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Outreach Education

Online Video Library 2009-2010 .........................................................................................................

Drug Affected Infants

. Jaime Ruddell, MN, ARNP, NNP-BC

February 4, 2010

.........................................................................................................

Program Handouts This information is provided as a courtesy by Children's Health Care System and its related organizations (CHCS). Persons accessing this information assume full responsibility for the use of the information and understand and agree that CHCS is not responsible or liable for any claim, loss or damage arising from the use of the information. The views and opinions of the document authors do not necessarily state or reflect those of CHCS. Neither the authors nor CHCS nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.

Marianne Gonterman -Outreach Education (206) 987-5318 or (800) 293-2462 ext. 2 marianne.gonterman@

seattlechildrens.org

mailto:[email protected]

mailto:[email protected]


Slide 1

Neonatal Abstinence Syndrome: Neonatal Abstinence Syndrome:

Evaluation and ManagementEvaluation and Management

Jaime Ruddell, RNC, NNP, MSNJaime Ruddell, RNC, NNP, MSN

Seattle ChildrenSeattle Children’’s Hospitals Hospital

Slide 2

Disclosure Statement

• I do not have any conflict of interest or will be discussing any off-label product use.

• This class has no commercial support or sponsorship, nor is it co-sponsored.

Slide 3 ObjectivesObjectives

•• Discuss Drug effects in PregnancyDiscuss Drug effects in Pregnancy

•• Define Neonatal Abstinence Syndrome (NAS) Define Neonatal Abstinence Syndrome (NAS) and its common presentation.and its common presentation.

•• Describe the use of Finnegan assessment toolDescribe the use of Finnegan assessment tool

•• Discuss alternative/supportive therapy for Discuss alternative/supportive therapy for withdrawalwithdrawal

•• Discuss Pharmacological interventions; when Discuss Pharmacological interventions; when should you treatshould you treat

•• Discuss process for weaning infants of NASDiscuss process for weaning infants of NAS

•• Should mothers be allowed to breastfeed the Should mothers be allowed to breastfeed the withdrawing infant?withdrawing infant?

•• What is known about long term outcomes?What is known about long term outcomes?


Slide 4

Presentation of Withdrawal

Slide 5

Drugs in Pregnancy: Drugs in Pregnancy: TobaccoTobacco

•• Multiple effects: Poor growth and delayed Multiple effects: Poor growth and delayed

development development

•• May be related to increased risk of SIDS?May be related to increased risk of SIDS?

•• Maternal smoking + narcotic addiction = Maternal smoking + narcotic addiction =

increased NAS effectsincreased NAS effects

Slide 6

Drugs in Pregnancy: Drugs in Pregnancy: AlcoholAlcohol

•• 10% pregnant women use alcohol10% pregnant women use alcohol

•• Damages architecture, neuronal migration, Damages architecture, neuronal migration,

synaptogenesissynaptogenesis of developing brainof developing brain

•• Fetal Alcohol Syndrome (FAS); Fetal Fetal Alcohol Syndrome (FAS); Fetal

Alcohol Effects (FAE)Alcohol Effects (FAE)

–– Growth deficiencyGrowth deficiency

–– Facial abnormalitiesFacial abnormalities

–– CNS Damage/DysfunctionCNS Damage/Dysfunction


Slide 7

Drugs In Pregnancy: Drugs In Pregnancy: CocaineCocaine

•• Psychoactive stimulantPsychoactive stimulant

•• Pregnancy effects:Pregnancy effects:

–– Stillbirth, prematurity, placental abruption, Stillbirth, prematurity, placental abruption,

IUGR, maternal anemia & malnutritionIUGR, maternal anemia & malnutrition

–– Neonatal neurobehavioral effectsNeonatal neurobehavioral effects

–– Hypertonic, irritable, tremulous, seizuresHypertonic, irritable, tremulous, seizures

NOT NOT ――withdrawalwithdrawal‖‖

Slide 8 Drugs In Pregnancy:Drugs In Pregnancy:

MethamphetaminesMethamphetamines

•• MethamphetamineMethamphetamine

•• Psychoactive stimulant; similar to cocainePsychoactive stimulant; similar to cocaine

