Care of the Neonate with Prenatal Opioid Exposure. Objectives. What is Neonatal Abstinence Syndrome (NAS)/ Neonatal Opiate Withdrawal Syndrome?
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1 Care of the Neonate with Prenatal Opioid Exposure Heather Pratt Chavez, MD Ann Winegardner, MD Objectives Review the latest population data on neonates with prenatal opioid exposure Describe the acute inpatient care of these neonates, understanding both the pharmacologic and non pharmacologic treatments available Reflect on the challenges of providing care for these infants and discuss a new statewide quality improvement initiative Opioid Epidemic/Public Health Crisis What is Neonatal Abstinence Syndrome (NAS)/ Neonatal Opiate Withdrawal Syndrome? Infant withdrawal following prenatal exposure to opioids (including narcotic pain relievers, heroin, methadone, and buprenorphine) Manifested as a widely variable, complex, and incompletely understood spectrum of signs of neonatal behavioral dysregulation 1
2 Increasing Incidence of NOWS (NAS) NAS by New Mexico County Rate of Neonatal Abstinence Syndrome per 1,000 live births, New Mexico and the U.S., Hospital discharges related to Neonatal Abstinence Syndrome by county of residence of the mother, Babies with Prenatal Opioid Exposure are Hard to Care For Babies with Prenatal Opioid Exposure are Hard to Care For Infant: Fussy Miserable Difficult to console Suffering because of the use of their mom Illness could have been prevented at so many points Long term effects are unknown Mother: Substance use disorder Psychiatric comorbidities Post partum Lack of social support Lack of access to care Guilt Stigma Babies with Prenatal Opioid Exposure are Hard to Care For Our own personal feelings and experiences with the opioid epidemic and patients with substance use disorders affect our approach Family Friends Patients Crime Challenges of Providing Care for Infants with Prenatal Opioid Exposure Despite our own judgment of mothers with drug exposed infants And our frustration with the fussy, difficult toconsole withdrawing infant, It is important to develop compassion and provide support to the mother with substance use disorder Improve the infant s short and long term outcome Serve vulnerable families well 2
3 Questions? Best Practices Three stages of care for infants with prenatal opioid exposure: 1. Identification History Testing 2. Observation not all infants need treatment! Scoring (72 96 hours) 3. Treatment Pharmacologic Non pharmacologic Identification of Infants at Risk for NAS: History Indications for screening varies by facility All women in labor Provider concern ( profiling ) Poor or no prenatal care History of maternal drug use Unexplained placental abruption, perinatal depression, neonatal seizures Identification of Infants at Risk for NAS: Testing Short term exposure Urine Longer term exposure Meconium Cord 3
4 What is the risk of NAS for babies if mom is taking Buprenorphine? Buprenorphine maintenance decreases the risk of NAS for babies, with approximately 20 to 50% requiring pharmacologic treatment NAS Clinical Presentation Central nervous system disturbances: High pitched cry, sleep/wake disturbances Hyperactive reflexes Hypertonicity, hypersensitivity Tremors Seizures NAS Clinical Presentation Metabolic, vasomotor, respiratory disturbances Sweating, fever Sneezing, nasal stuffiness Yawning Mottling Tachypnea NAS Clinical Presentation Gastrointestinal disturbances Emesis, loose stools Feeding difficulties, disorganized and excessive sucking Failure to thrive Observation: Diagnosis of NAS Modified Finnegan scale most widely used Presence and severity of 21 symptoms frequently observed in opioid exposed infants scored, then added up Score should reflect infant s symptoms over the past two to four hours (since last score) Observation: Diagnosis of NAS Threshold for pharmacologic treatment of NAS: Three consecutive scores of 8 or more Two or three consecutive scores that add up to at least 24 Must observe infant for a minimum of 72 hours, 96 hours generally recommended 4
5 Pharmacologic Treatment of NAS There are a variety of different protocols for the treatment of NAS (e.g., oral morphine vs. methadone), which may or may not be weight based In general, however, oral morphine is recommended for the treatment of NAS, particularly if the mother was maintained on buprenorphine Pharmacologic Treatment of NAS First line treatment Morphine Second line treatments used if at threshold scores despite maximum morphine dose or if morphine dose is limited by side effects (may require transfer to a higher level of care) Clonidine Phenobarbital Pharmacologic Treatment of NAS UNM score based dosing with increase or decrease as indicated, not weight based: Infant Score Morphine Dose 0 8 no treatment mg mg mg mg 25 or greater 0.2 mg Non Pharmacologic Treatment of NAS Breastfeeding is encouraged if Mother is positive only for prescribed methadone or buprenorphine and is in a treatment program May also help to ease infant withdrawal But mother must be warned to not abruptly stop breastfeeding Non Pharmacologic Treatment of NAS Skin to skin! Calming Promotes bonding Rooming in Quiet environment Dim lighting Minimal disturbances and clustering of care 5
6 Non Pharmacologic Treatment of NAS Swaddling Creates barrier and prevents flailing Side or stomach position Supine position can feel like falling Shushing Mimics sound of the womb Swinging Fast, tiny, back and forth movements Sucking (non nutritive) Pacifier or dry nuzzling Goal of NAS Treatment Decrease withdrawal severity and length of treatment for the infant Mother of the infant should be encouraged to participate in scoring and infant care as well as to provide the majority of non pharmacologic interventions Long Term Outcomes of NAS Limited data, difficult to separate ongoing environmental risks from the effects of prenatal opioid exposure Studies do show significant delays in cognitive skills, language, and social maturity Though there is the potential for neuroplasticity and recovery Infants with NAS should be referred to Early Intervention Statewide Initiative Perinatal Collaborative University of New Mexico Hospital Presbyterian Hospital ENVISION New Mexico Statewide Initiative Best Practices Standardization Support Training Sabbaticals Maintenance of Certification Continuing Medical Education Statewide Initiative Three stages of care for infants with prenatal opioid exposure Best Practices when to transport Identification of infants at risk for NAS Observation and diagnosis of NAS Treatment, pharmacologic and non pharmacologic 6
7 Statewide Initiative Caring for these babies is hard, and rewarding work! Let s do it together! hpchavez@salud.unm.edu awinegard@phs.org 7
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