Neonatal Abstinence Syndrome Flashcards
How many babies are born each year with NAS from non-iatrogenic causes?
13,500 babies
What is the trend of associated hospital costs with NAS treatment?
increased from $190 million in 2000 to $720 million in 2009
What is the trend of women using opioids during pregnancy?
5 fold increase
What is the trend of babies diagnosed with NAS?
3 fold increase
What is the range of reported LOS a/w NAS treatment?
8-79 days with an average of 30 days
Why does LOS vary among patients?
bc optimal treatment has not been identified
What percentage of NAS babies will require pharmacologic mgmt?
60-80%
What medications are a/w NAS?
opioids (heroin, methadone, fentanyl, ms, demerol & oxycontin) and non opioid depressants that may present with some or mimic symptoms of NAS (benzos, antidepressants, barbiturates, anticonvulsants, antipsychotics and alcohol)
What are some crucial properties of heroin?
20-25x stronger than MS; very addictive; enters fetal tissue within 1h after maternal consumption
What are some crucial properties of methadone?
substitute for heroin, detected in fetal brain 1-2h post ingestion and the metabolite present in urine up to 5d
What are some crucial properties of buprenorohine/ subutex?
similar to methadone, better outcomes and less likely to relapse, easily tapered for detox, approved for use with non-pregnant women
Why is subutex a/w better outcomes?
partial buprenorphine agonist so does not bind sa readily to the buprenorphine opioid receptors and therefore, better outcomes
What was the difference in peak NAS scores in infants of mothers treated with subutex as compared with methadone?
no difference
What was the difference in treatment needs in infants of mothers treated with subutex as compared with methadone?
% of neonates needing treatment was not significantly different
What does anecdotal evidence suggest about the severity of withdrawal symptoms in infants born to mothers treated with subutex?
more severe
What was the difference in LOS for infants of mothers treated with subutex as compared with methadone?
43% less time in the hospital- 10 days vs 17.5 days
What was the difference in morphine treatment needs in infants of mothers treated with subutex as compared with methadone?
89% less treatment with morphine- mean total dose 1.1 mg v 10.4mg
How are barbiturates and alcohol similar?
both depressants, cross the placenta readily, addictive and produces withdrawal symptoms
How is fetal alcohol spectrum disorder criteria ranked?
criteria are ranked from 1 (normal) to 4 (significant FAS)
What are some crucial properties of marijuana?
addictive element is delta 9 tetrahydrocannabinol, crosses the placenta, fat soluble and can be detected in the infant’s urine on the 1st sol and stool until dol 3
What are some crucial properties of PCP?
synthetic drug- hallucinogenic, extremely lipophillic; metabolites found in infant urine for 1-7d after MOB stopped using 3 months prior to delivery
What are common s/s of withdrawal with alcohol?
D, V, poor feeding, sweating, tachypnea, irritability, tremors, high pitched cry, sz, hypertonicity
What are common s/s of withdrawal with marijuana?
irritability and disturbed sleep; no recent studies looking at marijuana use in pregnancy that isn’t confounded by other drugs
What are common s/s of withdrawal with barbiturates?
sneezing, irritability, restlessness, tremors, disturbed sleep, increased crying and convulsions
What are some crucial properties of cocaine?
powerful CNS stimulant, crosses the placenta, metabolite present in urine (1-2d) and stool (>7d), half life ~ 60 +/- 30 min in adult, 6-8h in infants; powerful vasoconstrictor (may result in structural defects r/t insufficient blood supply)
How does cocaine affect with synaptic cleft?
norepi is not reabsorbed in the synaptic cleft and interferes with serotoninon and dopamine receptors
What are some crucial properties of methamphetamines?
highly addictive form of amphetamine; stimulant like cocaine; man-made where cocaine is plant-derived; damages neurons that produce serotonin and dopamine
What is the common withdrawal sign from stimulants?
depression
What are common s/s of withdrawal with PCP?
sneezing, D, V, poor feeding, fist sucking, irritability and increased crying
What are common s/s of withdrawal with cocaine?
poor feeding, drowsiness and increased sleep
What are common s/s of withdrawal with meth?
poor feeding drowsiness and increased sleep
Why is polydrug use potential confounding?
exacerbate withdrawal and make treatment very complex
What is the most common drug screen used?
urine; radio immunoassay or thin-layer chromatography
What can a urine screen detect?
ethanol, cannabis, cocaine, amphetamines, barbiturates, opiates and PCP; drugs taken the day before delivery; will only indicate the RX the baby was exposed to immediately before del
When should a urine screen be collected?
the first urine in the delivery (up to 65% false negative rate the longer you wait to collect the sample)
What can a mec screen detect?
cocaine, opiates, cannabis, PCP, amphetamines, cocathylene; 82% cocaine
How does a mec screen work?
uses florescent polarizing radio immunoassay; don’t need to wait for stool to become transitional
How is a mec screen altered by room air?
don’t want to have it exposed to RA >24h bc you can loose up to 25% of cocaine and marijuana concentrations
How quickly does hair grow in an infant?