•• Increased incidence of preterm delivery Increased incidence of preterm delivery

and placental abruptionand placental abruption

•• More likely to be SGA; LBWMore likely to be SGA; LBW

•• ?Increased fetal and maternal blood ?Increased fetal and maternal blood

pressurepressure

Slide 9

Drugs in Pregnancy: Drugs in Pregnancy: NarcoticsNarcotics

•• Attaches to Attaches to opioidopioid receptors on neuronal cell receptors on neuronal cell

membranes to inhibit neurotransmission of membranes to inhibit neurotransmission of

excitatory pathways: excitatory pathways:

--AcetylcholineAcetylcholine

--CatecholamineCatecholamine

--SerotoninSerotonin

•• Withdrawal results in increased Withdrawal results in increased

neurotransmitter releaseneurotransmitter release-- NASNAS


Slide 10

Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome

•• A generalized disorder that arises in an A generalized disorder that arises in an infant born addicted to narcotics or other infant born addicted to narcotics or other addictive substances, marked by a group addictive substances, marked by a group of common symptoms.of common symptoms.

•• Symptoms of withdrawal may include poor Symptoms of withdrawal may include poor gastrointestinal disposition, metabolic, gastrointestinal disposition, metabolic, vasomotor, and respiratory disturbances vasomotor, and respiratory disturbances as well as central nervous system as well as central nervous system disturbances.disturbances.

Slide 11 IncidenceIncidence

•• 33--50% depending on population 50% depending on population

•• OpioidOpioid withdrawal occurs in 55withdrawal occurs in 55--94% of infants 94% of infants

born to mothers addicted to narcotics born to mothers addicted to narcotics

•• Historical TrendsHistorical Trends

•• Current TrendsCurrent Trends

•• National Household Survey on DrugsNational Household Survey on Drugs

Slide 12

Presentation of Opiate withdrawalPresentation of Opiate withdrawal

•• Neurologic ExcitabilityNeurologic Excitability--tremorstremors

--irritability irritability

--sleeplessness sleeplessness

--high pitched cryhigh pitched cry

--hypertoniahypertonia

--increased deep tendon increased deep tendon reflexesreflexes

--exaggerated Moroexaggerated Moro

--seizures seizures 66

--frequent yawning and frequent yawning and sneezingsneezing


Slide 13

Presentation of Opiate WithdrawalPresentation of Opiate Withdrawal

•• Gastrointestinal Gastrointestinal DysfunctionDysfunction

--poor feeding poor feeding

--uncoordinated and uncoordinated and constant suckingconstant sucking

--vomitingvomiting

--Diarrhea Diarrhea

--Dehydration Dehydration

--Poor weight gainPoor weight gain

Slide 14

Presentation of Opiate withdrawalPresentation of Opiate withdrawal

•• Autonomic SignsAutonomic Signs

--Increased Sweating Increased Sweating

--nasal stuffinessnasal stuffiness

--FeverFever

--Mottling Mottling

--Temperature InstabilityTemperature Instability

Slide 15 Timing of WithdrawalTiming of Withdrawal

•• AlcoholAlcohol-- first 3first 3--12 hours after birth12 hours after birth

•• Narcotic Withdrawal (methadone Narcotic Withdrawal (methadone vsvsother)other)-- 4848--72 hours after birth??? (may be 72 hours after birth??? (may be later if BF)later if BF)

•• SedativeSedative--HypnoticsHypnotics-- 22--3 days after birth 3 days after birth (up to as late as 12(up to as late as 12--14 days)14 days)


Slide 16

Timing of WithdrawalTiming of Withdrawal

•• BarbituratesBarbiturates-- 44--7 days of life7 days of life

•• TobaccoTobacco-- first few hours of life and can be first few hours of life and can be severesevere

•• HeroinHeroin-- usually within 24 hours usually within 24 hours

•• Buprenorphine/SubutexBuprenorphine/Subutex within 12within 12--48 48 hourshours

Slide 17

The Antepartum Interview

Slide 18 The Reality of Drug Histories:The Reality of Drug Histories:

PolydrugPolydrug UseUse

•Abuse May Be Any Combination of Drugs- worsening withdrawal symptoms

•Abuse of prescribed Drugs

•Methadone Maintenance &/or Abuse


Slide 19 Know What Drugs are Popular in Your Town?

Slide 20

Drug History: You have to ask.

•Smoking Hx - How Many Cigarettes Do You Smoke Per Day?

•ETOH - How Many Drinks Do You Take Per Day?

•What OTC Drugs Do You Use?

•What Prescription Drugs Used?

Slide 21 Drug History Interview

•What Street/Recreational Drugs Have You Used?

