NAS

NEONATAL ABSTINENCE SYNDROME : 

NEONATAL ABSTINENCE SYNDROME

What is NAS? : 

What is NAS? Presence of withdrawal behaviors in neonates exposed to dependency-producing substances in utero. These behaviors include central nervous hypersensitivity, gastrointestinal dysfunction and vague autonomic symptoms. 25-40 % of infants with known exposure are asymptomatic or display only mild symptoms

Substances that can cause NAS : 

Substances that can cause NAS Opiates- (55-94% of neonates exposed in utero will have withdrawal symptoms) Alcohol Tobacco Benzodiazepines Barbiturates SSRIs (neonatal behavioral syndrome) ?Amphetamines ?Cocaine ?Marijuana

Diagnosis : 

Diagnosis Maternal history of drug use Positive identification of substance in maternal or neonatal specimen Scoring Once diagnosed- consult social services

Clinical Presentation : 

Clinical Presentation Onset of symptoms varies with the substance being used by the mother, the quantity, frequency and duration of intrauterine exposure, timing and amount of the last maternal use, as well as maternal and infant metabolism and excretion CNS Tremors, irritability, increased wakefulness, high-pitched crying, hypertonicity and hyperactive reflexes, seizures, yawning, sneezing and skin excoriation Gastrointestinal Poor feeding, uncoordinated and constant suck, vomiting or regurgitation, diarrhea, dehydration Autonomic Signs increased sweating. Nasal stuffiness. Rhinorrhea, mottling, temperature instability, fever, tearing

NAS : 

NAS video clip

NASS : 

NASS Used to initiate, adjust and wean pharmacologic treatment. Scoring should begin within 4 hours after birth and continue every 4 hours until the onset of symptoms. At the onset of symptoms scoring should be done every 3 hours for 24 hours and then every 4 hours for the duration of treatment. Observation should be made after feedings, newborns must be awake and calm to asses muscle tone, respirations and Moro reflex. Newborns should be observed for 20 to 30 minutes before scoring is determined.

Management : 

Management Supportive Swaddling ( decreases the added stimulation of startled movements) Reduction of environmental stimuli ( decreased light and noise) Frequent small feeding Frequent diaper change are necessary to reduce skin excoriation Monitor intake, output and weigh daily to assess hydration and caloric status related to vomiting, diarrhea and poor feeding status. Pharmacologic intervention is indicated for evidence of acute withdrawal such as seizures, poor feeding (excess weight loss), severe diarrhea, vomiting, dehydration, inability to sleep and fever not due to any infectious etiology 3 consecutive NAS scores of 8 or more or the average of 3 consecutive NAS scores is 8 or more. or 2 consecutive NAS scores of 12 or more or the average of 2 consecutive score is 12 or more. Pediatric consult is recommended when considering pharmacologic treatment. Cardio respiratory monitoring.

Pharmacologic Therapies in Neonatal Abstinence Syndrome : 

Pharmacologic Therapies in Neonatal Abstinence Syndrome Paregoric 0.2-0.5 ml/dose q 3-4 p.o. or 4-6 drops q 4-6h; may increase by 2 drops until clinical improvement Improves most of the withdrawal symptoms especially diarrhea, taper dose by 10-20% per day over 2-4 week after symptoms stable for 3-5 days. Neonatal Opium Dilution 0.4% solution (contains 0.4 mg morphine equivalent per ml) guidelines: 0.8 ml/kg/day for NAS 8-10 1.2 ml/kg/day for NAS 11-13 1.6 ml/kg/day for NAS 14-16 2.0 ml/kg/day for NAS >16 Doses given orally every 3-4 h with feeds ( not prn) Phenobarbital 15-20 mg/kg/day loading dose to achieve level of 20-40 mg/ml. Maintenance dose =2-8 mg/kg/day. Taper dose by 10-20% per day after symptoms stable for 3-5 days. Diazepam 0.3-0.5 mg/kg q 8 h; initial dose i.m then p.o Allows rapid suppression of symptoms, decreased suck, avoid in jaundice or premature infants.

Pharmacologic Therapies in Neonatal Abstinence Syndrome : 

Pharmacologic Therapies in Neonatal Abstinence Syndrome Methadone 0.1-0.5 mg/kg/day divided q 4 to 12 h Increase by 0.05mg/kg/dose until symptoms are well controlled Taper dose by 10-20% per day over 1 mo Treatment usually longer (5 days-4 mo) Long half-life (26 h ) Chlorpromazine 0.5-0.7 mg/kg/dose loading then 2-2.8 mg/kg/day in divided doses q 6 h Decrease dose over 2-3 wk Clonidine 0.5-1 ug/kg single dose then 3-5 ug/kg/day divided dose q 4-6 h Increase by 0.5 ug/kg over 1-2 days until maintenance dose is achieved

Weaning Guidelines : 

Weaning Guidelines Once NAS are consistently 6-8, maintain the same therapeutic dose 48 hours before weaning. Wean by 10% of maximum dose every 1-2 days. If symptoms increase, return to effective dose. Therapeutic agents should be gradually decreased over a 2-6 week period. Neonatal opium solution should be weaned first, then Phenobarbital.