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Neonatal Abstinence Syndrome

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.

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Neonatal Abstinence Syndrome

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  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

  7. 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

  8. 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

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

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

  11. Differential dx • Sepsis • Hypoglycemia • Hypocalcemia • hypomagnesemia • Hyperthyroidism • Perinatal asphyxia • IVH

  12. 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

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