•Are You in a Methadone Maintenance Program?Do You Supplement With Street Methadone?

Do you have periods of time when you feel the need for higher or supplemental dosing?

What do you do in that case?

Have You Experience Periods of Narcotic Withdrawal?

•Immediate Antepartum Drug Use:Types, Dosage, Timing and Routes


Slide 22 The Perinatal Intake Exam

• Common symptoms of a Woman Abusing Drugs…Is She…

Disoriented?

Physically Exhausted?

Pupils Extremely Dilated Or Constricted?

Does The Appearance Of The Pregnancy Coincide With The Stated Gestational Age?

Track Marks, Abscesses, ―picking sores‖?

Sinus Inflammation, Excoriation, Or Eroded Septum?

Does The Woman Appear Honest In Her Responses?

Gum and dental health

Slide 23 Reason to consider Reason to consider

Maternal Drug ScreeningMaternal Drug Screening

•• Lack of, or unexplained, late prenatal careLack of, or unexplained, late prenatal care

•• Previous unexplained fetal demisePrevious unexplained fetal demise

•• AbruptioAbruptio placentaplacenta

•• Hypertensive episodeHypertensive episode

•• Severe mood swingsSevere mood swings

•• CerebrovascularCerebrovascular accidents, MIaccidents, MI

•• Repeated spontaneous abortionsRepeated spontaneous abortions

Slide 24 Reasons to consider Reasons to consider

Neonatal Drug ScreeningNeonatal Drug Screening

•• Unexplained prematurityUnexplained prematurity

•• SeizuresSeizures

•• Severe Vomiting/DiarrheaSevere Vomiting/Diarrhea

•• Excessive weight loss/dehydrationExcessive weight loss/dehydration

•• Unexplained intrauterine growth restrictionUnexplained intrauterine growth restriction

•• Neurobehavioral abnormality Neurobehavioral abnormality

•• Atypical vascular accidents such as CVA, Atypical vascular accidents such as CVA, MI, and NEC in otherwise healthy term MI, and NEC in otherwise healthy term infantsinfants


Slide 25

Differential DiagnosisDifferential Diagnosis

•• Withdrawal signs may be mistaken for Withdrawal signs may be mistaken for

other common neonatal problems such asother common neonatal problems such as-- ColicColic

-- Infection/MeningitisInfection/Meningitis

-- Feeding or formula intoleranceFeeding or formula intolerance

-- Milk intoleranceMilk intolerance

-- Evidence of Hypoxic ischemic encephalopathyEvidence of Hypoxic ischemic encephalopathy

-- HypocalcaemiaHypocalcaemia

-- HyponatremiaHyponatremia

-- HypomagnesaemiaHypomagnesaemia

When in doubt, a urine and When in doubt, a urine and MeconiumMeconium drug screen drug screen maymaybe helpful, but identification of infants at risk is be helpful, but identification of infants at risk is cruciacrucial.l.

Slide 26

MeconiumMeconium and Urine Drug Testingand Urine Drug Testing

•• MeconiumMeconium-- obtain multiple samples, large quantityobtain multiple samples, large quantity

•• Reflects second half of pregnancyReflects second half of pregnancy

•• UrineUrine-- Obtain earlyObtain early

•• May result in false negativesMay result in false negatives

•• Earliest newborn urine will contain the highest Earliest newborn urine will contain the highest

concentration of substancesconcentration of substances

•• Newborn urine reflects exposure during preceding one to Newborn urine reflects exposure during preceding one to

three daysthree days

•• Cocaine metabolites may be present for 4Cocaine metabolites may be present for 4--5 days; 5 days;

marijuana for weeksmarijuana for weeks

•• Alcohol is nearly impossible to detectAlcohol is nearly impossible to detect

Slide 27

Treating Neonatal Abstinence Syndrome


Slide 28

AAP Recommendations• The goal to NAS treatment is to:

improve feeding and weight gain

prevent seizures

reduce unnecessary hospitalization

improve family interaction/care skills

reduce incidence infant mortality and abnormal neurological development

(AAP, 1998) (Osborne et al 2005) (Kandall, 1993)

Slide 29

Tools to assess WithdrawalTools to assess Withdrawal

•• LipsitzLipsitz Tool; simple; score >4= withdrawalTool; simple; score >4= withdrawal

•• Finnegan; complex , most widely usedFinnegan; complex , most widely used(1975)(1975)

