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Neonatal Abstinence Syndrome: Forget the Finnegans

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The nurse has a major role in care of the infant and engaging the caregiver. Goals ... Supportive Care for NAS. Principles. ANTICIPATE. Assess strengths and ... – PowerPoint PPT presentation

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Title: Neonatal Abstinence Syndrome: Forget the Finnegans


1
Neonatal Abstinence SyndromeForget the
Finnegans Treat One Baby at a Time!
  • Margaret McLaren, MD

2
Neonatal Abstinence Syndrome
  • A constellation of signs and symptoms which
    result from the abrupt cessation of a drug to
    which the fetus/neonate has become
    physiologically dependent

3
History of NAS
  • Illicit drugs (Heroin) / Methadone
  • Iatrogenic withdrawal
  • ECMO - Fentanyl infusions
  • Around 50 of neonates older children
    requiring ICU support experience WD

4
Drugs Causing NAS
  • Opiates
  • Heroin
  • Methadone
  • Morphine
  • Other
  • Oxycodone
  • Non-opiates
  • Alcohol
  • Barbiturates
  • Benzodiazepines
  • SSRIs
  • Other (caffeine, tricyclics, valproate,
    antihistamines)

5
Other ?????
  • Cocaine/ Amphetamines
  • PCP
  • Nicotine

6
SSRIs Neonatal Withdrawal
  • 3rd trimester exposure
  • Case reports in 1990s (paroxetine, fluoxetine,
    citalopram, sertraline)
  • Onset - within few days (long half life)
  • Duration - 1 month

7
Mechanism?
  • SSRI withdrawal (due to rebound cholinergic
    effect) ?, or
  • Serotonin syndrome?
  • Isbister GK, Dawson A, Whyte IM, Prior FH, Clancy
    C, Smith AJ. Neonatal paroxetine withdrawal
    syndrome or actually serotonin syndrome? Arch Dis
    Childhood Fetal Neonatal Ed 200185F147-148

8
Opiate Addiction
  • Heroin addiction on the rise
  • 0.1 pregnant women
  • Less expensive, purer, more potent, even via
    oral route
  • Prescription drugs
  • Available via the internet

9
Methadone Not simply another drug
  • Eases symptoms of physical dependency
  • Blocks euphoria
  • Longer duration than heroin (T/224-36 hrs)
  • Increases fetal safety
  • Enables mother to attend to her health
    nutrition
  • Stabilizes maternal metabolic processes/ ANS
  • Prevents fetal withdrawal
  • Optimal fetal growth

10
Methadone Maintenance in Pregnancy
  • Accelerated clearance from maternal circulation
    in late pregnancy due to
  • Larger blood volume
  • Increased metabolism (progestins)
  • Higher fetal tissue concentration
  • Pregnant women may need an increased/ split dose.

11
Alternatives to Methadone
  • Detoxification in a safe setting.
  • Buprenorphine (partial mu-opioid agonist
  • promising as preliminary reports show less
    severe less frequent NAS.

12
Mechanism of NAS ?
  • Neurochemical reaction due to depletion of drug
    from receptors in the brain.
  • The neonate is NOT addicted / psychologically
    dependent.

13
The Locus Ceruleus
  • Opiates activate receptors in the locus ceruleus
  • Inhibits adenyl cyclase activity
    cAMP
  • Decrease in noradrenaline
    dopamine
  • Over time the locus ceruleus adjusts upward to
    maintain homeostasis.
  • Depletion of opiates removes the inhibition
  • gtgtgtnoradrenergic overchargeltltlt

14

Onset and Frequency of NAS Factors
  • Drug properties
  • Placental factors
  • Infant factors
  • Other Polydrugs?
  • Timing, dose, T/2, maternal metabolism (genetics)
  • Lipid solubility, molecular wt., Protein binding,
    ionization
  • Placental blood flow, metabolism,
  • And type of transfer
  • Metabolism excretion of the drug - later in
    preterms
  • CNS maturity

15
Onset Frequency of NAS
  • Onset
  • Heroin 24-48 hr (1-6 days)
  • Methadone 48 72 hr (2-28 days)
  • Phenobarbitol 10 14 days
  • Frequency
  • 50-80
  • 60-90

