Current Trends In Identifying And Treating Newborns With Withdrawal Syndromes 6/24/2010.
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Transcript of Current Trends In Identifying And Treating Newborns With Withdrawal Syndromes 6/24/2010.
Current Trends In Identifying And
Treating Newborns With Withdrawal
Syndromes
Current Trends In Identifying And
Treating Newborns With Withdrawal
Syndromes6/24/20106/24/2010
Substance Exposed Newborns
Substance Exposed Newborns
Barbituates
Selective Serotonin Re-uptake inhibitors
Opiates
Marijuana
Anti-psychotics
Benzodiazepines
Alcohol
Tobacco
Caffeine
Amphetamines
Cocaine
Substance Exposed Newborns
Substance Exposed Newborns
Drug Use in Pregnant Women
2003 National Survey On Drug Use And Health.
4.3% of pregnant women, age 15-44 years, reported using illicit drugs.
Approximately 170,000.
Drug use during pregnancy typically decreases as pregnancy progresses.
OpiatesOpiatesUS 1999 National Household Survey on Drug Abuse reported that 6.7% of people reported illicit drug use in the last month.
0.1% heroin use.
3.4% of pregnant women reported illicit drug abuse.
Approximately 3,000 pregnant women use opiates during there pregnancy each year in the United States.
OpiatesOpiatesWithdrawal signs in exposed infants are variable and not all exposed infants experience withdrawal.
48-94% of infants will experience withdrawal
No resolution to the questions surrounding maternal opiate dose and withdrawal frequency or severity.
Literature split evenly on either side of this issue.
OpiatesOpiates
Scoring Systems
Neonatal Abstinence Scoring System
Finnegan
Lipsitz Tool
Neonatal Withdrawal Inventory
Ostrea
Neonatal Abstinence Scoring System
Neonatal Abstinence Scoring System
OpiatesOpiatesNeonatal Abstinence Scoring System
Neuromotor
Tremors, hyperreflexia, inconsolable cry.
Metabolic/Respiratory
Hyperthermia, mottling, tachypnea.
Gastrointestinal
Frequent stooling, diarrhea, poor PO feeding, emesis.
Score is totaled for each time point.(Feeding)
• 3 successive scores totaling 24 or more require treatment.
OpiatesOpiates
Treatment Options
Neonatal Morphine Solution
Methadone
Phenobarbital
Clonidine
Partial Agonists/Antagonists
OpiatesOpiatesInfant with 3 scores totaling 24 or more.
Neonatal Morphine Solution starts at 0.4 mg/kg/day.Every 3-4 hours depending on feeding schedule.
Infant continues to be assessed with each dose.
Up-titration continues as infant continues to have elevated scores.
OpiatesOpiatesInfant stabilized on same dose for 48 hours.
Infant is initially weaned every 48 hours based upon continued clinical stability without signs of
NAS.
Cessation variable depending upon institution,0.15 mg/kg/day.
Observation off medication for 48 hours.
OpiatesOpiates
Phenobarbital
First or second line agent.
Loading dose
20mg/kg/day or 10 mg/kg/day.
Starting or maintenance dose.
3-5 mg/kg/day.
OpiatesOpiatesClonidine
Adjunctive therapy at this point in time.
Oral or transdermal patch delivery system.
Recent randomized controlled trial demonstrated that oral clonidine as an adjunct to diluted tincture of opium reduced length of therapy.
OpiatesOpiatesPreterm Infants
Infants born preterm seem to demonstrate fewer withdrawal signs then full term infants.
Infants born preterm that do require treatment for neonatal abstinence ultimately require lower doses of neonatal opium solution and shorter courses of therapy.
BenzodiazepinesBenzodiazepines
Signs of neonatal withdrawal mimic the signs of withdrawal from opiates.
Poorly described and few populations of infants have been investigate only exposed to benzodiazepines.
No treatment for abstinence from benzodiazepines has been studied as mono-therapy.
BenzodiazepinesBenzodiazepines
Frequently complicates opiate addiction in pregnant women.
Infants with concomitant opiate and benzodiazepine exposure often experience a more complicated withdrawal course.
No quantification of this impact has yet been published.
CocaineCocaine
Cocaine exposure likely leads to a toxicity and not a withdrawal syndrome.
Infants often demonstrate many of the signs of opiate withdrawal.
Hyper-irritability, tachycardia, inconsolable cry.
Often present though early after delivery.
No specific therapy for cocaine exposure.
Selective SerotoninRe-uptake INhibitorsSelective SerotoninRe-uptake INhibitors
Widely used and studied in pregnant women.
Reports of an abstinence syndrome in infants still in small numbers in comparison to the large numbers of exposed women.
Several reports describe a withdrawal syndrome similar to opiates.
May more likely represent a toxicity and not true withdrawal syndrome.