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Neonatal Pathophysiology > Neonatal Abstinence Syndrome > Flashcards

Neonatal Abstinence Syndrome Flashcards

1
Q

How many babies are born each year with NAS from non-iatrogenic causes?

A

13,500 babies

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2
Q

What is the trend of associated hospital costs with NAS treatment?

A

increased from $190 million in 2000 to $720 million in 2009

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3
Q

What is the trend of women using opioids during pregnancy?

A

5 fold increase

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4
Q

What is the trend of babies diagnosed with NAS?

A

3 fold increase

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5
Q

What is the range of reported LOS a/w NAS treatment?

A

8-79 days with an average of 30 days

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6
Q

Why does LOS vary among patients?

A

bc optimal treatment has not been identified

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7
Q

What percentage of NAS babies will require pharmacologic mgmt?

A

60-80%

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8
Q

What medications are a/w NAS?

A

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)

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9
Q

What are some crucial properties of heroin?

A

20-25x stronger than MS; very addictive; enters fetal tissue within 1h after maternal consumption

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10
Q

What are some crucial properties of methadone?

A

substitute for heroin, detected in fetal brain 1-2h post ingestion and the metabolite present in urine up to 5d

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11
Q

What are some crucial properties of buprenorohine/ subutex?

A

similar to methadone, better outcomes and less likely to relapse, easily tapered for detox, approved for use with non-pregnant women

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12
Q

Why is subutex a/w better outcomes?

A

partial buprenorphine agonist so does not bind sa readily to the buprenorphine opioid receptors and therefore, better outcomes

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13
Q

What was the difference in peak NAS scores in infants of mothers treated with subutex as compared with methadone?

A

no difference

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14
Q

What was the difference in treatment needs in infants of mothers treated with subutex as compared with methadone?

A

% of neonates needing treatment was not significantly different

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15
Q

What does anecdotal evidence suggest about the severity of withdrawal symptoms in infants born to mothers treated with subutex?

A

more severe

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16
Q

What was the difference in LOS for infants of mothers treated with subutex as compared with methadone?

A

43% less time in the hospital- 10 days vs 17.5 days

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17
Q

What was the difference in morphine treatment needs in infants of mothers treated with subutex as compared with methadone?

A

89% less treatment with morphine- mean total dose 1.1 mg v 10.4mg

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18
Q

How are barbiturates and alcohol similar?

A

both depressants, cross the placenta readily, addictive and produces withdrawal symptoms

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19
Q

How is fetal alcohol spectrum disorder criteria ranked?

A

criteria are ranked from 1 (normal) to 4 (significant FAS)

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20
Q

What are some crucial properties of marijuana?

A

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

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21
Q

What are some crucial properties of PCP?

A

synthetic drug- hallucinogenic, extremely lipophillic; metabolites found in infant urine for 1-7d after MOB stopped using 3 months prior to delivery

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22
Q

What are common s/s of withdrawal with alcohol?

A

D, V, poor feeding, sweating, tachypnea, irritability, tremors, high pitched cry, sz, hypertonicity

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23
Q

What are common s/s of withdrawal with marijuana?

A

irritability and disturbed sleep; no recent studies looking at marijuana use in pregnancy that isn’t confounded by other drugs

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24
Q

What are common s/s of withdrawal with barbiturates?

A

sneezing, irritability, restlessness, tremors, disturbed sleep, increased crying and convulsions

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25
Q

What are some crucial properties of cocaine?

A

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)

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26
Q

How does cocaine affect with synaptic cleft?

A

norepi is not reabsorbed in the synaptic cleft and interferes with serotoninon and dopamine receptors

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27
Q

What are some crucial properties of methamphetamines?

A

highly addictive form of amphetamine; stimulant like cocaine; man-made where cocaine is plant-derived; damages neurons that produce serotonin and dopamine

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28
Q

What is the common withdrawal sign from stimulants?

A

depression

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29
Q

What are common s/s of withdrawal with PCP?

A

sneezing, D, V, poor feeding, fist sucking, irritability and increased crying

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30
Q

What are common s/s of withdrawal with cocaine?

A

poor feeding, drowsiness and increased sleep

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31
Q

What are common s/s of withdrawal with meth?

A

poor feeding drowsiness and increased sleep

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32
Q

Why is polydrug use potential confounding?

A

exacerbate withdrawal and make treatment very complex

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33
Q

What is the most common drug screen used?

A

urine; radio immunoassay or thin-layer chromatography

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34
Q

What can a urine screen detect?

A

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

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35
Q

When should a urine screen be collected?

A

the first urine in the delivery (up to 65% false negative rate the longer you wait to collect the sample)

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36
Q

What can a mec screen detect?

