Neonatal abstinence syndrome: Difference between revisions
(Text replacement - "opiates" to "opioids") |
ClaireLewis (talk | contribs) |
||
| (8 intermediate revisions by 4 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Condition caused by neonatal withdrawal from substance exposure in utero | *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 | *Polysubstance withdrawal must also be considered | ||
==Clinical Features== | ==Clinical Features== | ||
*Agitated - high-pitched cry, restlessness, | *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== | ||
| Line 17: | Line 18: | ||
*[[Hypocalcemia]] | *[[Hypocalcemia]] | ||
*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
*Vertically transmitted diseases ( | *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]]) | ||
==Evaluation== | ==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 | *Consider cranial [[ultrasound]] for cocaine-exposed neonates with abnormal neurologic signs | ||
==Management== | ==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 | ||
* | *[[Opioids]] when supportive measures fail | ||
*Morphine is 1st line for infants exposed to '''both''' opioids and benzos | **[[Morphine]] is 1st line for infants exposed to '''both''' opioids and benzos | ||
**Neonatal morphine 0.4mg/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 < 50mg (or other opiate) | ***Mother's [[methadone]] < 50mg (or other opiate) | ||
****Start morphine PO sln 0.1mg/kg q3hrs with feeds | ****Start morphine PO sln 0.1mg/kg q3hrs with feeds | ||
****Increase by 0.1mg/kg hourly if NAS score ≥ 8, max 1mg/kg | ****Increase by 0.1mg/kg hourly if NAS score ≥ 8, max 1mg/kg | ||
| Line 41: | Line 42: | ||
***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 | ||
* | *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 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs | **Morphine q4 hours vs. buprenorphine q8 hours if NAS scale > 12 | ||
**OR phenobarbital 3mg/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 | ||
**[[Midazolam]] 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs | |||
**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 | **16mg/kg load divided into two consecutive feedings for day 1 | ||
**24 hrs later, use 2-8mg/kg/day maintenance dose | **24 hrs later, use 2-8mg/kg/day maintenance dose | ||
Latest revision as of 18:30, 6 October 2019
Background
- Condition caused by neonatal withdrawal from substance exposure in utero
- 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
- Agitated - high-pitched cry, restlessness, tremors, hypertonia, convulsions
- Vasomotor - sweating, fever
- Respiratory - nasal congestion, persistent sneezing, RR > 60/min, nasal flaring
- Metabolic - poor feeding, vomiting, loose stools
Differential Diagnosis
- Neonatal sepsis
- Hyperthyroidism/hypothyroidism
- Hypocalcemia
- Hypoglycemia
- Vertically transmitted diseases (viral hepatitis HIV, etc.)
- Other withdrawal (caffeine, cocaine, nicotine, amphetamines, SSRIs)
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
- Neonatal morphine 0.4mg/ml PO sln
- 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
- Morphine is 1st line for infants exposed to both opioids and benzos
- 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
- Midazolam 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs
- 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