Neonatal Abstinence SyndromeKaren Estrella-Ramadan06/25/2012

• Acute use of heroin and other opioids stimulate opiate receptors in the brain which may result in symptoms including euphoria, resp depression, analgesia and nausea.

• Chronic use of opioids s associated with tolerance, which later leads to dependence, whereby the neurochemical balance in the CNS is altered and absence of the drugs leads to withdrawal syndrome

Opioids and pregnancy• Repetitive use and withdrawal leads to ftal hypoxia, fetal

demise, IUGR, SGA• Medication-assisted tx with methadone• Long half life• With advance pregnancy is metabolized faster and higher doses

are required

Neonatal Abstinence Syndrome• Timing– Heroin: 48-72hrs– Methadone: 4 days

• Screening:– Newborn urine:

• 24-48hrs• Amphetamines, barbiturates, benzos, cocaine, marijuana, some

opioids-my not include methadone or oxycodone

– Meconium toxicology• First 3-4 days• Ampehtamines, opiods, cocaine, marijuana

Clinical FeaturesNEUROLOGICAL:•Tremors•Irritability•Increased wakefulness•High-pitched crying•Increased muscle tone•Hyperactive deep tendon reflexes•Exaggerated Moro reflex•Seizures•Frequent yawning and sneezing

GI DYSFUNCTION:•Poor feeding•Uncoordinated and constant sucking•Vomiting•Diarrhea•Dehydration•Poor weight gainAUTONOMIC SIGNS: •Increased sweating•Nasal stuffiness•Fever•Mottling•Temperature instability

Treatment

• ~50-70% of infants will require tx• At delivery, NO naloxone= seizures• SCORING (modified Finnegan)• Before feeding

1. Supportive• Encourage maternal and paternal involvement• Decrease stimulation: no light, no loud sounds, examination• Swaddling, soothing, rocking (vertical)• Non-nutritive sucking: Pacifier• Skin-skin contact: Kangaroo care• Skin care: lotion to areas of abrassion• Frequent feedings: increase caloric intake (150-250

cal/kg/day)• May allow BF if neg Utox in mother, HIV neg

2. Pharmacological• Scoring >9 (x3: before and after feeding) or 2 >than 12• Short acting opioid: MORPHINE (0.4 mg/ml)– Start with 0.03 mg/kg/day

• 0.2 mg po q4hrs– Scoring: q8-12hrs

– If still high: increase by 0.16mg/kg/day q3hrs (max 0.8mg/kg/day)– Monitor:

– Over-sedation, decreased arousal, resp depression– Wean after 48hrs on scores <6

• Decrease 20% of daily dose• Continue scoring

– Wean after 28-72hrs on scores <6, and less freq feedings• Decrease 20% of daily dose

– d/c morphine– Once sub therapeutic dose is achieved, observe for 24-28 hrs off morphine– If sz: diff dx workup

– Add phenobarbital if no control of symptoms with max dosing

Discharge• Off morphine for 24hrs with score <6• Adequate nutrition• No more than 10% wt loss

• SW clearance• f/u with PMD

Other things to consider• Screens for:• Syphilis• Hepatitis B• Hepatitis C• HIV• Tb• DV

Differential dx• Sepsis• Hypoglycemia• Hypocalcemia• hypomagnesemia

• Hyperthyroidism• Perinatal asphyxia• IVH

References• http://www.uvm.edu/medicine/vchip/documents/VCHIP_5NE

ONATAL_GUIDELINES.pdf (University of Vermont)

• http://nctnc.org/workfiles/NAS.pdf (University of Connecticut)• NICU-SBH• http://pediatrics.aappublications.org/content/101/6/1079.full