1. Neonatal Abstinence Syndrome
Dr Jubal John
Paediatric Fellow
Sep 2014

2. Outline
Epidemiology
Antenatal aspects of care in chemical dependent mothers
Substances and their effects
Pathophysiology and symptoms
Supportive care
Scoring and assessing severity
Pharmacological management
Breastfeeding
Discharge and ongoing care

3. Key Points
Chemical dependence in the mother may cause neonatal abstinence syndrome (NAS) in newborn.
NAS is more common in babies born to opioid dependent women.
There is limited dose-response relationship between maternal opioid intake and NAS.
Don’t administer naloxone to the baby at birth.
Assessment of risk of harm or neglect to the baby should occur throughout the pregnancy and post-natally.
 These babies are at an increased risk of harm and poor developmental outcomes due to a complex interplay of psychosocial and environmental factors.

4. Principles
The care of the opioid-dependent pregnant woman from a drug and alcohol perspective based on "Harm Minimisation" principles.
The care of the newborn from a child protection perspective

5. The numbers
7.3 million (2 in 5) Australians have used illicit drugs, 3 million in the past year.
~6% of newborns are affected by drug use (based on NSW survey data)
Estimated that 60-90% of mothers on methadone will have an infant affected by NAS
Abdel-Latif, Bajuk, Lui
et al., 2007

6. During Pregnancy
All pregnant women should be screened for substance use during pregnancy. Often motivated to change.
Can have multiple associated problems:
obstetric - prematurity, growth restriction, fetal demise
medical - asthma, epilepsy, liver disease, coronary valve disease, blood-borne virus infection, nutritional deficiencies
neonatal - prematurity, growth restriction, neonatal withdrawal, sudden infant death
other psychiatric, social, legal domestic and financial problems
Statewide secondary consultation services are available from the Women's Alcohol and Drug Service (WADS) on (03)

7. Drug effects

8. Other medications causing withdrawal
SSRI
tremor
restlessness
rigidity
myoclonus.

9. Methadone substitution
Methadone substitution for heroin use in pregnancy results in:
improved fetal growth
improved survival
less risk of prematurity
Methadone stabilisation is recommended rather than dose reduction in pregnancy.
Withdrawal from narcotics is not recommend
miscarriage in the first trimester
premature labour in the third trimester
fetal distress
death in-utero

10. Withdrawal timeframes
90% of infants will display symptoms within 96hours (4days)
But can occur past the second week postnatally.
Subacute symptoms can last 4-6months (assoc with  cannabis, opiates, sedatives and tobacco)
variable muscle tone
agitation
sleep & feeding difficulties
Specific drugs:
Heroine – short half life, usually apparent in first 24hours
Methadone – 3-7 days
SSRI/SNRI – usually first 48 hours

11. Pathophysiology Activation of opiate receptors in locus ceruleus
Decreases NE and Dopamine release
With prolonged exposure
Upregulate NE and Dopamine receptors
At Birth
Remove inhibition = Noradernergic Overcharge

12. Symptoms
Gastrointestinal dysfunction (including feeding problems, vomiting, regurgitation, diarrhoea)
Respiratory symptoms (such as sneezing, yawning, tachypnoea);
CNS: mottling; fever; tremors; high-pitched cry and increased muscle tone.
The infant may also experience, sleep-wake abnormalities, dehydration, poor weight gain and occasionally seizures.
Can mimic sepsis, hypoglycaemia, hypcalcaemia

13. Supportive care First line of management quiet setting breastfeeding
use of a pacifier (if parents give consent)
small frequent feeds
cuddling
swaddling
close skin contact

15. Scoring
Finnegan scoring
Severity
Response to tx

18. Pharmacotherapy Morphine Phenobarbitone Opioid dependent mother
Babies need apnoea monitor
Overdosing: abdominal distention, constipation and respiratory depression
Phenobarbitone
Used concurrently when morphine not adequate
Non-opioid (esp benzodiazepine) or unknown maternal drugs

19. Morphine
Decrease dose interval before increasing total dose.
Once abstinence has been controlled (three consecutive scores less than 8) the following should be implemented:
maintain control for 72 hours
initiate the detoxification process by decreasing the total daily dose by 10% of maximum dose every hours
when dosage levels reach mg/kg/day - maintain this dose for 72 hours prior to ceasing all medication
when oral morphine treatment is discontinued, NAS scoring should continue for a further 72 hours
Give the morphine before the feed. If baby has a large vomit after being given morphine:
re-dose if vomits within 10 minutes of dose,
give half dose if vomits between minutes after dose,
do not give further morphine if baby vomits more than 30 minutes after feed, (always err on side of caution)

20. Morphine
Give the morphine before the feed. If baby has a large vomit after being given morphine:
Re-dose if vomits within 10 minutes of dose,
Give half dose if vomits between minutes after dose,
Do not give further morphine if baby vomits more than 30 minutes after feed, (always err on side of caution)
Ensure baby is not overfed

21. Phenobarbitone
Once NAS symptoms have been assessed as controlled (three consecutive scores less than 8) for 48 hours, then phenobarbitone dose should be reduced by 2mg per dose every 4th day or longer until less than 2mg/kg/day, depending on paediatric assessment of clinical condition.

22. Breastfeeding Generally encouraged but contraindicated in:
HIV, or Hep C with bleeding nipples
Safe to breastfeed on methadone

23. Discharge Feeding and growing
Completed period of monitoring and there are no signs of continuing significant withdrawal. There is a significant risk of unsupervised withdrawal occurring at home if infants are discharged earlier than 7 days, particularly if mother is on methadone.
The infant requiring medical therapy for withdrawal has been off all medication for at least 72 hours.
Safe home: Any child protection issues and significant parental issues (eg suitable accommodation) have been appropriately addressed.
The infant should have early medical follow up (within 2 weeks of discharge) and have early and regular review by domiciliary/maternal and child health nurses.

24. Continuing care

25. References/Useful resources
Royal Womens’ Hospital neonatal handbook
Neontal eHandbook: