Managing infants born to mothers who have used opioids during pregnancy

Question 1

Risks of opioids in pregnancy

Answer 1

• prematurity
• low birth weight
• increased risk spont. abortion
• SIDS
• infant neurobehavioural abnormalities
• Other health risks: infections (hep B, C, syphilis, HIV), insufficient maternal nutrition or access to antenatal care, social risk factors (screen and manage)

Question 2

When do withdrawal symptoms occur?

Answer 2

• usually within 48-72 hr
• might be later: 5-7 days post birth for methadone or buprenorphine
• initial acute symptoms for 10-30 days
• milder symptoms 4-6 mo (irritability, sleep disorders, feeding problems )

Question 3

Who is at lower risk of withdrawal?

Answer 3

Prems

• shorter in utero exposure time
• decreased placental transmission
• inability to fully excrete drugs by immature kidneys and liver
• minimal fat stores leading to lower opioid deposition and activity
• limited capacity to express classic NAS symptoms by immature brain

Question 4

Minimum days of life for Finnegan scores?

Answer 4

• Finnegan scores
  
  • within 1-2 hr post delivery then q3-4 hrs
  • minimum 72-120h of scoring should be done if infant exposed to long acting morphine (methadone or buprenorphine)

Question 5

• Nonpharmacological interventions for withdrawal?

Answer 5

• rooming-in model of care
• Breastfeed (HIV-negative who are stable on opioid maintenance with morphine or buprenorphine)
• Supplement with concentrate or increase caloric intake if poor wt gain
• skin-to-skin contact
• safe swaddling
• gentle waking
• quiet environment
• minimal stimulation
• lower lighting
• developmental positioning
• music
• massage therapy

Question 6

Pharmacological interventions for withdrawal?

When do you start meds?

Answer 6

• First line: Morphine & methadone, can use sublingual buprenorphine
  
  • Start morphine if score >= 8 on 3 or >=12 on 2 consecutive measures. Start 0.32 mg/kg/day divided q4-6 hr
    
    • increase by 0.16 mg/kg/day q4-6 h if scores >= 8 on 3 evals
    • taper by 10% of total daily dose q48-72 hr
• Adjunct: phenobarb, clonidine
  
  • clonidine effective if autonomic symptoms present
  • phenobarb may have GI side effects