Neonatal abstinence syndrome: Difference between revisions
 
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==Background==
==Background==
*Polysubstance combining opiates and cocaine must be considered
*Condition caused by neonatal withdrawal from substance exposure in utero
*Withdrawal within first 24-48 hrs --> fetal alcohol syndrome
**Withdrawal within first 24-48 hrs → fetal [[alcohol]] syndrome
*Withdrawal within 48-72 hrs --> heroin
**Withdrawal within 48-72 hrs → [[heroin]]
*Withdrawal at 7-14 days --> methadone
**Withdrawal at 7-14 days → [[methadone]]
*Incidence has quadrupled since 1999 from 1.5 per 1000 hospital births to 6.0 per 1000 in 2013<ref>Ko JY et al. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. Weekly / August 12, 2016 / 65(31);799–802.</ref>
*Polysubstance withdrawal must also be considered


==Clinical Presentation==
==Clinical Features==
*Agitated - high-pitched cry, restlessness, tremors, hypertonia, convulsions
*Agitated - high-pitched cry, restlessness, [[tremor]]s, hypertonia, [[seizure (peds)|convulsions]]
*Vasomotor - sweating, fever
*Vasomotor - sweating, [[fever (Peds)|fever]]
*Respiratory - nasal congestion, persistent sneezing, RR > 60/min, nasal flaring
*Respiratory - nasal congestion, persistent sneezing, [[shortness of breath (peds)|RR > 60/min]], nasal flaring
*Metabolic - poor feeding, vomiting, loose stools
*Metabolic - [[failure to thrive (peds)|poor feeding]], [[vomiting]], [[diarrhea (peds)|loose stools]]


==Differential Diagnosis==
==Differential Diagnosis==
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*[[Hypocalcemia]]
*[[Hypocalcemia]]
*[[Hypoglycemia]]
*[[Hypoglycemia]]
*Vertically transmitted diseases (HepB, HepC, [[HIV]], etc.)
*Vertically transmitted diseases ([[viral hepatitis]] [[HIV]], etc.)
*Other withdrawal (caffeine, cocaine, nicotine, amphetamines, SSRIs)
*Other withdrawal ([[caffeine withdrawal|caffeine]], [[cocaine withdrawal|cocaine]], nicotine, [[amphetamines]], [[SSRIs]])


==Diagnosis==
==Evaluation==
*Pharmacologic treatment when 3 consecutive ≥ 8 on NAS([http://www.lkpz.nl/docs/lkpz_pdf_1310485469.pdf Finnegan scale]
*Pharmacologic treatment when 3 consecutive ≥ 8 on NAS([http://www.lkpz.nl/docs/lkpz_pdf_1310485469.pdf Finnegan scale]
*Enzyme immunoassay, urine toxicology, meconium analysis
*Enzyme immunoassay, urine toxicology, meconium analysis
*Consider cranial US for cocaine-exposed neonates with abnormal neurologic signs
*Consider cranial [[ultrasound]] for cocaine-exposed neonates with abnormal neurologic signs


==Treatment==
==Management==
*Supportive - swaddling to decrease sensory stimulation, frequent small feedings of 24 cal/oz formula
*Supportive - swaddling to decrease sensory stimulation, frequent small feedings of 24 cal/oz formula
*Opiates when supportive measures fail
*[[Opioids]] when supportive measures fail
*Morphine is 1st line for infants exposed to both opiates and benzos
**[[Morphine]] is 1st line for infants exposed to '''both''' opioids and benzos
**Neonatal morphine 0.4 mg/ml PO sln
***Neonatal morphine 0.4mg/ml PO sln
***Watch for side effect limiting dose (urinary retention)
****Watch for side effect limiting dose ([[urinary retention]])
***Withdrawal symptoms need to be stabilized for 3-5 days before taper
****Withdrawal symptoms need to be stabilized for 3-5 days before taper
***Mother's methadone < 50 mg (or other opiate)
***Mother's [[methadone]] < 50mg (or other opiate)
****Start morphine PO sln 0.1 mg/kg q3hrs with feeds
****Start morphine PO sln 0.1mg/kg q3hrs with feeds
****Increase by 0.1 mg/kg hourly if NAS score ≥ 8, max 1 mg/kg
****Increase by 0.1mg/kg hourly if NAS score ≥ 8, max 1mg/kg
***Mother's methadone > 50 mg
***Mother's methadone > 50mg
****Start 0.2 mg/kg q3hrs
****Start 0.2mg/kg q3hrs
****Increase by 0.2 mg/kg hourly if NAS score ≥ 8, max 1 mg/kg
****Increase by 0.2mg/kg hourly if NAS score ≥ 8, max 1mg/kg
**If NPO, use preservative free morphine at 50 mcg/ml
**If NPO, use preservative free morphine at 50 mcg/ml
***Load 30 mcg/kg over 1hr, then infusion at 2 mcg/kg/hr
***Load 30 mcg/kg over 1hr, then infusion at 2 mcg/kg/hr
***Increase by 1 mcg/kg/hr hourly until NAS < 8, max 6 mcg/kg/hr
***Increase by 1 mcg/kg/hr hourly until NAS < 8, max 6 mcg/kg/hr
*Benzo withdrawal treatment
*Longer acting [[buprenorphine]] may significantly reduce hospital admission and treatment duration as compared to morphine<ref>Kraft WK et al. Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome. May 4, 2017DOI: 10.1056/NEJMoa1614835.</ref>
**Midazolam 0.1 mg/kg IV q3hrs or 0.3 mg/kg PO q3hrs
**Morphine q4 hours vs. buprenorphine q8 hours if NAS scale > 12
**OR phenobarbital 3 mg/kg IV or PO q24hrs
**[[Buprenorphine]] dosed initially at 5 mcg/kg q8 hrs to max dose of 20 mcg/kg q8 hrs
*Phenobarbital for seizures OR side effect limiting morphine effects OR max morphine dose reached
*[[Benzodiazepine withdrawal]] treatment
**16 mg/kg load divided into two consecutive feedings for day 1
**[[Midazolam]] 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs
**24 hrs later, use 2-8 mg/kg/day maintenance dose
**OR [[phenobarbital]] 3mg/kg IV or PO q24hrs
*[[Phenobarbital]] for seizures OR side effect limiting morphine effects OR max morphine dose reached
**16mg/kg load divided into two consecutive feedings for day 1
**24 hrs later, use 2-8mg/kg/day maintenance dose
 
