sm04 neonatal abstinence - March of Dimes Assessment of neonatal abstinence ©2015 March of Dimes...

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Karen D’Apolito, PhD, NNP-BC, FAAN

Assessment of neonatal abstinence


©2015 March of Dimes Foundation Slide 2

Disclosure

The authors and planning committee members have no financial, professional or personal relationships that could potentially bias the content.

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Accreditation

March of Dimes Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

The March of Dimes also is approved by the California Board of Registered Nursing, Provider #CEP11444.

Contact hours are available for this activity. See the landing page for this activity for current information or visit marchofdimes.org/nursingfor up-to-date information on all of our CNE activities.



Purpose statement

This presentation is for health care professionals who care for infants diagnosed with neonatal abstinence syndrome (NAS). The module provides a review of the cost of care for infants hospitalized with NAS, screening methods and physical and behavioral assessment of the signs of NAS.

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Activity objectives

After studying this module, nurses will be able to:

1. Define NAS and its incidence in the United States

2. Describe key considerations when screening for drug exposures in the neonatal population

3. Describe the signs of NAS associated with specific drugs

4. Apply objective criteria to increase the reliability of assessing neonates for signs of drug withdrawal


©2015 March of Dimes Foundation


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What is NAS?

� Also known as neonatal withdrawal syndrome

� A constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs during gestation (Hudak, 2012)



What is NAS? (continued)

NAS causes alterations in functioning (Finnegan et al., 1975)

� Central nervous system (CNS) disturbances

� Metabolic, vasomotor, respiratory disturbances

� Gastrointestinal disturbances

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How do babies get NAS? (Hamdan, 2014)

� Maternal use of licit and illicit drugs during pregnancy

� Postnatal exposure (fetanyl, morphine)



Incidence of NAS (Patrick et al., 2012)

� An estimated13,500 babies were born with NAS from non-iatrogenic causes in 2009.

� One baby is born each hour in the United States with signs of neonatal abstinence.

� The cost of NAS increased from 2000 to 2009:

o Total estimated hospital costs increased from $190 million to $720 million.

o 5-fold increase in the number of women using opioids during pregnancy

o 3-fold increase in the number of babies diagnosed with NAS

o Hospital costs per baby increased from $39,000 to $53,000.

� Normal newborn cost: $870 to $1,700 for a 1- to 2-day stay (Ross-Roussos & Reisfield, 2013)

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Length of stay (LOS)

� Data from a retrospective review of approximately 21,000 babies from 2000 to 2009, the LOS was 16 days (Patrick et al., 2012).

� Infants treated with methadone had a reported median LOS of 40 days (n=17; range 30 to 51 days) compared to infants treated with morphine who had a median LOS of 36 days (n=29; range 33 to 39) (Lainwala, Brown,

Weinschenk, Blackwell & Hagadorn, 2005).

� LOS varies because optimal treatment for NAS has not been identified (Jackson, Ting, McKay, Galea &

Skeoch, 2004).



LOS (continued)

� Infants treated with tincture of opium had a reported mean LOS of 26.9 days (n=16; range 8 to 51 days) compared to an average LOS of 29.8 days (n=17; range 10 to 62 days) for those treated with oral morphine (Langenfeld et al., 2005).

� Recent information suggests the drug used to treat NAS does not matter. LOS can be shortened if a specific treatment protocol is used (Hall et al, 2014).

o 417 infants received stringent weaning protocol; 130 did not.

o LOS is shorter for those receiving weaning protocol (23 days vs. 32 days).

� 60 to 80 percent of these babies require pharmacologic management (Sarkar & Dunn, 2008).

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Is it clear which drugs lead to NAS?

� NAS is currently an area of emerging interest and research.

� The list of prescription and illicit drugs associated with NAS is in flux as new research is published. Sometimes studies come to the same conclusions as prior research, and sometimes study findings conflict.