16
Maternal Methadone NAS
  • Dose
  • No consistent correlation with incidence and
    severity of NAS
  • No evidence to jeopardize adequate maternal
    treatment
  • Onset (T/2 24 hrs)
  • 48-52 hrs after the last maternal dose
  • Serum methadone lt 0.06 ug/ml

17
Clinical Features
18
Clinical features of NAS
  • CNS majority of signs especially
  • Irritability sleep
    disturbance
  • ANS
  • GI
  • In preterms less frequent milder
  • Non specific
  • R/O other conditions sepsis, hypoglycemia,
    hyperthyroidism, hypocalcemia, hypomagnesemia,
    asphyxia

19
  • W - wakefulness
  • I - irritability
  • T -tremors, twitching, tachypnea
  • H - hyperventilation, hypertonia,
    hyperpyrexia,
  • hyperaccusis, hiccups
  • D - diarrhea, diaphoresis,
  • R - rub marks
  • A - alkalosis
  • W - weight loss
  • A - apnea
  • L - lacrimation,
  • S - seizures (myoclonic), sneezing, skin
    mottling

20
Frequency of Clinical Signs
  • Disturbed sleep 53
  • Mottling 53
  • Excess sucking 45
  • Tremors 43
  • Tachypnea 43
  • Hypertonia 41
  • Fever 40
  • Seizures 2-11 (often later)

21
Sleep Disturbances- Related to NAS severity
  • Regulation of quiet sleep is specifically
    affected
  • Increased wakefulness
  • Increased indeterminate sleep
  • Decreased quiet sleep
  • Sleep fragmentation (gt 59 arousals leading to
    wakefulness) in those requiring Tx
  • Lower threshold for arousal
  • Obrien Jeffery, 2002

22
Sleep Disturbances in NAS Mechanism
  • Hypotheses.
  • CNS changes due to opiate dependency in utero -
    persist after withdrawal BUT less at 5 weeks.
    Also increased RR
  • CNS hyperactivity due to withdrawal decrease
    when stabilized on treatment.
  • Negative effect on maternal-infant
    interaction
  • Prepare caregivers for sleep disturbance.

23
Hyperphagia
  • Prevalence 26 at day 8, 56 at day 16
  • Maximum intake 290 kcal/kg/day
  • More significant wt loss in week 1
  • In 1st month - no significant increase in wt,
    vomiting/ diarrhea
  • Represents higher metabolic needs/ inadequate
    control of withdrawal
  • Martinez A, Kastner B, Taeusch HW. Arch Dis Child
    Fetal Neonatal Ed 199980178-182

24
Assessment of NAS
  • Potential for withdrawal
  • Detection history, urine, meconium, hair
  • Timing of last dose, gestational age?
  • Polydrug exposure?
  • Assess severity of withdrawal symptoms/signs -
    TOOLS

25
Monitoring Tools for NAS (None developed on
preterms)
  • Neonatal Narcotic Withdrawal Index
  • 7 items, 1-2 point scale
  • Inter-observer reliability - 77
  • Physician-based
  • Lipsitz scale
  • 11 indicators, 1-3 point scale
  • Neonatal abstinence scoring system (Finnegan)
  • Validated in 1975
  • 21 items, 1-5 point scale
  • Inter-observer reliability - 82

26
Do not throw away the Finnegans but use and
interpret them correctly !
  • Assess infant post feeding.
  • Do not hold off feeds until assessment time.
  • Tremors and hypertonia may persist.
  • Wakefulness increases with age.
  • Ensure staff is adequately trained.

27
The Finnegans are just an adjunct
  • Additional monitoring is needed
  • Daily weight and ability to feed
  • Ability to achieve a quiet alert state for social
    interaction

28
Management of NAS- A dyadic approachThe nurse
has a major role in care of the infant and
engaging the caregiver.
29
Goals
  • Alleviate signs/ symptoms of withdrawal
  • Maintain optimal nutrition and development
  • Facilitate positive caregiver-infant interaction
    bonding
  • Ongoing parental education and support until
    symptoms are resolved.

30
Supportive Care for NAS Principles
  • ANTICIPATE
  • Assess strengths and needs of each infant
  • Sensitivity to different sensory stimuli
  • Soothing responses
  • Develop an individual care plan
  • Assess the strengths and needs of the caregiver.

