1. Neonatal Abstinence Syndrome: Preserving the Infant-Maternal Bond Haneme Idrizi, MD, FAAP Assistant Professor of Pediatrics, University of Texas Health Science Center at San Antonio Stephanie Reeves, DO, FAAP Assistant Professor of Pediatrics, University of Texas Health Science Center at San Antonio

3. Neonatal Abstinence Syndrome (NAS) Constellation of signs & symptoms in newborn due to substance or medication withdrawal Opioids are most frequent drugs giving rise to signs of withdrawal Predominant symptoms related to CNS irritability, autonomic over- reactivity and GI tract dysfunction

4. Epidemic In neonates with in utero opioid exposure, 55% to 94% will develop withdrawal signs 2009 National Survey on Drug Use & Health noted 4.5% of pregnant women 15 to 44 years of age reported recent use of illicit drugs U.S. rates of NAS increased threefold between 2000 and 2009 One child being born every 25 minutes with NAS NAS rate in Texas has increased almost 60% over the past 5 years

5. Date of download: 2/29/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 NAS indicates neonatal abstinence syndrome. Error bars indicate 95% CI. P for trend <.001 over the study period. The unweighted sample sizes for rates of NAS and for all other US hospital births are 2920 and 784 191 in 2000; 3761 and 890 582 in 2003; 5200 and 1 000 203 in 2006; and 9674 and 1 113 123 in 2009; respectively. Figure Legend:

6. Management of NAS In 2012, the American Academy of Pediatrics formally recommended that each nursery managing NAS should develop a treatment protocol: Pharmacologic Intervention Non-Pharmacologic Intervention

7. Protocol Implementation Length of stay prior to protocol implementation: 27.5 days Length of stay post protocol implementation: 19 days

8. Preservation of Infant-Maternal Bond Promoting breastfeeding Rooming-in with mother Friendly visiting policy Community Outreach: Mommies Program Skin to skin: Kangaroo care

9. Kangaroo Care Funded by the TX Department of State Health Services Salivary cortisol levels to monitor stress during skin to skin sessions

10. Conclusions Protocols standardize care of infants with opioid withdrawal resulting in improved care and decreased length of stay. Preservation of infant-maternal bond is possible through rooming-in, breastfeeding, kangaroo care and community outreach. Ongoing education for all infant caregivers is vital. Real time refinement of protocol is ongoing and may result in additional benefits to patient population.

11. References American Academy of Pediatrics Committee on Drugs. Neonatal Drug Withdrawal. Pediatrics. 1998;101(6):1079– 1088 Hudak ML, Tan RC. American Academy of Pediatrics Committee on Drugs and The Committee on Fetus and Newborn, Neonatal Drug Withdrawal. Pediatrics 2012;129:e540-e560 Jansson L, Velez M, Harrow C. The opioid exposed newborn: Assessment and pharmacologic management. J Opioid Manag 2009;5(1):54. Texas Department of State Health Services: The Mommies Program Workshop