Infant born with neonatal abstinence .The Infant Born With Neonatal Abstinence Syndrome by Karen

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Text of Infant born with neonatal abstinence .The Infant Born With Neonatal Abstinence Syndrome by Karen

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    The Infant Born With Neonatal Abstinence Syndrome

    by

    Karen DApolito, Ph.D., APRN, NNP-BC, FAAN

    Professor & Program Director, NNP Specialty

    Vanderbilt University School of Nursing

    FacultyDisclosure

    IamthedeveloperoftheinterobserverreliabilityprogramfortheFinneganScoringTool.

    Objectives

    1) Describe the incidence of drug dependence within the neonatal population.

    2) Identify screening methods used to diagnose neonatal drug exposure.

    4) Describe NAS scoring tools and the importance of being reliable in using these tools.

    5) Describe the item definitions for the signs of NAS using the Finnegan Scoring Tool.

    Objectives

    6)IdentifywhenNASscoringshouldoccur.7)Describehowtodetermineyourinter

    observerreliabilitywiththeFinneganScoringTool.

    CaseStudy

    BabyboyAisa36weekinfantadmittedtotheNICUat12hoursofagefortachypnea,tremors,vomiting,highpitchedcryandhypertonicity.Themotherhadnoprenatalcare.Whatisgoingonwiththisbaby?

    DifferentialDiagnosis Hypoglycemia glucoseis96 Hypocalcemia calciumis9 Hypomagnesemia magnesiumis1.58 Hyponatremia Nais140 CNSinsult Apgars 8&9 Allmustbeconsideredandevaluated

    Hamdan, et., al, 2012

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    CaseStudy

    Checkfurtherinthehistoryandyoufind: Mothersurinetoxicologyispositiveforopiates,marijuanaandcocaine.

    Checkwiththelabor&deliveryroomnurseandfindthemotherwasinamethadonetreatmentprogramduringthelatterpartofherpregnancy.

    Motherhashadherthreeotherchildrentakenawayfromherduetoherdruguse.

    FinalDiagnosis

    NeonatalAbstinenceSyndrome Generalizeddisorder Licit&illicitdrugs Polydruguse

    WhatisAddiction?

    Achronic,relapsing,diseaseinvolvingdrugseekingandabusebylonglastingchemicalchangesinthebrain

    Uncontrollablecraving,seeking,anduseofasubstancesuchasadrugoralcohol

    Fenton, Aivadyn & Hasin, 2013; American Society of Addiction Medicine, 2011.

    ARE INFANTS BORN ADDICTED TO DRUGS?

    YES??

    YES??

    NO??

    NO??

    YES??

    YES??

    YES??

    NO??

    ???

    ???

    NO??

    YES??NO??

    YES??

    ??? YES??

    NO??

    ???

    WhatisNAS?Two types:

    Maternal use during pregnancy

    Postnatal use (fetanyl, morphine)

    Hudak & Tan, 2012; Hamdan, 2010

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    WhatisNAS?

    Causes alterations in functioning: CNS disturbances Metabolic, vasomotor, Respiratory

    Disturbances Gastro-Intestinal Disturbances

    Finnegan, et al, 1975

    Epidemic of Prescription Opiate Use/Abuse

    In2006theestimatedtotalcostintheUnitedStatesofnonmedicaluseofprescriptionopioidswas$53.4billion $42billionwasattributabletolostproductivity, $8.2billiontocriminaljusticecosts $2.2billiontodrugabusetreatment $944milliontomedicalcomplications

    Hansen et al. 2011

    OpiatePainRelievers(OPRs)

    DeathsfromOPRs: increased5foldbetween1999and2010forwomen.

    Morewomenhavediedeachyearfromdrugoverdosesthanfrommotorvehicleaccidents.

    In2010enoughOPRswereprescribedtomedicateeveryadultinUSwithatypicaldoseof5mgofhydrocodonetakenevery4hoursfor1month.

