SOUTH CENTRAL NEONATAL NETWORK GUIDELINE. South Central (North) Guideline for Neonatal Drug Withdrawal

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1 SOUTH CENTRAL NEONATAL NETWORK GUIDELINE South Central (North) Guideline for Neonatal Drug Withdrawal Approved by & South Central Neonatal Steering Group for South Central North. date Date of Implementation January 2011 Review date January 2014 Authors Distribution Dr Rekha Sanghavi, Consultant Paediatrician South Central (North) Clinical Advisory Board South Central Neonatal Network website 1.0 Aim of Guideline This guideline covers common drugs abused during pregnancy and their effects on the newborn. Maternal alcohol abuse and its consequences are beyond the scope of this guideline. No need for action if cannabis usage alone Most problems with withdrawal in the neonatal period are secondary to opiate use. No clear withdrawal syndrome has been reported with cocaine use. 2.0 Scope of Guideline The guideline applies to all neonates who fulfil the criteria for cooling set out in the guidance below, who are born in neonatal units and maternity units covered by South Central North Neonatal Network. This includes the following hospitals: North Network Milton Keynes General Hospital, MK John Radcliffe Hospital, Oxford Horton General Hospital, Banbury Stoke Mandeville Hospital, Ayelesbury Royal Berkshire Hospital, Reading Wexham Park Hospital, Slough Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 1 of 8

2 3.0 Guideline Antenatal Management (may vary in different hospitals) Check maternal viral serology including Hep B, Hep C, HIV Refer to the local rehab group (Turning Point) and to Social Services Refer to the local Substance misuse liaison midwife (Crystal Team) Discussion between Senior Paediatrician, Subs abuse liaison midwife and Social Services +/- Rehab team to formulate management plan. A Prebirth Case Conference may be necessary in some cases. Regular review of management plan with the above team Plan of action to be documented in pending cases file on Special Care Baby Unit and updated onto the Antenatal High Risk spreadsheet on the Intranet (Shared Drive). Social worker/midwife to ensure that mother is aware of plan At delivery Avoid use of Naloxone as it may precipitate sudden withdrawal and possibly seizures (These seizures are best treated with IV Morphine) Ensure that Social Services are aware of the birth. Postnatal Care If there are facilities these babies should be admitted to the Transitional Care Unit in order to provide closer supervision of babies for withdrawal and also assessment of maternal parenting skills. If the baby is admitted to the postnatal ward a daily paediatric review is necessary. Baby s Urine for toxicology after maternal consent. Make sure you are aware of all prescription drugs recently given to mother before interpreting the result. See table 2. Severity of neonatal abstinence syndrome does not correlate to maternal opiod dose. Nurse in quiet environment with low lighting. Swaddling may help. Frequent high calorie feeds bearing in mind that the caloric requirement maybe as high as cal/kg/day 7,8. Monitor using the withdrawal chart Routine Hep B immunisation should be offered and follow up arrangements made for repeat serology. Breast Feeding Provided there are no other contraindications (e.g. HIV) breast feeding is safe in most women on withdrawal programmes. Advise mother to take medication after feeding baby. Withdrawal may in fact be smoother in breast fed babies 2. Breast feeding shortly after Crack (IV Cocaine) can cause seizures. If heavy user and baby having seizures breast feeding should be discouraged. Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 2 of 8

3 Clinical Features of Neonatal Narcotic Withdrawal Neurological Gastrointestinal Tremors/ Jitteriness Poor feeding Irritability Uncoordinated / constant sucking Increased wakefulness Vomiting High-pitched crying Diarrhoea Increased muscle tone Poor weight gain Exaggerated Moro reflex Autonomic Seizures Sweating Frequent yawning and sneezing Nasal stuffiness Tachypnoea Fever / Temp instability Increased risk of Prematurity and IUGR Differential Diagnosis: Sepsis, Birth asphyxia, Hypocalcaemia, Hypoglycaemia, CNS bleeds Withdrawal Scoring Score half way between feeds every 4-6 hours. When score is more than 6 or more on 2 successive occasions drug treatment should be considered. See chart - attached Pharmacological Treatment 1,3,4 For inconsolable crying with low treatment score consider chloral hydrate for symptomatic relief. (usual sedative dose) Oral Morphine 40 mcg/kg 6 hourly. Increase dose by 20 mcg/kg. after each dose till symptoms settling. Max. Dose 250 mcg/kg (rarely needed) Beware of respiratory depression at high doses and place on apnoea alarm. Once symptoms settle for 2 days reduce dose by 50 mcg every 2-3 days. If score increases again may need to go back to higher dose. May take 3-4 weeks before fully weaned. Sedative-Hypnotic withdrawal consider Phenobarbitone. Seizures Loading dose of Phenobarbitone in addition to Morphine as above. Phenobarbitone alone may not be effective in treating seizures caused by narcotic withdrawal. Discharge and follow up Although some symptoms may appear late the majority of them will have started appearing in hours. These babies should therefore be kept in for monitoring for a minimum of 3-5 days. The social aspect of the discharge planning may however take longer making it even more important to plan antenatally and prepare mothers that baby may well need to be observed in hospital for up to 1 week. If no symptoms of withdrawal discharge to primary care If baby does show signs of withdrawal observe in hospital till resolving / drug treatment is commenced Babies needing treatment can be discharged when on a weaning regime (usually after about 2 weeks of hospital treatment) 6. Individual hospital policy may vary. Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 3 of 8

