NEONATAL ABSTINENCE SYNDROME (NAS)

NEONATAL ABSTINENCE SYNDROME (NAS) : 

NEONATAL ABSTINENCE SYNDROME (NAS) Dr Samarnath Sen Staff Grade Paediatrician Doncaster Royal Infirmary

Definition : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 2 Definition Generalized disorder in neonates presenting a clinical picture of CNS hyperirritability, gastrointestinal dysfunction, respiratory distress and vague autonomic symptoms caused by maternal drug abuse.

Clinical Presentations : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 3 Clinical Presentations Onset of symptoms varies with the drug being used by the mother, the quantity, frequency, and duration of intrauterine exposure, and the timing of the withdrawal (last dose prior to delivery) Symptoms begin to appear during the first 24 to 48 hours of life, although in some instances symptoms may not appear until day 5 to 10 Withdrawal from methadone, because of its longer half life, tends to appear later when compared to symptoms of withdrawal from heroin

Symptoms & Signs : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 4 Symptoms & Signs

Neonatal Abstinence Scoring : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 5 Neonatal Abstinence Scoring Indication: Positive maternal toxicology screen. Maternal history of drug use. Positive toxicology screen on the infant (urine toxicology , meconium and breast milk may also be evaluated).

Scoring system : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 6 Scoring system Loretta Finnegan, et al ’Finnegan Score' Treatment decisions should be based on daily average scores or a trend in scores over 24 to 48 hours. Score >12 on 3 or more consecutive occasions

Management : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 7 Management While up to 90% of newborns exposed to narcotics during foetal life have some symptoms, only 50 to 75% will require treatment. Hepatitis B,Hepatitis C & HIV status ? Breast or Formula ? Duration of stay?

Non pharmacological treatment : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 8 Non pharmacological treatment Swaddling Frequent small feedings Hypercaloric formula Observation - sleeping habits - temperature stability - weight gain/loss - change in status (symptoms)

Pharmacologic management : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 9 Pharmacologic management Morphine sulphate (MS) Advantages Oral administration Inhibition of gut motility Low level of sedation improves effectiveness of sucking Increases nutrient consumption Effective in treating seizures secondary to withdrawal Disadvantages Large dose required Long withdrawal period

Pharmacologic management : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 10 Pharmacologic management Phenobarbital Advantages non-specific CNS depression controls irritability and insomnia Disadvantages little to no effect on G. I. symptoms not effective in treating seizures secondary to withdrawal impairs suck reflex large dose required to achieve desired effect(s) and toxicity/efficacy levels are quite close. Need to monitor levels using blood samples

Pharmacologic management : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 11 Pharmacologic management Diazepam Advantages safe rapid suppression of symptoms Disadvantages interferes with sucking reflex marked sedation contraindicated if patient is hyperbilirubinemic elimination may continue for more than 4 weeks questionable efficacy

Pharmacologic management : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 12 Pharmacologic management Chlorpromazine Advantages decreases CNS symptoms very efficacious for G. I. symptoms Disadvantages contraindicated in newborns with elevated bilirubin prolonged excretion (reported to be as long as 18 months)

Follow Up of Babies : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 13 Follow Up of Babies Community Midwife Paediatrics Hepatitis B & Hepatitis C Social Services ? GP

Outcome : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 14 Outcome Intrauterine exposure to narcotics causes passive addiction (NAS) as well as smaller birth weight and head circumference. Despite the host of negative factors there is little evidence that the prenatal exposure results in cognitive deficits for the affected newborns.

THANK YOU : 

29/10/2010 Dr.Samarnath Sen/Neonatal Meeting 15 THANK YOU