Stephanie Carner, DO, MHANeonatalogist

Newborn Specialists of TulsaTulsa, Oklahoma

Objectives

Definition Pathophysiology Screening Diagnosis Management/Treatment Long term Outcomes Common misconceptions

NASDefinition

Set of symptoms that develop in infants secondary to exposure (usually prolonged) to medications or illicit substances

2 types Prenatal○ In utero exposure via placental transfer

Post-natal○ Long term opiate use in critically ill infants

NASPathophysiology- Prenatal Occurs following the abrupt cessation of in utero

exposure to maternally administered drugs Most commonly associated with opiates

Generally more severe and for longer duration Occurs in 55-94% Prescribed or not prescribed

○ Heroin, fentanyl, methadone, lortab, norco, oxycodone, subutex

May occur with exposure to other substances Benzodiazepines, barbiturates, tobacco, SSRIs, alcohol Possibly coccaine, methamphetamines, amphetamines,

THC?

NASPathophysiology- Post natal

Long-term exposure to opiates in critically ill infants Fentanyl, morphine

NASScreening

Identify at-risk infants Inadequate prenatal care○ <5 prenatal visits

Maternal clinical concerns○ Disorientation, slurred speech, somnolence,

smell of EtOH/chemicals, physical signs (needle marks, etc)

Known history within the past 3 years Positive maternal toxicology○ At or greater than 20 weeks gestation

NASDiagnosis Maternal Toxicology

UDS○ Multiple can be helpful○ Exclude any labor medications

Neonatal Toxicology UDS

○ Fast but least accurate○ First catch○ Negative does not rule out exposure

MDS○ Somewhat more accurate○ Harder to obtain○ Long processing time

NASDiagnosis

Neonatal Toxicology (cont) Cord stat○ Blood from umbilical cord○ Multiple tests available○ Most accurate*○ Processing time 5-7 days○ Not always available

NASDiagnosis

Symptoms most commonly occur at 2-5 days of life

Symptoms of Withdrawal

Neurologic Gastrointestinal Autonomic•Irritability•Increasedwakefulness•High-pitched cry•Tremors•Increased muscle tone•Hyperactive reflexes•Frequent sneezing•Seizures

•Vomiting•Diarrhea•Dehydration•Poor weight gain•Poor feeding•Uncoordinated sucking•Hyper sucking

•Diaphoresis•Nasal stuffiness•Fever•Mottling•Temperature instability•Increased RR

NASDiagnosis Observe for minimum of 5 days Finnegan scoring

Taking the subjective and making it objective○ Assigns numeric value to individual symptoms

Start 3 hours after birth Scoring occurs every 3hrs, 30 min after feeding Scores of 8 or higher consistently is indication

for treatment Continues for full observation and/or treatment

period Most effective with experienced nurses

NASManagement/Treatment

Prenatal consult/education Observation for at least 5 days NICU Social Services consult

DHS

NASManagement/Treatment Non-pharmacologic Treatment

Low lighting, low noise, swaddling, pacifier May need minimal handling Close monitoring of GI symptoms

○ Daily weight○ I/O- especially loose stools○ Minimize overfeeding

Breast milk○ Usually not contraindicated (unless for other

medical reasons)○ Small amount of opiates excreted in BM○ May reduce symptoms○ Recommend against abruptly stopping

NASManagement/Treatment

Pharmacological Treatment Morphine is the first-line and main treatment Administered with feeds, every 3hrs Initiated if FS of 8 or greater consistently Dosing based on severity of symptoms○ Higher the scores, higher the dose

NASManagement/Treatment

NST practice

Finnegan Score Initial dose (q 3hrs)8-10 0.04mg/kg/dose11-13 0.06mg/kg/dose14-16 0.08mg/kg/dose>16 0.1mg/kg/dose

NASManagement/Treatment

May need escalation of dosing if scores remain high Increase dose by 0.02mg/kg/dose Max dose of 0.1mg/kg/dose○ Higher at some institutions

Baby is considered “captured” once all scores are less than 8 for at least 24hrs

Once captured, continue same dose for minimum of 48hrs

NASManagement/Treatment

Weaning Morphine May start weaning 48hrs after baby is

captured Biggest variability in practices○ Dose of weaning○ Timing of weaning

Based on FS○ Average score <6 (24hr period), decrease

dose by 0.02mg/dose daily until off Once off, monitor for at least 48hrs

NASManagement/Treatment Adjunctive Therapy

If max dose of morphine reached and infant continues to have high scores (>8)

Phenobarbital○ Not recommended as single therapy○ More commonly needed in poly substance abuse○ Dosed every 12hrs○ Morphine weaned first○ May be discharged home on phenobarb Usually baby outgrows dose (natural wean) Requires PCP be comfortable managing Reliable family

NASManagement/Treatment

Up and Coming Clonidine Methadone

NASLong Term Outcomes

Studies are difficult Difficult to isolate substance exposure as causal

Thought to be associated with neurodevelopmental and learning deficits, behavioral disorders ADHD, learning disabilities, oppositional defiant

Developmental Pediatric follow-up is essential

More studies needed

NASCommon Misconceptions

Misconception TruthNAS refers to all substances Mainly OpiatesAll withdrawal can be treated Only opiatesWhen my baby goes home, he/she is no longer in withdrawal

No longer withdrawing enough formedical treatmentMay exhibit signs for up to 18months

Can’t use breast milk Very few contraindications for BM useMay aid in decreasing withdrawal symptoms

NAS only applies to illegal drug use Most are prescription useMy baby will only need to be in the hospital for 2 weeks

May be 5 days to 2 months or moreCan be some of the longest NICU stays

I took “x” with my last baby is he/she is fine

Every baby is differentLong-term outcomes not well understood

NAS

Questions?

References1. American Academy of Pediatrics Committee on Drugs (2012).

Neonatal Drug Withdrawal. Pediatrics 2012; 129; e540.2. Klein, J, MD. University of Iowa Children’s Hospital

Identification of Neonatal Abstinence and Treatment Protocol, September 2012

3. Bio LL, Siu A, and Poon CY. Update on the pharmacologic management of neonatal abstinence syndrome. Journal of Perinatology (2011) 31, 692-701.

4. Thomas Reuters. Neofax. 2011. 24th Edition.5. Coyle, MG, MD. Brown University Women and Infants’

Hospital Neonatal Abstinence Syndrome Policy and Treatment Protocol, November 2009

6. Coyle, MG, Ferguson A, Lagasse L, Liu J, Lester B. Neurobehavioral effects of treatment for opiate withdrawal.

7. Finnegan LP, Connaughton JF, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis 1975;2: 141-58.