� “Association” and “causation” are not the same. Exposure to a drug may lead to a clinical picture that mimics hallmarks of NAS. Later it may be determined that an infant did not have NAS but had a different diagnosis, such as fetal alcohol spectrum disorder, or that a different exposure than first suspected caused NAS.

� Many infants exhibiting signs of NAS are exposed to more than one prescription or illicit drug during the pregnancy.

� To stay current about substances associated with NAS and substances associated with other neurobehavioral problems in newborns, nurses must engage regularly in continuing education about this and related topics.



Some drugs that have been associated with signs of NAS

Stimulants

� Cocaine

� Crack

� Methamphetamine

� Nicotine

Hallucinogens

Marijuana

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Some drugs that have been associated with signs of NAS (continued)

Non-opioid CNS depressants

May present with some or mimic signs of NAS

� Benzodiazepines (anti-anxiety): Xanax ®

� SSRIs (anti-depressants): Prozac ®

� Barbiturates (tranquilizers): Phenobarbital

� Anticonvulsants: Ativan ®, Phenobarbital

� Antipsychotics: Prozac

� Alcohol



Drugs known to cause NAS: Opioids

Heroin

� 10 times stronger than morphine (McKim,1991)

� Very addictive (McKim, 1991)

� Crosses the placenta (Rayburn, 2007)

� Transplacental passage <60 minutes (Farrell, 1994)

� Withdrawal begins between 6 and 48 hours after birth (Farrell, 1994).

Methadone: Substitute for heroin

� Recommended treatment for opioid dependence during pregnancy (Hamdan, 2014)

� Withdrawal begins from 48 hours to as long as 7 to 14 days after birth (Hamdan, 2014).

o Can be delayed for 4 weeks after birth

o Sub-acute signs at 6 months (Hamdan, 2014)

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Drugs known to cause NAS: Opioids (continued)

Buprenorphine (Hamdan, 2014)

� Semi-synthetic

� New treatment for opioid dependence in pregnancy

� Withdrawal begins 12 to 48 hours after birth (Jones & Fischer, 2003).

o Peak is reached in 72 to 96 hours.

o Resolves by 7 days



Drugs known to cause NAS: Opioids (continued)

Prescription Opioids (Desai, et al, 2015)

� Medicaid data from 45 states

� 290,000 women; 1,700 cases of NAS

� Higher relative risk

o Long-term use vs. short-term use (30 days vs <30 days) (RR 2.05)

o Mothers had a history of other drug misuse, smoking, alcohol and psychotropic medications (RR 1.01).

o Late use (all three trimesters) vs. early use (first two trimesters) (RR 1.24)

� Withdrawal (Desai, et al, 2015)

o Respiratory signs

o Feeding difficulties

o LOS mean 5 to 7 days

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Physiologic signs of withdrawal: Opioids

Sign Drugs

Physiologic signs Heroin Methadone Buprenorphine

Sneezing X2 X2,5 X3

Stuffy nose X1,2,4 X2,5 X3

Spitting/Drooling — X2 —

Diarrhea X1,2,4 X2 X3

Vomiting X1,2,4 X2 —

Sweating X1,2,4 X2,5 —

Fever X2 X2 —

Mottling X2 X2 —

Tachypnea X2,4 X2 —

Dehydration X2 X2 —

Poor feeding X2,4 X2 —

Excoriation X2 X2 —

1. Alroomi, Davidson, Evan Galea & Howat, 1988

2. Finnegan et al., 1975

3. Gaalema et al., 2012

4. Gorski, Davidson & Brazelton, 1979

5. Ostrea, Chavez & Strauss, 1975



Neurobehavioral signs of withdrawal:

