Neonatal Abstinence Syndrome (NAS)

1. Neonatal Abstinence Syndrome (NAS) LaResaJanousek, RN, NNP-BC Idaho Perinatal Project February 21, 2013

2. Objectives • Increase awareness of opioid use and pregnancy. • Identify and screen for maternal opioid use/abuse. • Describe the clinical characteristics of Neonatal Abstinence Syndrome. • Understand how to manage patients with NAS. • Recognize the importance of parental support and involvement.

3. Topics • The Problem • NAS assessment and treatment • Parent communication and education

4. Opioid Natural and synthetic drugs with morphine-like properties, although the chemical structure may differ from that of morphine. 2 Endogenous opioids include enkephalins, endorphins, and endomorphins.

5. Opioid Uses • Induce or supplement anesthesia. • Cough suppressants. • Gastrointestinal disorders. • Analgesic properties to treat pain. • Opioid addiction.

6. Opioid Use for Pain • Analgesics: disconnect from pain • Euphoria, disconnection, sedation • Oversedation, respiratory depression fentanyl hydromorphone Methadone morphine pethidine buprenorphine Oxycodone codeine dihydrocodeine dextropropoxyphene

7. Drug Trends

8. Drug Addiction • Drug addiction is a mental illness: • characterized by compulsive drug craving, seeking, and use despite devastating consequences. • that stem from drug-induced changes in brain structure and function.

9. Drug Abuse Consequences Health and social consequencesExacerbated medical conditions Inadequate treatment Resistance to seek treatment *http://oas.samhsa.gov/nsduh/2k9nsduh/2k9Results

10. Characteristics of Chemically Involved Pregnant Women • Low self-esteem • Limited family support • Hx of violent or unhealthy relationships • Likely to be victims of early sexual or physical abuse • Limited education • Frequently unemployed • Problems maintaining adequate stable housing • Little prenatal care • Poor parenting skills • Hx of dysfunction/chemically dependent families • Need for a wide range of services • Poly drug use • Mental health problems

11. Drug Abuse in Pregnancy • Poly-drug abuse is common • Less likely to receive prenatal care • Increased risk of associated infectious diseases, including syphilis, gonorrhea, hepatitis, and HIV • Increased incidence of psychiatric disorders

12. Drug Abuse in Pregnancy • 4.3% of pregnant women ages 15-44 self-reported illicit drug use in past month, and may actually be as high as 15-30% National Survey on Drug Use and Health (2002-2003) • Opiate use in pregnant women ranges anywhere from 1% to 21%.1 • Tobacco use in pregnancy: 20.3% 20 • Alcohol use in pregnancy: 14.8% 20

13. Neonatal Withdrawal Syndrome • Neonatal Abstinence Syndrome (NAS) • 60% to 80% of newborns exposed to opioids in the womb are reported to have NAS signs and symptoms.

14. Heroin • Passes to the fetus within 1 hour of administration • Accumulates in amniotic fluid • Limited fetal detoxification • Changes in drug levels causes placental changes

15. Opioid Maintenance • Less drug-seeking and criminal behavior, fewer relapses, decreased STDs, improved prenatal care and compliance, improved nutrition. • Consistent maintenance opioid treatment prevents repeated fetal withdrawals.

16. Opioid Maintenance • Methadone • Subutex (Buprenorphine) • Suboxone (Buprenorphine/Naloxone) • Oral slow release morphine

17. Methadone • Pregnancy Category C • Full mu opioid agonist • First-line treatment of opioid addiction in pregnancy in the US. • Requires daily visits to methadone clinic.

18. Methadone • Higher infant BW and less IUGR than seen in heroin-addicted moms. • NAS in 60-100% of neonates. • Longer duration of NAS treatment vs. buprenorphine & heroin. • Methadone NAS – appears in 1st 24 hours. Dose-dependent relationship with methadone and severity of NAS symptoms.

19. Subutex • Buprenorphine (Category C) • Long-acting partial mu opioid agonist & kappa antagonist. • Not FDA-approved for use during pregnancy. • Considered safe in pregnancy. • May have less placenta exposure than methadone.

20. Subutex • May lower liability for NAS. • Shorter duration of NAS treatment vs. methadone. • Buprenorphine NAS – appears in first 2 days of life, peaks at 3-4 days, and lasts 5-7 days. May be delayed onset up to 7 days.

