1. NEONATAL ABSTINENCE SYNDROME
Assessment, Identification and Treatment
Kate Colvin RNC-OB, C-EFM, LCCE, BSN

2. OPIUM: “THE PLANT OF JOY”
Known for euphoric effects for over 6000 years
Used in Ancient Egypt for religious rituals, painless death, and to calm children
Medical uses: treating pain (headache, cramps)
respiratory issues (asthma, cough)
infections (fever, leprosy)
mental problems (melancholy)
As opium use spread throughout Europe and China, so did it’s abuse and addiction

3. MORE POTENT IS LESS ADDICTIVE?
Theory: if potency is increased, less drug is needed, resulting in less addiction
Morphine was isolated from opium in 1803
Has 10x the euphoric effect of opium
Used as a treatment for opium addiction, pain relief, and alcoholism
Proved to be just as addictive as opium, so the search continued for an opium derivative that would not cause addiction

4. HEROIN 1898: derivative of morphine developed at Bayer lab in Germany
2-5x more potent than morphine
Named heroin, from the German heroisch, meaning heroic, strong
Marketed in the early 1900s as an over-the-counter treatment for colds, sore throats, pneumonia, and tuberculosis
Believed to be safe for pregnant women and infants
Proposed as a treatment for morphine addiction

5. MORE POTENT IS NOT LESS ADDICTIVE
Early 1900s: Opiate addiction skyrocketed
Public perception: opiate addiction was better than alcoholism
Poor governmental regulation of the sale and distribution of narcotics
300,000 addicts, with 2/3 being women

6. METHADONE AND BUPRENORPHINE
1946: Synthesis of methadone for use as a maintenance med for opiate addiction programs, including treatment of pregnant opiate addicts
Late 1950’s: Term “opioid” refers to synthetic narcotics
1966: Buprenorphine discovered, less addictive than methadone
1985: Buprenorphine approved by the FDA, but only approved for use in opioid treatment programs until 2000 (Drug Addiction Treatment Act)

7. OPIOID ADDICTION
Mid to late 1980s: Opioid treatment for chronic pain becomes popular based on the (incorrect) assumption that chronic opioid use would not lead to addiction
2012: 259 million Rx for opioid meds in the U.S.
2014: 19,000 deaths from opioid overdose
Stricter guidelines for opioid Rx has led to an increase in heroin use (often easier to find)
2015: 2 million people living with substance abuse disorder r/t Rx opioids in the U.S.
591,000 people living with heroin abuse disorder
13,000 died from heroin overdose (5x the number in 2002)

8. OPIOID USE DURING PREGNANCY
: opioid Rx for pregnant women doubled
Pregnant women addicted to opioids may not seek treatment for fear of legal issues
Stopping opioids in pregnancy is not advised- can lead to poor neonatal outcomes
Methadone and buprenorphine seem to be safe for treating pregnant women with opioid addiction

9. CONGENITAL MORPHINISM
Perceptions prior to 1875:
Women who used morphine were sterile and/or had a loss of sexual desire
Infants born to opioid dependent mothers were not affected
1875: Infants born to morphine-dependent mothers were noted to be dying
Called “Congenital Morphinism”
Full-term infants that appeared normal at birth, but started crying inconsolably 3 days later (some developing seizures)
Lack of treatment due to lack of knowledge about the meaning of these symptoms
1901: Breastfeeding infants with CM and/or giving small amounts of meds could ease symptoms
Between late 1800s and mid 1900s, mortality rate for untreated infants with CM was >90%

10. WHAT IS NAS?
Neonatal Abstinence Syndrome (NAS) is the medical term for infants experiencing withdrawal as a result of the abrupt cessation of passive transfer of maternal opioids used during pregnancy
Opioid drugs could be Rx pain meds, Rx maintenance meds for opiate addictions, or illicit street drugs
Important to remember that infants are not “addicted” to drugs
Infants are passively exposed to drugs in utero
After birth, infants experience withdrawal, but do not seek drugs or have uncontrollable cravings

11. INCIDENCE
Premature infants may have fewer NAS symptoms because their CNS is immature, they have lower body fat, and have lower total exposure than full-term babies
: NAS increased from 1.2 to 3.4 per 1000 births
Total hospital charges increased from $190 million to $720 million
2009: 13,500 babies treated for NAS, representing approx. 1 baby per hour
Average length of stay is 2 days for non-NAS infant and days for NAS infant

