Download Management of the infant with neonatal abstinence syndrome (NAS

MANAGEMENT OF THE INFANT WITH
NEONATAL ABSTINENCE SYNDROME
(NAS)—LITERATURE REVIEW
BACKGROUND
Neonatal abstinence syndrome (NAS) is a syndrome of drug withdrawal observed in infants of mothers
physically dependent on drugs. Also known as neonatal withdrawal syndrome or passive addiction, NAS is a
condition resulting from exposure in utero or postnatal exposure to opioids and other illicit drugs. Prenatal
NAS, or neonatal withdrawal as a result of the mother’s dependence on drugs during pregnancy, is
characterised by signs and symptoms of central nervous system hyperirritability, gastrointestinal dysfunction,
respiratory distress and vague autonomic symptoms that include yawning, sneezing, mottling and fever. This
syndrome normally begins within 72 hours of birth, but may take at least two weeks for the symptoms to
become evident.1-3 Postnatal or iatrogenic NAS may occur as a result of the abrupt withdrawal of opioids
following prolonged exposure to analgesia.
NAS is more common in infants born to opioid-dependent women than in infants born to women dependent
on other drugs or alcohol.4 Table 1 lists a number of drugs that are known to be associated with neonatal
withdrawal problems.
Opioids
Buprenorphine
Codeine
Heroin
Meperidine
Methadone
Morphine
Pentazocine
Propoxyphene
Table 1
Barbiturates
Butalbital
Phenobarbital
Secobarbital
Miscellaneous
Alcohol
Amphetamine
Chlordiazepoxide
Clomipramine
Cocaine
Desmethylimipramine
Diazepam
Diphenhydramine
Ethchlorvynol
Fluphenazine
Gamma-Hydroxybutyrate (GHB)
Glutethimide
Hydroxyzine
Imipramine
Inhalants and Solvents
Meprobamate
Phencyclidine
Drugs Associated with Neonatal Abstinence Syndrome5
EARLY RECOGNITION
Early identification of those infants likely to require clinical or pharmacologic interventions can help to reduce
the incidence of mortality and morbidity. An accurate history of maternal drug use in the antenatal period is a
potentially sensitive means of detecting drug use that can assist in the early identification of newborns that
are at risk. However only 40-60% of pregnant women with positive urine tests for drugs in the United States
had previously been identified through self-reported drug use questionnaires and interviews.6
The signs and symptoms of withdrawal include both physiologic and behavioural responses which are similar
to those also observed in cases of hypoglycaemia, hypocalcaemia and sepsis. Glucose and calcium values
are reported to be within normal limits for this group of infants, however. Fetal exposure to narcotics
commonly results in decreased birth weight, increased weight loss during the early neonatal period and
increased length of hospital stay.7, 8
SIGNS AND SYMPTOMS
It is estimated that 60-90% of infants born to substance using mothers will develop signs and symptoms of
NAS, and of these 50-75% will require treatment.9-14 The severity and course of the syndrome is extremely
varied. Symptoms usually begin to appear during the first 24 to 48 hours of life, onset of symptoms can
range from birth to the end of the second week and beyond, with acute and subacute phases lasting for up to
twelve months.9, 11, 12, 15-20
Although the time onset of symptoms may vary, 90% of infants will display symptoms within 96 hours of
birth. Onset of symptoms varies according to the drug used by the mother, the quantity, frequency, and
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
duration of intrauterine exposure, the timing of the withdrawal (last dose prior to delivery) and maturity of the
neonate/infant.14 Onset and severity may be transient, mild, delayed or characterised by intermittent phases
of symptoms. If a week or more has elapsed between last maternal drug use and delivery, the incidence of
neonatal withdrawal will be relatively low. Symptoms of withdrawal from methadone tend to appear later than
symptoms of withdrawal from heroin because of the longer half life, and in both cases the newborn appears
normal at birth, both physically and behaviourally.
The effects of prenatal drug exposure and possible neonatal sequelae can be found in the Common Signs
of Neonatal Withdrawal, Intoxication or Neonatal Exposure chart. Newborn infants may or may not exhibit
any or all of these signs.