31
Supportive Care - Mainstay of therapy
  • Optimal nutrition
  • Modify environment
  • Containment/Soothing
  • Skin care
  • Safe, undisturbed sleep
  • Support to the caregiver

32
Promote Optimal Nutrition
  • Problems
  • Disorganized suck
  • Prolonged sucking bursts (29x20secs)
  • State instability
  • Increased calorie needs
  • Hypermetabolic
  • Increased losses
  • Interventions
  • Low stimulation
  • Swaddling
  • Anticipate augment calories frequency of feeds

33
Breastfeeding ?
  • Encourage if HIV negative and no active drug use.
  • What about methadone maintained mothers?
  • 1994, AAP safe lt 20mg dose
  • AAP Revised Recommendations NO dose limit
  • An effective treatment strategy !

34
Methadone and Breastfeeding
  • Advantages
  • Less hospital days
  • (8 days)
  • Reduced risk of SIDS
  • Brain development
  • Motivation for recovery
  • Disadvantages
  • Potential withdrawal if abrupt cessation (high
    maternal dose)
  • HIV risk
  • Exposure to other drugs

35
Supportive Care Modify the Environment
  • Rationale
  • Promote sleep
  • Enhance capacity to interact
  • Decrease calorie expenditure
  • Interventions
  • Low-light/noise
  • Minimal stimulation
  • Gentle handling and holding
  • Music (HR rhythm)
  • Avoiding strong perfumes

36
Supportive Care-Soothing
  • Rationale
  • Decrease energy expenditure
  • Prevent escalation
  • Promote positive interaction
  • Interventions
  • Early response to cry
  • Swaddling
  • Containment
  • Vertical rocking, swing
  • Carrying
  • Non-nutritive sucking
  • Warm bath
  • Deferring circumcision

37
Supportive CareSkin Care
  • Prevention
  • Swaddle
  • Soothe
  • Massage
  • Protect buttocks frequent diaper changes,
    barrier
  • Treat diaper rash aggressively triple cream,
    consider yeast.

38
Supportive Care Safe Undisturbed Sleep
  • Rationale
  • Increased risk of SIDS if opiate/ methadone
    exposed.
  • Sleep fragmentation
  • Interventions
  • Back position
  • Quiet environment
  • Allow to complete sleep cycles
  • Containment

39
Engage the Caregiver
  • Key to her babys recovery
  • Barriers
  • Guilt
  • Lack of trust
  • Fear
  • Poor self esteem
  • Anxiety/ depression
  • Arousal
  • Goldfish bowl

40
Attitudes of Staff
  • Self report questionaire of 50 nurses/ midwives
  • Generally negative, stereotypical, judgmental
  • Inadequate knowledge base
  • Experienced nurses - more judgmental
  • Need for specialist education inservices on
    substance use and effects on mother and infant.
  • Raeside, 2003

41
Support to Caregiver
  • Staff to Caregiver
  • Non judgmental
  • Show empathy
  • Realistic expectations
  • fatigue is a major trigger to relapse
  • visitation
  • Acknowledge as a parent first
  • Include in care plan
  • Keep informed
  • Caregiver to Infant
  • Help read infant cues
  • Educate on soothing techniques feeding
  • Signs of engagement overstimulation e.g. gaze
    aversion
  • Affirm positive interaction
  • Maintain connection photograph etc

42
  • Ideally preparation of the mother should begin
    PRIOR to the birth
  • How her infant will be monitored
  • Her role in her infants care
  • Supportive care and treatment
  • Breastfeeding if appropriate
  • Length of stay
  • Home nursing visit

43
PharmacotherapyIndications
  • Inadequate feeding/ wt loss
  • Severity of signs/ symptoms
  • FS gt8 3 scores/24 hrs or mean of 3 consecutive
    scores
  • FS gt12 2 scores or mean of 2 consecutive scores
  • Severe diarrhea / buttock escoriation
  • Inability to sleep/ interact

44
Pharmacologic Options
Paregoric (0.4mg/ml morphine equivalent) Tincture of Opium 10mg/ml Dil 25x Methadone Morphine PO/IV/SQ 4mg/ml
Phenobarb. Chlorpromazine extrapyramidal effects Clonidine Limited use CVS effects Diazepam
45
Current Recommendations
  • Drug of first choice
  • Opioid dependency - Opioid
  • Mixed opioid dependency Opioid
  • Non-opioid dependency Phenobarbitol
  • If not controlled at maximum dose of first line
    drug, add a second drug.