OpioidsSign Drugs

Neurobehavioral Heroin Methadone Buprenorphine

Fist sucking X2 X7 —

Irritability X5 X7 —

Restlessness X5 X7 —

Tremors X1,2 X2,7 X3

High-pitch cry X1,5 X2,7 —

Seizures X2,5 X2,7 —

Yawning X2,7 X2,7 —

Disturbed sleep X6 X6 —

Increased crying — X6 —

Increased tone X2,5 X2 X3

Hyperactive moro X2 X2 —

Constant sucking X8 X8 —

1. Alroomi et al., 1988

2. Finnegan et al., 1975

3. Fischer et al., 2000

4. Gaalema et al., 2012

5. Gorski et al., 1979

6. Kron, Kaplan, Finnegan, Litt & Phoenix, 1975

7. Ostrea, Chavez & Strauss, 1975

8. Suresh & Anund., 1998

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Depressants

Barbiturates/Benzodiazepine/Alcohol(Coupey, 1997; LaMar & Hamernik, 2003; McElhatton, 1994)

� All depressants

� Cross the placenta readily

� Very addictive

� Produce severe withdrawal in infants

� Barbiturate withdrawal begins 4 to 7 days after birth (Coupey, 1997).

� Benzodiazepine withdrawal begins in hours to weeks (Rementería & Bhatt,

1977).

� Alcohol withdrawal begins in 3 to 12 hours (Pierog, et al., 1977).



Signs of withdrawal: Barbiturates

Barbiturates: Neurobehavioral (Coupey, 1997; Desmond, Schwanecke, Wilson, Yasunaga &

Burgdorff, 1972)

� Irritability

� Restlessness

� Tremor

� Disturbed sleep

� Increased crying

� Increased tone

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Signs of withdrawal: Benzodiazepines

Physiologic (Rementeria & Bhatt, 1977)

� Poor suck

� Hypothermia

� Apnea

� Tachypnea

� Vomiting

Neurobehavioral

� Irritability (Massachusetts General Hospital, 2001)

� Sleep disruption (Massachusetts General Hospital, 2001)

� Seizures (Massachusetts General Hospital, 2001)

� Hypotonia (Laegreid, Hagberg & Lundberg,1992)

� Depression (Laegreid, Hagberg & Lundberg,1992)



Signs of withdrawal: Alcohol

Physiologic (Finnegan & McNew, 1974)

� Vomiting

� Poor feeding

� Tachypnea

Neurobehavioral

� Irritability (Finnegan & McNew, 1974; Rosett, Ouellette, Weiner & Owens, 1988)

� Restlessness (Finnegan & McNew, 1974)

� Tremor (Finnegan & McNew, 1974; Rosett et al., 1988)

� Increased crying (Powell, 1981)

� Disturbed sleep (Powell, 1981; Scher, Richardson, Coble, Day & Stoffer, 1998)

� Increased tone (Finnegan & McNew, 1974)

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Stimulants

Cocaine, crack

� Rapidly crosses the placenta (Hamdan, 2014)

� Effects can be seen in infants 2 to 3 days postnatally (Hamdan, 2014).

� Half-life is from 1.2 to 4.2 hours (Jufer, Wstadik, Wlsh, Levine & Cone, 2000).

Methamphetamine

� Crosses the placenta (Garcia-Bournissen, Rokach, Karaskov & Koren, 2007)

� Half-life is from 5 to 12 hours (Schep, Slaughter & Beasley, 2010).

Nicotine (Wickstrom, 2007)

� Crosses the placenta 15 to 30 minutes after smoking

� Half-life is 2 hours.



Signs of withdrawal: Stimulants

Cocaine/Crack (Oro & Dixon, 1987)

� Poor feeding

� Drowsiness

� Increased sleep

Methamphetamine (Chomchai, Na Manorom,

Watanarungsan, Yossuck & Chomchai, 2010)

� Agitation

� Vomiting

� Tachypnea

� In a 2003 study of 134 exposed infants, 49 percent had signs of withdrawal, but only 4 percent required treatment (Smith, Yonejura,

Berman, Kuo & Berkowitz, 2003).