At birth the newborn infant may display signs related to the substance used by their mother and will need
time to process and clear any free or stored illicit drugs from their system, especially if the mother has been
taking large amounts of drugs for a long time. Withdrawal may be mild and transient, delayed in onset, have
a stepwise increase in severity, be intermittently present or have a biphasic course which includes acute
neonatal withdrawal followed by improvement and then the onset of acute withdrawal. Recovery from the
abstinence syndrome is gradual and occurs as the infant's metabolism is re-programmed to adjust to the
absence of the dependence-producing agent.21, 22
Clinical studies are complicated by numerous confounding factors and polydrug use. A recent study23 by the
Center for the Evaluation of Risks to Human Reproduction (CERHR) on the potential adverse reproductive
and developmental effects of methamphetamine exposure concluded that “studies that focused upon
humans were uninterpretable due to such factors as a lack of control of potential confounding factors and the
issue of the purity and contaminants…”
The American Academy of Pediatrics (AAP) recommends the use of an objective abstinence scoring method
to measure the severity of withdrawal.14 The Finnegan or Modified Finnegan Scoring System is the
recommended scoring tool for use in Western Australia. It is the most commonly used scoring system24 for
assessing the infant for potentially life-threatening signs, such as vomiting, diarrhoea, weight loss, irritability,
tremors, and tachypnoea. Other scoring systems include the Lipsitz and Ostrea scoring systems. The AAP
favours the Lipsitz method which has a relatively simple numerical scoring method and a reported 77%
sensitivity using a value >4 as an indication of significant signs of withdrawal. The AAP considers that the
usefulness of the 6 criteria in the Ostrea system is limited by the use of simple ranking rather than a numeric
scale which allows summing of the severity scores for multiple signs of withdrawal. They consider the
Finnegan method, which uses a weighted scoring of 31 items, as possibly too complex for routine use in a
busy clinical service.14
TREATMENT – FACTORS TO BE CONSIDERED
A number of factors need to be considered when planning the care of drug-exposed neonates and infants:
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Maternal history of drug use during pregnancy
Maternal history of drug use in the seven days prior to birth
Drug use during labour and birth
Quality and quantity of antenatal care
Level of withdrawal symptoms
Competence of staff re: NAS Assessment and use of the appropriate tool
Birth into a Supportive Environment
Supportive therapies implemented by parents and staff
Morphine Pharmacotherapy or Phenobarbitone Pharmacotherapy if required
Interdisciplinary health care team and parents planning for discharge and follow-up
The WITHDRAWAL mnemonic is a useful aid to recognising and remembering the clinical symptoms of
withdrawal.25
W
I
T
H
D
ithdrawal
rritability
remors
yperactive, high pitched cry, hypotonia
iarrhoea, disorganized suck
R
A
W
A
L
espiratory distress, rhinorrheoa
pnoeic attacks
eight loss
lkalosis – respiratory
acrimation
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
DIAGNOSIS AND MANAGEMENT OF NEONATAL WITHDRAWAL SYMPTOMS 2, 14, 26
A maternal history of substance use during pregnancy often forms the basis for diagnosis of subsequent
symptoms of neonatal withdrawal. Use of a NAS score chart, such as the Modified Finnegan Scoring System
is frequently used to monitor the infant and exclude other possible causes for jitteriness and irritability
(hypoglycaemia, hypocalcaemia, sepsis, etc). The weighted numeric score is then used in conjunction with
supportive or pharmacologic treatment guidelines to monitor the infant’s clinical response and provide a
comprehensive and objective way of assessing the onset, progression and diminution of symptoms of
abstinence.
Once diagnosed, initial treatment for neonatal withdrawal should be primarily supportive since medical
interventions may prolong hospitalisation and subject the infant to drugs that may not be necessary.14 NAS
can be a major disruption to mother-infant attachment and unnecessary separation of mother and infant
should be avoided if at all possible. Parents should be provided with information regarding the use of
supportive therapy and encouraged to use it as an ongoing part of the infant’s care.
Any decision to treat should be based on data obtained with an objective scoring device. Infants with
confirmed exposure and NO SIGNS of withdrawal do not necessarily need to be treated. Intravenous fluids
and replacement electrolytes may be necessary to stabilize the infant’s condition in the acute phase without
the need for pharmacologic intervention.14 The use of supportive therapy has been shown to reduce the
effects of withdrawal in neonates and should be implemented as soon as possible following birth. Babies
with mild symptoms can be cared for using supportive therapy alone, the main components of which are
outlined in Tables 2 and 3.