•• OstreaOstrea; numeric score; numeric score

•• Neonatal Narcotic Withdrawal Neonatal Narcotic Withdrawal IndexIndex(Grear(Grear and and SuffetSuffet, ,

1975)1975)

•• Opiate Weaning Flow SheetOpiate Weaning Flow Sheet (Frank and (Frank and ViardiViardi, 1995), 1995)

•• OpioidOpioid and Benzodiazepine withdrawal Scoreand Benzodiazepine withdrawal Score(Frank, (Frank, NaughtonNaughton and Winter, 2004)and Winter, 2004)

Slide 30

Finnegan Assessment ToolFinnegan Assessment Tool


Slide 31 1 2 3

Time

Signs & Symptoms Score

High Pitched Cry 2

Continuous High Pitched

Cry

3

Sleeps <1 Hour After Feed 3

Sleeps < 2 Hours After

Feed

2


Feed

1

Hyperactive Moro Reflex 2

Mild Tremors When

Disturbed

1

Marked Tremors When

Disturbed

2

Mild Tremors Undisturbed 3

Marked Tremors

Undisturbed

4

Increased Muscle Tone 2

Generalized Seizures 5

Frantic Fist Sucking 1

Poor Feeding 2

Regurgitation 2

Projectile Vomiting 3

Loose Stools 2

Watery Stools 3

Dehydration 2

Frequent Yawning 1

Sneezing 1

Nasal Stuffiness 1

Sweating 1

Mottling 1

Fever < 101F (38°c) 1

Fever > 101F (38°c) 2

Resp Rate > 60 1

Resp Rate > 60 with Retrx 2

Excoriation Nose 1

Excoriation Knees 1

Excoriation Toes 1

Date

Auto

nom

ic D

istu

rban

ceN

euro

logi

cGI

Dis

turb

ance

Slide 32

Finnegan: GI Disturbance

Frantic Fist Sucking 1

Poor Feeding 2

Regurgitation 2

Projectile Vomiting 3

Loose Stools 2

Watery Stools 3

Dehydration 2GI D

istu

rb

an

ce

Slide 33

Finnegan: NeurologicHigh Pitched Cry 2

Continuous High Pitched

Cry

3

Sleeps <1 Hour After Feed 3


Feed

2


Feed

1

Hyperactive Moro Reflex 2

Mild Tremors When

Disturbed

1

Marked Tremors When

Disturbed

2

Mild Tremors Undisturbed 3

Marked Tremors

Undisturbed

4

Increased Muscle Tone 2

Generalized Seizures 5

Ne

uro

log

ic


Slide 34

Finnegan; Autonomic

Frequent Yawning 1

Sneezing 1

Nasal Stuffiness 1

Sweating 1

Mottling 1

Fever < 101F (37-38°c) 1

Fever > 101F (38°c) 2

Resp Rate > 60 1

Resp Rate > 60 with Retrx 2

Excoriation Nose 1

Excoriation Knees 1

Excoriation Toes 1

Au

ton

om

ic D

istu

rba

nce

Slide 35

Slide 36

Lipsitz Assessment ToolAdapted from Lipsitz et al. Clin Pediatr 14:592-594, 1975


Slide 37 Symptom Date

AM/PM

Date

AM/PM

Date

AM/PM

Date

AM/PM

Date

AM/PM

Date

AM/PM

Date

AM/PM

Date

AM/PM

Tremors

Reflexes

Irritability

Stools

Muscles tone

Abrasions

Resp. Rate

Sneezing

Yawning

Vomiting

Fever

Total Score

Slide 38 0-normal 1=Minimal Increase

2= moderate inc disturbed

3= marked continuous increase

Tremors

Irritability

Reflexes

Stools >8 x/day

Muscle Tone Rigidity

Skin Abrasions

Redness Break in skin

RR/min <55 55-75 76-95

Sneezing no yes

Vomiting no yes

fever no yes

Slide 39 Initial Supportive TherapyInitial Supportive Therapy

Always implement first and continue as an Always implement first and continue as an adjunct to pharmacological therapy!adjunct to pharmacological therapy!

•• Tight swaddling to decrease sensory Tight swaddling to decrease sensory stimulation.stimulation.

•• Consistent Rocking or swingingConsistent Rocking or swinging

•• NonNon--nutritive suckingnutritive sucking

•• Frequent small feedings (higher calorie?)Frequent small feedings (higher calorie?)

