NOWS The Time Caring for the Infant with Neonatal Opiate Withdrawal Syndrome Meghan Howell, MD FAAP Assistant Professor of Pediatrics Clinical Director, Tulane NICU Graduate Clinic Tulane University School of Medicine, New Orleans, LA
Disclosure I have no financial disclosures or conflicts of interest.
Objectives Review how the diagnosis of NOWS is made, recommended care of the withdrawing infant, and long-term consequences of prenatal drug exposure. Discuss gaps in identifying infants at risk of NOWS, including barriers to maternal disclosure of drug use. Review systems-based approaches to caring for NOWS infants and their caregivers
What is NOWS? Neonatal Opiate Withdrawal Syndrome Previously more commonly referred to as Neonatal Abstinence Syndrome (NAS) Clinical symptoms consistent with an infant s withdrawal from opiate exposure in utero Neurological Gastrointestinal Cardiovascular/Respiratory
Cost of NOWS CDC estimates that in 2012, the U.S. spent $1.2 billion caring for infants with NOWS Mean length of stay = 16.9 days Estimated cost per infant = $66,700 Infants per year in U.S. = 5.8 per 1000 births Louisiana rates are almost double national average
NOWS in the News
How Do Moms and Babies Get Screened? Screening for Mothers American Academy of Pediatrics (AAP) and American College of Obstetrics and Gynecology (ACOG) recommend screening all mothers for substance use at each prenatal visit Using a verbal screening tool
How Do Moms and Babies Get Screened? Screening for Mothers Use of biological screening methods (i.e. urine, hair) is up to the discretion of the provider Screening for Infants Urine/meconium studies to test for substances Newer testing i.e. umbilical cord but less widely used NO FEDERAL GUIDELINES PROVIDE CRITERIA FOR ASSESSING SUBSTANCE USE IN PREGNANT WOMEN OR IDENTIFYING THEIR AT-RISK INFANTS Variations in practices among OB/GYNs Variations in hospital-based screening Variations in how infants are screening
The Argument for Universal Biological Screening 2956 moms 5.4% urine tox screens were positive (n= 159) 3.2% of total were positive for opiates (n=96) 20% of these were in mothers without screening risk factors (representing 19 of 96 +opiate screens) 37% of these required NICU admission for pharmacological tx for withdrawal (representing 7 of 19 infants) The equaled about $500,000 in healthcare expenses in an 18-month period For infants born to mothers without risk factors
Limitations to Biologics Maternal & Infant Urine Toxicology False positives, false negatives Inaccurate and inconsistent Infant Meconium Takes longer to result 7 days at our facility More widely used as a confirmatory test Umbilical Cord Testing Growing literature base, but inconsistent literature Not available at all institutions
How about Louisiana?
Louisiana Substance Use in Pregnancy Toolkit Algorithms for how to screen Dialogue scripts for providers Tips for motivational interviewing Open ended questions, reflective listening, etc. How to refer & statewide resources Treatment programs, Other substances tobacco, alcohol Infectious diseases hep B, hep C, HIV
Perinatal Commission Sampled a subgroup of birthing hospitals across the state 26 responded Louisiana hospitals : NEITHER Use evidence based verbal screens to universally screen for substance use among women during pregnancy NOR do they universally perform urine drug screens on pregnant women who present to labor and delivery. Several hospitals reported conducting urine drug screens upon hospital admission for pregnant women when there was a concern for substance use
What Happens to the Baby in the Hospital? Finnegan Scoring Evaluation tool based on 31 clinical signs of withdrawal Scored by trained providers Consistent elevated scores (>8) prompts further treatment/monitoring Newer Models Eat, Sleep, Console Shorter stays
What Happens if the Infant Shows Significant Withdrawal? Infant is monitored & scored for withdrawal symptoms In the Newborn Nursery If Infants scores increase, sent to NICU for treatment Transferred to NICU Infants are weaned from medications and prepared to go home In the NICU
When Do We Notify DCFS? Federal Child Abuse Prevention and Treatment Act (CAPTA) designates that mandated reporters must report families to DCFS to be investigated for prenatal neglect when a child 30 days or younger has withdrawal symptoms, a positive screen or observable harmful effects in physical appearance or functioning and the mother unlawfully used (or in a manner not prescribed) a controlled dangerous substance.
LA Recommendations for Reporting to DCFS Prenatal neglect means exposure to chronic or severe use of alcohol or the unlawful use of any controlled dangerous substance, as defined by R.S. 40:961 et seq., or in a manner not lawfully prescribed, which results in symptoms of withdrawal in the newborn or the presence of a controlled substance or a metabolite thereof in his body, blood, urine or meconium that is not the result of medical treatment, or observable and harmful effects in his physical appearance or functioning.
