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 Opioid Epidemic/Public Health Crisis What is Neonatal Abstinence Syndrome (NAS)? Increasing Incidence of NAS 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 Rate of Neonatal Abstinence Syndrome per 1,000 live births, New Mexico and the U.S., 2003 2013 Wylder Lecture Series 1
NAS by New Mexico County Best Practices Terms billing, clinical precision, common use Neonatal abstinence syndrome Neonatal opiate withdrawal syndrome ICD 10 CM P96.1 Neonatal withdrawal symptoms from maternal use of drugs of addiction Hospital discharges related to Neonatal Abstinence Syndrome by county of residence of the mother, 2009 2013 Babies with Prenatal Opioid Exposure are Hard to Care For Babies with Prenatal Opioid Exposure are Hard to Care For Woman Trauma/illness Lack of preventative care Substance use disorder Lack of treatment Lack of routine healthcare/family planning Pregnancy Lack of prenatal care Lack of care for substance use disorder Infant with symptoms of opioid exposure 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 Our own personal feelings and experiences with the opioid epidemic and patients with substance use disorders affect our approach Family Friends Patients Crime Wylder Lecture Series 2
Challenges of Providing Care for Infants with Prenatal Opioid Exposure Questions? 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 a substance use disorder Improve the infant s short and long term outcome Serve vulnerable families well Best Practices Care of neonates with prenatal opioid exposure Physiology of withdrawal Pharmacologic treatment Non pharmacologic treatment Long term outcomes 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 You are working in the newborn nursery when you start to examine your newest patient, a baby girl named A.J. Mom is a 24 year old G1P1 with known heroin use during the beginning of her pregnancy. She has been enrolled in a substance abuse program and receiving buprenorphine daily since 25 weeks gestation. 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 Wylder Lecture Series 3
Identification of Infants at Risk for NAS: Testing Short term exposure Urine Longer term exposure Meconium Cord A.J. is an AGA female born at 37 weeks via SVD with Apgar scores of 8 and 9. A.J. s mom denies using alcohol or other illicit substances currently. Her urine drug screen was negative at the time of delivery except for buprenorphine. What is the risk of NAS for A.J.? Buprenorphine maintenance decreases the risk of NAS for babies, with approximately 20 to 50% requiring pharmacologic treatment After careful review of mom s chart and discussion with her substance abuse counselor and provider, it is decided that she can breastfeed. However, on day of life one, you notice that A.J. is becoming more irritable. She latches to the breast well, but is starting to spit up frequently. Physiology of Opioid Withdrawal NAS Clinical Presentation Central nervous system disturbances: High pitched cry, sleep/wake disturbances Hyperactive reflexes Hypertonicity, hypersensitivity Tremors Seizures Kocherlakota 2014 Wylder Lecture Series 4
NAS Clinical Presentation NAS Clinical Presentation Metabolic, vasomotor, respiratory disturbances Sweating, fever Sneezing, nasal stuffiness Yawning Mottling Tachypnea 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 You start scoring A.J. with the modified Finnegan scale. Upon review of her scores the following morning, you find that her last three scores were 8, 10, and 9. You notify mom of the need to start medication. Mom is tearful when you tell her that her baby needs medication but understands the need. 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 Wylder Lecture Series 5
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 has score based dosing with increase or decrease as indicated, not weight based: Infant Score Morphine Dose 0 8 no treatment 9 12 0.04 mg 13 16 0.08 mg 17 20 0.12 mg 21 24 0.16 mg 25 or greater 0.2 mg Pharmacologic Treatment of NAS Presbyterian Hospital has weight based dosing with increase or decrease as indicated by scores: Initiation Initial PO dose 0.04 mg/kg/dose q3hr Titration Increase by 0.02 mg/kg/dose q12hr (maximum 0.14 mg/kg) Weaning Decrease dose by 0.1 mg/kg/dose every other day (minimum 0.02 mg/kg) Decrease dosing interval from q3hr to q6hr to q12hr Finally, discontinue morphine and observe for 72 hours A.J. is started on morphine and does not require much escalation in dose. Scores are done every three hours or so and cares are clustered. A.J. is able to undergo her first morphine wean on day of life four. She is rooming in with mom, feeding well and gaining weight. 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 Wylder Lecture Series 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 Mom continues to be an active participant in A.J. s daily cares and has been seeing her counselor on a regular basis. On day of life sixteen, A.J. is given her last dose of morphine. She continues to eat and gain weight well. A.J. is discharged home after 72 hours of observation. Goal of NAS Treatment Long Term Outcomes of NAS Decrease severity of withdrawal 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 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 Wylder Lecture Series 7
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 Statewide Initiative Care of these babies is hard! Let s do it together! hpchavez@salud.unm.edu awinegard@phs.org Wylder Lecture Series 8