A

cocaine, opiates, cannabis, PCP, amphetamines, cocathylene; 82% cocaine

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37
Q

How does a mec screen work?

A

uses florescent polarizing radio immunoassay; don’t need to wait for stool to become transitional

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38
Q

How is a mec screen altered by room air?

A

don’t want to have it exposed to RA >24h bc you can loose up to 25% of cocaine and marijuana concentrations

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39
Q

How quickly does hair grow in an infant?

A

1cm/mo

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40
Q

How long is the metabolite of a drug present in the hair follicle?

A

for the life of the hair- drugs gets into the microfibrils, can tell you drug use for months; can use neonatal hair

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41
Q

What can a hair screen detect?

A

cocaine, cannabis and opioids

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42
Q

How much umbilical cord is need for drug testing?

A

10 cm section of cord at delivery

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43
Q

How should an umbilical cord be collected for drug testing?

A

rinse with sterile saline, place in sterile container

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44
Q

What can an umbilical cord screen detect?

A

methamphetamine, opiates, cocaine, PCP and marijuana

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45
Q

What are the benefits of umbilical cord screening?

A

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

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46
Q

What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for amphetamine?

A

96.6% agreement

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47
Q

What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for opiates?

A

95% agreement

48
Q

What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for cocaine?

A

99% agreement

49
Q

What is the agreement of specificity and sensitivity of umbilical cord screen as compared with a mec screen for cannabinoids?

A

91% agreement

50
Q

What is the gold standard in NAS screening?

A

Finnegan scoring system; diagnostic tool

51
Q

How is the Finnegan screen divided?

A

divided into 3 systems with 21 total items

1) CNS disturbances
2) metabolic, vasomotor and respiratory
3) gastrointestinal

52
Q

What is the main problem with the Finnegan tool?

A

subjective judgement of scoring tool; which can be detrimental to the baby as treatment is dependent on scores and can increase LOS

53
Q

What s/s are included in CNS disturbances in the Finnegan?

A

crying, sleep, hyperactive moro, disturbed tremors, undisturbed tremors, increased muslce tone, excoriation, myoclonic jerk and generalized convulsions

54
Q

What s/s are included in metabolic, vasomotor and respiratory disturbances in the Finnegan?

A

sweating, fever, frequent yawning, mottling, nasal stuffiness, sneezing, nasal flaring and tachypnea

55
Q

What s/s are included in gastrointestinal disturbances in the Finnegan?

A

excessive sucking, poor feeding, regurgitation, projective vomiting, loose stools and watery stools

56
Q

How frequently should the Finnegan be scored?

A

Q3-4h

57
Q

How should crying be scored?

A

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

58
Q

When does the sleep interval begin?

A

when they fall asleep and when they wake themselves up

59
Q

How should sleeping be scored?

A

based on longest period of sleep light or deep after feeding; score 3 if < 1h, score 2 if < 2h, score 1 if < 3h

60
Q

How should the moro reflex be assessed in an infant with NAS?

A

elicit from quiet infant

61
Q

What deserves a score of 2 for moro reflex?

A

hyperactive jitteriness that is rhythmic, symmetrical and involuntary

62
Q

What deserves a score of 3 for moro reflex?

A

a markedly hyperactive moro reflex; for jitteriness as above with clonus of hands/arms. may test at hands or feet if unclear

63
Q

What is a clonus?

A

more than 8-10 beats of hands/arms

64
Q

What are tremors?

A

involuntary, rhythmical and equal strength; differentiated with mild v mod-severe; then differentiate on disturbed v undisturbed

65
Q

How should disturbed tremors be scored?

A

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)

66
Q

What do undisturbed tremors indicate?

A

the CNS state is very irritable

67
Q

When can a tremor be considered undisturbed?

A

baby is left alone 15-30 seconds

68
Q

How should undisturbed tremors be scored?

A

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

69
Q

How can increased muscle tone be assessed?

A

perform pull to sit maneuver; other maneuvers may be used

70
Q

What deserves a score of 2 for increased muscle tone?

A

no head lag with total body rigidity. do not test while asleep or crying

71
Q

What is excoriation secondary to for NAS infants?

A

persistent rubbing, restlessness; do not score diaper area if related to loose or frequent stools

72
Q

What deserves a score of 1 for excoriation?

A

if present at nose, chin, cheeks, elbows, knees or toes; won’t go away in 3h; score as you see it each time

73
Q

What are myoclonic jerks?

A

involuntary twitching of muscles, not observed very often

74
Q

What deserves a score of 3 for myoclonic jerks?

A

twitching at face/ extremities or jerking at extremities- more pronounced than jitteriness of tremors

75
Q

What deserves a 5 for generalized seizures?

A

tonic seizures with extension or flexion of limbs; does not stop with containment. may include few clonic beats and/or apnea

76
Q

How can you control for temperature lability in a NAS infant?

