Download Neonatal Abstinence Syndrome

Impact and Treatment of Newborns
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Addiction is a disease that effects at least two
patients:
◦ A mother with the chronic, relapsing disease of
addiction that involves biological changes in oxytocin
and dopamine in the brain, resulting in disorders of
attachment and reward
◦ An infant
 Impacted by the effect of drug exposure in utero and
potentially by withdrawal and further drug exposure after
birth
 With immediate needs for permanence and stability
impacted by potential disorders of attachment and bonding
of the mother
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More likely
◦ To be born preterm
◦ To have lower birth weights and lower
head circumferences
◦ To require resuscitation
◦ To be admitted to a SCN or NICU
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Risk for withdrawal
◦ Prolonged hospitalization
◦ Medical treatment with further drug exposure to the
developing brain
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Three fold higher risk for child abuse and neglect
Increased risk for developmental delays, learning
disabilities and behavior problems
Babies with poor in utero growth have increased
incidences of heart disease, hypertension, and type
2 diabetes mellitus as adults
The infant’s future ability to mother, via epigenetic
modifications of gene expression, may be impacted
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Attachment is an innate biological system
promoting contact between an infant and
mother, in order to increase the likelihood of
survival
Changes in oxytocin and dopamine during
pregnancy and lactation prime the mother to
attach to and nurture her infant
Infant contact stimulates oxytocin release,
which may result in activation of the dopamine
reward pathway, reinforcing the maternal
response to the infant’s social cues
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Stress during pregnancy may reduce oxytocin
receptor binding, and chronic drug abuse
reduces oxytocin levels
Mom’s dopamine response does not occur
normally due to the impact of drug abuse on
the dopamine reward system. Naturally
rewarding behaviors no longer have the normal
impact on mom to reinforce those behaviors
Either results in increases in maternal anxiety
and decreased maternal bonding behavior.
Decreased maternal bonding behavior may
then result in decreased oxytocin receptor
binding in the offspring.
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Early maternal caregiving influences the
infant’s programming of the oxytocin and
dopamine neuroendocrine systems, which
then influences that infant’s maternal
behavior in adulthood
A neglected infant is biologically vulnerable
to become a neglectful mother
•
Urine –
• Detects only recent use
• Need first void to get highest concentration
• Values set for adults – may give false negatives for
infants
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Meconium
• Need ALL meconium
• Must be mixed before testing
• Rarely done correctly in collection or at lab
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Cord
• Easy to collect
• Most sensitive/accurate
• Quicker than waiting to collect all meconium
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A constellation of symptoms characterized by
◦ Central nervous system irritability
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Excessive/continuous crying – may be high pitched
Difficulty sleeping
Hyperactive moro, increased muscle tone
Tremors, disturbed and/or undisturbed
Myoclonic jerks, seizures
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Sweating
Fever
Nasal stuffiness, sneezing, frequent yawning, mottling
Nasal flaring, increased respiratory rate
◦ Autonomic over-reactivity
◦ Gastrointestinal tract dysfunction
 Frequent sucking
 Poor feeding
 Regurgitation, projectile vomiting, loose or watery stools
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Most often measured using the Finnegan NAS Scoring Tool
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Any positive screen during this pregnancy or
admitted history of opiate or other drug use –
baby will be scored in nursery for minimum
of 5 days
If scores remain below 8 and infant otherwise
doing well, discharged to home with follow
up
If scores are greater than 10 for two
consecutive times, infant transferred to NICU
Transfer to
NICU
Then increase clonidine if scores remain above 10.
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Since implementing our protocol have seen
◦ Decrease in length of stay from 50.4 to 25.1 for
term babies
◦ Reduced length of exposure to drugs
 Morphine exposure decreased from 30.3 days to 17.4
 Clonidine exposure decreased from 44.3 days to 20.1
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Parental presence is a key part of the
treatment!
Parental contract reviewed and signed
explaining importance of their presence – for
most if not all of the time.
◦ Shown to reduce medication use, weaning time,
length of stay
◦ Potential to improve bonding
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Will monitor for compliance issues and for
impacts on medication use and length of stay
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Discharge Criteria
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Home Therapy Candidate on phenobarb
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Off morphine for 48 hours
Off clonidine for 24 hours
Stable phenobarbital wean
Scores of 8 or less for 24 hours
Consistent weight gain
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Good social situation
A score of 7 or less for 24 hours
Consistent weight gain
Able to wean phenobarbital two times consecutively
Safety plans in place with CPS follow up
Developmental referrals in place