21. Suboxone • Buprenorphine (Category C) + Naloxone (Category B) • Limited studies in pregnant women. • US DHHS Center for Substance Abuse Tx: • cautious use of naloxone in opioid-addicted pregnant women  may precipitate withdrawal in both mother & fetus. • Recommends buprenorphine monotherapy, though admit it has great potential for abuse & diversion.

22. Opioid Maintenance – Monitoring in pregnancy • Urine Drug Screen (UDS) • At increased risk for: anemia, malnutrition, HTN, hyperglycemia, STDs, TB, hepatitis, and preeclampsia. • Regular Prenatal panel • LFTs, Renal function, PPD, glucose intolerance, anti-HCV antibody. • Consider repeat CBC, serology at 24-28 wks.

23. Opioid Maintenance-Dosing in pregnancy Controversial. If attempt to wean, suggested in 1st vs. 2nd Trimester • 1st – theoretical risk of miscarriage11 • 3rd – risk of premature labor or fetal death. Increased dosage of maintenance therapy may be required in 2nd-3rd trimester.

24. Opioid Maintenance • Improved outcomes when therapy includes: • prenatal care • addiction treatment • other social services, including individual/group/family therapy to address the psychological and psychosocial factor of substance abuse.

25. Obstetric Complications • SAB • LBW • IUGR • Preeclampsia • Placental abruption • PROM • PTB • Fetal distress • Fetal demise • Malpresentation, Low APGAR scores, PPH, septic thrombophlebitis, Meconium aspiration, Chorioamnionitis

26. Labor & Delivery May require higher and more frequent doses of opioid analgesics to maintain pain control. NO Stadol or Nubain! • Opioid agonist-antagonists, thus can displace the maintenance opioid from the mu receptor, precipitating acute withdrawal.

27. Neonatal Complications • Prematurity • Low birth weight • Postnatal growth deficiency • Microcephaly • Neurobehavioral problems • Increased neonatal mortality • 74-fold increase in sudden infant death syndrome (SIDS) • Neonatal abstinence syndrome (NAS)

28. Opioid Maintenance-Breastfeeding • Contraindications: • HIV • Illicit drug use • Buprenorphine: • breastfeeding infant will receive only 1/5 to 1/10 of the total available buprenorphine. • No evidence to support theory that breastfeeding will help suppress NAS. • Likewise, NAS does not occur after breastfeeding is discontinued.

29. Opioid Maintenance- Treasure Valley Richard Montgomery, M.D. 413 North Allumbaugh Street Suite 101 Boise, ID 83704(208) 323-1125 John B. Casper 8050 West Rifleman Suite 100 Boise, ID 83704(208) 321-0634 Intermountain Hospital of Boise 303 North Allumbaugh Street Boise, ID 83704(208) 377-8400 Riverside Rehabilitation 7711 West Riverside Drive Boise, 83714 Personal Development 1009 West Hemingway Boulevard Nampa, ID 83651. Port of Hope Centers Inc 508 East Florida Street Nampa, ID 83686. Raise the Bottom Training and Counseling Services 9196 W. Barnes St. Boise, ID 83709(208) 433-0400 Center for Behavioral Health Idaho Inc 92 South Cole Road Boise, ID 83709(208) 376-5021 Center for Behavioral Health Idaho Inc 1965 South Eagle Road, Suite 180 Meridian, ID 83642(208) 288-0649  Patrick James Dwyer, M.D. 5985 West State Street Boise, ID 83703(208) 853-0071 Kristina J. Harrington 5985 West State Street Suite 555 Boise, ID 83703(208) 853-0071

30. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. May 2012Patrick SW • A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases.

31. 2000 and 2009: • It was estimated that 14,539 babies were born with NAS in 2009 • Rate of newborns diagnosed with NAS rose from 1.20 per 1,000 hospital births per year to 3.39 per 1,000. • The number of pregnant mothers using or dependent on opiates. • The amount hospitals charged, on average for newborns diagnosed with NAS rose by 35%. • Estimates for total hospital charges nationwide, adjusting for inflation, rose from $190 million.

