Current Trends In Identifying And Treating Newborns With Withdrawal Syndromes 6/24/2010

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1 Current Trends In Identifying And Treating Newborns With Withdrawal Syndromes 6/24/2010

2 Substance Exposed Newborns Alcohol Tobacco Caffeine Amphetamines Cocaine Barbituates Selective Serotonin Re-uptake inhibitors Opiates Marijuana Anti-psychotics Benzodiazepines

3 Substance Exposed Newborns Drug Use in Pregnant Women 2003 National Survey On Drug Use And Health. 4.3% of pregnant women, age years, reported using illicit drugs. Approximately 170,000. Drug use during pregnancy typically decreases as pregnancy progresses.

4 US 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.

5 Withdrawal signs in exposed infants are variable and not all exposed infants experience withdrawal % 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.

6 Scoring Systems Neonatal Abstinence Scoring System Finnegan Lipsitz Tool Neonatal Withdrawal Inventory Ostrea

7 Neonatal Abstinence Scoring System

8 Neonatal Abstinence Scoring System Neuromotor Tremors, hyperreflexia, inconsolable cry. Metabolic/Respiratory Hyperthermia, mottling, tachypnea. Score is totaled for each time point.(feeding) 3 successive scores totaling 24 or more require treatment. Gastrointestinal Frequent stooling, diarrhea, poor

9 Treatment Options Neonatal Morphine Solution Methadone Phenobarbital Clonidine Partial Agonists/Antagonists

10 Infant 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.

11 Infant 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.

12 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.

13 Clonidine 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.

14 Preterm 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.

15 Benzodiazepines 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.

16 Benzodiazepines 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.

17 Cocaine 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.

18 Selective Serotonin Re-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.

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