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Signs of withdrawal: Stimulants (continued)

Nicotine (Garcia-Algar, Puig, Mendez & Vall, 2001)

� Limited information

� 33 newborns whose mothers smoked more than 20 cigarettes a day were screened using the Finnegan Neonatal Abstinence Scoring Tool (FNAST).

o 22 showed no signs of withdrawal.

o 11 showed signs of withdrawal: 7 scored between 1 and 4; 4 scored between 5 and 7.

o Signs

• Tremor

• Irritability

• Increased startle reflex (Hamdan, 2014)



Hallucinogens: Marijuana

� Lipid soluble (Ashton, 2001)

� Stays in fatty tissue (Ashton, 2001)

� Half-life is 7 days with complete elimination in 30 days (Ashton, 2001).

� 25 percent is eliminated in urine; 75 percent by the gut (Ashton, 2001)

� Readily crosses the placenta (Zuckerman et al., 1989)

Signs of withdrawal

� No evidence of withdrawal (Hamdan, 2014)

� Irritability (Ostrea et al., 1975)

� Tremor (Ostrea et al., 1975)

� Disturbed sleep (Scher et al., 1998)

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Selective serotonin reuptake inhibitors (SSRIs) (Hamdan, 2014)

� Antidepressants

� Used frequently during pregnancy

� Neonates have neonatal adaptation syndrome if exposed during the last trimester.

Neonatal adaptation syndrome from SSRIs

Signs CNS Irritability, seizures

Motor Agitation, tremors, increased tone

Gastrointestinal Emesis, diarrhea, difficulty feeding

Autonomic Fever

Respiratory Increased respiratory rate, nasal congestion

Onset • Several hours to several days• Self-limiting• Disappear by 2 weeks



Detection and screening of fetal exposure to drugs

Urine (Ostrea, 2001)

� Obtain sample as soon as possible after birth.

� High false-negative (up to 60 percent) rate because urine samples report only recent drug exposure

Meconium (Ostrea, 2001)

� Better than urine

� Drug exposure from 16 weeks gestational age

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Detection and screening (continued)

Hair analysis (Ostrea, 2001)

� Radio immunoassay

� Grows 1 cm/month

� Metabolite present for life of hair

� Tells you drug use for months

� Gets into microfibrils

� Can use neonatal hair




Umbilical cord (Montgomery et al., 2006)

� 10-cm section of cord at delivery

� Rinse with sterile saline.

� Place in sterile container.

� Enzyme-linked immunosorbent assay (ELISA)-based test

� For more information: usdtl.com

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Comparison of umbilical cord tissue to meconium

Drug Umbilical cord

Amphetamine Agreement: 96.6 percentSpecificity: 97 percentSensitivity: 95 percent

Opiates Agreement: 95 percentSpecificity: 96 percentSensitivity: 78 percent

Cocaine Agreement: 99 percentSpecificity: 100 percentSensitivity: 75 percent

Cannabinoids Agreement: 91 percentSpecificity: 91 percentSensitivity: 89 percent

Montgomery et al., 2006




Maternal history (Cleary et al., 2010)

� History of drug use

� Methadone treatment (A high dose does not mean an infant will have NAS.)

� Family history of drug abuse

� Prior involvement with Child Protective Services

� Incarceration for drug abuse

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Differential diagnoses (Hamdan, 2014)

� Hypoglycemia

� Infection

� Hypocalcemia

� Hypomagnesemia

� Hyperthyroidism

� CNS injury




Assess infant for signs of withdrawal(Hamdan, 2014)

� CNS excitability

� Gastrointestinal dysfunction

� Autonomic signs

� Respiratory system

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Onset of NAS

Determined by several factors:

� Half-life of the drug

� Timing of maternal last dose

� Infant metabolism of the drug



Onset of NAS (continued)

Drug Onset of NAS

Heroin or opioids with short half-life

Within 6 to 48 hours; peak within 48 to 72 hours in 50 to 80 percent of newborns (Hamdan, 2014; Farrell, 1994)

