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Neonatal abstinence syndrome – risk factors, recognition, and management

Neonatal Abstinence Syndrome – Risk Factors, Recognition, and Management Lauren A. Johnson-Robbins, MD Associate in Neonatology Janet Weis Children's Hospital  Identify risk factors based on prenatal and neonatal history for NAS  Discuss the application of the Finnegan score in managing NAS  Review the preferred agents for medically In the news -
Tennessee ranks among the top states
dealing with prescription drug abuse
About half of all babies in intensive care at one
hospital suffer from drug withdrawal
Opioids, like oxycodone, are the
main drugs in these babies' systems
Most are diagnosed with
neonatal abstinence syndrome, or NAS
Number of US newborns
with drug withdrawal triples
Researchers find that a baby is born every hour in the US with signs of opiate drug withdrawal Actually not surprising: Number of newborns
in drug withdrawal triples in last decade
12:18 pm May 1, 2012, by Theresa Walsh Giarrusso  From 2000-2009 in the US, 5-fold increase in rate of mothers using opioids at time of delivery  Antepartum opioid use increased from 1.19 to 5.63 per 1,000 births.  NAS from 1.2 to 3.39 per 1,000 births  Concurrently costs to provide care rose Neonatal Abstinence Syndrome  What is NAS? NAS refers to a constellation of typical signs & symptoms of withdrawal that occur in infants that have been exposed to, and have developed dependence to, certain illicit drugs or prescription medications during fetal life.  Characterized by CNS irritability, gastrointestinal dysfunction, and autonomic abnormalities. Maternal Risk Factors  No prenatal care  Preterm Labor  Previous unexplained fetal demise  Intermittent hypertensive episodes  Cerebrovascular accidents  Severe mood swings or bizarre behavior  Placental abruption or repeated spontaneous  History of STD's  History of physical and/or sexual abuse  History of substance abuse  Incarceration  Clinical evidence of substance abuse in family But the reality is that many women do not fit into one of these categories. Neonatal Risk Factors  Unexplained IUGR or prematurity  Unexplained microcephaly  Abnormal CNS exam (jitteriness, hypertonicity, irritability, poor state control)  Unexplained cerebral infarct  Vomiting and diarrhea associated with typical symptoms of withdrawal Drugs & Substances of Abuse  Drugs/substances of abuse based on frequency  Cigarettes (most common)  Alcohol  Marijuana  Non-medical uses of prescription drugs  Cocaine  Hallucinogens  Heroin (least common) Substances associated with NAS  Opiates/opioids – heroin, morphine, codeine, opium, methadone,buprenorphine, fentanyl, demerol, percodan, darvon, oxycodone,….  Benzodiazepines – valium, librium, placidyl, xanax, atarax,….  Barbiturates  Substances not associated with NAS
 Cocaine, antidepressants (except SSRI's), and/or amphetamines - may experience symptoms that resemble NAS but are actually toxic effects of these drugs on the CNS  Caffeine, marijuana, tobacco, and volatile substances have been associated with abnormal neurobehavioral findings that typically subside within a few days & for which only supportive care is indicated.  Selective inhibitor of neuronal reuptake of serotonin (ex. Paxil, Prozac).  Literature showing an association with withdrawal, particularly with paroxetine.  At peak use, up to 20 to 30% of babies exposed in utero to SSRI's  WHO in February 2005 came out recommending Paxil not be used during pregnancy. Treatment for Substance Abuse during Pregnancy -  Methadone first used to treat drug dependency in the 1960's.  Began using in pregnancy in the 1970's.  Methadone clearance changes during pregnancy typically leading to a need to increase the dose.  Suboxone/Subutex  Buprenorphine is a C-III controlled substance  Prescribing this agent to outpatients requires special approval  Providers must undergo training program and then complete the DEA application process  Use during pregnancy instead of methadone increasing Subutex/Suboxone Use in Pregnancy MOTHER Study – NEJM 2010  Randomized treatment-naïve pregnant women to methadone vs. buprenorphine  Buprenorphine-exposed newborns had an average LOS of 10 days vs.17.5 for methadone-exposed  Conclusion: Safe alternative to methadone during pregnancy Neonatal Screening  Committee on Substance Abuse of the American Academy of Pediatrics recommends a comprehensive medical and psychological history including specific information related to maternal drug use as part of every newborn evaluation.  Most states do not require (including PA) written consent from parents to obtain a tox screen in a newborn but hospitals may have their own guidelines/requirements.  Screening of all patients at delivery is not  Timing of onset of symptoms is variable and depends on the drug(s), timing, and amount of last maternal use, as well as maternal and infant metabolism, and rate of excretion.  Majority of withdrawal start within 72 hours ONSET of SYMPTOMS Neonatal Evaluation  Collect meconium and/or urine for toxicology screen – know what your drug screen tests for.  Begin NAS scoring 2 to 4 hours after birth  If clinically indicated - CBC, sepsis work up, metabolic screen, and/or neurologic evaluation.  Screen for hepatitis B, HIV, and STD  Precludes early discharge.  Certain facilities keep infants through day of life 5.

