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
This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.
Definition
• Withdrawal after prenatal exposure to certain drugs
Drug
Opioids
Benzodiazepines
Estimated Onset of Signs/ Symptoms
24-72 hours, up to 7 days pending half-life
hours – weeks
Alcohol
3-12 hours
• 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.
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Signs / Symptoms
Central Nervous System
Autonomic
Gastrointestinal
Irritability
High pitched crying
Temperature
instability
Nasal stuffiness
Poor feeding
& weight gain
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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Primary Pharmacologic Options
Drug
Diluted Tincture
of Opium (DTO)
Morphine
Methadone
Sublingual
Buprenorphine
Neonatal Dosing (oral)
Comments
- Treatment Options
No longer common
Pharmacologic
practice
0.03-0.1 mg/kg/dose Q3-4H
Wean by: 10-20%
pending s/sx
0.05-0.1 mg/kg/dose Q6-24H
Wean by: 10-20%
pending s/sx
Dosing not established
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.
Equally efficacious
as DTO
Longer half-life
than morphine
Requires additional
studies
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Adjuvant Therapy
Drug
Phenobarbital
Clonidine
Neonatal Dosing (oral)
Comments
Load: 16 mg/kg day 1
Fallen out of favor
Maintenance: 1-4 mg/kg/dose Q12H due to cognitive
Wean by: 20% every other day
behavioral effects
≥ 35 week gestation:
0.5-1 mcg/kg Q4-6H
Weaning not established
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.
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 Trimester
B. 2nd Trimester
C. 3rd Trimester
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QUESTIONS?
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Thank You
Heather Rodman, PharmD
PGY-2 Pediatric Pharmacy Resident
Peyton Manning Children’s Hospital
St. Vincent Hospital and Health Services
September 2014
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