1cm/mo
How long is the metabolite of a drug present in the hair follicle?
for the life of the hair- drugs gets into the microfibrils, can tell you drug use for months; can use neonatal hair
What can a hair screen detect?
cocaine, cannabis and opioids
How much umbilical cord is need for drug testing?
10 cm section of cord at delivery
How should an umbilical cord be collected for drug testing?
rinse with sterile saline, place in sterile container
What can an umbilical cord screen detect?
methamphetamine, opiates, cocaine, PCP and marijuana
What are the benefits of umbilical cord screening?
as reliable as mec screen, not more expensive, general immunoassay for presence of drugs and can get a result within 24h; specific RX takes longer
What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for amphetamine?
96.6% agreement
What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for opiates?
95% agreement
What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for cocaine?
99% agreement
What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for cannabinoids?
91% agreement
What is the gold standard in NAS screening?
Finnegan scoring system; diagnostic tool
How is the Finnegan screen divided?
divided into 3 systems with 21 total items
1) CNS disturbances
2) metabolic, vasomotor and respiratory
3) gastrointestinal
What is the main problem with the Finnegan tool?
subjective judgement of scoring tool; which can be detrimental to the baby as treatment is dependent on scores and can increase LOS
What s/s are included in CNS disturbances in the Finnegan?
crying, sleep, hyperactive moro, disturbed tremors, undisturbed tremors, increased muslce tone, excoriation, myoclonic jerk and generalized convulsions
What s/s are included in metabolic, vasomotor and respiratory disturbances in the Finnegan?
sweating, fever, frequent yawning, mottling, nasal stuffiness, sneezing, nasal flaring and tachypnea
What s/s are included in gastrointestinal disturbances in the Finnegan?
excessive sucking, poor feeding, regurgitation, projective vomiting, loose stools and watery stools
How frequently should the Finnegan be scored?
Q3-4h
How should crying be scored?
DETERMINED BY LENGTH OF TIME: score 2 if excessive high pitched and unable to self console in 15 secs or continuous up to 5 min despite intervention; score 3 if unable to self soothe in 15 sec or continuous >5 min despite intervention
When does the sleep interval begin?
when they fall asleep and when they wake themselves up
How should sleeping be scored?
based on longest period of sleep light or deep after feeding; score 3 if < 1h, score 2 if < 2h, score 1 if < 3h
How should the moro reflex be assessed in an infant with NAS?
elicit from quiet infant
What deserves a score of 2 for moro reflex?
hyperactive jitteriness that is rhythmic, symmetrical and involuntary
What deserves a score of 3 for moro reflex?
a markedly hyperactive moro reflex; for jitteriness as above with clonus of hands/arms. may test at hands or feet if unclear
What is a clonus?
more than 8-10 beats of hands/arms
What are tremors?
involuntary, rhythmical and equal strength; differentiated with mild v mod-severe; then differentiate on disturbed v undisturbed
How should disturbed tremors be scored?
1: for mild/disturbed of hands OR feet while being handled 2: for mod/severe disturbed of whole arms or legs while being handled (whole arm and whole leg)
What do undisturbed tremors indicate?
the CNS state is very irritable
When can a tremor be considered undisturbed?
baby is left alone 15-30 seconds
How should undisturbed tremors be scored?
3: for mild undisturbed tremors of the hands or feet when not handled; 4: for moderate/severe undisturbed tremors of arms or legs when not handled
How can increased muscle tone be assessed?
perform pull to sit maneuver; other maneuvers may be used
What deserves a score of 2 for increased muscle tone?
no head lag with total body rigidity. do not test while asleep or crying
What is excoriation secondary to for NAS infants?
persistent rubbing, restlessness; do not score diaper area if related to loose or frequent stools
What deserves a score of 1 for excoriation?
if present at nose, chin, cheeks, elbows, knees or toes; won’t go away in 3h; score as you see it each time
What are myoclonic jerks?
involuntary twitching of muscles, not observed very often
What deserves a score of 3 for myoclonic jerks?
twitching at face/ extremities or jerking at extremities- more pronounced than jitteriness of tremors
What deserves a 5 for generalized seizures?