 A tool that gives a quantitative measure of the severity of symptoms of withdrawal.  Tracks progression and then response to  Attempts to standardize.  Requires nursing staff to be proficient in the use and application of this tool.

Finnegan Scoring - CNS symptoms – Irritability Tone Sleep pattern

Treatment  First try supportive non-pharmacological interventions – successful <30% of the time  Quiet, private environment for care w/ dim lighting.  Frequent feedings of regular or hypercaloric formula (methadone is not contraindicated in breast feeding)  Swaddling, rocking, swinging.  Soft music  Pacifier  Soft bedding to minimize excoriations – contradicts SIDS recommendations.  Frequent diaper changes Pharmacologic Therapy  Drug therapy must be individualized.  Infants with Finnegan scores below 7 do not require drug therapy.  Pharmacologic therapy is indicated when scores are consistently (three consecutive scores) above 8 despite comfort measures.  Vomiting & diarrhea associated with dehydration due to narcotic withdrawal are indications for treatment even in the absence of high abstinence scores.

Drugs for the Treatment of NAS  Drug choice determined by  Availability  Agent from which infant is withdrawing – opiates are only for opiate withdrawal.  Personal preference  AAP supports oral morphine or tincture of Oral Morphine Solution  Must be diluted to 0.4 mg/ml (available as 4 mg/ml or 2 mg/ml)  Equivalent to tincture of opium and paregoric  Has no additives or high alcohol content  Has a short half life making it ideal for treatment  Has the least effect on sucking Tincture of Opium  Has no additives or high alcohol content  Must dilute to 0.4 mg/ml (available as 10 mg/ml)  Has a short half life  Improves sucking quickly  Superior treatment for GI symptomatology  Associated with a lower incidence of seizures than with any other drugs.  Drug of choice for non-opiate and alcohol  Suppresses agitation well  Has no effect on diarrhea or other GI symptoms  High doses may impact feeding  Has a long half life  Does not prevent seizures due to opiate  Several small studies looking at neonatal  Still at the feasibility stage  Non-narcotic that effectively reduces withdrawal symptoms  Should be used with caution with a short  Several small feasibility trials where it was found to shorten amount/time opioids were used for NAS Dosing for Oral Morphine or Tincture of Opium Dose (give q 4 hours)  If scores continue to increase, or an adequate response is not achieved within 12 hours, the dose may be increased by 0.16 mg/kg/day increments.  Consider adding Phenobarbital if CNS symptoms cannot be controlled with opiates alone. Phenobarbital: load with 10-15 mg/kg followed by 3-5 mg/kg/day.  Not contraindicated with methadone Contraindicated with cocaine, heroin, and heavy alcohol use  Conflicting recommendations on suboxone  Contraindicated in HIV-positive mothers  Mother's with hepatitis should be counseled that while breastfeeding is not contraindicated, theoretically viral transmission may occur. Discharge Planning  Length of hospitalization varies depending on drug used, severity of withdrawal, and social factors.  Need to establish close follow up with PCP  Parental education should be ongoing throughout the hospitalization and must include signs & symptoms of withdrawal.  Early Intervention and/or Developmental Follow



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