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Impact and Treatment of Newborns 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 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 Risk for withdrawal ◦ Prolonged hospitalization ◦ Medical treatment with further drug exposure to the developing brain 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 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 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. 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 • Meconium • Need ALL meconium • Must be mixed before testing • Rarely done correctly in collection or at lab • Cord • Easy to collect • Most sensitive/accurate • Quicker than waiting to collect all meconium A constellation of symptoms characterized by ◦ Central nervous system irritability Excessive/continuous crying – may be high pitched Difficulty sleeping Hyperactive moro, increased muscle tone Tremors, disturbed and/or undisturbed Myoclonic jerks, seizures 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 Most often measured using the Finnegan NAS Scoring Tool 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. 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 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 Will monitor for compliance issues and for impacts on medication use and length of stay Discharge Criteria Home Therapy Candidate on phenobarb ◦ ◦ ◦ ◦ ◦ Off morphine for 48 hours Off clonidine for 24 hours Stable phenobarbital wean Scores of 8 or less for 24 hours Consistent weight gain ◦ ◦ ◦ ◦ 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