Neonatal Abstinence Syndrome: An Evidence-Based Review for ...
Neonatal Abstinence Syndrome
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Transcript of Neonatal Abstinence Syndrome
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Neonatal Abstinence SyndromeKaren Estrella-Ramadan06/25/2012
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• 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
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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
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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
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Clinical FeaturesNEUROLOGICAL:•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 gainAUTONOMIC SIGNS: •Increased sweating•Nasal stuffiness•Fever•Mottling•Temperature instability
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Treatment
• ~50-70% of infants will require tx• At delivery, NO naloxone= seizures• SCORING (modified Finnegan)• Before feeding
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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
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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• Decrease 20% of daily dose
– 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
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Discharge• Off morphine for 24hrs with score <6• Adequate nutrition• No more than 10% wt loss
• SW clearance• f/u with PMD
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Other things to consider• Screens for:• Syphilis• Hepatitis B• Hepatitis C• HIV• Tb• DV
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Differential dx• Sepsis• Hypoglycemia• Hypocalcemia• hypomagnesemia
• Hyperthyroidism• Perinatal asphyxia• IVH
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References• http://www.uvm.edu/medicine/vchip/documents/VCHIP_5NE
ONATAL_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