neonatal abs,nence syndrome - omed 2017 · neonatal abs,nence syndrome how we got here and where we...

NeonatalAbs,nenceSyndromeHowWeGotHereandWhereWeAreGoing

KathrynZiegler,DO,FAAPNewbornSpecialCareAssociates

AbingtonJeffersonHealth

Disclosures

•  Ihavenofinancialdisclosures•  Wewilldiscusstheuseofmorphineininfantswhichisanofflabeluse

Objec,ves

•  Discusstheincidence/epidemiologyofopioiduse

•  Discusstheincidence/epidemiologyofNeonatalAbs,nenceSyndrome

•  DiscusstreatmentstrategiesforNeonatalAbs,nenceSyndrome

•  DiscussQualityImprovementEffortsforNeonatalAbs,nenceSyndrome

Opioids

•  Natural,endogenousandsynthe,c•  BindµreceptorsinCNS– Supraspinalanalgesia– Seda,on,euphoria,miosis,respiratorydepressionanddecreasedGImo,lity

– Prolongedusecausesphysicalandpsychologicaldependence

OpioidReceptors

Opioids

•  Natural– Morphine(extractedfromopium)

•  Synthe,c– Codeine,heroin,hydromorphone,fentanyl,methadone

•  Endogenous– Enkephalins,endorphins,endomorphins

TheProblem

•  Overdosedeathrateincreasedby137%since2000– 200%increasedindeathfromopioidoverdose

•  Americansconsume80%ofglobalopioidsupply– 99%ofhydrocodonesupply

•  Heroinoverdoseshavetripledinlast4years– Pastmisuseofprescrip,onopioidsclearlylinked

Manchinka,,etal

IncreasingDeathfromOpioids•  Sex:

•  Males(7.6%)•  Females(4.7%)

•  Age•  25-34yearolds(10.5%)•  35-44yearolds(8.7%)•  55-64yearolds(5.7%)•  ≥65yearolds(7.7%)

•  Race•  White,nonhispanic(8%)•  Black,nonhispanic(8.2%)

•  Geography•  Northeast(8.8%)•  Midwest(9.6%)•  South(6.9%)

Rudd,R.A.etal

IncreasesinDrugandOpioidOverdoseDeaths—UnitedStates,2000–2014

AmericanJournalofTransplantaConVolume16,Issue4,pages1323-1327,22MAR2016DOI:10.1111/ajt.13776hgp://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full#ajt13776-fig-0002

TheProblem

1986Publica,onthatopioidscanbeusedin

peoplewithoutcancer

andpain

1996AmericanPain

SocietyTradmarkspainasthe5thVS

1996

PurduePharmareleasesoxycon,n

1998VA/JCHAO

makepain5thVS

1998Federa,onofStateMedicalBoards-Drscan

safelyRxnarco,cs

TheProblem

2001JCHAOissuesstandardsurging

hospitalstoregularlyaskpa,entsabout

pain

2001JCHAO

publishesguidetoaddressphysician

concernsaboutaddic,onandtolerance

2007Purdue

Pharmapleadsguiltyto

misbrandingofoxycon,n

2012259

millionopioidRxwrigen$9billion

2013Opioiddeathssurpasscaraccidentsas

leadingcauseofaccidentaldeath

TheProblem

•  Pregnantwomendonotescapethereachofopioidaddic,on– 4.5%ofpregnantwomenreportusingillicitdrugs

•  InfantsborntowomenonopioidsareatriskofNeonatalAbs,nenceSyndrome(NAS)

•  300%increaseinNAS(2000-2013)– 1.5à6cases/1000hospitalbirths

hgps://www.cdc.gov/mmwr/volumes/65/wr/mm6531a2.htm

TheProblem

Source:Patrick,etal.JournalofPerinatology2015

Source:PennsylvaniaHealthcareCostContainmentCouncil

Source:PennsylvaniaHealthcareCostContainmentCouncil

Source:PennsylvaniaHealthcareCostContainmentCouncil

PennsylvaniaData

Source:PennsylvaniaHeatlhcareCostContainmentCouncil

PennsylvaniaData

TheProblem

•  Pennsylvaniabythenumbers(2000-2015)– Neonatalstaysrelatedtosubstanceabuse

• é250%(6.5à19.6/1000neonatalstays)