Methadone From 48 hours to as long as 7 to14 days (longer half-life) (Hamdan, 2014)

Cocaine After first week of life (Oro & Dixon,1987); drug effects from 2 to 3 days after birth (Hamdan, 2014)

SSRIs Several hours to several days (Hamdan, 2014)

Barbiturates Median onset from 4 to 7 days; range of 1 to 14 days (Bleyer & Marshall, 1972; Desmond et al., 1972)

Alcohol From 3 to12 hours (Nichols, 1967; Pierog et al., 1977)

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Assessment tools

Several tools

� Lipsit (Lipsit, 1975)

� Neonatal Withdrawal Inventory (Green & Suffet, 1981)

� Neonatal Narcotic Withdrawal Index (Zahorodny et al., 1998)

� FNAST (Finnegan et al., 1975)

Concerns with all tools

� Subjective

� No one believes the score.

� Big problem: Pharmacologic treatment is based on the scores.



FNAST

� Diagnostic tool divided into three systems with 21 total items

1. CNS disturbances

2. Metabolic, vasomotor and respiratory disturbances

3. Gastrointestinal disturbances

� Scoring interval

o Every 3 or 4 hours

o Includes everything that happened during that 3- or 4-hour period

o Dynamic scoring tool

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Inter-observer reliability program (Polit & Beck, 2012)

� Define the items comprising the tool.

� Everyone learns the definitions and uses them when scoring the baby.

� Periodically two staff members score the baby at the same time, independently.

� Independent scores are compared to determine their inter-observer reliability.

� There can be disagreement with two items to maintain reliability in using the tool.

� When there are disagreements, the item is discussed and the baby is given an agreed-upon score.



D’Apolito & Finnegan, 2010. Adapted from Finnegan & Kaltenbach,1992.

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FNAST item definitions (D’Apolito & Finnegan, 2010)

Crying

� Score 2 for excessive high-pitched crying and baby is unable to self- console in 15 seconds or up to 5 minutes of continuous crying despite intervention.

� Score 3 if baby is unable to self-console in 15 seconds or >5 minutes of continuous crying despite intervention.

Sleep: Base on longest period of sleep, light or deep, after feeding.

� Score 3 if <1 hour.

� Score 2 if <2 hours.

� Score 1 if <3 hours.

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FNAST item definitions (D’Apolito & Finnegan, 2010) (continued)

Moro reflex: Elicit from quiet infant.

Hyperactive Moro reflex

Score 2 for hyperactive-jitteriness that is rhythmic, symmetricaland involuntary. You will see it as the hands are brought to the chest after the reflex begins or immediately after the reflex has been elicited.

Markedly hyperactive Moro reflex

Score 3 for jitteriness as above with clonus of hands/arms. May test at hands or feet if unclear (more than 8 to 10 beats).




Tremors: Involuntary, rhythmical and equal strength

Disturbed

� Score 1 for mild tremors/disturbed of hands or feet while being handled.

� Score 2 for moderate-severe tremors/disturbed of arms or legs while being handled.

Undisturbed

� Score 3 for mild tremors/undisturbed of hands or feet when not handled.

� Score 4 for moderate-severe tremors undisturbed of arms or legs when not handled.

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Increased muscle tone: Perform pull to sit maneuver.

Score 2 if no head lag with total body rigidity. Do not test while asleep or crying.

Excoriation

� Score 1 if present at nose, chin, cheeks, elbows or heals.

� Do not score for diaper rash. If the baby has a diaper rash and loose stools, the rash is included with the loose stools.




Myoclonic jerks: Involuntary twitching of muscle

Score 3 for twitching at face/extremities or jerking at extremities. This is more pronounced than jitteriness of tremors.

Generalized seizures

Score 5 for tonic seizures with extension or flexion of limb(s) that does not stop with containment. May include few clonic beats and/or apnea.