•• Observation and support of sleeping habits, Observation and support of sleeping habits, temperature stability, weight gain or loss.temperature stability, weight gain or loss.

•• May need IVF for hydration and or electrolyte May need IVF for hydration and or electrolyte replacementreplacement


Slide 40

Treatment OptionsTreatment Options

•• Supportive CareSupportive Care

•• MorphineMorphine-- recommendedrecommended

•• PhenobarbitalPhenobarbital

•• AtivanAtivan

•• Tincture of OpiumTincture of Opium

•• Paregoric (not recommended Paregoric (not recommended d/td/t toxic toxic

effects of additives)effects of additives)

Slide 41 MorphineScore 8-10

320 micrograms/kg/daily

Scores 11-13


Scores 14-16


Scores 17+


• Benefits

• Pitfalls

• Length and efficacy of therapy

Slide 42

PhenobarbitalPhenobarbital

Load with PhenobarbitalLoad with Phenobarbital

1010--20mg/kg x 1 dose20mg/kg x 1 dose

MaintenanceMaintenance

5mg/kg/day divided into two doses5mg/kg/day divided into two doses

•• BenefitsBenefits

•• DownfallsDownfalls

•• Long Term OutcomesLong Term Outcomes


Slide 43 AtivanAtivan

Load with Load with AtivanAtivan

0.050.05--0.1mg/kg/dose q 6 hours0.1mg/kg/dose q 6 hours

Increase by 0.02mg/kg/dose to desired Increase by 0.02mg/kg/dose to desired

effect effect (increase as needed every 12 hours)(increase as needed every 12 hours)




Slide 44 MethadoneMethadone

Start with 0.05Start with 0.05--0.1mg/kg every 6 hours0.1mg/kg every 6 hours

Increase by 0.02mg/kg/dose to desired Increase by 0.02mg/kg/dose to desired

effecteffect(increase as often as every 12 hours)(increase as often as every 12 hours)




Slide 45

Weaning NAS Therapy


Slide 46 Weaning NAS TherapyWeaning NAS Therapy

MorphineMorphine•• Target Score for Target Score for ――ControlControl‖‖

–– Consistent scores Consistent scores >12>12, consider increasing , consider increasing

pharmacologic therapypharmacologic therapy

–– Consistent scores Consistent scores 77--1111, Adequate Therapy, Adequate Therapy

–– Consistent scores Consistent scores <7<7, consider slow weaning , consider slow weaning

protocolprotocol

Slide 47 Weaning By ProtocolWeaning By Protocol

•• Stabilize With Scores < 11 for 72 HoursStabilize With Scores < 11 for 72 Hours

•• Decrease Dose by 10% of Decrease Dose by 10% of MaximumMaximum Narcotic Dose Narcotic Dose

(Do Not Adjust for Weight Gain)(Do Not Adjust for Weight Gain)

•• Wean Dose Q 48Wean Dose Q 48--72 Hours As Tolerated72 Hours As Tolerated

•• If Scores Increase After Wean Increase to Last If Scores Increase After Wean Increase to Last

Successful DoseSuccessful Dose

•• Trial DC Narcotic at 40mcg every 3 hours Trial DC Narcotic at 40mcg every 3 hours

•• ? DC Home on Narcotic, With the Family Scoring the ? DC Home on Narcotic, With the Family Scoring the

InfantInfant

Wean 20% Wean 20% maxmax dose per Week (very slow dose per Week (very slow

stable weaning pattern) (dose changes twice stable weaning pattern) (dose changes twice

weekly)weekly)

Family & PCP Score the InfantFamily & PCP Score the Infant

Slide 48 Home Weaning Schedule

Wean Date

Max dose 500 mcg Narcotic Dilution 0.4mg mg/1ml

Dose Directions

PO Q4°

Plan revised 8/22/03

8/21/03 380 mcg=0.95ml By mouth every 4 hours








9/18/03 Discontinue Narcotic -------------


Slide 49

Weaning Strategies

•• Utilize the Family/Volunteers as much as Utilize the Family/Volunteers as much as

possiblepossible

•• SystematicSystematic

•• Dynamic and flexible related to the infants Dynamic and flexible related to the infants

response.response.

