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

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

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

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

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

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

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 (150-250 cal/kg/day) May allow BF if neg Utox in mother, HIV neg

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 24-28 hrs off morphine If sz: diff dx workup Add phenobarbital if no control of symptoms with max dosing

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

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

Differential dx Sepsis Hypoglycemia Hypocalcemia hypomagnesemia Hyperthyroidism Perinatal asphyxia IVH

References http://www.uvm.edu/medicine/vchip/documents/VCHIP_5NEONATAL_GUIDELINES.pdf (University of Vermont) http://nctnc.org/workfiles/NAS.pdf (University of Connecticut) NICU-SBH http://pediatrics.aappublications.org/content/101/6/1079.full