Download Neonatal Abstinence Syndrome Case Study

Neonatal Abstinence Syndrome Case Study
Ms. S delivered Baby S, a female infant, early this morning at 0400. Ms. S is a 29 year old G4 P2
-> 3 Preterm 0, Ab 1, Living Children 1 -> 2, who delivered at 39 weeks by NSVD. The baby
had grunting, flaring and retractions noted in Labor and Delivery, and came to the ICN3 for
observation. Ms S began prenatal care at 18 weeks. At her first prenatal visit she disclosed using
oxycontin 10 mg “four or five times” daily for chronic back pain after a fall from a horse in
2004. After starting prenatal care, she accepted a referral to the Milagro Program where she
converted her pain medication to Methadone. She took 80 mg daily at the end of her pregnancy.
She informed the nurses after delivery that she planned to breastfeed Baby S. What other
information needed to plan management?
1) What other information needed to plan management?
Toxicology screening of the mother and baby will assist with understanding recent
drug exposure to Baby S at the time of delivery. Given Ms S’ history, the medical
team anticipates a positive screen for her that shows methadone. At the time of
delivery, technical issues around collecting urine from the baby may influence
results. Those include the challenges of obtaining a urine from the standard urine
collection bag, the type of screen done by the lab at UNM versus Tricore labs, and
the degree of urine concentration by the baby. The technique of placing a urine
collection bag presents challenges as the adhesive on the plastic surface applied to
the perineum may not stick to skin well allowing leakage of the urine into the
diaper. The contents of the bag may become contaminated by meconium. Delays in
collection may reduce the likelihood of obtaining a positive screen, as the levels of
drugs appearing in urine will fall as a function of length of time from delivery. The
first urine produced by the infant would be predicted to have the highest level of
drug or drug metabolite. The type of test done has an influence on interpretation of
results. Currently the rapid lab at UNM may test the infant’s urine with a dipstick
test that has not been validated in newborn practice. This testing method seems to
create false negatives based on negative results that when retested with more
sensitive tests show positives. Either type of testing assays for drugs or their
metabolites above a specific quantitative threshold. Tests are reported positive if the
concentration of the chemical exceeds the testing threshold. Conversely, the results
are reported as negative if below the threshold. A metabolite for cocaine,
benzoylecognine, for example, is not produced by human metabolic pathways from
any other precursor except cocaine, so any level detected would imply prenatal use
by the mother with passage into the body of the baby. Therefore, a negative drug
screen has low specificity especially in context of a positive history of recent drug
use by the mother. Finally, some parents may interfere with the collection by
removing the bag before the nursing staff are notified.
2) The results of Ms S’ urine drug screen returns collected from Labor and Delivery. How
would you interpret the results? What do you do with the results?
Ur Amphetamine Screen Interpretation
Negative
Ur Barbiturate Screen Interpretation
Negative
Ur Benzodiazepine Screen Interpretation
Negative
Ur Cannabinoid Screen Interpretation
Negative
Ur Cocaine Screen Interpretation
Negative
Ur Darvon Screen Interpretation
Negative
Ur Methadone Screen Interpretation
Negative
Ur Opiate Screen Interpretation
Negative
The results do not seem to fit with the clinical picture. Currently, the rapid
laboratory at UNM uses an approved dipstick testing kit. The clinical experience of
the medical teams has found that the dipstick testing may provide negative results in
the face of expected positives. The more appropriate test that the team should order
is the “Urine Drug Quantitative Test.”
3) The repeat test from Ms S with the following results. How would you interpret them?
Ur Amphetamine Screen Interpretation
Negative
Ur Barbiturate Screen Interpretation
Negative
Ur Benzodiazepine Screen Interpretation
Negative
Ur Cannabinoid Screen Interpretation
Positive
Ur Cocaine Screen Interpretation
Negative
Ur Darvon Screen Interpretation
Negative
Ur Methadone Screen Interpretation
Positive
Ur Opiate Screen Interpretation
Positive
The results from the more sensitive test suggest that Ms S received methadone as
she described. In addition, the results suggest that she used marijuana and opiates
close to the time of delivery. The pattern of results will require additional history
taking to understand Baby S’ drug exposure.
4) The results from Baby S Urine Drug Quantitative Test returns with the following results.
How would you interpret them?
Ur Amphetamine Screen Interpretation
Negative
Ur Barbiturate Screen Interpretation
Negative
Ur Benzodiazepine Screen Interpretation
Negative
Ur Cannabinoid Screen Interpretation
Positive
Ur Cocaine Screen Interpretation
Negative
Ur Darvon Screen Interpretation
Negative
Ur Methadone Screen Interpretation
Positive
Ur Opiate Screen Interpretation
Negative
The results from the more sensitive test indicate that Baby S had exposure to
methadone consistent with the mother’s history. She also had exposure to marijuana
near the time of delivery. She also had exposure to opiates early and possibly later in
pregnancy. The exposure to opiates places Baby S at risk for Neonatal Abstinence
Syndrome.
