Transcript Current Trends In Identifying And Treating Newborns With

Current Trends In
Identifying And Treating
Newborns With
Withdrawal Syndromes
6/24/2010
Substance Exposed
Newborns
Alcohol
Tobacco
Caffeine
Amphetamines
Cocaine
Barbituates
Selective Serotonin Re-uptake
inhibitors
Opiates
Marijuana
Anti-psychotics
Benzodiazepines
Substance Exposed
Newborns
Drug Use in Pregnant Women
2003 National Survey On Drug Use And
Health.
4.3% of pregnant women, age 15-44
years, reported using illicit drugs.
Approximately 170,000.
Drug use during pregnancy typically
decreases as pregnancy progresses.
Opiates
US 1999 National Household Survey on
Drug Abuse reported that 6.7% of people
reported illicit drug use in the last month.
0.1% heroin use.
3.4% of pregnant women reported illicit
drug abuse.
Approximately 3,000 pregnant women use
opiates during there pregnancy each year
in the United States.
Opiates
Withdrawal signs in exposed infants are
variable and not all exposed infants
experience withdrawal.
48-94% of infants will experience
withdrawal
No resolution to the questions surrounding
maternal opiate dose and withdrawal
frequency or severity.
Literature split evenly on either side of
this issue.
Opiates
Scoring Systems
Neonatal Abstinence Scoring System
Finnegan
Lipsitz Tool
Neonatal Withdrawal Inventory
Ostrea
Neonatal Abstinence Scoring
System
Opiates
Neonatal Abstinence Scoring
System
Neuromotor
Tremors, hyperreflexia,
inconsolable cry.
Score is totaled for each
time point.(Feeding)
Metabolic/Respiratory
Hyperthermia, mottling,
tachypnea.
Gastrointestinal
Frequent stooling, diarrhea, poor
•
3 successive scores
totaling 24 or more require
treatment.
Opiates
Treatment Options
Neonatal Morphine Solution
Methadone
Phenobarbital
Clonidine
Partial Agonists/Antagonists
Opiates
Infant with 3 scores totaling 24 or more.
Neonatal Morphine Solution starts at 0.4 mg/kg/day.
Every 3-4 hours depending on feeding schedule.
Infant continues to be assessed with each dose.
Up-titration continues as infant continues to have
elevated scores.
Opiates
Infant stabilized on same dose for 48 hours.
Infant is initially weaned every 48 hours based upon
continued clinical stability without signs of NAS.
Cessation variable depending upon institution,
0.15 mg/kg/day.
Observation off medication for 48 hours.
Opiates
Phenobarbital
First or second line agent.
Loading dose
20mg/kg/day or 10 mg/kg/day.
Starting or maintenance dose.
3-5 mg/kg/day.
Opiates
Clonidine
Adjunctive therapy at this point in time.
Oral or transdermal patch delivery
system.
Recent randomized controlled trial
demonstrated that oral clonidine as an
adjunct to diluted tincture of opium
reduced length of therapy.
Opiates
Preterm Infants
Infants born preterm seem to
demonstrate fewer withdrawal signs then
full term infants.
Infants born preterm that do require
treatment for neonatal abstinence
ultimately require lower doses of
neonatal opium solution and shorter
courses of therapy.
Benzodiazepines
Signs of neonatal withdrawal mimic the
signs of withdrawal from opiates.
Poorly described and few populations of
infants have been investigate only
exposed to benzodiazepines.
No treatment for abstinence from
benzodiazepines has been studied as
mono-therapy.
Benzodiazepines
Frequently complicates opiate addiction in
pregnant women.
Infants with concomitant opiate and
benzodiazepine exposure often experience
a more complicated withdrawal course.
No quantification of this impact has yet
been published.
Cocaine
Cocaine exposure likely leads to a toxicity
and not a withdrawal syndrome.
Infants often demonstrate many of the
signs of opiate withdrawal.
Hyper-irritability, tachycardia,
inconsolable cry.
Often present though early after delivery.
No specific therapy for cocaine exposure.
Selective Serotonin
Re-uptake INhibitors
Widely used and studied in pregnant
women.
Reports of an abstinence syndrome in
infants still in small numbers in comparison
to the large numbers of exposed women.
Several reports describe a withdrawal
syndrome similar to opiates.
May more likely represent a toxicity and
not true withdrawal syndrome.