NEONATAL ABSTINENCE SYNDROME. Osama Naga, M.D. PGY2

Transcription

1 NEONATAL ABSTINENCE SYNDROME Osama Naga, M.D. PGY2

2 Objective: Describe the common causes of NAS Clinical Presentation Diagnosis Identify the different scoring system for pharmacologic therapy Minimize neuroexcitation during withdrawal Prenatal counseling in setting of known exposure

3 Clinical Presentation Narcotics and Barbiturates Narcotics are the most frequent cause of NAS Example: Heroin Methadone Morphine Oxycodone Codeine Bubprenorphine

4 Clinical Presentation Narcotic and Barbiturate Time frame of appearance of NAS: At birth Peak 3-4 days May not appear until days Sub acute opiate withdrawal may persist for 4-6 months

5

6 Narcotics and Barbiturates Benefits Reduced incidence of RDS Reduced incidence of Jaundice Reduced incidence of Jaundice Prognosis Increase the risk of SIDS Increase the risk of strabismus

7 Clinical Presentations Stimulants (Amphetamine, Cocaine) Direct stimulant effect No withdrawal symptoms from its effect Commonly seen in the first 72 hours after delivery Tremors High pitched cry Irritability Excess suck Hyperaletness Apnea Tachycardia Increase rate of prematurity IUGR Poly drug use

8 Clinical Presentation Depressant and Sedative Ethanol withdrawal begins 3-12 hours after birth Irritability Restlessness Poor feeding Crying Impaired neurobehavioral functioning Sedative hypnotics presents few days even up to 21 days after birth

9 Clinical Presentation SSRIs Start 48 hours after delivery Resolve within 48 hours: Tremors Increased muscle tone Sleep disruption GI disturbance High pitched crying Increase rate of RD

10 Diagnosis History Most useful and least reliable Urine Reflects intake only few days before delivery Meconium Drugs may be found up to 3 days after delivery Hair The most sensitive Not widely available

11 Abstinence Scoring Systems Finnegan scoring system 20 most common signs grouped into: Neurologic State Respiratory Gastrointestinal

12 Abstinence Scoring Systems Finnegan scoring system Score 1 for Least potential for adverse effect Score 5 for most potential for adverse effect No pharmacologic therapy Total score 7 or less Pharmacologic therapy Score 8 or more

13

14 Treatment and Weaning General Gentle handling Noise control Swaddling Demand feeding

15 Treatment and Weaning Pharmacologic treatment Finnegan score 8 or more is considered severe and required medical therapy Goal of therapy Decrease the dose of medication so the infant can tolerate the mild symptoms of withdrawal Feed well Sleep appropriate intervals between feeds

16 Treatment and Weaning Pharmacologic therapy Oral morphine sulfate is the most effective Buprenorphine

17 Treatment and Weaning Oral morphine sulfate High dose regimen mg/kg every 4 hours Low dose regimen mg/kg every 4 hours The dose can increase by 20% of the initial dose every 8 hours until the sign Maximum dose 0.2mg/kg/dose

18 Treatment and Weaning Phenobarbital and diazepam Significant for depressive effects Preferred for non opiate withdrawal especially CNS irritability loading dose 16mg/kg/day Maintenance dose 2-6mg/kg/day BID Weaning Simple approach Maintain the same dose for 72 hours Decrease the dose by 20% every other day

19 Parent counseling Teratogenicity Alcohol Is only drug known to cause significant birth defects Opiates and stimulants Opiates and stimulants IUGR Spontaneous abortion Preterm delivery Still birth Abruptio placentae Meconium staining

20 Parent counseling Teratogenicity Cocaine and methamphetamine May have long -term effects on neurodevelopment Prenatal exposure? Prenatal exposure? Home environment?

21 Parent counseling Expected Clinical Course Observation of the baby Scoring for signs of withdrawal Mild symptoms Only supportive treatment Severe and persistent symptoms Require oral medical therapy Therapy may last days or months

22 Parent counseling Breast feeding and lactation Continue breast feeding SSRI Concentration of common narcotics is very low in human milk Postnatal adverse events has been reported Pump and dump the milk 8-9 hours after drug use

23 Parent counseling Social Consideration Mother always feels anxiety and guilt Show empathy Do not be judgmental Maternal psychosocial status Should be considered before discontinuing or changing mother s medications

24 Thank you? Reference is NeoReview Vol 10 May 2009 Up-to-date