4 If discharging on treatment Dispense only 1 week s prescription at a time. Paediatric community Nurse should be involved in addition to HV. Weekly Clinic review with named consultant/specialist nurse. Long term f/up not often necessary 5 Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 4 of 8

5 Table 1: Time of onset of symptoms Name of drug Onset of symptoms Comments Heroin hours Cocaine hours May be hours Amphetamines Similar to cocaine Methadone 96 hours Can be up to 4 weeks. Barbiturates 4-7 days Can be 1-14 days Benzodiazepines Can be >10 days Table 2: Length of time urine will remain positive Drug Length of time urine will be positive after last dose Adult Infant Marijuana 7d 1 mth hrs Cocaine hrs hrs Heroin 24 hrs hrs Methadone Up to 10 days Cocaine 9 Use increasing in pregnant women. No clearly defined abstinence syndrome. Clinical features are similar to narcotic withdrawal. Withdrawal score is higher with both cocaine and heroin. Increased risk of hypoxic-ischaemic cerebral injury. Cerebral infarctions & intracranial haemorrhage including subarachnoid bleeds have been reported Cranial USS and BP check prior to discharge Teratogenic Examine carefully for congenital anomalies (gastroschisis, genitourinary, gut atresias, limb reduction defects) Abnormal visual fixation and ocular abnormalities (uncertain clinical significance) - If there are clinical concerns get an ophthalmology opinion. Useful Local contacts Turning Point Substance Misuse Liaison Midwife Paediatric Social Worker Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 5 of 8

6 HEATHERWOOD & WEXHAM PARK HOSPITALS TRUST DIRECTORATE OF OBSTETRICS & GYNAECOLOGY HEPATITIS B PARENT INFORMATION LEAFLET We are offering your baby Hepatitis B vaccination. This needs a course of three injections at 0, 1 & 2 months and a booster dose at one year, with a blood test to check that the baby has been successfully protected against Hepatitis B. The first dose is given in hospital and the other doses at your GP surgery. Although you have tested negative for hepatitis B, it is still an infection for which you may be at increased risk in the future and to which the baby may be exposed. If the baby is given the full course of immunisation, then the chance of the baby contracting hepatitis B is very small indeed, so it is well worth-while. What do I need to do? With this letter you will also be given a card with details of the injections needed. Please give the card to your Health Visitor when she comes to see you, so it can be added to your baby's Child Health Record (Red Book). Make sure you keep all the appointments at your doctor for the immunisations. If you move house, make sure your health visitor knows, so appointments don t get lost. If you have any further questions, please ask the paediatrician who checks your baby over. What about other immunisations? All the other baby immunisations can be given at the normal times. Dr Ros Jones, Consultant Paediatrician, October 2009 Baby s name. date of birth. Mother s name.. Hospital number. I have read this leaflet and agree for my baby to be given the Hepatitis B vaccine. or I have read this leaflet and decided I do not wish my baby to have the Hepatitis B vaccine. Signature. Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 6 of 8

7 Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 7 of 8

8 4.0 References: E-medicine article 1. L Jackson, A Ting et al. Archives of diseases in childhood. 2004; 89:F Mohamed E. Abdel-Latif. Paediatrics Vol 117, No.6 June2006 ppe1163-e Lainwala-Shabnam et al. Advances in Neonatal Care Oct2005, Vol 5(5) Pg Drug and alcohol Dependence 7 Jan 2005 Vol 77 No.1 Pg Geraldine S Wilson, MD, et al. The Journal of Paeds. Follow-up of methadonetreated and untreated narcotic-dependent women and their infants: Health, developmental, and social implications 6.Oei J, Feller J M and Lui K. Journal of Paediatrics and Child Health (2001) 37, Hill RM, Desmond MM. Paediatric Clinics of North America 1963:10: Wilson GS. Addict Dis. 1975; 2: Elke H. Roland et al. Paediatric Neurosciences 1989; 15:88-94 Suggested reading: American academy of paediatrics Committee on drugs. Neonatal Drug Withdrawal Pediatrics Vol. 101 No. 6 June 1998 Roberton Textbook of neonatology Rekha Sanghavi, February 2007, reviewed date Jan 2011, next review Jan 2014 p 8 of 8