    CDC MMWR, July 5, 2013

    MothersUseofOpiatesper1,000HospitalBirths

    Patrick, et al, 2012

    Prescription narcotic use during pregnancy at Mayo Clinic: 5- to 6-fold increase in 12 years

    Kellogg, et al., 2011

    MagnitudeofProblem

    Estimated that 13,500 babies are born each year with NAS from non-iatrogenic causes

    One baby born each hour in the US with signs of neonatal abstinence.

    Patrick et al, 2012

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    NeonatalCostofCare

    2000 $190million 2009 $720million 5fold # women using opioids during

    pregnancy 3 fold in babies diagnoses with NAS

    Patrick et al, 2012

    DrugsAssociatedwithNASOpioids:HeroinMethadoneFentanylMorphineDemerolOxyCodoneBuprenorphine

    NonopioidCNSDepressantsMaypresentwithsomeormimicsymptomsofNAS

    BenzodiazepinesSSRIsBarbituratesAnticonvulsantsAntipsychoticsAlcohol

    Properties

    Heroin 2025timesstrongerthanmorphine Veryaddictive Fetaltissuewithin1hour

    Methadone Substituteforheroin Detectedinfetalbrain:12hrs Metabolitepresentinurineupto5days

    Buprenorphine

    Buprenorphine Similartomethadone Betteroutcomes/lessrelapse Easilytaperedfordetox Lesswithdrawal Approvedforusewithnonpregnantwomen Preliminarystudies

    New England Journal of Medicine, December 9, 2010

    Funded byNIDA

    Findings

    131babies(58buprenorphine;73methadone

    %ofneonatesneedingtreatmentwasnotsignificantlydifferent(p=0.26)

    NodifferenceinpeakNASscores(p=0.04)

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    Findings

    Significantdifferences BuprenorphinevsMethadone:

    89%lesstreatmentwithmorphinemeantotaldose1.1mgvs10.4mg

    (p=0.0091) 43%lesstimeinthehospital 10daysvs17.5days(p=0.0091)

    SignsofWithdrawalinNeonate

    SignsofWithdrawalinNeonates Barbiturates/Alcohol

    Commonalitiesa) depressantsb) cross placenta readilyc) addictived) produce withdrawal

    AlcoholUseDuringPregnancy

    Note: These data were averaged over 2 years

    SAMSA (Substance Abuse and Mental Health Services Administration), 2013

    FetalAlcoholSpectrumDisorder

    Spectrumofdeformities Criteriaarerankedfrom1(normal)to4(significantofFAS)

    EliminationoftheFAEterm Includesdysmorphology scoringsystem Moreobjectivediagnosis

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    FASD

    Fetal Alcohol Spectrum Disorders Center for Excellence, 2013

    Marijuana

    1) Cannabis plant

    2) Delta 9 Tetrahydrocannabinol (THC)

    3) Crosses placenta

    4) Detected in infants urine 1st day & stool for up to 3 days

    Nicotine

    Tobaccoistheonlysourceofnicotine Activeingredientintobacco Stimulant&relaxant Causesrelaxation,calmness,alertness,decreasesappetiteandincreasesmetabolismthroughreleaseofchemicals

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    Nicotine

    Releaseof: Acetylcholine concentration, memory Norepinephrine - arousal Acetylcholine & Beta-Endorphin - pain Beta-Endorphin - anxiety Dopamine - arousal and reward

    http://en.wikipedia.org/wiki/Nicotine

    SignsofWithdrawalinNeonates

    SignsofWithdrawalinNeonates Phencyclidine(PCP)

    Psychoactive Drug

    Used as anesthetic before 1965

    Low doses: numbness in extremities & intoxication (staggering, slurred speech)

    Moddoses:analgesia&anesthesia Highdoses:convulsions

    http://en.wikipedia.org/wiki/Phencyclidine

    Phencyclidine(PCP)