Pharmacologic intervention is indicated for evidence of acute withdrawal, such as seizures, and may be
indicated if: 3 consecutive NAS scores are ≥ 8 or the average of three consecutive scores is ≥ 8, 2
consecutive NAS scores are ≥ 12 or the average of 2 consecutive scores is ≥ 12. Scoring should be applied
in a consistent manner by experienced personnel, using a four-hourly scoring interval until the infant has
been stabilised.8
SUPPORTIVE ENVIRONMENT 2, 14
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Place the infant in a quiet environment with dim lighting and reduced stimulation
Closely wrap or swaddle infant to decrease sensory stimulation
Handle infant gently
Hold newborn infant firmly and close to the body
Promote cuddling, skin to skin contact with mother and use of infant sling
Massage infant or try relaxation baths
Rock gently, talk, sing or hum softly
Play heart beat audiotapes
Decrease stimulation at first signs of distress
Feed on demand (frequent small feeds with rests between sucking)
Give frequent small feeds of hypercaloric formula to supply additional caloric requirements
Assess coordination of suck/swallow reflex – support cheeks and jaw if necessary
Consult with mother on the use of a pacifier for excessive sucking
Use mittens to prevent trauma to fingers and wrists
Use short-haired sheepskin with soft cotton sheet
Change nappy frequently, use barrier cream to protect skin/prevent damage
Use gentle suction if nasal secretions cause obstruction to ensure adequate respiratory function
Monitor sleeping habits, temperature stability, weight gain or loss, and any other changes in clinical
status that might suggest another disease process
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
Table 2
Supportive therapy for care of the infant with NAS (aligned with Modified Finnegan
Scoring System – only symptoms that respond to supportive therapy are included)
2, 9-14, 17, 27-33
Gastrointestinal Disturbances
Metabolic/ Vasomotor/ Respiratory
Disturbances2, 9-12, 14, 18, 26, 27, 29-32
9, 13, 14, 19, 26-28
Central Nervous System
Disturbances
Signs and Symptom
Intervention
Excessive or high-pitched crying
Reduce environmental stimuli. Hold newborn
infant firmly and close to the body, gentle rocking,
talking/singing/humming, and use of infant sling.
Sleeplessness
Wrap or swaddle infant, minimise handling, skin to
skin contact, and use of infant sling.
Myoclonic jerks, tremors, jitteriness,
irritability
Prepare everything prior to disturbing the infant to
minimise handling. Slow movements, reduced
lighting, reduced noise levels, soft music, massage,
and relaxation baths.
Excoriation (chin, knees, elbow, toes, nose)
Apply barrier creams to affected areas to protect
skin and prevent damage. Bedding - short haired
sheepskin covered with a soft cotton sheet.
Sweating
Clean skin regularly, dry clean clothing and
bedding to prevent skin infection.
Hyperthermia – temperature > 37.2ºC
Ensure adequate hydration and reduce
environmental temperature. Avoid heavy bedding
and use of Perspex cot. Dress or swaddle in loose
light fabrics, skin to skin contact with mother.
Nasal flaring / tachypnoea
Avoid swaddling so that respiration can be
observed. Refer to medical staff if cyanosis or
mottling observed. Nurse in supine position unless
continuously monitored.
Nasal stuffiness / excessive nasal
secretions
Use gentle suction if nasal secretions cause
obstruction to ensure adequate respiratory function.
Excessive sucking – fists, fingers, thumbs
Apply mittens, keep hands clean, consult with
mother re use of pacifier (dummy) for non-nutritive
sucking to provide comfort and prevent trauma to
fingers and fists.
Poor feeding
(infrequent/uncoordinated suck)
Feed on demand.
Reduce environmental stimuli during feeding.
Frequent small feeds with rest between sucking.
Weigh and assess hydration daily.
Assess coordination of suck/swallow reflex –
support cheeks and jaw if necessary.
If insufficient fluid intake refer to medical staff.
Regurgitation / vomiting
Burp or wind when infant stops sucking and at end
of feed.
Loose stools / diarrhoea
Frequent nappy changes using barrier creams
Occasional skin exposure to allow buttocks to dry.
