Neonatal Abstinence Syndrome
(NAS)
LaResa Janousek, RN, NNP-BC
Idaho Perinatal Project
February 21, 2013
Objectives
•
Increase awareness of opioid use and pregnancy.
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Identify and screen for maternal opioid use/abuse.
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Describe the clinical characteristics of Neonatal Abstinence
Syndrome.
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Understand how to manage patients with NAS.
•
Recognize the importance of parental support and
involvement.
Topics
• The Problem
• NAS assessment and treatment
• Parent communication and education
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.
Opioid Uses
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Induce or supplement anesthesia.
Cough suppressants.
Gastrointestinal disorders.
Analgesic properties to treat pain.
Opioid addiction.
Opioid Use for Pain
• Analgesics: disconnect from pain
• Euphoria, disconnection, sedation
• Oversedation, respiratory depression
fentanyl
Methadone
pethidine
Oxycodone
dihydrocodeine
hydromorphone
morphine
buprenorphine
codeine
dextropropoxyphene
Drug Trends
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.
Drug Abuse Consequences
Health and social consequences
Exacerbated medical conditions
Inadequate treatment
Resistance to seek treatment
*http://oas.samhsa.gov/nsduh/2k9nsduh/2k9Results
Characteristics of Chemically
Involved Pregnant Women
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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
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
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
• 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.
Heroin
– Passes to the fetus within 1
hour of administration
– Accumulates in amniotic fluid
– Limited fetal detoxification
– Changes in drug levels causes
placental changes
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.
Opioid Maintenance
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Methadone
Subutex (Buprenorphine)
Suboxone (Buprenorphine/Naloxone)
Oral slow release morphine
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.
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.
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.
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.
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.
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.
Opioid MaintenanceDosing 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.
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.
Obstetric Complications
– SAB
– LBW
– IUGR
– Preeclampsia
– Placental abruption
– PROM
– PTB
– Fetal distress
– Fetal demise
– Malpresentation, Low APGAR scores, PPH, septic
thrombophlebitis, Meconium aspiration,
Chorioamnionitis
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.
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)
Opioid MaintenanceBreastfeeding
 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.
Opioid Maintenance- Treasure Valley
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
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.
Neonatal abstinence syndrome and
associated health care expenditures:
United States, 2000-2009. May 2012
Patrick 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.
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.
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.
Indicators for Neonatal
Drug Screening
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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)
Differential Diagnosis
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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.
Neonatal Screening
Urine Drug Toxicology
Meconium Sampling
Umbilical Cord Analysis
Finnegan Assessment Tool
Finnegan
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.
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.
Scoring using Finnegan
CNS
• 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
Scoring using Finnegan
CNS
• 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
Scoring using Finnegan
CNS
• 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
Scoring using Finnegan
Metabolic, 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
Scoring using Finnegan
Metabolic, 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
Scoring using Finnegan
Metabolic, 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
Scoring using Finnegan
GI 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
NAS Treatment
• Therapeutic handling
– Swaddling
– Holding in C position
• Calming techniques
– Sway
– Vertical rock
– Cuddlers
NAS Treatment
• Feeding
– Frequent smaller feeds
– Higher caloric feeds
– IV fluids
– Breast feeding
NAS Treatment
• Pharmacologic interventions:
– Morphine
– Phenobarbital
St.Luke’s NBN algorythm
Safe Discharge
• Social Work involvement
–Support structures
• Decreased symptoms –
physiologically stable
• Appropriate growth with adequate
intake
Safe Discharge
• Caregiver instructions
– Medication administration
– Symptoms of withdrawal
– When to seek medical help
– How to reduce stimulation at home
– Calming techniques
– Equipment instruction
– Feeding instructions
Safe Discharge
• Rooming in
– Assists caregiver to learn successful techniques
– Promotes bonding
– Enhances teaching
• Follow up after discharge
– Primary care provider
– Community resources
Family Resources
• http://www.kap.samhsa.gov/products/brochu
res/pdfs/med_assisted_tx_facts.pdf
• http://www.marchofdimes.com/pregnancy/al
cohol_illicitdrug.html
• http://www.mayoclinic.com/print/prescriptio
n-drugabuse/DS01079/METHOD=print&DSECTION=a
ll