Current Trends In Identifying And

Treating Newborns With Withdrawal

Syndromes

Current Trends In Identifying And

Treating Newborns With Withdrawal

Syndromes6/24/20106/24/2010

Substance Exposed Newborns

Substance Exposed Newborns

Barbituates

Selective Serotonin Re-uptake inhibitors

Opiates

Marijuana

Anti-psychotics

Benzodiazepines

Alcohol

Tobacco

Caffeine

Amphetamines

Cocaine

Substance Exposed Newborns

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.

OpiatesOpiatesUS 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.

OpiatesOpiatesWithdrawal 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.

OpiatesOpiates

Scoring Systems

Neonatal Abstinence Scoring System

Finnegan

Lipsitz Tool

Neonatal Withdrawal Inventory

Ostrea

Neonatal Abstinence Scoring System

Neonatal Abstinence Scoring System

OpiatesOpiatesNeonatal Abstinence Scoring System

Neuromotor

Tremors, hyperreflexia, inconsolable cry.

Metabolic/Respiratory

Hyperthermia, mottling, tachypnea.

Gastrointestinal

Frequent stooling, diarrhea, poor PO feeding, emesis.

Score is totaled for each time point.(Feeding)

• 3 successive scores totaling 24 or more require treatment.

OpiatesOpiates

Treatment Options

Neonatal Morphine Solution

Methadone

Phenobarbital

Clonidine

Partial Agonists/Antagonists

OpiatesOpiatesInfant 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.

OpiatesOpiatesInfant 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.

OpiatesOpiates

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.

OpiatesOpiatesClonidine

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.

OpiatesOpiatesPreterm 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.

BenzodiazepinesBenzodiazepines

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.

BenzodiazepinesBenzodiazepines

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.

CocaineCocaine

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 SerotoninRe-uptake INhibitorsSelective SerotoninRe-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.