– Neonatalabs,nencesyndrome• é870%(1.6à16/1000neonatalstays)

– Cost•  28,000days•  $20million

NeonatalAbs,nenceSyndrome

•  Constella,onofsymptomsseenininfantswhoareexposedtoopiatesinutero

•  Somevaria,oninonsetandseverityofsymptoms–  Timingofmostrecentdrugusepriortodelivery– Maternalmetabolism–  Placentalmetabolism–  Infantmetabolism/excre,on–  Concomitantuseofotherdrugs/substances

NeonatalAbs,nenceSyndrome

•  55-94%ofinfantsexposedinuteroexhibitsymptoms

•  Seldomeffectsinfants<34weeksgesta,on

OpioidReceptors

OpioiduseinPregnancy

•  Opioidsaresmall,lipophilic,lowmolecularweight– Crossplacentalandbloodbrainbarriers

•  Detoxifica,onassociatedwithincreasedriskoffetaldistressandloss

NeonatalAbs,nenceSyndrome

•  CNSsymptoms– Con,nuousand/orhigh-pitchedcrying– Difficultysleeping– Hyperac,veMoroReflex– Tremors– Hypertonicity– Skinexcoria,on– Generalizedconvulsions/seizures

NeonatalAbs,nenceSyndrome

•  AutonomicSymptoms– Temperatureeleva,on– Sneezing/nasalstuffiness– Mogledskin– Tachypnea– Swea,ng– Yawning

NeonatalAbs,nenceSyndrome

•  Gastrointes,nalsymptoms– Feedingdifficul,es

•  Unabletoorganizetofeed•  Bi,ngnipple•  Lackofcoordina,on

– Frequentwatery/loosestools•  Leadstoskinbreakdown

– Regurgita,on– Excessivesucking– Failuretothrive

NeonatalAbs,nenceSyndrome

Substance OnsetofSymptoms

Heroin Birth–3days

Methadone/buprenorphine

Birth–7days(subacutesignsupto6months)

Benzodiazapene Hours-2weeks

NonNarco,cSubstanceExposure

•  Cocaine– Nowithdrawal

•  NEC,abrup,on,fetaldistressandIUGR

•  Alcohol– Hyperac,vity,tremors,poorsuck,hyperphagia– Sxatbirth

•  Caffeine–  Jigeriness,bradycardia,vomi,ng,tachypnea– Sxatbirthandfor1-7days

NonNarco,cSubstanceExposure

•  Barbiturates– Similartoopioids– Sxatbirthupto14days

•  SSRI’s–  Irritability,tremors,poorsuck,feedingdifficul,es,hypertonia,fever,hypoglycemia,seizures

– Sxhourstodays

NonNarco,cSubstanceExposure

•  Benzodiazapene– Similartoopioids

•  Hypo/hypertonia•  Poorsuck•  Hypothermia•  Apnea•  Tremors•  Vomi,ng•  Tachypnea

– Onsethourstoweeks

Differen,alDiagnosis

•  Sepsis– meningi,s

•  Electrolyteabnormality•  Hematologicirregulari,es•  Perinatalasphyxia•  Intracranialpathology

Diagnosis

•  History,history,history– Maternalmedical,familyandsocialhistory– Pregnancyhistory– Birthhistory

•  Labs– Cbc,bmp,+/-bloodculture(ifillappearing)– Urine/meconiumdrugscreens

•  Risk/benefitevalua,on– RarelyLPifhistoryc/wNAS

Drugtes,ng

•  IdeallyUDSfrommotheronadmission•  InfantUDS(preferablyfirstvoid)•  InfantMeconiumdrugscreen– Reflectsexposurefrom20weeksGA– Collectfirsttwosamples

•  Infanthair•  Umbilicalcord,ssue

MaternalUrineToxicology

Source:PEDIATRICSVolume129,Number2,February2012

Poten,alFalsePosi,ves

Source:PartnershipHealthPlanofCalifornia,2015

PhysicalExam

•  Hypertonicity– Globalvs.extremi,es– Headlag– Ventralsuspension

PhysicalExam

•  Skin– Mogling– Diaperarea– Excoria,on

Assessment

•  FinneganScoring– DevelopedbyDr.LoregaFinneganin1975– Providesquan,ta,veassessmentofNAS– PredominanttoolusedinUnitedStates– Usedfortermneonates<3weeksofage