32. Neonatal Screening • The Committee on Substance Abuse of the American Academy of Pediatrics recommends obtaining a comprehensive medical and psychological history that includes specific information regarding maternal drug use as part of every newborn evaluation.

33. Indicators for Neonatal Drug Screening • Unexplained abruption • inconsistent prenatal care • antenatal social work recommendation • emergency department care plan • independent physician care plan • obviously intoxicated • history of drug abuse in the last two years or during a prior or current pregnancy • drug abuse by spouse • CPS and legal involvement • unexplained infant neurological complication (IVH, seizures)

34. Differential Diagnosis • Serum glucose level. • Serum calcium level. • CBC with differential. • Consider blood culture and other cultures. • Confirm maternal hepatitis status and treat accordingly. • Confirm human immunodeficiency virus (HIV) status.

35. Neonatal Screening Urine Drug Toxicology Meconium Sampling Umbilical Cord Analysis Finnegan Assessment Tool

36. Finnegan

38. NAS scoring • Designed for term babies on four-hourly feeds and may therefore need modification for preterm infants. • The NAS score sheet lists 21 symptoms that are most frequently observed in opiate-exposed infants. • Each symptom and its associated degree of severity are assigned a score.

39. NAS scoring • The first abstinence score should be recorded approximately two hours after birth or admission. • Scoring is dynamic. All signs and symptoms observed during the scoring interval are included in the point-total for that period. • If the infant’s score at any scoring interval is >8, scoring is increased to 2-hourly and continued for 24 hours from the last total score of 8 or higher. • If pharmacotherapy is not needed the infant is scored for the first 4 days of life at 4-hourly intervals.

40. Scoring using FinneganCNS • High pitched cry • High pitched at peak – 2 • High pitched throughout – 3 • Scored if crying is prolonged • Sleep • Score longest uninterrupted interval of sleep • Scoring for premature infant on 3 hr feeds • 1 if <2 hours 2 if <1 hour 3 if does not sleep • Moro reflex • Hyperactive - pronounced jitteriness of hands • Markedly hyperactive - jitteriness/clonus of hands/feet

41. Scoring using FinneganCNS • Tremors • Undisturbed • Mild – tremors of hands/feet when not being handled • Moderate/severe –tremors of arms/legs when not being handled • Disturbed • Mild – tremors of hands/feet during handling • Moderate/severe – tremors of arms/legs during handling • Increased muscle tone • Scored if no head lag or unable to extend arm/leg • Excoriation • Score when first appears or increases

42. Scoring using FinneganCNS • Myoclonic Jerks • Involuntary spasms of the muscle in face, arms and legs • Irregular, quick and localized • Seizures (generalized convulsions) • Generalized jerky involuntary movements • Subtle seizure activity • Movement is not affected by interventions

43. Scoring using FinneganMetabolic, Vasomotor and Respiratory • Sweating • Score if sweating is spontaneous • Hyperthermia (Fever) • Axillary temperature • Mild pyrexia from increased muscle tone/tremors • Yawning • Sign of over stimulation • Score if >3 yawns within scoring interval

44. Scoring using FinneganMetabolic, Vasomotor and Respiratory • Mottling • Marbling discoloration of the skin • Also occurs when infant is chilled or premature • Nasal Stuffiness • Score if infant sounds congested • Sneezing • Sign of over stimulation • Score if >3 sneezes within scoring interval

45. Scoring using FinneganMetabolic, Vasomotor and Respiratory • Nasal flaring • Score if present without other signs of respiratory disease • Respiratory rate • Count for one minute • Score 1 if >60 without other signs of respiratory disease • Score 2 if >60 with retractions

46. Scoring using FinneganGI Dysfunction • Excessive sucking • Hyperactive/disorganized sucking • Poor feeding • Score if does not take adequate volume in 30 minutes or needs support to take minimum volumes • If premature, adjust for gestational age • Regurgitation • Score if at least one episode is observed • Loose/watery stools

47. NAS Treatment • Therapeutic handling • Swaddling • Holding in C position • Calming techniques • Sway • Vertical rock • Cuddlers

48. NAS Treatment • Feeding • Frequent smaller feeds • Higher caloric feeds • IV fluids • Breast feeding

49. NAS Treatment • Pharmacologic interventions: • Morphine • Phenobarbital

50. St.Luke’s NBN algorythm