Neonatal Abstinence Syndrome: Taking Care of Mom and Baby

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Neonatal Abstinence Syndrome: Taking Care of Mom and Baby. Heather Rodman, PharmD PGY-2 Pediatric Pharmacy Resident Peyton Manning Children’s Hospital St. Vincent Hospital and Health Services September 2014 - PowerPoint PPT Presentation

Text of Neonatal Abstinence Syndrome: Taking Care of Mom and Baby

Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome: Taking Care of Mom and BabyHeather Rodman, PharmDPGY-2 Pediatric Pharmacy ResidentPeyton Manning Childrens HospitalSt. Vincent Hospital and Health ServicesSeptember 2014

This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.1DefinitionWithdrawal after prenatal exposure to certain drugs

Dysregulation of the central, autonomic, and gastrointestinal functioning of the neonate2Hudak, 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.DrugEstimated Onset of Signs/ SymptomsOpioids24-72 hours, up to 7 days pending half-lifeBenzodiazepineshours weeksAlcohol3-12 hoursDrugs not associated with NAS: Amphetamines, cocaine, marijuana, tobacco2Signs / Symptoms3Central Nervous SystemAutonomicGastrointestinalIrritabilityTemperature instabilityPoor feeding & weight gainHigh pitched cryingNasal stuffinessUncoordinated suckingTremors & seizuresSweatingDiarrhea & diaper rashHudak, 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.Validated Scoring Tool for nurses to monitor these symptoms on the inpatient side3Taking Care of Mom44Prenatal CareEnrollment in an opioid maintenance program Minimizes cravings and optimizes maternal health Prevents fetal stress and suppresses withdrawal Anticipatory neonatal withdrawalMethadone is most commonly chosen Buprenorphine may shorten treatment duration and hospital stay of the neonate Increased dropout rate with buprenorphineIncreased doses may be required during 3rd trimester5Hudak, 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): 2320-2331.5Addiction ResourcesIndiana Addictions Issues Coalition (IAIC) http://recoveryindiana.org/index.phpUnited States Recovery List of support groups and treatment centers by state http://www.usrecovery.info/index.htmNational 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.phpAmerican Congress of Obstetricians and Gynecologists (ACOG) http://www.acog.org/Patients/FAQs/Tobacco-Alcohol-Drugs-and-Pregnancy66Taking Care of The Neonate77Non-Pharmacologic MeasuresDark, quiet environmentSwaddling and comforting techniques Swaying, rocking Skin-to-skin contact (parents only) Music therapySmall but frequent feedingsBreast feeding approved by AAP Contraindications: HIV (+) Relative contraindications: Hepatitis C (+), heroin, cocaine, alcohol abuseFamily education8Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Check the AAP recs on breastfeeding - the only absolute contraindication to breastfeeding is HIV + status. The others are relative contraindications and generally left to the discretion of the physician89Pharmacologic Treatment OptionsLangenfeld 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 OptionsDrugNeonatal Dosing (oral)CommentsDiluted Tincture of Opium (DTO)-No longer common practiceMorphine0.03-0.1 mg/kg/dose Q3-4HWean by: 10-20% pending s/sx Equally efficacious as DTOMethadone0.05-0.1 mg/kg/dose Q6-24HWean by: 10-20% pending s/sxLonger half-life than morphineSublingual BuprenorphineDosing not establishedRequires additional studiesDTO contains a combination of opioid alkaloids including morphine, 910Langenfeld 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 TherapyDrugNeonatal Dosing (oral)CommentsPhenobarbitalLoad: 16 mg/kg day 1Maintenance: 1-4 mg/kg/dose Q12HWean by: 20% every other dayFallen out of favor due to cognitive behavioral effectsClonidine 35 week gestation: 0.5-1 mcg/kg Q4-6HWeaning not establishedNot as well studied as phenobarbitalDTO contains a combination of opioid alkaloids including morphine, 10Long-Term OutcomesDifficult to evaluate Confounding variablesWithdrawal seizures respond to opiates and do not necessarily carry an increased risk of poor outcomesNeurocognitive delays possible during infancy Working memory updating - Resolved at ~ 7 months Regulation and quality of movement Excitability Delay in milestones: Independent sitting, crawling

11Hudak, 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.Add risks of long term phenobarb tx?11Take Home PointsPregnant 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 program12Add risks of long term phenobarb tx?12Assessment QuestionDuring which trimester is a pregnant woman most likely to require her highest dose of methadone?1st Trimester2nd Trimester3rd Trimester13Add risks of long term phenobarb tx?13Questions?14Thank You15Heather Rodman, PharmDPGY-2 Pediatric Pharmacy ResidentPeyton Manning Childrens HospitalSt. Vincent Hospital and Health ServicesSeptember 2014