Can t You Predict Who Will Withdraw? We don t fully understand how opiates cross the placenta or the full on impact of exposure Boys more likely withdraw and we don t know why Drugs have varying half-lives which makes predicting time to peak withdrawal tricky at best Heroin 30 minutes Buprenorphine 69 hours
Opiates & NOWS Drug Half-Life (PO) Incidence of NOWS Time to Onset of NOWS sx Time to peak withdrawal Duration of withdrawal Buprenorphin e 24-42 hours 7-67% 36-60 hours 72 hours > 28 days Buprenorphin e/naloxone 24-42 hours/ 2-12 hours 40% 36-60 hours 72 hours > 28 days Methadone 9-87 hours 13-94% 36-72 hours 96-144 hours > 30 days Heroin < 30 minutes 18-80% 8-48 hours 36-72 hours 8-10 days Hydrocodone 4 hours 5-20% 8-12 hours 36-72 hours 10-30 days Oxycodone 3-5 hours 5-20% 8-12 hours 36-72 hours 10-30 days Morphine 2-4 hours 5-20% 8-12 hours 36-72 hours 10-30 days
What Are the Long Term Consequences? Neurodevelopmental Complicated due to impact of caregiving environment Long term perception of pain in exposed infants? Otherwise, we don t really know Very limited studies have been done Very limited sample size typically only a few dozen infants per study Inconsistent treatment regimens add an extra variable
So What Barriers Exist to Identifying These Babies? Since 1991, Louisiana Medicaid has prohibited reimbursement for the use of narcotics including methadone in the treatment of substance use disorders Anecdotal Reports: Addiction treatment providers dismiss pregnant patients from their care for fear of liability and concern for poor outcomes Conflicting thoughts on best route to take prenatally Rapid detox Continued maintenance
Maternal Considerations What s going on in the brain of mothers addicted to opiates? Difficult to watch infant s withdrawal Maternal guilt, anxiety about her ability to parent Secondary blame (partners, family, healthcare) Responding to infant s cues Based on mom s working mental models BUT Maternal brain plasticity
How do these babies make you feel?
How do these babies make you feel?
Doesn t Breastmilk Fix Everything? Data estimates that only about 25% of eligible mothers breastfeed to some extent Average duration = just under 6 days Methadone & buprenorphine both compatible with breastfeeding
Breastfeeding and NOWS Primarily breastmilk v. primary formula resulted in: Later onset of NAS (10 days v. 3 days) Required opiate treatment less often (53% v. 79%) Shorter LOS (15 days v. 19 days) Mothers who breastfed infants for 72 hours reduced odds that infant would require opiate treatment by half
Breastfeeding and NOWS Breastfeeding has been associated with: Reduced severity Delayed onset Decreased need for opiates Benefits also seen when mothers room in with babies 79% decrease in need for treatment for NOWS
So what s a pediatrician to do? Lack of comprehensive centers taking the lead on following these children, ensuring families are accessing services (i.e. Early Steps) and limited attention is paid to ensuring to supporting positive parent-child interactions
Final Thoughts Maternal substance use and subsequent infant opiate withdrawal is a complex physiological and social interplay that needs compassionate, evidence-based systematic approaches to ensure proper care of the maternal-infant dyad Ideal care should be based on centers of excellence dedicated to streamlining continuity of care and providing the absolute best treatment for moms and their babies
Opportunities Prenatal Improved access to perinatal providers comfortable with and capable of treating maternal opiate dependence throughout the spectrum of pregnancy Postnatal Enhanced breastfeeding education and support for mothers with opiate use
Opportunities Logistical Comprehensive centers of excellence to promote smooth prenatal to perinatal to neonatal transition for infants exposed to intra-uterine opiates and their mothers Academic Increased research into additional modalities, including psychosocial interventions, to help decrease costs and facilitate smooth transitions
Thank you!
Questions or Comments for the Group?
References Ko JY et al. CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome. Morbidity and Mortality Weekly Report, 66(9):242-5. March 10, 2017. Wexelblatt SL et al. Universal Maternal Drug Testing in a High Prevalance Region of Prescription Opiate Abuse. J Peds 2015 Oct;166(3):582-586 http://new.dhh.louisiana.gov/assets/docs/behavioralhealth/nasbooklet.pdf http://new.dhh.louisiana.gov/assets/docs/behavioralhealth/nasbooklet.pdf https://wwwcfprd.doa.louisiana.gov/boardsandcommissions/rulesandregulation s/223_response%20to%20house%20concurrent%20resolution%20162-final3-1-2016%20(3).pdf https://wwwcfprd.doa.louisiana.gov/boardsandcommissions/rulesandregulation s/223_response%20to%20house%20concurrent%20resolution%20162-final3-1-2016%20(3).pdf https://wwwcfprd.doa.louisiana.gov/boardsandcommissions/rulesandregulation s/223_response%20to%20house%20concurrent%20resolution%20162-final3-1-2016%20(3).pdf
References Velez M et al.the opioid dependent mother and newborn dyad: nonpharmacological care. J Addict Med. 2008 Sep 1;2(3):113-120. https://wwwcfprd.doa.louisiana.gov/boardsandcommissions/rulesandr egulations/223_response%20to%20house%20concurrent%20resolutio n%20162-final3-1-2016%20(3).pdf Wachman EM et al. Breastfeeding rates among mothers of infants with neonatal abstinence syndrome. Breastfeed Med 2010 Aug;5(4):159-164. Holmes AP et al. Breastfeeding considerations for mothers of infants with neonatal abstinence syndrome. Pharmacotherapy. 2017 Jul;37(7):861-869. Abdel-Latif ME et al. Effects of Breast Milk on the Severity and Outcome of Neonatal Abstinence Syndrome among Infants of Drug-Dependent Mothers. Pediatrics 2006;117(6) McQueen KA et al. The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Adv Neonatal Care. 2011;11(4):282-90.