although they not have typical neonatal withdrawal symptoms If present, the intensity and duration of symptoms are much shorter than in opioid-exposed infants Most importantly, these infants should be evaluated for additional substance exposure, as many pregnant women using cocaine may also demonstrate polysubstance use Amphetamines The effects of amphetamine and methamphetamine use are similar to cocaine, acting as a CNS stimulant, but with a longer duration of action There is a similarly increased risk of miscarriage, prematurity, growth restriction, and placental abruption Infants may present with disturbances in state regulation and sleep, as well as feeding disturbances, hypertonia, and tremors Marijuana The effects of marijuana, and specifically tetrahydrocannabinol (THC) are dose dependent Infants with higher intrauterine exposure are more likely to present with lethargy, hypotonia, and decreased responses to stimuli Infants may exhibit increased startle reflexes or tremors Infants rarely present with typical symptoms of NAS, although long-term studies are lacking Selective Serotonin Reuptake Inhibitors There has been increased use of antidepressants in pregnancy over the last decade, particularly the use of selective serotonin reuptake inhibitors Emerging literature suggests prenatal SSRI exposure may result in infant withdrawal symptoms of altered state regulation and autonomic reactivity There have been reports of more serious reactions, such as tachycardia and cyanosis Symptoms appear to be self-limited, and current therapy is largely supportive, although longterm studies regarding the safety of SSRI use in pregnancy are still warranted Abnormal Tone Hypotonia in the neonate can interfere with adequate oral intake, and in progressive or severe forms, may impede normal respiratory function These infants may present with failure to thrive, respiratory distress and impending respiratory failure, aspiration pneumonia, apnea, including sleep apnea, or apparent life-threatening events (ALTEs) The goals of treatment are to stabilize the infant with supportive care, including intubation and assisted ventilation when appropriate, and then initiating the diagnostic evaluation for the low tone (see Table 96.5 ) The differential for hypotonia is quite broad and extends beyond neurologic disorders Systemic illness, including infections, endocrine disorders,