Neonatal abstinence syndrome: Difference between revisions
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***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 | *Benzo withdrawal treatment | ||
**Midazolam 0.1mg/kg IV q3hrs or 0. | **Midazolam 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs | ||
**OR phenobarbital | **OR phenobarbital 3mg/kg IV or PO q24hrs | ||
*Phenobarbital for seizures OR side effect limiting morphine effects OR max morphine dose reached | *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 | ||
Revision as of 15:32, 20 July 2016
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
- 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 (HepB, HepC, HIV, etc.)
- Other withdrawal (caffeine, cocaine, nicotine, amphetamines, SSRIs)
Diagnosis
- Pharmacologic treatment when 3 consecutive ≥ 8 on NAS(Finnegan scale
- Enzyme immunoassay, urine toxicology, meconium analysis
- Consider cranial US for cocaine-exposed neonates with abnormal neurologic signs
Management
- Supportive - swaddling to decrease sensory stimulation, frequent small feedings of 24 cal/oz formula
- Opiates when supportive measures fail
- Morphine is 1st line for infants exposed to both opiates 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 < 50 mg (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 > 50 mg
- Start 0.2 mg/kg q3hrs
- Increase by 0.2 mg/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
- Neonatal morphine 0.4mg/ml PO sln
- Benzo 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