1. Neonatal Abstinence Syndrome
Karen Estrella-Ramadan
06/25/2012

2. Acute use of heroin and other opioids stimulate opiate receptors in the brain which may result in symptoms including euphoria, resp depression, analgesia and nausea.
Chronic use of opioids s associated with tolerance, which later leads to dependence, whereby the neurochemical balance in the CNS is altered and absence of the drugs leads to withdrawal syndrome

3. Opioids and pregnancy
Repetitive use and withdrawal leads to ftal hypoxia, fetal demise, IUGR, SGA
Medication-assisted tx with methadone
Long half life
With advance pregnancy is metabolized faster and higher doses are required

4. Neonatal Abstinence Syndrome
Timing
Heroin: 48-72hrs
Methadone: 4 days
Screening:
Newborn urine:
24-48hrs
Amphetamines, barbiturates, benzos, cocaine, marijuana, some opioids-my not include methadone or oxycodone
Meconium toxicology
First 3-4 days
Ampehtamines, opiods, cocaine, marijuana

5. Clinical Features NEUROLOGICAL: Tremors Irritability
Increased wakefulness
High-pitched crying
Increased muscle tone
Hyperactive deep tendon
reflexes
Exaggerated Moro reflex
Seizures
Frequent yawning and
sneezing
GI DYSFUNCTION:
Poor feeding
Uncoordinated and constant sucking
Vomiting
Diarrhea
Dehydration
Poor weight gain
AUTONOMIC SIGNS:
Increased sweating
Nasal stuffiness
Fever
Mottling
Temperature instability

6. Treatment ~50-70% of infants will require tx
At delivery, NO naloxone= seizures
SCORING (modified Finnegan)
Before feeding

9. 1. Supportive Encourage maternal and paternal involvement
Decrease stimulation: no light, no loud sounds, examination
Swaddling, soothing, rocking (vertical)
Non-nutritive sucking: Pacifier
Skin-skin contact: Kangaroo care
Skin care: lotion to areas of abrassion
Frequent feedings: increase caloric intake ( cal/kg/day)
May allow BF if neg Utox in mother, HIV neg

10. 2. Pharmacological
Scoring >9 (x3: before and after feeding) or 2 >than 12
Short acting opioid: MORPHINE (0.4 mg/ml)
Start with 0.03 mg/kg/day
0.2 mg po q4hrs
Scoring: q8-12hrs
If still high: increase by 0.16mg/kg/day q3hrs (max 0.8mg/kg/day)
Monitor:
Over-sedation, decreased arousal, resp depression
Wean after 48hrs on scores <6
Decrease 20% of daily dose
Continue scoring
Wean after 28-72hrs on scores <6, and less freq feedings
d/c morphine
Once sub therapeutic dose is achieved, observe for hrs off morphine
If sz: diff dx workup
Add phenobarbital if no control of symptoms with max dosing

11. Discharge Off morphine for 24hrs with score <6 Adequate nutrition
No more than 10% wt loss
SW clearance
f/u with PMD

12. Other things to consider
Screens for:
Syphilis
Hepatitis B
Hepatitis C
HIV Tb DV

13. Differential dx Sepsis Hypoglycemia Hypocalcemia hypomagnesemia
Hyperthyroidism
Perinatal asphyxia
IVH

14. References
(University of Vermont)
(University of Connecticut)
NICU-SBH