Download Neonatal Abstinence Syndrome - Dr Jubal John

Neonatal Abstinence
Syndrome
Dr Jubal John
Paediatric Fellow
Sep 2014
Outline
• Epidemiology
• Antenatal aspects of care in chemical dependent mothers
• Substances and their effects
• Pathophysiology and symptoms
• Supportive care
• Scoring and assessing severity
• Pharmacological management
• Breastfeeding
• Discharge and ongoing care
Key Points
• Chemical dependence in the mother may cause
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neonatal abstinence syndrome (NAS) in newborn.
NAS is more common in babies born to opioid
dependent women.
There is limited dose-response relationship between
maternal opioid intake and NAS.
Don’t administer naloxone to the baby at birth.
Assessment of risk of harm or neglect to the baby should
occur throughout the pregnancy and post-natally.
• These babies are at an increased risk of harm and poor
developmental outcomes due to a complex interplay of
psychosocial and environmental factors.
Principles
• The care of the opioid-dependent pregnant woman from a
drug and alcohol perspective based on "Harm
Minimisation" principles.
• The care of the newborn from a child protection
perspective
The numbers
• 7.3 million (2 in 5) Australians have used illicit drugs, 3
million in the past year.
• ~6% of newborns are affected by drug use (based on
NSW survey data)
• Estimated that 60-90% of mothers on methadone will
have an infant affected by NAS
During Pregnancy
• All pregnant women should be screened for substance
use during pregnancy. Often motivated to change.
• Can have multiple associated problems:
• obstetric - prematurity, growth restriction, fetal demise
• medical - asthma, epilepsy, liver disease, coronary valve disease,
blood-borne virus infection, nutritional deficiencies
• neonatal - prematurity, growth restriction, neonatal withdrawal,
sudden infant death
• other psychiatric, social, legal domestic and financial problems
• Statewide secondary consultation services are available
from the Women's Alcohol and Drug Service (WADS) on
(03) 8345 3931.
Drug effects
Other medications causing withdrawal
• SSRI
• tremor
• restlessness
• rigidity
• myoclonus.
Methadone substitution
• Methadone substitution for heroin use in pregnancy results in:
• improved fetal growth
• improved survival
• less risk of prematurity
• Methadone stabilisation is recommended rather than dose
reduction in pregnancy.
Withdrawal from narcotics is not recommend
• miscarriage in the first trimester
• premature labour in the third trimester
• fetal distress
• death in-utero
Withdrawal timeframes
• 90% of infants will display symptoms within 96hours
(4days)
• But can occur past the second week postnatally.
• Subacute symptoms can last 4-6months (assoc
with cannabis, opiates, sedatives and tobacco)
• variable muscle tone
• agitation
• sleep & feeding difficulties
• Specific drugs:
• Heroine – short half life, usually apparent in first 24hours
• Methadone – 3-7 days
• SSRI/SNRI – usually first 48 hours
Pathophysiology
• Activation of opiate receptors in locus ceruleus
• Decreases NE and Dopamine release
• With prolonged exposure
• Upregulate NE and Dopamine receptors
• At Birth
• Remove inhibition = Noradernergic Overcharge
Symptoms
Supportive care
• First line of management
• quiet setting
• breastfeeding
• use of a pacifier (if parents give consent)
• small frequent feeds
• cuddling
• swaddling
• close skin contact
Scoring
• Finnegan scoring
• Severity
• Response to tx
Pharmacotherapy
• Morphine
• Opioid dependent mother
• Babies need apnoea monitor
• Overdosing: abdominal distention, constipation and respiratory
depression
• Phenobarbitone
• Used concurrently when morphine not adequate
• Non-opioid (esp benzodiazepine) or unknown maternal drugs
Morphine
• Decrease dose interval before increasing total dose.
• Once abstinence has been controlled (three consecutive
scores less than 8) the following should be implemented:
• maintain control for 72 hours
• initiate the detoxification process by decreasing the total daily dose
by 10% of maximum dose every 48-72 hours
• when dosage levels reach 0.10 -0.12mg/kg/day - maintain this dose
for 72 hours prior to ceasing all medication
• when oral morphine treatment is discontinued, NAS scoring should
continue for a further 72 hours
Morphine
• Give the morphine before the feed. If baby has a large
vomit after being given morphine:
• Re-dose if vomits within 10 minutes of dose,
• Give half dose if vomits between10 - 30 minutes after dose,
• Do not give further morphine if baby vomits more than 30 minutes
after feed, (always err on side of caution)
• Ensure baby is not overfed
Phenobarbitone
• Once NAS symptoms have been assessed as controlled
(three consecutive scores less than 8) for 48 hours, then
phenobarbitone dose should be reduced by 2mg per dose
every 4th day or longer until less than 2mg/kg/day,
depending on paediatric assessment of clinical condition.
Breastfeeding
• Generally encouraged but contraindicated in:
• HIV, or Hep C with bleeding nipples
• Safe to breastfeed on methadone
Discharge
• Feeding and growing
• Completed period of monitoring and there are no signs of
continuing significant withdrawal. There is a significant risk of
unsupervised withdrawal occurring at home if infants are
discharged earlier than 7 days, particularly if mother is on
methadone.
• The infant requiring medical therapy for withdrawal has been
off all medication for at least 72 hours.
• Safe home: Any child protection issues and significant parental
issues (eg suitable accommodation) have been appropriately
addressed.
• The infant should have early medical follow up (within 2 weeks
of discharge) and have early and regular review by
domiciliary/maternal and child health nurses.
Continuing care
References/Useful resources
• Royal Womens’ Hospital neonatal handbook
• Neontal eHandbook:
http://www.health.vic.gov.au/neonatalhandbook/conditions/infant-chemicallydependent-mother.htm
• http://speciosum.curtin.edu.au/local/docs/nas/NAS_LitReview.pdf
• http://www.health.qld.gov.au/qcg/documents/g_nas5-0.pdf
• http://www0.health.nsw.gov.au/policies/gl/2013/pdf/GL2013_008.pdf