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
PHARMACOLOGICAL TREATMENT OF NEONATAL WITHDRAWAL SYMPTOMS
If pharmacologic management is necessary, the American Academy of Pediatrics recommends use of drugspecific therapy, preferably with a drug from the same class as that causing withdrawal. Benzodiazepines for
alcohol withdrawal and methadone for opioid withdrawal are the only drugs approved by the US Food and
Drug Administration (FDA) for the treatment of drug withdrawal. However paregoric and a number of other
drugs that do not have FDA approval are also used to treat symptoms of neonatal withdrawal.14
Paregoric, a household remedy that has been widely used since the 19th Century to calm fretful children,
contains ingredients that are potentially hazardous to infants (alcohol, benzoic acid, and camphor). It is no
longer recommended for ameliorating withdrawal symptoms in opioid-dependent neonates and has generally
been replaced by preparations such as diluted tincture of opium, morphine, clonidine, phenobarbital,
chlorpromazine, and diazepam.14, 34
In the United States a national survey to determine the monitoring and treatment of NAS in neonatal
intensive care units (NICUs) following opioid or polydrug exposure in utero, found that opioids (tincture of
opium or morphine sulphate solution) were most commonly used for management of both opioid (63%) and
polydrug withdrawal (52%), followed by phenobarbital (32%) for polydrug withdrawal and methadone (20%)
for opioid withdrawal.24 Overall 70% of the respondents use phenobarbital and 25% use intravenous
morphine to control opioid withdrawal seizures, with 81% of respondents using phenobarbital for polydrug
withdrawal seizures.24 Only 70% of respondents always use a scoring system when deciding whether to
start, titrate or cease pharmacologic treatment for neonatal withdrawal.24
Opioid withdrawal
A number of different types of drugs have been used to treat neonatal opioid withdrawal, but few studies
have compared the efficacy of different treatments of neonatal drug withdrawal. Data about the relationship
between the severity of withdrawal, the short-term efficacy of treatment, or, importantly, the longer-term
infant outcome after different treatment regimens are not reported. Treatment regimens include:14
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Tincture of opium (morphine concentration of 10 mg/mL)
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Paregoric (morphine concentration of 0.4 mg/mL)
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Oral preparations of morphine (2 mg/mL and 4 mg/mL) with the dose calculated to deliver the same
quantity of morphine equivalent usually supplied in paregoric
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Methadone (0.05 to 0.1 mg/kg every 6 hours)
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Oral clonidine (0.5 to 1.0 µg/kg in a single dose, followed by a maintenance dose of 3 to 5 µg/kg/day,
divided into 4 to 6 hourly doses)
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Chlorpromazine (0.55 mg/kg every 6 hours intramuscularly or orally)
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Phenobarbitone [phenobarbital]
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Diazepam14
The American Academy of Pediatrics recommends that drug selection should match the type of agent
causing withdrawal.14 Morphine is the drug of choice for managing withdrawal in infants of mothers who
have used opioids such as methadone, heroin and pethidine during pregnancy. Morphine has been shown to
be superior to phenobarbitone for management of symptomatic NAS when maternal opioid use is
prevalent.35 In addition the shorter treatment duration and lower requirement for higher intensity nursing
morphine may have significant cost advantages.
In Australia an opioid should be used as the initial treatment for infants with NAS symptoms resulting from
opioid withdrawal.4 The opioid of choice is morphine.4, 36 The benefits of using phenobarbitone in addition to
an opioid for infants with opioid-related NAS are unclear. If other drugs have been used concurrently in
pregnancy, particularly benzodiazepines, and symptoms of NAS are not adequately suppressed by an opioid
alone, phenobarbitone may be indicated as an additional therapy.4, 36 If an infant has signs of NAS and the
type of drugs used by the mother are unknown, a full assessment of maternal drug use should be made by
an experienced clinician. In addition, infant urine and meconium may be used for toxicological analysis.4
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
King Edward Memorial Hospital for Women (KEMH) prepares morphine as a 1.0mg/ml aqueous solution.37
The Royal Prince Alfred Hospital Pharmacy prepares morphine as a 0.5mg/ml aqueous solution.38 Both
hospitals recommend the following regimen for opioid withdrawal,37, 38 with KEMH also recommending that
where the control of symptoms is difficult the morphine daily dose should be administered in 6 divided doses
rather than 4.37
NAS score (score every 4 hours)
Dose / Action
Score averages ≥ 8 for 3 scores
Morphine 0.5 mg/kg/day in 4 divided doses orally
If score persists ≥ 8 despite morphine 0.5 mg/kg/day
Morphine 0.7 mg/kg/day in 4 divided doses orally
If score persists ≥ 8 despite morphine 0.7 mg/kg/day
Morphine 0.9 mg/kg/day in 4 divided doses orally
When infants are on 0.9 mg/kg/day
Monitor cardiorespiratory function
♣
There is little evidence on how to wean these babies from morphine so all decisions are empirical.37 After
scores fall below treatment level (score ≤ 8) for 48 hrs, the dose should be reduced by 0.05 mg per dose
every 4 days or longer, depending on the scores.37 Given the half-life of morphine it is more appropriate to
reduce the dose rather than the frequency.37 The usual length of morphine treatment ranges from one to
several months.37, 38 Cardiorespiratory monitoring should continue for 4 days or until dose is reduced.38
Management of the vomiting baby: ensure that the infant is not being overfed and that the infant is being
appropriately postured during and after feeding. Give the morphine before the feed.
