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NEONATAL ABSTINENCE SYNDROME

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NEONATAL ABSTINENCE SYNDROME What is NAS? Presence of withdrawal behaviors in neonates exposed to dependency-producing substances in utero. These behaviors include ... – PowerPoint PPT presentation

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Title: NEONATAL ABSTINENCE SYNDROME


1
NEONATAL ABSTINENCE SYNDROME
2
What is NAS?
  • Presence of withdrawal behaviors in neonates
    exposed to dependency-producing substances in
    utero.
  • These behaviors include central nervous
    hypersensitivity, gastrointestinal dysfunction
    and vague autonomic symptoms.
  • 25-40 of infants with known exposure are
    asymptomatic or display only mild symptoms

3
Substances that can cause NAS
  • Opiates- (55-94 of neonates exposed in utero
    will have withdrawal symptoms)
  • Alcohol
  • Tobacco
  • Benzodiazepines
  • Barbiturates
  • SSRIs (neonatal behavioral syndrome)
  • ?Amphetamines
  • ?Cocaine
  • ?Marijuana

4
Diagnosis
  • Maternal history of drug use
  • Positive identification of substance in maternal
    or neonatal specimen
  • Scoring
  • Once diagnosed- consult social services

5
Clinical Presentation
  • Onset of symptoms varies with the substance being
    used by the mother, the quantity, frequency and
    duration of intrauterine exposure, timing and
    amount of the last maternal use, as well as
    maternal and infant metabolism and excretion
  • CNS
  • Tremors, irritability, increased wakefulness,
    high-pitched crying, hypertonicity and
    hyperactive reflexes, seizures, yawning, sneezing
    and skin excoriation
  • Gastrointestinal
  • Poor feeding, uncoordinated and constant suck,
    vomiting or regurgitation, diarrhea, dehydration
  • Autonomic Signs
  • increased sweating. Nasal stuffiness. Rhinorrhea,
    mottling, temperature instability, fever, tearing

6
NAS
  • video clip

7
NASS
  • Used to initiate, adjust and wean pharmacologic
    treatment.
  • Scoring should begin within 4 hours after birth
    and continue every 4 hours until the onset of
    symptoms. At the onset of symptoms scoring should
    be done every 3 hours for 24 hours and then
    every 4 hours for the duration of treatment.
  • Observation should be made after feedings,
    newborns must be awake and calm to asses muscle
    tone, respirations and Moro reflex. Newborns
    should be observed for 20 to 30 minutes before
    scoring is determined.

8
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9
Management
  • Pharmacologic intervention is indicated for
    evidence of acute withdrawal such as seizures,
    poor feeding (excess weight loss), severe
    diarrhea, vomiting, dehydration, inability to
    sleep and fever not due to any infectious
    etiology
  • 3 consecutive NAS scores of 8 or more or the
    average of 3 consecutive NAS scores is 8 or
    more.
  • or 2 consecutive NAS scores of 12 or more or the
    average of 2 consecutive score is 12 or more.
  • Pediatric consult is recommended when considering
    pharmacologic treatment.
  • Cardio respiratory monitoring.
  • Supportive
  • Swaddling ( decreases the added stimulation of
    startled movements)
  • Reduction of environmental stimuli ( decreased
    light and noise)
  • Frequent small feeding
  • Frequent diaper change are necessary to reduce
    skin excoriation
  • Monitor intake, output and weigh daily to assess
    hydration and caloric status related to vomiting,
    diarrhea and poor feeding status.

10
Pharmacologic Therapies in Neonatal Abstinence
Syndrome
  • Paregoric
  • 0.2-0.5 ml/dose q 3-4 p.o. or 4-6 drops q 4-6h
    may increase by 2 drops until clinical
    improvement
  • Improves most of the withdrawal symptoms
    especially diarrhea, taper dose by 10-20 per day
    over 2-4 week after symptoms stable for 3-5 days.
  • Neonatal Opium Dilution 0.4 solution (contains
    0.4 mg morphine equivalent per ml) guidelines
  • 0.8 ml/kg/day for NAS 8-10
  • 1.2 ml/kg/day for NAS 11-13
  • 1.6 ml/kg/day for NAS 14-16
  • 2.0 ml/kg/day for NAS gt16
  • Doses given orally every 3-4 h with feeds ( not
    prn)
  • Phenobarbital
  • 15-20 mg/kg/day loading dose to achieve level of
    20-40 mg/ml. Maintenance dose 2-8 mg/kg/day.
  • Taper dose by 10-20 per day after symptoms
    stable for 3-5 days.
  • Diazepam
  • 0.3-0.5 mg/kg q 8 h initial dose i.m then p.o
  • Allows rapid suppression of symptoms, decreased
    suck, avoid in jaundice or premature infants.

11
Pharmacologic Therapies in Neonatal Abstinence
Syndrome
  • Methadone
  • 0.1-0.5 mg/kg/day divided q 4 to 12 h
  • Increase by 0.05mg/kg/dose until symptoms are
    well controlled
  • Taper dose by 10-20 per day over 1 mo
  • Treatment usually longer (5 days-4 mo)
  • Long half-life (26 h )
  • Chlorpromazine
  • 0.5-0.7 mg/kg/dose loading then 2-2.8 mg/kg/day
    in divided doses q 6 h
  • Decrease dose over 2-3 wk
  • Clonidine
  • 0.5-1 ug/kg single dose then 3-5 ug/kg/day
    divided dose q 4-6 h
  • Increase by 0.5 ug/kg over 1-2 days until
    maintenance dose is achieved

12
Weaning Guidelines
  • Once NAS are consistently 6-8, maintain the
    same therapeutic dose 48 hours before weaning.
    Wean by 10 of maximum dose every 1-2 days. If
    symptoms increase, return to effective dose.
    Therapeutic agents should be gradually decreased
    over a 2-6 week period. Neonatal opium solution
    should be weaned first, then Phenobarbital.

13
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