Sweating

� Score 1 for wetness at forehead, upper lip or back of neck.

� Do not score related to the environment — be consistent with dressing and linen.

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Fever

� Score 1 if fever is 37.2 to 38.3 C (≤101 F).

� Score 2 if 38.4 C (>101 F).

Frequent yawning

Score 1 if >3 within interval.

Mottling: Marbled appearance (pink & white)

Score 1 if present at chest, trunk, arms or legs.




Nasal stuffiness: Nares partially blocked from drainage with noisy respiration

Score 1 if present with/without runny nose.

Sneezing: Individual or serial

Score 1 for >3 during scoring interval.

Nasal flaring: Nostrils flared out during respirations

Score 2 if present.

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Respiratory rate: Tachypnea >60 with/without retractions

� Score 1 for rate >60 without retractions.

� Score 2 for rate >60 with retractions.

� Count for 1 full minute.

Excessive sucking: Rooting with attempts to suck fist, hand or pacifier before or after feeding

Score 1 for >3 attempts noted.

Allowing the baby to suck on a pacifier

is a part of non-pharmacologic care (Velez & Jansson, 2008; Torrence & Horns, 1989). In this situation the infant is not capable of successfully sucking on the pacifier.




Poor feeding: Excessive sucking (increased rooting while displaying rapid swiping movements of hand across the mouth in an attempt to suck) prior to a feeding, yet sucks infrequently or uncoordinated, taking small amounts of feeding. May also have uncoordinated suck/swallow reflex and gulp with frequent rest periods to breath.

Score 2 for either.

Regurgitation: Effortless; not associated with burp

Score 2 for two or more episodes.

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Projectile vomiting: Forceful during or after feed

Score 3 for 1 or more episodes.

Stools

� Score 2 for loose stool: loose, curdy, seedy or liquid without water ring.

� Score 3 for watery stool: soft, liquid or hard with water ring.



Accuracy in assessing infants for NAS (D’Apolito & Finnegan, 2010)

� Know item definitions.

� Monitor inter-observer reliability frequently.

� Re-educate if reliabilities are low.

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Accuracy in assessing infants for NAS (D’Apolito & Finnegan, 2010) (continued)

90 percent or greater inter-observer reliability

Inter-observer reliability percent score

Total number of agreements

Total number of disagreements

Score

21 0 100 percent

20 1 95 percent

19 2 90 percent

18 3 85 percent



Conclusion

� NAS is commonly seen among neonates exposed to drugs in utero.

� NAS is responsible for increased length of stay and hospital costs.

� Screening and assessment methods should be accurate to correctly diagnose NAS. Umbilical cord testing may be an alternative to meconium screening.

� It is important to decrease the subjectivity when assessing neonates for signs of withdrawal. This can be remedied by defining each item on the assessment tool.

� Reliability of staff using the tool must be maintained to assure the severity of withdrawal is accurately assessed so appropriate pharmacologic treatment can be given.

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Thank you



About the author

Karen D’Apolito , PhD, APRN, NNP-BC, FAANDr. D’Apolito is a professor and program director of the neonatal nurse practitioner program at the Vanderbilt University School of Nursing. She has made national and international contributions to the care of drug-exposed infants through both education and research. She developed a unique inter-observer reliability program to train healthcare professionals in assessing infants for signs of drug withdrawal. She has published several articles related to neonatal drug addiction in referred journals. In 2008, she received the National Perinatal Association's Individual Contribution to Maternal Child Health Award for her work to improve the care of drug-affected infants. Dr. D’Apolito has been a coinvestigator on two multisite federally funded grants involving infants with intrauterine drug exposure and she has been invited to speak nationally and internationally on the topic of addiction in pregnancy and neonatal abstinence.

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Contact information

� For questions on the content of this presentation, contact the author at: [email protected]

� For technical questions, contact the March of Dimes at: [email protected]



marchofdimes.org/nursing

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