•• Concrete Administration scheduleConcrete Administration schedule

•• Consistent, Unbiased AssessmentConsistent, Unbiased Assessment

Slide 50 Obstacles to WeaningObstacles to Weaning

•• Gestational ageGestational age

•• Chronological ageChronological age

•• SensitivitySensitivity

•• Availability of Breast MilkAvailability of Breast Milk

•• Presence of the FamilyPresence of the Family

•• Differentiating between Differentiating between

irritable irritable ――newbornnewborn‖‖ activity activity

and withdrawaland withdrawal

Slide 51

Rules for WeaningRules for Weaning

•• Choose a toolChoose a tool

•• Monitor Carefully and Monitor Carefully and ConsistetnlyConsistetnly

•• Review documented responses to the doseReview documented responses to the dose

•• Be willing to adjust the dose/weaning Be willing to adjust the dose/weaning

schedule based on responseschedule based on response

•• Utilize the FamilyUtilize the Family


Slide 52

WeaningWeaning

•• Most sources recommend 10Most sources recommend 10--20% of 20% of

original dose every other day.original dose every other day.

•• Find a pattern that works, and donFind a pattern that works, and don’’t t

change it unless necessary.change it unless necessary.

•• Choose an end pointChoose an end point

Slide 53

Slide 54

Breastfeeding the Addicted Infant


Slide 55 Breastfeeding on MethadoneBreastfeeding on Methadone

•• 73% of Infants in New Zealand continue to 73% of Infants in New Zealand continue to

BF during wean and through discharge.BF during wean and through discharge.

•• Women on Methadone, who are eligible to Women on Methadone, who are eligible to

BF, may need increased lactation support.BF, may need increased lactation support.

•• Ensure a consistent supply of Breast milk at Ensure a consistent supply of Breast milk at

every feeding.every feeding.

•• May help the mother feel a sense of May help the mother feel a sense of ――helping helping

―― the baby.the baby.

•• May encourage more regular visits and May encourage more regular visits and

supportive measures.supportive measures.

Slide 56

Outcomes

Slide 57 Drugs in Pregnancy:Drugs in Pregnancy:

Contributors to Neonatal OutcomeContributors to Neonatal Outcome

•• Drug withdrawalDrug withdrawal

•• PolyPoly--drug usedrug use

Other contributors to outcomeOther contributors to outcome

•• PovertyPoverty

•• Maternal depressionMaternal depression

•• Poor maternal nutritionPoor maternal nutrition

•• Neglect; abuseNeglect; abuse


Slide 58 DrugDrug--exposed infants:exposed infants:

Pediatric OutcomesPediatric Outcomes

•• Increased risk for SIDS?Increased risk for SIDS?

•• NeurobehavioralNeurobehavioral——Increased risk for Increased risk for

ADHD, learning disabilities, autism?ADHD, learning disabilities, autism?

•• Social Stigma/LabelsSocial Stigma/Labels

•• SelfSelf--fulfilling propheciesfulfilling prophecies

•• UnUn--adoptable?adoptable?

•• Increased risk for child abuse, neglectIncreased risk for child abuse, neglect

Slide 59 Research StatementsResearch Statements

•• Research shows that despite Research shows that despite

exposure to illicit drugsexposure to illicit drugs, kids have, kids have

the capability to do well if raised in athe capability to do well if raised in a

supportive nurturing environment. supportive nurturing environment.

(Marcellus, 2007)(Marcellus, 2007)

•• Illicit drug exposure is not as bad as poverty on Illicit drug exposure is not as bad as poverty on neurodevelopmentalneurodevelopmental outcomes. outcomes.

•• The greatest impediment to cognitive The greatest impediment to cognitive development in children is not drug use, but development in children is not drug use, but poverty. poverty.

Slide 60

Long Term OutcomesLong Term Outcomes

•• Behavioral Disturbances Behavioral Disturbances

•• Poor emotional state control Poor emotional state control

•• Brief attention span Brief attention span

•• Temper Outbursts Temper Outbursts

•• Leaning disabilities Leaning disabilities

•• Delayed speech Delayed speech

•• Developmental delayDevelopmental delay


Slide 61 Discharge Plans and Follow upDischarge Plans and Follow up

•• Discharge once baby has been stabilized Discharge once baby has been stabilized medically and socially.medically and socially.

•• A plan is in place to monitor and address any A plan is in place to monitor and address any child protection issueschild protection issues

•• Referral to appropriate community support Referral to appropriate community support agenciesagencies

•• Infants of Infants of OpioidOpioid using mothers have been using mothers have been monitored for monitored for minimumminimum 48 hours48 hours

•• The infant must be monitored for adequate The infant must be monitored for adequate weight gain and intakeweight gain and intake

•• A plan is in place for long term follow up and A plan is in place for long term follow up and evaluation. evaluation.