If the infant has a large vomit after being given morphine:
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if infant vomits within 10 minutes of dose, re-dose
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if infant vomits after 10 minutes, give ½ dose
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if infant vomits after feed, do not give further morphine (always err on side of caution).37
Non-opioid CNS depressant withdrawal (benzodiazepines, barbiturates, alcohol)
If the mother uses central nervous system depressants such as alcohol, benzodiazepines, and barbiturates
rather than opioids, then phenobarbitone is the drug of choice for the management of NAS.32 In one study
infants treated with a loading dose regimen of phenobarbitone have a significantly reduced time to control of
symptoms than infants treated with no loading dose and titration only (33 versus 64 hours).39
King Edward Memorial Hospital for Women and the Royal Prince Alfred Hospital recommends the following
phenobarbitone regimen for non-opioid CNS depressant withdrawal:37, 38
NAS score (score every 4 hours)
Dose / Action
Score averages ≥ 8 for 3 scores
Phenobarbitone 15 mg/kg oral or IMI stat (loading
dose) then 6 mg/kg/day in 2 divided doses orally
(maintenance dose)
If score persists ≥ 8 despite phenobarbitone 6
mg/kg/day
Phenobarbitone 8 mg/kg/day in 2 divided doses
orally
If score persists ≥ 8 despite phenobarbitone 8
mg/kg/day
Phenobarbitone 10 mg/kg/day in 2 divided doses
orally
When infants are on 10 mg/kg/day
Monitor cardiorespiratory function♣
Barbiturate withdrawal:
After scores fall below treatment level (score consistently ≤ 8) for 48 hours the dose should be reduced by
2mg per dose every 4th day or longer depending on scores.38
♣
opioids and phenobarbitone in high doses are powerful respiratory depressants
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
Non-barbiturate withdrawal (e.g. benzodiazepines):
The dose may be reduced more rapidly after withdrawal symptoms settle.38
COMPLICATIONS, ADVANTAGES AND DISADVANTAGES OF PHARMACOTHERAPY**
Complications of excessive pharmacotherapy:40
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Diminished or absent reflexes - Moro, sucking, swallowing, Galant, Perez, tonic neck, corneal, grasp
(palmar or plantar)
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Truncal (central) or circumoral cyanosis or persistent mottling not associated with ambient
temperature decreases
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Decreased muscle tone with passive resistance to extension of extremities or decreased neck or
trunk tone
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Altered state of arousal (reduced reaction to stimuli or comatose)
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Diminished response to painful stimuli
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Inability to follow moving objects visually
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Impaired thermoregulation, particularly hypothermia
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Altered respirations - irregular (periodic breathing in term infants), shallow (decreased air entry),
decreased respiratory rate (< 20 per minute) and apnoea
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Cardiac changes - irregular heart rate, distant heart sounds with weak peripheral pulses, reduced
heart rate (80 to 100 beats/minute), poor peripheral perfusion (pale, grey, mottled), cardiac arrest
Morphine – advantages:40
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Reduces bowel motility and loose stools
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20%-40% bioavailability when administered orally
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Facilitates feeding and interpersonal interaction
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Drug of choice for opioid exposure
Morphine – disadvantages:40
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Respiratory depressant
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Hypotension
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Delayed gastric emptying
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Ileus or loss of bowel motility
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Urinary retention
Phenobarbitone – advantages:40
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Drug of choice for polydrug use
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Controls irritability and insomnia
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Controls symptoms in 50% of infants regardless of the mother’s choice of drug
Phenobarbitone – disadvantages:40
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Does not prevent loose stools
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Infant needs to be closely monitored (may need transfer to the Special Care Nursery)
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May mask the severity of NAS symptoms
** Caution should always be used when treating the neonate or infant with morphine and/or
phenobarbitone. If uncertain, consult the Paediatric Registrar at King Edward Memorial
Hospital for Women (available 24/7 on (08) 9340 8222).