tonic seizures with extension or flexion of limbs; does not stop with containment. may include few clonic beats and/or apnea
How can you control for temperature lability in a NAS infant?
use consistent layers to maintain a consistent environment, if febrile, then it will indicate withdrawal
What deserves a score of 1 for sweating?
wetness at the forehead, upper lip or back of the neck
How is a fever scored?
axillary temps; 1: if 37.2-38.3; 2: if >38.4
How is frequent yawning scored?
score 1 if >3 within interval, doesn’t have to be consecutive
What is mottling and how is it scored?
marbled appearance of pink and white; score 1 if present at chest, trunk, arms or legs
What is nasal stuffiness and how is it scored?
nares partially blocked from drainage with noisy respiration; score 1 if present with or without runny nose
How is sneezing scored?
individual or serial; score 1 if >3 during scoring interval
What is nasal flaring and how is it scored?
nostrils flared out during respirations; score 2 if present
How is tachypnea defined and how is it scored?
RR >60 with/without retractions count for 1 full minute; score 1 for rate >60bpm without rtx, score 2 for are >60bpm with rtx
What is excessive scoring and how is it scored?
rooting with attempts to suck fist, hand or pacifier before or after feeding; score 1 for >3 attempts noted (head goes back and forth, can’t grip the object to be sucked)
How is poor feeding quantified and scored?
excessive sucking but infrequent or uncoordinated with feeding; gulping with frequent rest periods to breathe (score 2 for either)
How is regurgitation quantified and scored?
effortless (not a/w burping); score 2 for 2 or > episodes
How is projectile vomiting quantified and scored?
forceful during or after feed; score 3 for 1 or > episodes
How are loose stools and liquid stools differentiated?
the presence of a water ring
What stool description earns a score of 2?
loose, curdy,seedy or liquid without a water ring
What stool description earns a score of 3?
soft, liquid or hard with water ring
How can accuracy in assessing infants for NAS be reinforced?
know item definitions, complete a training program, monitor inter-observer reliability frequently and re-educate if reliabilities are low
What is inter-observer reliability?
independent scoring- want at least 90% consistent documentation (agree on at least 19 elements)
When should reliability testing be completed?
initially, each new staff member caring for the baby, two staff score at the same time and annually
What action is indicated by a Finnegan score of 1-7?
manage with conservative measures; morphine is not indicated
What action is indicated by a Finnegan score of 8-10?
require pharmacologic intervention
What action is indicated by a Finnegan score >10?
increased scores require increased dosing
What are some non-pharm interventions for NAS treatment?
swaddling- holding firmly & close to the body w/ slow rocking; modify environmental stimulation; soothing music; minimal handling; non-nutritive sucking; frequent diaper ∆; demand feedings- may need increased calories position of comfort/frequent position ∆; soft linens to minimize excoriation
When should oral morphine be given?
when withdrawing from opiates
When should phenobarbital be given?
not first line for NAS withdrawal unless opiate naive; when withdrawing from barbiturates, ethanol, sedatives & hypnotics
Why is methadone difficult to wean?
because of very long half life
When should Finnegan scoring be initiated?
after period of transition (4-6h post del) then Q3-4h
How long should Finnegan scoring be continued?
as long as morphine treatment and weaning is necessary
When should morphine not be given?
if scores are < 8; not given on a sliding scale or on a PRN basis
What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 9-12?
add 0.02mg to initial dose
What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 13-16?
add 0.04mg to initial dose
What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 17-20?
ass 0.06mg to initial dose
How should morphine escalate treatment be increased?
continue to increase using these doses Q3-4 while the withdrawal score is still bw the indicated score range
What should be done once comfort is achieved with MS therapy?
once comfort is attained, maintain for 24h, then begin to wean and maintain score t want to play catch up
How should morphine therapy be weaned?
wean by 0.05 mg/kg or /05 cc/d every 1-2d
When should morphine therapy be discontinued?
dc can occur when the baby is stable on a dose of 0.05-0.1 for 1-2d
When can a NAS baby be dc’d?
observe for 24-48h after MS dc before discharge
When should a re-escalation scale be utilized?
if a baby has a score bw 0-8 and 4h later has a score >8, use re-escalation dosing and continue using this scale for the remainder of the time
How is the upper limit of morphine therapy defined?
if baby requires greater than 0.2mg Q3-4 of PO MS or infant appears somnolent or difficult to rouse, notify provider
How should methadone be dosed?
0.05-0.2mg/kg/dose PO Q12-24h
What is the approximately half life of methadone in the neonate?
56h