12. SIGNS AND SYMPTOMS Neurologic Gastrointestinal Metabolic/Vasomotor
Respiratory
Excessive and/or high pitched cry
Disturbed sleep pattern
Hyperactive Moro) reflex
Tremors and/or seizures
Increased muscle tone
Excoriation (except in diaper area)
Excessive sucking
Poor feeding
Uncoordinated sucking/swallowing
Regurgitation
Projectile vomiting
Loose and/or watery stools
Sweating
Fever
Mottling
Nasal stuffiness
Sneezing
Nasal flaring
Tachypnea

13. FINNEGAN NAS TEST (FNAST)
Developed in 1975 as an objective and reliable tool to identify infants with NAS
Considered to be the gold standard assessment tool
Consist of 21 items evaluating the S/S of NAS
Scoring begins 2 hours after birth and then every 3-4 hours (usually with feeds)
Scores < 8 : non-pharmacologic treatment
Scores > 8 for three consecutive periods or >12 for two consecutive periods: pharmacologic treatment may be considered

14. Video of Dr. Karen D'Apolito demonstrating the assessment of an infant with NAS.

15. TREATMENT
The goal of treatment is to “ensure that the infant receives adequate nutrition and sleep in order to achieve weight gain and integrate into the social environment” – Clark and Rohan, 2015
Small, frequent feedings to minimize GI upset and promote weight gain
Non-pharmacologic: comfort measures, swaddling, decreased environmental stimuli, pacifier, gentle rocking, massage
Medications: morphine, methadone, buprenorphine, phenobarbital
Teach parents about the S/S of NAS, treatments (both meds and non-pharm), SIDS prevention
Mothers on methadone or buprenorphine should be encouraged to breastfeed

16. DOES TYPE OF DRUG MATTER?
Prenatal dosage of methadone does not seem to correlate with NAS development
Prenatal use of buprenorphine seems to require shorter treatment time than methadone
Heroin: NAS usually develops within 6 hours of birth
Methadone/ Buprenorphine: NAS usually develops after 36 hours

17. NURSING CARE CONSIDERATIONS
Comfort measures: swaddle, encourage KC, decrease stimuli, dark/quiet room, infant seat or swing, pacifier
Assess and document:
VS and NAS scores
Sleep/wake cycles
Intake (amount and length of feeds)
Output (voids and stools)
Daily weights
Calming methods and response
Response to handling
Foster a positive relationship with the mother
Involve her in infant care
Respect her dignity and communicate on a personal level

18. WHAT DOES NCLEX WANT YOU TO KNOW?
ATI book, Chapter 27, pages
Manifestation of S/S of NAS is related to the amount and type of drug, length of time exposed, maternal and infant drug metabolism, genetic factors
Nursing assessments for NAS infants
Nursing care of NAS infants
Treatments including non-pharm and meds
Lab tests to differentiate between NAS and CNS disorders
CBC, glucose, electrolytes, thyroid hormones, drug screen in mom
Chest X Ray for FAS to rule out congenital heart defects

19. MORE NCLEX REVIEW
Heroin withdrawal: associated with low birth weight, NAS, and increased risk of SIDS
Marijuana withdrawal: increased risk for meconium-stained amniotic fluid, preterm birth, deficits in attention, cognition, memory, and motor skills
Amphetamine withdrawal: increased risk for preterm birth, SGA, delayed growth/development
Tobacco: increased risk for SIDS, bronchitis, pneumonia, developmental delays, prematurity, SGA
Fetal Alcohol Syndrome: facial anomalies, deafness, abnormal palmar creases, irregular hair, organ anomalies, delayed growth/development, sleep disturbances

20. WHAT DOES THIS MEAN FOR WV?
2016: WV had the highest number of opioid deaths in the U.S.: 733 deaths (a rate of 43.4 deaths per 100,000)
2013: WV had the highest incidence of NAS in the U.S.: infants per 1000 births (lowest was Hawaii at 0.7 per 1000)

21. REFERENCES
Gomez-Pomar, E., & Finnegan, L. P. (2018). The Epidemic of Neonatal Abstinence Syndrome,
Historical References of Its’ Origins, Assessment, and Management. Frontiers in Pediatrics , 6 , 33. Retrieved from
Jones, H. E., & Fielder, A. (2015). Neonatal abstinence syndrome: Historical perspective,
current focus, future directions. Preventive Medicine , 80 , 12–17. Retrieved from
Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics , 134 (2), e547–e561.
Retrieved from
National Institute on Drug Abuse. (2018, February 28). West Virginia Opioid Summary.
Retrieved from
opioid-summaries-by-state/west-virginia-opioid-summary
Heroin Overview : Origin and History | Methoide. (n.d.). Retrieved from