5) On further questioning, Ms S provides further information that she continued to have back
pain especially the last week before she delivered. She found some 10 mg oxycontin tablets
and took one every morning and at bedtime to help reduce her pain. She also explained that
she smoked marijuana “two or three times a week for nausea.” She did not communicate her
use of oxycontin or marijuana to her counselors at Milagro. She does not know why her drug
screens remained negative except for methadone at the end of her pregnancy. How does this
information affect your plans for observing and caring for Baby S?
The recent use of daily oxycontin may place Baby S at risk of early symptoms of
Neonatal Abstinence Syndrome. The presence of shorter acting opiates may result in
more rapid declines in brain and serum levels in Baby S. The fall in levels correlates
with the appearance of symptoms. At this time, you should refer to the Neonatal
Abstinence Score sheet to understand the possible symptoms in the syndrome and to
understand the scoring system to evaluate the severity of symptoms.
6) The mother communicates with the nurses that she may have to go home tomorrow to take
care of her other child. She wants to know if the baby will be ready to leave. How long
should the baby stay in the hospital?
Based on the work of Finnegan at Jefferson Memorial Hospital in Philadelphia,
90% of infants that will have Neonatal Abstinence Syndrome and require
pharmacologic treatment manifest symptoms in 96 hours. The experienced nursing
staff has begun observing Baby S for symptoms and recording their findings on the
bedside chart. At this time the baby has had scores of 3, 4 and 6.
7) Ms S receives the information about Baby S having Neonatal Abstinence Syndrome and
after thinking on it agrees to stay for another day. She asks you to explain the syndrome.
What do you tell her?
Neonatal Abstinence Syndrome occurs in babies who have prenatal exposure to
opiates and methadone. The syndrome involves many body systems and presents
with effects on the central nervous system, effects to the gastrointestinal system, and
disturbances of the metabolic, respiratory, and vasomotor functions of the baby.
The signs of the syndrome increase over time as the levels of opiates or methadone
fall in the babies’ brain and serum. To manage the syndrome, the nursery and
medical staff observe the baby carefully and assign scores for the severity of signs.
They use the scores to determine how well the baby handles the syndrome’s effects
and to determine what interventions to use.
The scores for babies who do not have the syndrome did not exceed 5 in the
studies of Finnegan. Babies who had the syndrome scored above 5. With scores
between 5 and 7, babies receive supportive care. With scores of 8 or higher three
times consecutively or when three consecutive scores average 8 or higher, babies
begin receiving pharmacologic treatment. Generally that means the babies receive
methadone to treat the syndrome. Please see handout with methadone dosing
schedule.
•Symptoms found more in term infants
•Severity of NAS possibly correlated with
–Maternal methadone dosage
–More rapid drop in umbilical cord methadone levels
•Term infants had more NAS–related seizures
•Symptoms present in 3 categories seen most in Neonatal Abstinence Syndrome
–CNS disturbances
Excessive high pitched cry
Sleeps less than 2 hours after eating
–Vasomotor, Respiratory, Metabolic disturbances
Moderate tremors, increased muscle tone
Sweating, skin mottling
Nasal Stuffiness
Fast breathing, more than 60 per minute
–Gastrointestinal disturbances
Excessive sucking, problems eating
Loose stools
•Premature infants have less NAS symptoms at first
•Reduced symptoms in preterms may be from:
–Immature development of brain dendritic ramifications,
–Immature neurotransmitter function in brain,
–Immaturity of specific opiate receptors
–Reduced total drug exposure in pregnancy
–Less muscle mass affecting neuromotor symptoms
Long term effects from exposure apparent with age
8) She continues to express an interest in breastfeeding. What information do you need and
what will you counsel?
Ms S states that she had a prenatal breastfeeding consult with the doctors in
the
FOCUS Program. When you review the notes in her prenatal electronic medical
record, you find a note from the eighth month of her pregnancy. The note confirms
that Ms S has had a past addiction to oxycontin, that she has established prenatal
care with Milagro, and that her toxicology screens to the date of the consult have
shown positive only for methadone. The consult note goes on to state that the
FOCUS Program medical team would support Ms S initiating breastfeeding if she
and her baby have toxicology screens negative for all other substances besides
methadone. The note recommends contact with the FOCUS team if the results show
otherwise.
