Improving breastfeeding rates in Neonatal Abstinence ...cal .Improving breastfeeding rates in Neonatal

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  • Improving breastfeeding rates in Neonatal Abstinence Syndrome

    infants in the NICU

    Donna Garey MD MPH

    Lisa Stellwagen MD

    UC San Diego Medical Center

    Division of Neonatology

    January 2015

  • FACULTY DISCLOSURE INFORMATION

    Lisa Stellwagen MD

    I have a relevant financial relationship to disclose:

    Medela, Inc: speaker

    Donna Garey MD MPH

    I have a relevant financial relationship to disclose:

    none

  • Objectives

    Identify current evidence based reasons to encourage

    breastfeeding of the Neonatal Abstinence Syndrome

    (NAS) infant

    Identify what concrete steps can be implemented to

    improve breastfeeding rates at discharge in the NAS

    infant

    Learn the what is currently known about the effects of

    Marijuana during pregnancy and lactation, and then be

    able to accurately counsel mothers on this issue

  • Neonatal Abstinence Syndrome

    (NAS)

    Due to abrupt discontinuation of

    chronic exposure to opioids in utero

    Generalized multi-system disorder

    Incidence of NAS increasing around

    the US

  • Date of download: 1/27/2015 Copyright 2015 American Medical

    Association. All rights reserved.

    From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009

    JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951

    Error bars indicate 95% CI. P for trend < .001 over the study period. The unweighted sample sizes for mothers diagnosed with and

    without antepartum opiate use are 987 and 833 494 in 2000; 1058 and 849 133 in 2003; 2160 and 879 910 in 2006; and 4563 and

    816 554 in 2009; respectively.

    Figure Legend:

  • Date of download: 1/27/2015 Copyright 2015 American Medical

    Association. All rights reserved.

    From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009

    JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951

    NAS indicates neonatal abstinence syndrome. Error bars indicate 95% CI. P for trend < .001 over the study period. The unweighted

    sample sizes for rates of NAS and for all other US hospital births are 2920 and 784 191 in 2000; 3761 and 890 582 in 2003; 5200

    and 1 000 203 in 2006; and 9674 and 1 113 123 in 2009; respectively.

    Figure Legend:

  • NAS Timeline

    NAS. Pediatrics. Kocherlakota. 2014

  • Opiates

    Mimic natural endogenous endorphins at and receptors on the neuronal cell membrane

    Block transmission of noxious stimuli from the periphery to the spinal cord

    Develop tolerance to analgesia, sedation, and euphoria

    Cross the placenta Lipophilic, low molecular

    weight compounds

  • Heroin -opioid receptor agonist

    Approx 40-80% of infants have NAS

    Earlier onset and shorter withdrawal

    Onset of withdrawal symptoms at 24 to 48

    hours

    Duration of withdrawal is 8-10 days

  • Prescription Narcotics

    Long-Acting Opioids Fentanyl Transdermal Patch

    Oxymorphone or Oxycodone

    hydrochloride extended-release

    Morphine sulfate extended-release

    Short-Acting Opioids Hydrocodone

    Oxycodone

    Tramadol

    Fentanyl (IV) or Morphine (IV)

    Codeine

    Hydromorphone

    Frequency of NAS

    depends on amount

    and duration of

    maternal use

    Onset and duration of

    withdrawal depends on

    half-life of the drug

    Approx 5-20%

    experience NAS

  • Treatment for opioid addiction

    Methadone

    -opioid receptor agonist

    Half Life 23-48 hours

    Typical dose is 20 to 120

    mg per day

    Mean hospital stay for NAS

    17.5 days

    Later onset and longer

    withdrawal

    Buprenorphine

    partial -opioid agonist

    Half-life 26-34 hours

    Mean hospital stay for NAS

    10 days

    Later onset and longer

    withdrawal

    Minimal relationship between maternal

    opioid dose and NAS.

  • Buprenorphine +/- Naloxone Synthetic opioid receptor agonist

    Prescribed in a doctors office by qualified MD

    Available formulations:

    Tablets - 2 and 8 mg tablets

    Sublingual film - 2-4-8-12 mg

    Patch form for chronic pain

    Less respiratory depression than other narcotics

    Can cause coma/death if combined with benzos, alcohol, other respiratory

    depressants

    Shorter duration of NAS

  • Onset, Duration, and Frequency of NAS

    Opioids Onset

    (hours)

    Frequency

    (%)

    Duration

    (days)

    Heroin 24-48 40-80 8-10

    Prescription

    Opioids

    36-72 5-20 10-30

    Buprenorphine 36-60 22-67 Up to 28 or

    more

    Methadone 48-72 13-94 Up to 30 or

    more

  • Infants Admitted for Observation for Neonatal Abstinence Syndrome

    Admit to NICU:

    NAS (Finnegan score) q 4 hr.