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
DISCHARGE PLANNING AND FOLLOW-UP
Services need to be coordinated throughout the antenatal, perinatal and postnatal periods to ensure smooth
transition for mother and baby. It is critical that services be maintained in the postnatal period following
discharge from hospital, when infants may be at greatest risk.41 Planning for post-discharge follow-up and
parenting support is ideally initiated early in the pregnancy, and should consider the health status of both
mother and infant, psychosocial issues and the care-giving environment (see Antenatal Care for the
Substance Using Mother Guideline and Algorithm). Consistent standards of practice that engage whole
families need to be established. An effective and well coordinated discharge plan is an essential component
of the continuum of care.
The timing of discharge may depend on a number of factors including family or social issues and treatment
issues surrounding the mother. Involvement of the multidisciplinary care team is vital for helping the
physician to assess the status of the home environment and whether it is safe to discharge the infant. The
length of in-hospital observation should be determined on an individual basis. Postpartum and neonatal
length of stay should be flexible and may extend beyond seven days as withdrawal symptoms may not
present for 7-9 days.42 A non-judgmental and supportive atmosphere is likely to help ensure future
compliance with paediatric follow-up.43
Discharge planning and after-care case management should consider:44
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Spelling out a process for discharge planning
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Identifying a case manager
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Identifying a schedule of visits
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Specialised needs of the infant if indicated
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How long the woman and her family should be followed up after delivery
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Handover to future services for follow-up
At the time of discharge there must be a formal transfer of responsibilities from the hospital to the community
services that will be continuing the delivery of care, and referrals and supports must be in place. The
referring provider should actively follow-up with community services to ensure that the woman has engaged
with the service. Where engagement has not occurred, the referring provider should follow-up with the
woman or her family.4
Early discharge of the drug-exposed infant:
Very few studies have adequately addressed the issue of early discharge of the substance exposed infant.
One study45 that investigated the effect of early discharge and other factors on the readmission rates of a
small sample of newborn infants reported that prenatal substance use was not related to readmission.
However, this study did not address other important issues such us early weight gain and compliance with
follow-up visits.
Mothers should be strongly discouraged from going home early where there is a high risk of infant
withdrawal resulting from complex polydrug use or very high methadone intake, as onset of NAS is
frequently delayed. If the mother insists on going home against medical advice, a community services
(DoCS) notification should be considered.44
Discharge before 48 hours is contraindicated in infants of mothers with a history of opioid use, even if there
is no evidence of withdrawal symptoms, due to the possibility of delayed onset.46 Early discharge is not
usually appropriate for drug dependent women. Opioid and sedative-dependent women should be prepared
for a postnatal stay of five or more days to allow assessment of neonatal abstinence syndrome.4
General discharge criteria for drug-exposed infants:
Prior to discharge a case conference should be convened by the multidisciplinary care team to formulate a
discharge plan that defines clear responsibilities and timeframes. The discharge planning meeting should be
attended by parents or carers and representatives of all organisations involved who will be involved in the
provision and delivery of support and care.
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
All mothers and infants should be assessed adequately before discharge with respect to current drug use
and psychological stability, parent-crafting abilities, social situation and the infant’s wellbeing.44
Infants should not be discharged from hospital without a formal discharge plan or:
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If there is excessive weight loss (> 10% of birth weight)
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Before the baby is five days old
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If there is suspected infant neglect or abuse (as communicated by social worker)
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If there is suspected home violence (as communicated by social worker)
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If a court order prevents the baby from being discharged home
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If further assessment for withdrawal is required.4, 37, 44
Additional contraindications to home discharge include:
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Inadequate home support or acceptance of assistance from external agencies
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Inadequate housing or material goods
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Erratic behaviour or continued drug or polydrug use
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Inadequate parenting skills (such as failure to consistently demonstrate the ability to feed and
provide appropriate care for the infant during hospitalisation
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Inability to participate in required paediatric follow-up program.4, 37
There are insufficient data to determine the safety of discharge of infants on morphine. Before an infant is
discharged home on morphine or phenobarbitone, the treatment team must be satisfied of the safety of the
home environment and of the parents’ parenting abilities and ability to administer treatment. Careful and
frequent supervision by the treatment team is required.4, 44
Discharge checklists are used by a number of organisations. These vary in content but normally include
discharge planning meetings, paediatric assessment and follow-up, social work or child at risk assessment,
drug health assessment, information on safe sleeping, storage of drugs in the home and referral to support
services.
