(54) Clinical Characteristics of Neonates with In-utero Xylazine Exposure

Background: Illicit opioid use during pregnancy is a leading cause of maternal and neonatal morbidity, including neonatal opioid withdrawal syndrome (NOWS). While the neonatal consequences of in-utero opioid exposure have been described, xylazine, an alpha-2 adrenergic receptor agonist, has been increasingly identified as an adulterant in the illicit opioid supply. Despite this, any additional effects that in-utero xylazine exposure may have on neonatal outcomes, including additional withdrawal symptoms, are unknown.

Objectives: To describe the clinical characteristics of and the treatment course for infants exposed to both opioids and xylazine in-utero.

Design/Methods: We conducted a retrospective cohort study of pregnant women with opioid use disorder (OUD) and their infants who delivered at the University of Pittsburgh Medical Center’s Magee Women’s Hospital between May 2023 and April 2025. Among these mother-infant dyads, we identified infants with xylazine exposure, defined as a maternal urine drug screen (UDS) positive for xylazine at delivery or an infant UDS positive for xylazine at birth. Maternal and infant data was extracted from the electronic medical record. Descriptive statistics were used to describe maternal and infant characteristics.

Results: Across 2 years, we identified 22 mother-infant dyads who had xylazine present in their UDS. Among these dyads, 18 (81.8%) had xylazine in the maternal UDS, 4 (18.2%) in the infant UDS, and 3 (13.6%) in both maternal and infant UDS. Among maternal participants, most were white, Medicaid insured, had limited ( < 4 visits) or no prenatal care, 11 (50%) had hepatitis C, and 9 (40.9%) used medications for OUD (MOUD) (n=2 buprenorphine, n=7 methadone) during pregnancy. Among infant participants, 8 (36%) were small for gestational age, 12 (55%) were microcephalic, 6 (27%) were preterm, 2 (9%) were low birth weight ( < 2000 g), 5 (23%) had respiratory distress, 5 (23%) for escalation of withdrawal symptoms, and 19 (86%) were admitted to the NICU. Overall, 13 (59%) required pharmacologic management of withdrawal symptoms. Of the infants who required pharmacologic treatment, 50% required adjunctive clonidine. Three infants required transfer to the level IV NICU for subspecialty care.

Conclusions: In our cohort, most infants exposed to xylazine and opioids required NICU admission, morphine, and alpha-agonist treatment demonstrating a need for further characterization and study of this population to provide improved treatment of withdrawal symptoms in these babies.