    Psychological effects out of body experiences, paranoia, hallucinations, euphoria, suicidal impulses

    Infant: metabolites found in urine for 1-7 days after mother stopped using 3 months before delivery

    http://en.wikipedia.org/wiki/Phencyclidine

    Crack/Cocaine

    PowerfulCNSstimulant Crossesplacenta Metabolitepresentinurine&stoo

    (urine12days;meconium>7days) t~60+/ 30mininadult;68hr ininfant Powerfulvasoconstrictor

    Askin & Diehl-Jones, 2001

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    Methamphetamine

    1)Highly addictive form of amphetamine2) Stimulant like cocaine3) man-made where cocaine is plant-derived4) Damages neurons that produce serotonin &

    dopamine

    NIDA Notes, September 2000; April 2002

    SelectiveSerotoninReuptakeInhibitors(SSRIs)

    Increasestheavailabilityofserotonin Weakaffinityforacetylcholineanddopamine Uses:

    Depression Generalanxietydisorder Obsessivecompulsivedisorder Eatingdisorders

    http://en.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor

    SignsofWithdrawalinNeonates

    SignsofWithdrawalinNeonates FrequencyofNAS

    5080%ofheroinexposedinfantsdevelopNAS

    6090%ofmethadoneandbuprenorphineexposedinfantsdevelopNAS

    6080%ofinfantswithNASwillrequirepharmacologicmanagement

    Handan, 2014; Farid, et al, 2008; Sarkar & Dunn, 2006

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    Onset of Signs

    Dependsupon: Typeofdrug AdditionalSubstances Timingofmaternaldose Infantmetabolism Gestationalageandbirthweight Genetics????

    Hudak & Tan, 2012; Ashraf et al, 2014

    OnsetofSigns

    Alcohol 312hours Barbiturates 114days Caffeine Atbirth SSRI Hourstodays Heroin(opioidswithshortt1/2) 1224/peak72hrs

    Methadone 48hourstoaslongas714daysHamdan et, al, 2012; Sanz, et al, 2005; Pierog, et al, 1977; Tierney, 2013

    OnsetofSigns

    Cocaine/Methamphetamine Afterthefirstweekoflife Firstweek:signsaredrugeffect

    Irritability Hyperactivity Tremors Increasedcrying Increasedsucking

    Oro & Dixon, 1987

    PrematureInfant

    LowerriskofhavingsignsofNAS

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    DetectionandScreening

    Testingfordrugexposure:Urine

    Obtainassoonaspossibleafterbirth Highfalsenegative(upto60%)ratebecauseonlyreportsrecentdrugexposure

    Meconium Betterthanurine Drugexposurefrom16weeksGA

    Ostrea, 2001

    Screening

    UmbilicalCord 10cmsectionofcordatdelivery Risewithsterilesaline Placeinsterilecontainer ELISAbasedtest Information:www.usdtl.com

    Montgomery et al, 2008

    ComparedtoMeconium

    Drug UCAmphetamine Agreement 96.6%

    Specificity 97%Sensitivity 95%

    Opiates Agreement 95%Specificity 96%Sensitivity 78%

    Montgomery, et al, 2005

    ComparedtoMeconium

    Drug UCCocaine Agreement 99%

    Specificity 100%Sensitivity 75%

    Cannabinoids Agreement 91%Specificity 91%Sensitivity 89%

    Montgomery, et al, 2005

    DetectionandScreening

    HairAnalysis: Radioimmunoassay Grows1cm/month Metabolitepresentforlifeofhair Tellsyoudruguseformonths Getsintomicrofibrils Canuseneonatalhair

    Ostrea, 2001

    NeonatalAbstinenceScoringTools

    Lipsit NeonatalWithdrawalInventory NeonatalNarcoticWithdrawalIndex FinneganNeonatalAbstinenceScoringTool

    Lipsit, 1975; Green & Suffet, 1981; Zahorodny, 1998; Finnegan, 1975

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    LipsitHypert