Neonatal Abstinence Syndrome: Taking Care of Mom and Baby

Heather Rodman, PharmDPGY-2 Pediatric Pharmacy ResidentPeyton Manning Children’s Hospital

St. Vincent Hospital and Health ServicesSeptember 2014

This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

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Definition

• Withdrawal after prenatal exposure to certain drugs

• Dysregulation of the central, autonomic, and gastrointestinal functioning of the neonate

Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.

Drug Estimated Onset of Signs/ SymptomsOpioids 24-72 hours, up to 7 days pending half-life

Benzodiazepines hours – weeksAlcohol 3-12 hours

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Signs / Symptoms

Central Nervous System Autonomic Gastrointestinal

Irritability Temperature instability

Poor feeding & weight gain

High pitched crying Nasal stuffiness Uncoordinated sucking

Tremors & seizures Sweating Diarrhea & diaper rash

Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.

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TAKING CARE OF MOM

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Prenatal Care

• Enrollment in an opioid maintenance program• Minimizes cravings and optimizes maternal health• Prevents fetal stress and suppresses withdrawal• Anticipatory neonatal withdrawal

• Methadone is most commonly chosen• Buprenorphine may shorten treatment duration and hospital stay of the neonate• Increased dropout rate with buprenorphine

• Increased doses may be required during 3rd trimester

Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.Jones HE, et al. NEJM. Dec 2010; 363(24): 2320-2331.

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Addiction Resources

• Indiana Addictions Issues Coalition (IAIC)• http://recoveryindiana.org/index.php

• United States Recovery• List of support groups and treatment centers by state• http://www.usrecovery.info/index.htm

• National Institute on Drug Abuse (NIH)• Resources for professionals, patients, and families• http://www.drugabuse.gov/

• National Council on Alcoholism and Drug Dependence• http://ncadd.org/index.php

• American Congress of Obstetricians and Gynecologists (ACOG)• http://www.acog.org/Patients/FAQs/Tobacco-Alcohol-Drugs-and-Pregnancy

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TAKING CARE OF THE NEONATE

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Non-Pharmacologic Measures

• Dark, quiet environment• Swaddling and comforting techniques• Swaying, rocking• Skin-to-skin contact (parents only)• Music therapy

• Small but frequent feedings• Breast feeding approved by AAP• Contraindications: HIV (+) • Relative contraindications: Hepatitis C (+), heroin, cocaine, alcohol abuse

• Family education

Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

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Pharmacologic Treatment Options

Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36.Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856.Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165.Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

Primary Pharmacologic OptionsDrug Neonatal Dosing (oral) Comments

Diluted Tincture of Opium (DTO)

- No longer common practice

Morphine 0.03-0.1 mg/kg/dose Q3-4HWean by: 10-20%

pending s/sx

Equally efficacious as DTO

Methadone 0.05-0.1 mg/kg/dose Q6-24HWean by: 10-20%

pending s/sx

Longer half-life than morphine

Sublingual Buprenorphine

Dosing not established Requires additional studies

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Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36.Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856.Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165.Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.

Adjuvant Therapy

Drug Neonatal Dosing (oral) Comments

Phenobarbital Load: 16 mg/kg day 1Maintenance: 1-4 mg/kg/dose

Q12HWean by: 20% every other day

Fallen out of favor due to cognitive

behavioral effects

Clonidine ≥ 35 week gestation: 0.5-1 mcg/kg Q4-6H

Weaning not established

Not as well studied as

phenobarbital

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Long-Term Outcomes

• Difficult to evaluate• Confounding variables

• Withdrawal seizures respond to opiates and do not necessarily carry an increased risk of poor outcomes

• Neurocognitive delays possible during infancy• Working memory updating - Resolved at ~ 7 months• Regulation and quality of movement• Excitability• Delay in milestones: Independent sitting, crawling

Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.

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Take Home Points

• Pregnant women on methadone may require higher doses during pregnancy

• Buprenorphine is now considered a safe, alternative option for pregnant women enrolled in an opioid maintenance program

• Breastfeeding is beneficial for NAS even while the mom is still enrolled in the maintenance program

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Assessment Question

• During which trimester is a pregnant woman most likely to require her highest dose of methadone?A. 1st TrimesterB. 2nd TrimesterC. 3rd Trimester

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QUESTIONS?

Thank You

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Heather Rodman, PharmDPGY-2 Pediatric Pharmacy ResidentPeyton Manning Children’s Hospital

St. Vincent Hospital and Health ServicesSeptember 2014