    Implement non-pharmacologic

    therapies

    Observation and Monitoring:

    NAS < 8 continue to monitor until safe for

    discharge

    NAS >8 times 2 implement therapy

    Observation Period:

    Short acting prescription narcotics: 4 days

    Benzo + opiates: 4-7 days

    Heroin/methadone: 5-7 days

    Suboxone: 5-6 days

  • Why treat maternal drug abuse and neonatal withdrawal?

    Decreases illicit drug use

    When combined with good obstetrical care improves fetal

    outcomes

    Avoids complications of NAS such as seizures and

    dehydration due to poor feeding, vomiting, and diarrhea.

    Allows infant to have normal feeding and infant

    interactions.

  • Risk Factors for Increased Severity/Intensity of NAS

    Term

    Polydrug abuse

    Combination with benzodiazepines

    Specific gene polymorphisms of the -opioid receptor

    (OPRM1) and catechol-O-methyltransferase (COMT)

    Smoking

    Methadone

    Combination with SSRIs

  • Withdrawal in Preterm Infants

    Decreased intensity and severity

    Decreased cumulative exposure

    Decreased transmission across placenta in

    early gestation

    Decreased receptor development and

    sensitivity

    Decreased fatty tissues

    Methadone accumulates in fatty tissues

  • Modified Finnegan

    Zimmerman-Baer U, et al. Addiction. 2010.

  • Infants Admitted for Observation for Neonatal Abstinence Syndrome

    Admit to NICU:

    NAS (Finnegan score) q 4 hr.

    Implement non-pharmacologic therapies

    Observation and Monitoring:

    NAS < 8 continue to monitor until

    safe for discharge

    NAS >8 times 2 implement therapy

    Observation Period:

    Short acting prescription narcotics: 4 days

    Benzo + opiates: 4-7 days

    Heroin/methadone: 5-7 days

    Suboxone: 5-6 days

  • CNS Signs and Symptoms

  • Excessive High Pitched Cry

    Scored infants 30 60

    minutes after a feed.

    If the infant requires rocking

    to quiet during this time.

    Their cry is considered

    prolonged.

    If infants cry is high pitched at its peak even

    though it is not prolonged

    score 2.

    If cry is high pitched

    throughout, or if crying is

    prolonged, even if not high

    pitched score 3.

  • Increased muscle tone

    Score if excessive or

    above-normal muscle

    tone.

    For instance: no head lag

    when being pulled to a

    sitting position or tight

    flexion of the infants arms and legs.

  • Moro Reflex

    If the infant exhibits

    pronounced jitteriness

    (rhythmic tremors that are

    symmetrical and involuntary) of

    the hands during or at the end

    of a Moro reflex score 2.

    If jitteriness and clonus

    (repetitive involuntary jerks) of

    the hands and/or arms are

    present during or after a Moro

    score 3.

  • Myoclonic jerks

    Score if involuntary muscular

    contractions which are

    irregular and exceedingly

    abrupt (usually involving a

    single muscle group) are

    observed.

  • Tremors

    Mild, Moderate, and Severe

    Disturbed or Undisturbed

    Undisturbed means that the

    baby is either sleeping or at

    rest in its bed.

  • Seizures

    Most commonly seen as tonic

    extensions of all limbs.

    Unusual limb movements may

    accompany a seizure. In the

    upper limbs these often

    resemble swimming or rowing

    in the lower limbs, they

    resemble pedaling or bicycling.

    Other subtle signs may include

    staring, rapid involuntary eye

    movement, chewing, back

    arching, and fist clenching.

    Occurs in 2-11% of infants with NAS

  • Gastrointestinal Signs and Symptoms

  • Excessive Sucking

    Score if hyperactive or

    disorganized sucking,

    increased rooting reflex.

  • Loose/watery stools

    Score if loose (curds/seedy

    appearance) or watery stools

    (water ring on nappy around

    stool) are observed.

    Score if at least one episode

    of regurgitation is observed.

    Vomiting

  • Poor Feeding

    Score if the infant

    demonstrates excessive

    sucking prior to feeding,

    yet sucks infrequently

    during a feeding, taking a

    small amount; a