==Disposition==
*Admit


==See Also==
==See Also==
*[[Opioid withdrawal]]
*[[Opioid withdrawal]]


==Sources==
==References==
*Hudak et al. Neonatal Drug Withdrawal AAP Policy. PEDIATRICS Vol. 129 No. 2 February 1, 2012, pp. e540 -e560.
<references/>
*Hamdan et al. Neonatal Abstinence Syndrome. Medscape 2014. http://emedicine.medscape.com/article/978763-overview#showall.
 
*Klein, J. Identifying Neonatal Abstinence Syndrome (NAS) and Treatment Guidelines. University of Iowa Children's Hospital 2/11/13. http://www.uichildrens.org/uploadedFiles/UIChildrens/Health_Professionals/Iowa_Neonatology_Handbook/Pharmacology/Neonatal%20Abstinence%20Syndrome%20Treatment%20Guidelines%20Feb2013%20revision.pdf
[[Category:Pediatrics]]
*Perinatal Quality Collaborative of North Carolina. Best Practice Neonatal Abstinence Syndrome. Document online.
[[Category:Toxicology]]

Latest revision as of 18:30, 6 October 2019

Background

  • Condition caused by neonatal withdrawal from substance exposure in utero
    • Withdrawal within first 24-48 hrs → fetal alcohol syndrome
    • Withdrawal within 48-72 hrs → heroin
    • Withdrawal at 7-14 days → methadone
  • Incidence has quadrupled since 1999 from 1.5 per 1000 hospital births to 6.0 per 1000 in 2013[1]
  • Polysubstance withdrawal must also be considered

Clinical Features

Differential Diagnosis

Evaluation

  • Pharmacologic treatment when 3 consecutive ≥ 8 on NAS(Finnegan scale
  • Enzyme immunoassay, urine toxicology, meconium analysis
  • Consider cranial ultrasound for cocaine-exposed neonates with abnormal neurologic signs

Management

  • Supportive - swaddling to decrease sensory stimulation, frequent small feedings of 24 cal/oz formula
  • Opioids when supportive measures fail
    • Morphine is 1st line for infants exposed to both opioids and benzos
      • Neonatal morphine 0.4mg/ml PO sln
        • Watch for side effect limiting dose (urinary retention)
        • Withdrawal symptoms need to be stabilized for 3-5 days before taper
      • Mother's methadone < 50mg (or other opiate)
        • Start morphine PO sln 0.1mg/kg q3hrs with feeds
        • Increase by 0.1mg/kg hourly if NAS score ≥ 8, max 1mg/kg
      • Mother's methadone > 50mg
        • Start 0.2mg/kg q3hrs
        • Increase by 0.2mg/kg hourly if NAS score ≥ 8, max 1mg/kg
    • If NPO, use preservative free morphine at 50 mcg/ml
      • Load 30 mcg/kg over 1hr, then infusion at 2 mcg/kg/hr
      • Increase by 1 mcg/kg/hr hourly until NAS < 8, max 6 mcg/kg/hr
  • Longer acting buprenorphine may significantly reduce hospital admission and treatment duration as compared to morphine[2]
    • Morphine q4 hours vs. buprenorphine q8 hours if NAS scale > 12
    • Buprenorphine dosed initially at 5 mcg/kg q8 hrs to max dose of 20 mcg/kg q8 hrs
  • Benzodiazepine withdrawal treatment
  • Phenobarbital for seizures OR side effect limiting morphine effects OR max morphine dose reached
    • 16mg/kg load divided into two consecutive feedings for day 1
    • 24 hrs later, use 2-8mg/kg/day maintenance dose

Disposition

  • Admit

See Also

References

  1. ↑ Ko JY et al. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. Weekly / August 12, 2016 / 65(31);799–802.
  2. ↑ Kraft WK et al. Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome. May 4, 2017DOI: 10.1056/NEJMoa1614835.
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