The completed discharge plan assumes that:
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Both mother and baby have been appropriately stabilised and managed from a medical perspective
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The infant is at least five days old
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The infant is feeding well and gaining weight over two consecutive days
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The parent or carer is actively involved in caring for the infant
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There is no evidence of NAS
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There is a plan in place to address any child protection concerns
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Referrals to appropriate community support agencies have been made and are in place
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Continuing drug and alcohol management arrangements are in place for the mother following
discharge
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Ongoing methadone treatment has been arranged and confirmed with the woman’s methadone
prescriber or methadone clinic (for mothers on methadone maintenance)
Post-discharge management of infants discharged on medication
Infants requiring ongoing pharmacological management of opioid withdrawal may continue management in
the home environment, providing that the family has access to appropriate support and follow-up. Home
management of the infant helps to prevent prolonged disruption to the mother-infant relationship, and
provides health care professionals with the opportunity to observe the family’s ability to provide adequate
care for their infant.37
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
Different hospitals have a range of discharge criteria that may need to be met prior to discharging the infant
into the care of the parent or carer. Criteria that may be included in a discharge checklist include the
following:
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‰
‰
‰
‰
‰
‰
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‰
‰
‰
‰
‰
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‰
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Modified Finnegan Neonatal Abstinence score remains consistently below 8
Respiratory or apnoea monitor (if used) has been removed for 48 hours and is no longer required
Multidisciplinary care team agree to discharge care of the infant to the parent or carer
Parent or carer has received information on Neonatal Abstinence Syndrome (NAS) and understands
the possible timeframe that withdrawal symptoms may persist in the infant
Parent or carer’s ability and confidence to care for the infant, and their competence to score NAS,
has been demonstrated
Parent or carer has agreed to attend scheduled Outpatient clinic appointments
Parent or carer has completed the contact sheet and provided contact numbers and addresses
Parent or carer understands when to seek medical assistance for the infant
Parent or carer has been provided with emergency contact numbers
Parent-crafting education on techniques such as swaddling, settling, massage, relaxation baths and
dummies/pacifiers has been completed
SIDS education has been completed
Neonatal resuscitation education session has been attended by parent or carer
Effective pharmacotherapy has commenced and a weaning program established
Medication dispensing schedule has been explained to the parent or carer
Parent or carer can demonstrate the ability to administer the infant’s medication
Visiting Nurse/ Child Health Nurse/ Community Nurse visits arranged while on medication
General Practitioner and Child Health Nurse have been provided with a copy of the infant’s
discharge medication schedule and summary of care
To be eligible for the NAS Home Management Program at KEMH, the infant needs to have been stabilised
on morphine, be medically stable, feeding regularly and showing consistent weight gain.37 Families are
asked to agree to a number of program requirements. These include:37
•
Visiting and providing safe care for the baby throughout the baby’s stay in the nursery
•
Administering the medication at home to the infant as prescribed
•
Attending the hospital pharmacy every week to return empty medication bottles and collect the
weekly supply of medication
•
Attending the scheduled doctor’s clinic appointments and contacting the Follow-Up Coordinator to
reschedule an appointment if unable to attend a scheduled appointment
•
Agreeing to visits and care by the Home Visiting Nurse and/or local Child Health Nurse
•
Arranging to be at home with the infant at the times arranged with the Home Visiting Nurse for home
visits and contacting the Home Visiting Nurse to reschedule a home visit if necessary
•
Demonstrating the ability to safely give medication, feed and care for baby by staying overnight in
parent-crafting rooms for 1–2 nights prior to discharge.
Parents should be given instructions on the administration of medication in the week prior to discharge. All
NAS infants discharged home on medication are referred to the Home Visiting Nurse (if discharged from the
Special Care Nursery) or to Princess Margaret Hospital (PMH) Home Visiting Nurse Services for in-home
support, and monitoring of weight gain and NAS symptoms.37
© Western Australian Centre for Evidence Based Nursing & Midwifery, January 2007 (RHSET 01660A)
All guidelines should be read in conjunction with the Disclaimer
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MANAGEMENT OF THE INFANT WITH NEONATAL
ABSTINENCE SYNDROME (NAS)—LITERATURE REVIEW
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All guidelines should be read in conjunction with the Disclaimer
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