46
Tincture of Opium Vs Paregoric
  • Tincture of Opium
  • Preferred drug (AAP)
  • 18 alcohol
  • No toxic additives
  • Must be diluted 25-fold
  • (0.4mg morphine equivalent per ml)
  • Paregoric
  • One of first drugs used
  • 44-46 alcohol
  • Potentially toxic additives
  • Camphor (CNS stimulant)
  • Anise oil (habituation)
  • Benzoic acid (gasping baby syndrome, jaundice)
  • Glycerin (diarrhea)

47
Oral Morphine
  • No randomized/comparative studies of
    effectiveness
  • Available as 2 4 mg/ml
  • Less alcohol (10)
  • Should be diluted to the same ME as Paregoric

48
Titration of Dose
  • Initial dose 0.8cc/kg/day (0.1cc/kg/dose every 3
    hours)
  • Increase by 0.05 cc/kg/dose every 12 hours until
    FS lt 8.
  • If control not achieved, consider adding
    phenobarbitol, if supportive care is optimal and
    no other cause for symptoms.

49
Opiate WeaningGoal Prior to discharge
  • Allow 3 good days
  • Criteria Wt stabilized/ increased FS lt 8
  • Method
  • Decrease by 10 of dose/ day
  • If tolerated for 3 consecutive days, decrease by
    20
  • D/C at 0.05cc/kg/dose or 0.02mg me/kg/day

50
Methadone
  • Advantages
  • Effective orally and parenterally
  • Duration of action is 8-10 hrs - infrequent
    dosing more physiologic care
  • Enteral/ parenteral
  • Disadvantages
  • Pharmacokinetics data in neonates is lacking
  • Difficult to titrate dose
  • Stigma

51
Phenobarbitol
  • Drug of choice for non-opiate withdrawal
  • NOT recommended as first line in opiate
    withdrawal
  • Depression of suck reflex
  • Tolerance induction of drug metabolism
  • Seizures
  • Hyperalgesic effect
  • No effect on GI symptoms
  • May discharge prior to weaning???????

52
Combination Therapy
  • In 1 partially randomised study (n20)
  • Opiate dependent infants treated with DTO
    phenobarbitol
  • Decrease in hospital stay (77d to 32d) and
  • Average cost savings of 35,856 per patient.
  • Rationale Phenobarb increases opiate depletion
    offset by DTO
  • Infants weaned off opiate prior to discharge and
    continued on phenobarbitol.
  • Coyle MG et al, J Pediatr, 2002140561-564.

53
Methadone Weaning at Breast
  • Gradual tapering
  • Mother tapers dose slowly 2 to 2.5 mg/ 10 days.
  • Minimal risk of WD if abrupt weaning at dose lt
    20 mg
  • Wean slowly from breastmilk by intro of 1 oz
    formula per day/ 1 bottle formula/week

54
In-Hospital Stay
  • Minimum
  • Heroin/ prescription drugs 4 days
  • Methadone 7 days
  • Most infants show some signs of NAS, requiring
    supportive care.
  • If require pharmacotherapy average LOS 21 days.

55
Factors Leading to Shorter Hospital Stays
  • Dosing interval
  • Peak dose
  • Breastfeeding
  • A caregiver available to provide support to the
    infant during the stay

56
Discharge Readiness
  • Able to feed and grow
  • Abstinence score lt 8
  • Weaned off opiate medication
  • Safe home environment
  • Caregiver able to calm and feed infant
    bio/foster
  • Anticipatory guidance
  • supportive care, prevention of SIDS
  • Early and frequent follow-up
  • Home-care

57
The light at the end of the tunnel!
  • Exaggerated crying curve in first 2 to 3 months
  • By 4 months most infants have no s/ s of
    withdrawal
  • Severity of NAS does not affect prognosis.
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