Slide 62

References

Slide 63

ReferencesReferences

1.1. Committee on Drugs (1998) Neonatal Drug Withdrawal, Committee on Drugs (1998) Neonatal Drug Withdrawal, Pediatrics, Vol.101, no.6Pediatrics, Vol.101, no.6

2.2. HadeedHadeed, A.J., Siegel, S.R. Maternal cocaine use during pregnancy: , A.J., Siegel, S.R. Maternal cocaine use during pregnancy: effect on the newborn infant. Pediatrics.1989;84:205effect on the newborn infant. Pediatrics.1989;84:205--210.210.

3.3. Dicker, M., Leighton, E.A. 1991. Trends in diagnosed drug Dicker, M., Leighton, E.A. 1991. Trends in diagnosed drug problems among newborns. Drug and Alcohol dependency. 28: problems among newborns. Drug and Alcohol dependency. 28: 151151--165.165.

4.4. FrickerFricker, H.S., Segal, S. 1978. Narcotic , H.S., Segal, S. 1978. Narcotic adictionadiction, pregnancy, and , pregnancy, and the newborn. the newborn. The American Journal of Disabled Children. 132: The American Journal of Disabled Children. 132: 360360--366366..

5.5. Adams, E.H., Adams, E.H., GfroererGfroerer, J.C., Rouse, B.A. 1989. Epidemiology of , J.C., Rouse, B.A. 1989. Epidemiology of substance Abuse including alcohol and cigarette smoking. substance Abuse including alcohol and cigarette smoking. Annals Annals of New York Academy of Science. 562; 14of New York Academy of Science. 562; 14--20.20.


Slide 64

ReferencesReferences6.6. DoberczakDoberczak, T.M., , T.M., KandallKandall, S.R., Friedman, P. 1993. Relationships , S.R., Friedman, P. 1993. Relationships

between maternal methadone dosage, maternalbetween maternal methadone dosage, maternal--neonatal neonatal methadone dosage, maternal methadone levels and neonatal methadone dosage, maternal methadone levels and neonatal withdrawal. Obstetrics and withdrawal. Obstetrics and GynocolgyGynocolgy. 81; 936. 81; 936--940.940.

7.7. KandallKandall, S.R., , S.R., DoberczakDoberczak, T.M., , T.M., MauerMauer, K.R., , K.R., StrashumStrashum, R.H., , R.H., KortsKorts, , D.C. 1983. Opiate D.C. 1983. Opiate vsvs CNS depressant therapy in neonatal drug CNS depressant therapy in neonatal drug abstinence syndrome. American abstinence syndrome. American JounrnalJounrnal Diseases in Children. 137; Diseases in Children. 137; 378378--382.382.

8.8. Substance Abuse and Mental Health Services Administration, OfficSubstance Abuse and Mental Health Services Administration, Office e of Applied Studies. (2004) National Survey on drug use and healtof Applied Studies. (2004) National Survey on drug use and health: h: National Findings. Washington, DC. U.S. Department of Health andNational Findings. Washington, DC. U.S. Department of Health andHuman Services. Human Services.

9.9. Blackburn, S. (2003). Maternal, fetal, and neonatal physiology: Blackburn, S. (2003). Maternal, fetal, and neonatal physiology: A A clinical perspective (2clinical perspective (2ndnd ed., pp180ed., pp180--212). St. Louis: WB Saunders.212). St. Louis: WB Saunders.

10.10.OsbourneOsbourne, D., Cole, M, Jeffry, H. (2005) Opiate treatment for , D., Cole, M, Jeffry, H. (2005) Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database of opiate withdrawal in newborn infants. Cochrane Database of Systemic Reviews, 3, CD002059.Systemic Reviews, 3, CD002059.

Slide 65


11.11.Finnegan, L.P., Finnegan, L.P., ConnaughtonConnaughton, J.F. Jr, , J.F. Jr, KronKron, R.E. & , R.E. & EmichEmich, J. (1975). , J. (1975).

Neonatal Abstinence Syndrome: Assessment and Management. Neonatal Abstinence Syndrome: Assessment and Management.

Addictive Diseases, 2, 141Addictive Diseases, 2, 141--158.158.

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