UsingtheFinneganScore

•  Beginscoringwheninfantsshowsignsofwithdrawal– Scoreq3-4hours,auerfeedswheninfantatbest

•  Start“treatment”when3scores≥24or2scores≥24oronescoreof≥14

Treatment

•  Nonpharmacologic– Swaddling– Holding,rocking,swaying– Quiet,dark,nons,mula,ngenvironment– Encourageroomingin

•  Extendedfamily

BreasxeedingandNAS?

•  YES!!!–  Ifmotherisinatreatmentprogram– UDSisposi,veonlyformethadone/buprenorphine

•  AssociatedwithlesssevereNASthatpresentslaterandislesssevere

•  Lessfrequentlyrequirespharmacologicinterven,on

BreasxeedingandNAS

•  Smallamountsmethadone/buprenorphinesecretedintobreastmilk

•  Longtermneurodevelopmentalinforma,onnotavailable

•  Notenoughdatatodiscouragebreasxeeding•  Frankdiscussionwithmotheraboutslowweaning

PharmacologicTreatment

•  83%ofcliniciansintheUnitedStatesuseanopioidasthedrugoffirstchoice– MorphineorMethadone

•  Phenobarbitalismosttypicalsecond-linedrugifopiatedoesnotcontrolsymptoms

•  Clonidineasadjunc,vetherapyalsoanop,on•  Alsoconsiderusingmethadone

QualityImprovement

•  Recentlymul,plestudieshavesurfacedlookingatthecareofNAS

•  FocusondecreasedLOS– Decreasedcost

•  Standardiza,onoftreatments•  NASEduca,on•  RoomingIn

NASatAbingtonHospital

•  AbingtonHospital– 8milesnorthofPhiladelphia–  Approximately5000deliveries/year– 34bed;Level3bNICU

•  Increasingopioidexposedinfants•  NAStaskforceformedin2014

NASatAbingtonHospital

•  PreData–  June2013-June2015– 101infantswithposi,veUDS/MDS– 36infantsrequiredtreatmentwithmorphine– LOSwithNAS22.4days– LOSwithoutNAS4.1days

37

9

2

25

25

17

82

Methadone

Cocaine

PCP

Oxycodone

Opiates

MJ

Benzo's

Barbituartes

AbingtonHospital-Posi,veDrugScreen

AbingtonHosp,al–JeffersonHealthProtocol

PostData

•  July2015-May2016– 38babiesopioidexposed– 18babiestreatedforNAS– LOS16.8days

FutureDirec,ons

•  YaleNewHavenChildren’sHospital•  Standardiza,onofnonpharmacologic

care•  Parentaleduca,on•  NovelAssessmentApproach•  Morphineprn•  BypassingtheNICU

•  NovelApproachtoNAS•  Func,onalAssessment•  Abilitytoeat•  BFeffec,velyortake>1oz/feed

•  Abilitytosleep•  Undisturbed>1hour

•  Abilitytobeconsoled•  Within10minutes

•  NovelapproachtoTreatment•  Ifonscheduledmorphine•  10%weanTID

•  Auermaximumnonpharmacologicinterven,ons•  1doseofmorphinegiven(0.05mg/kg)•  Reassesed3hourslater•  Ea,ng,sleepingandconsolingwell•  Nofurtherdoses

•  55infantspreimplementa,on•  44infantspostimplementa,on–  LOS:22.4à5.9days–  PharmacologicTx:98%à14%–  Costs:$44,000à$10,000–  Noreadmissions,noadverseevents

Summary

•  Opioidaddic,oniscurrentlyanepidemic•  Pregnantwomencanbeaddicted•  NeonatalAbs,nenceSyndrome–treatmenthasbeenstablethroughtheyears

•  Breastfeedwhenable•  AssessmentchangehasnoADRs•  Nonpharmacologictreatmentisfeasible

Acknowledgements

•  NASTaskForceatAbingtonHospitalJeffersonHealth

•  MoiraWinstanley,NNP-BC•  AndrewLoh,MD

Thankyou!

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