Neonatal Abstinence Syndrome: An Emerging Epidemic?

Transcription

1 Neonatal Abstinence Syndrome: An Emerging Epidemic? March 11, 2013 Balaji Govindaswami, MD, MPH Chief Newborn Medicine, Director - NICU Santa Clara Valley Health and Hospital System, San Jose, CA Clinical Professor (Affiliated) of Pediatrics Neonatal and Developmental Medicine Stanford University School of Medicine, Palo Alto, CA

2 Conflicts All pharmacologic suggested treatments may be considered off-label drug use. Dr. Govindaswami receives NIH-funding from R01 HD A1 (PI Gary Peltz Stanford University) Ondansetron Study Our NICU receives Funding Support from First 5 of Santa Clara County and VMC Foundation. SCVMC NICU is part of the 2013 VON-NAS collaborative (Site PI: Priya Jegatheesan, MD)

3 From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, JAMA. 2012;307(18): doi: /jama Figure Legend: NAS indicates neonatal abstinence syndrome. Error bars indicate 95% CI. P for trend <.001 over the study period. The unweighted sample sizes for rates of NAS and for all other US hospital births are 2920 and in 2000; 3761 and in 2003; 5200 and in 2006; and 9674 and in 2009; respectively. Date of download: 3/7/2013 Copyright 2012 American Medical Association. All rights reserved.

4 From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, JAMA. 2012;307(18): doi: /jama Figure Legend: Date of download: 3/7/2013 Copyright 2012 American Medical Association. All rights reserved.

5 From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, JAMA. 2012;307(18): doi: /jama Figure Legend: Date of download: 3/7/2013 Copyright 2012 American Medical Association. All rights reserved.

6 Suggested Reading [Best Evidence] [Guideline] Hudak ML, Tan RC. Neonatal Drug Withdrawal. Pediatrics. January 2012;129(2):e Neonatal Abstinence Syndrome Treatment & Management Ashraf H Hamdan, April, clinical#a0217

7 NAS Complex disorder Constellation of behavioral and physiological signs and symptoms Remarkably similar inspite of marked differences in causal agent Prenatal: Maternal exposure Postnatal: predominately Opiate

8 Substances frequently associated with NAS Opiates & Narcotics Heroin, Methadone Meperidine (Demerol) Oxycodone, Morphine Hydromorphone (Dilaudid) Butorphanol (Stadol) Pentazocine Propoxyphene (Darvon) Chlordiazepoxide Buprenorphine Other Barbiturates, SSRIs, Antihistamines THC, Cocaine Nicotine, Caffeine, Alcohol Meprobamate Phencyclidine (PCP) angeldust Ethchlorvynol (Placidyl) Glutethemide Benzodiazepines: Diazepam, Lorazepam, chlordiazepoxide (Librium)

9 Pathophysiology Addiction in both Mom and Baby Placental barrier varies with agent Lipophilic, low molecular wt drugs CNS Facilitated placental transfer Fetus immature kidneys, enzyme systems Disruption of transplacental transfer at birth results in subsequent withdrawal

10 Maternal exposure 3% of 4.1 million women of childbearing age who abuse drugs are believed to continue drug use during pregnancy Poor PNC, abruption, IV drug marks, skin, nutritional and dentition deficiencies History of use is unreliable and underestimates exposure when compared to maternal hair or when compared to infant meconium analysis (44% underestimated) 1 Thus, every newborn should have comprehensive maternal medical and psychological history including history of drug use % of exposed infants may exhibit NAS 1. Lester BM, ElSohly M, Wright LL, Smeriglio VL, Verter J, Bauer CR. The Maternal Lifestyle Study: drug use by meconium toxicology and maternal selfreport. Pediatrics. Feb 2001;107(2): [Medline] 2. (Guideline) American Academy of Pediatrics Committee on Substance Abuse. Drug-exposed infants. Pediatr. Aug 1995;96(2 Pt 1): [Medline]

11 NAS variable Drug Withdrawal Onset of symptoms Peak Symptoms as late as Heroin ( in 50-80% infants exposed) Benzodiazepines Barbiturates 6 days Longer Longer 2 weeks Methadone 48 h or 7-10 days 4 weeks to 6 months for subacute signs

12 Infants Examination Maturity & Growth, IUGR, head growth Dysmorphic features, malformations, infection CNS, SERIAL EXAMINATION Metabolic, Cardio(vasomotor) Respiratory Gastrointestinal Specific to agent of exposure eg FAS Recognize co-morbidities

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14 CNS dysfunction Irritable, High-pitched cry Restlessness, with sleep duration less than 1-3 hours after feeding Stiff, Hypertonia, Hyperactive reflexes Jittery, Tremulous, Myoclonic jerks Generalized convulsions

15 Metabolic, Respiratory, Vasomotor Sweating, fever, mottling Frequent yawning Sneezing (>3 times per interval) Nasal flaring Tachypnea, retractions Apnea

16 Gastro Intestinal Excessive (frantic) sucking or rooting Poor feeding and weight gain Hyperphagia also with poor weight gain Regurgitation or projectile vomiting Loose or watery stools

17 Treatment CURRENTLY UNSATISFACTORY! Supportive Non-pharmacological Pharmacological Investigational Dietary/ Nutrition / Breast milk Family Support / Intervention

18 Resources for families Drug Dependence and Abuse Narcotic Abuse Substance Abuse

19 Recent Reviews/ References Irner TB, Teasdale TW, Nielsen T, Vedal S, Olofsson M. Substance use during pregnancy and postnatal outcomes. J Addict Dis. Jan 2012;31(1): Kandall RS. Improving Treatment for Drug-Exposed Infants Treatment Improvement Protocol (TIP) Series 5. Available at Wouldes TA, Woodward LJ. Maternal methadone dose during pregnancy and infant clinical outcome. Neurotoxicol Teratol. Jan Dryden C, Young D, Hepburn M, Mactier H. Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG. Apr 2009;116(5): Substance Abuse and Mental Health Services Administration Office of Applied Studies National Survey on Drug Use & Health: Results. US Department of Health and Human Services. Available at Accessed December, Hytinantti T, Kahila H, Renlund M, Jarvenpaa AL, Halmesmaki E, Kivitie-Kallio S. Neonatal outcome of 58 infants exposed to maternal buprenorphine in utero. Acta Paediatr. Aug 2008;97(8): Lim S, Prasad MR, Samuels P, Gardner DK, Cordero L. High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome. Am J Obstet Gynecol. Jan 2009;200(1):70.e1-5. Hale TW. Pharmacology review: drug therapy and breastfeeding: antidepressants, antipsychotics, antimanics, and sedatives. NeoReviews. May 2004;e451 -e456.

20 Thank You!