE SEROTONIN REUPTAKE INHIBITOR. Pediatric Oncall [serial online] 2014[cited 2014 January-March 1];11. Art #7. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=672&type=J&tid=&imgid=&reportid=382&tbltype=
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.