You contact the FOCUS team through the hospital social workers. The
doctor remembers Ms S, listens to the report of the toxicology screens, and agrees to
meet with Ms S to further discuss her interest. The plan might include clarification
with Ms S that she cannot use additional oxycontin or use any marijuana and have
support for breastfeeding. If she agrees that the passage of additional drugs to Baby
S presents additional and unacceptable risk to the baby, the FOCUS team may
recommend that Ms S pump and dump her colostrum and breastmilk until her
urine quantitative drug toxicology screen becomes negative. At that time she might
be able to initiate breastfeeding with support including frequent urine quantitative
drug screens.
9) Ms. S agrees to pump and dump her breastmilk and to provide daily urine quantitative drug
screens until they become negative. Then she would plan to breastfeed. She wants to know if
breastfeeding while taking methadone will delay Baby S’ treatment.
Initial transfer of methadone in colostrum and breastmilk is very hard to quantify
but thought to transfer at a low level. Early literature suggested babies might
successfully wean without treatment except breastfeeding by mothers receiving
methadone treatment. However, the consistency of care and observation required
seem too great a barrier to support newborn treatment with only methadone
transferred by breastfeeding in the current standard of care. The clinical experience
has not shown that breastfeeding has made the hospital stay longer in a very small
series of babies.
Summary points for ideal management.
 Develop plan in prenatal care at FOCUS clinic
 Possible benefit to mother and baby in bonding
 Presumed small quantity passes in breastmilk
 Amounts may influence weaning protocol
 Risk of delayed NAS with stopping of breastfeeding
 Discourage breastfeeding if
 –Relapse to opiate use
 –Use of cocaine, methamphetamine
 Long-term effects unknown
10) Baby S observed to have signs associated with Neonatal Abstinence Syndrome. "How
would you plan management of baby S if she has moderate NAS and what would be
the goals of treatment? How would you plan management if she has more severe
NAS and what would be the goals in this case?"
Treatment of Moderate Neonatal Abstinence Syndrome
Scores >5 but < 8, supportive care for moderate NAS.
–Reduce stimuli
–Swaddling
–Pacifier
Treatment of More Severe Neonatal Abstinence Syndrome
Scores above threshold means more severe NAS, use medication
–Long acting preferred; methadone
–Short acting medications effective; however increased dosing and greater
risk of medication error
Goals of treatment
Reduction in symptoms
–Prevent dehydration from GI symptoms
–Prevent increased CNS instability
Withdrawal has uncoordinated and ineffectual sucking reflex
Improve nutrition and maintain hydration
Stabilize sleep and wake cycles
Increase quiet-alert state
Not to sedate!
Methadone is best treatment for Neonatal Abstinence Syndrome
Starting methadone dose is 0.7 mg / kg
–Divided in 6 doses for first 24 hours, loading model
–Next 24 hours, given 1/2 dose every 4 hours
Weaning by lengthening interval between doses
Scores of < 8 = acceptable control
Poor control indicated when
–Scores >= 8 three consecutive periods or
–Mean >= 8 over three consecutive periods
Treatment stops progression of syndrome signs
Score sheet used to monitor treatment
Methadone adjusted based on scores
–Scores more than 8 requires more methadone
–Scores less than 8 means less methadone
Goal is to help babies become more alert
–Reduce risk of higher scores
–Intervene before severe symptoms like seizures occur
Goal is to help babies become more alert
–Reduce risk of higher scores
–Intervene before severe symptoms like seizures occur
11) Now on Day 9 of life, Baby S has received treatment with methadone and Ms S
successfully establishes breastfeeding. On day eight Baby S received a dose of methadone at
1700. The baby has had scores since then of 2, 3, 2, 4, 3, and 5. How do you decide when to
stop treatment and what do you need to do to plan discharge?
As babies wean to every 24 hour treatment and scores remain low, usual protocol
calls for observation for approximately 48 hours in the ICN3 off methadone with
scores below 8 to clear Baby S for discharge.
Given that Ms S continues to breastfeed on a daily dose of 80 mg of
methadone, the medical care of the baby calls for an outpatient appointment with
the FOCUS Program in the next seven days for follow up. Also, the social worker in
the ICN3 has made a referral to FOCUS for case management services. The FOCUS
team has assigned a staff member to work with Ms S, and a meeting will occur in
the ICN3 prior to discharge of Baby S.
The medical team following Baby S will see the mother and baby weekly to
determine that the baby has adjusted well to being home. Ms S will provide a urine
quantitative drug test at her weekly visits. The goal will be to maintain
breastfeeding through the first six months of life so that with good growth the dose
of methadone passed to the baby drops relative to the baby’s weight and that the
amount of breastmilk received by the baby decreases with introduction of solid
foods. Ms S agrees to the discharge plan.