A

use consistent layers to maintain a consistent environment, if febrile, then it will indicate withdrawal

77
Q

What deserves a score of 1 for sweating?

A

wetness at the forehead, upper lip or back of the neck

78
Q

How is a fever scored?

A

axillary temps; 1: if 37.2-38.3; 2: if >38.4

79
Q

How is frequent yawning scored?

A

score 1 if >3 within interval, doesn’t have to be consecutive

80
Q

What is mottling and how is it scored?

A

marbled appearance of pink and white; score 1 if present at chest, trunk, arms or legs

81
Q

What is nasal stuffiness and how is it scored?

A

nares partially blocked from drainage with noisy respiration; score 1 if present with or without runny nose

82
Q

How is sneezing scored?

A

individual or serial; score 1 if >3 during scoring interval

83
Q

What is nasal flaring and how is it scored?

A

nostrils flared out during respirations; score 2 if present

84
Q

How is tachypnea defined and how is it scored?

A

RR >60 with/without retractions count for 1 full minute; score 1 for rate >60bpm without rtx, score 2 for are >60bpm with rtx

85
Q

What is excessive scoring and how is it scored?

A

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)

86
Q

How is poor feeding quantified and scored?

A

excessive sucking but infrequent or uncoordinated with feeding; gulping with frequent rest periods to breathe (score 2 for either)

87
Q

How is regurgitation quantified and scored?

A

effortless (not a/w burping); score 2 for 2 or > episodes

88
Q

How is projectile vomiting quantified and scored?

A

forceful during or after feed; score 3 for 1 or > episodes

89
Q

How are loose stools and liquid stools differentiated?

A

the presence of a water ring

90
Q

What stool description earns a score of 2?

A

loose, curdy,seedy or liquid without a water ring

91
Q

What stool description earns a score of 3?

A

soft, liquid or hard with water ring

92
Q

How can accuracy in assessing infants for NAS be reinforced?

A

know item definitions, complete a training program, monitor inter-observer reliability frequently and re-educate if reliabilities are low

93
Q

What is inter-observer reliability?

A

independent scoring- want at least 90% consistent documentation (agree on at least 19 elements)

94
Q

When should reliability testing be completed?

A

initially, each new staff member caring for the baby, two staff score at the same time and annually

95
Q

What action is indicated by a Finnegan score of 1-7?

A

manage with conservative measures; morphine is not indicated

96
Q

What action is indicated by a Finnegan score of 8-10?

A

require pharmacologic intervention

97
Q

What action is indicated by a Finnegan score >10?

A

increased scores require increased dosing

98
Q

What are some non-pharm interventions for NAS treatment?

A

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

99
Q

When should oral morphine be given?

A

when withdrawing from opiates

100
Q

When should phenobarbital be given?

A

not first line for NAS withdrawal unless opiate naive; when withdrawing from barbiturates, ethanol, sedatives & hypnotics

101
Q

Why is methadone difficult to wean?

A

because of very long half life

102
Q

When should Finnegan scoring be initiated?

A

after period of transition (4-6h post del) then Q3-4h

103
Q

How long should Finnegan scoring be continued?

A

as long as morphine treatment and weaning is necessary

104
Q

When should morphine not be given?

A

if scores are < 8; not given on a sliding scale or on a PRN basis

105
Q

What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 9-12?

A

add 0.02mg to initial dose

106
Q

What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 13-16?

A

add 0.04mg to initial dose

107
Q

What is the dosing of morphine added for escalated treatment for an infant with a Finnegan score of 17-20?

A

ass 0.06mg to initial dose

108
Q

How should morphine escalate treatment be increased?

A

continue to increase using these doses Q3-4 while the withdrawal score is still bw the indicated score range

109
Q

What should be done once comfort is achieved with MS therapy?

A

once comfort is attained, maintain for 24h, then begin to wean and maintain score t want to play catch up

110
Q

How should morphine therapy be weaned?

A

wean by 0.05 mg/kg or /05 cc/d every 1-2d

111
Q

When should morphine therapy be discontinued?

A

dc can occur when the baby is stable on a dose of 0.05-0.1 for 1-2d

112
Q

When can a NAS baby be dc’d?

A

observe for 24-48h after MS dc before discharge

113
Q

When should a re-escalation scale be utilized?

A

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

114
Q

How is the upper limit of morphine therapy defined?

A

if baby requires greater than 0.2mg Q3-4 of PO MS or infant appears somnolent or difficult to rouse, notify provider

115
Q

How should methadone be dosed?

A

0.05-0.2mg/kg/dose PO Q12-24h

116
Q

What is the approximately half life of methadone in the neonate?

A

56h

Neonatal Pathophysiology (17 decks)

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