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Neonatal withdrawal or neonatal abstinence syndrome (NAS) is a withdrawal syndrome of infants after birth caused by in utero exposure to drugs of dependence.[1] There are two types of NAS: prenatal and postnatal. Prenatal NAS is caused by discontinuation of drugs taken by the pregnant mother, while postnatal NAS is caused by discontinuation of drugs directly to the infant.[2][3]

Neonatal abstinence syndrome
Nina wcześniak.jpg
Prematurity can accompany withdrawal
SpecialtyPediatrics Edit this on Wikidata

Contents

CausesEdit

Some drugs are more likely to cause NAS than others, but nearly all have some effect on the baby. Opiates, such as heroin and methadone, cause withdrawal in over half of babies exposed prenatally. Cocaine may cause some withdrawal, but the main symptoms in the baby are due to the toxic effects of the drug itself. Other drugs, such as amphetamines and barbiturates, can also cause withdrawal. Alcohol use causes withdrawal in the baby, as well as a group of problems including birth defects called fetal alcohol spectrum disorders (FASDs). [4]

ConcernsEdit

When a mother uses illicit substances, she places her baby at risk for many problems. A mother using drugs may be less likely to seek prenatal care, which can increase the risks for her and her baby. In addition, women who use drugs are more likely to use more than one drug, which can complicate the treatment. The risk of contracting HIV and AIDS is also greater among intravenous (IV) drug users.[5]

In addition to the specific difficulties of withdrawal after birth, problems in the baby may include, but are not limited to, the following:

  • Poor intrauterine growth
  • Premature birth
  • Seizures
  • Birth defects [6]

Signs and symptomsEdit

Drug and alcohol use during pregnancy can lead to many health problems in the fetus and baby, Neonatal Abstinence Syndrome(NAS). These issues may include:

  • Tremors (trembling)
  • Irritability (excessive crying)
  • Sleep problems
  • High-pitched crying
  • Tight muscle tone
  • Hyperactive reflexes
  • Seizures
  • Yawning, stuffy nose, and sneezing
  • Poor feeding and suck
  • Vomiting
  • Diarrhea
  • Dehydration
  • Sweating [7]

Heroin and methadone withdrawalEdit

Heroin and other opiates, including methadone, can cause significant withdrawal in the baby, with some symptoms lasting as long as four to six months. Seizures may also occur in babies born to methadone users.[8]

Amphetamine withdrawalEdit

Prenatal use of amphetamines is associated with low birthweight and premature birth.[9]

Alcohol withdrawalEdit

Alcohol use in pregnancy also has significant effects on the fetus and the baby. Growth during pregnancy and after birth is slowed. Specific deformities of the head and face, heart defects, and intellectual disability are seen with FASDs. [10]

Marijuana withdrawalEdit

Marijuana used during pregnancy is linked to low birth weight. [11]

NicotineEdit

Cigarette smoking has long been known for its effects on the fetus. Generally, smokers have smaller babies than nonsmokers. Babies of smokers may also be at increased risk for premature birth and stillbirth. [12]

TreatmentEdit

Specific treatment for NAS will be determined by your baby's doctor based on:

  • Your baby's gestational age, overall health, and medical history
  • Extent of the disease
  • Your baby's tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the disease
  • Your opinion or preference [13]

Babies suffering from withdrawal are irritable and often have a difficult time being comforted. Swaddling, or snugly wrapping the baby in a blanket, may help comfort the baby. Babies also may need extra calories because of their increased activity and may need a higher calorie formula. Intravenous (IV) fluids are sometimes needed if the baby becomes dehydrated or has severe vomiting or diarrhea.

Some babies may need medications to treat severe withdrawal symptoms, such as seizures, and to help relieve the discomfort and problems of withdrawal. The treatment drug is usually in the same family of drugs as the substance the baby is withdrawing from. Once the signs of withdrawal are controlled, the dosage is gradually decreased to help wean the baby off the drug. Consult your baby's doctor to learn which treatments might be effective for your baby. [14]

PreventionEdit

Neonatal abstinence syndrome is a totally preventable problem. However, it requires that a mother stop using drugs before pregnancy, or as soon as she learns she is pregnant if her doctor believes it is safe to do so. [15]

CausesEdit

The drugs involved may be, for example, opioids, selective serotonin reuptake inhibitors (SSRIs), ethanol and benzodiazepines.[1] Neonatal abstinence syndrome does not happen in prenatal cocaine exposure. Prematurity and exposure to other drugs may instead be the cause of symptoms.[16]

MechanismsEdit

Drugs and chemicals pass through the placenta that connects the baby to its mother in the womb. The baby becomes dependent on the drug along with the mother. If the mother continues to use the drugs within the week or so before delivery, the baby will be dependent on the drug at birth. Because the baby is no longer getting the drug after birth, withdrawal symptoms may occur as the drug is slowly cleared from the baby's system.[1] Nicotine, medications and alcohol have side effects related to unsafe higher dosages, but neonates may respond differently. Newborns are less able to metabolize drugs and therefore the substance stays in their system for a relatively longer length of time when compared to those who are older and have fully functioning livers and kidneys.[17][citation needed]

DiagnosisEdit

Confirming the presence of withdrawal in the neonate can be assessed from obtained a detailed medical history from the mother. In some cases neonatal drug withdrawal can be mistaken for central nervous system disorders.[18] Typically the tests that are ordered are CBC, hair analysis, drug screen (of mother and infant), thyroid levels, electrolytes, and blood glucose. Chest x-rays can confirm or infirm the presence of heart defects.[19][1] The diagnosis for babies with signs of withdrawal may be confirmed with drug tests of the baby's urine or stool. The mother's urine will also be tested.[1]

There are at least two different scoring systems for neonatal withdrawal syndrome. One difficulty with both is that they were developed to assess opiate withdrawal. The Finnegan scoring system is more widely used.[18]

PreventionEdit

Neonatal withdrawal is prevented by the mother abstaining from substance abuse. In some cases, a prescribed medication may have to be discontinued during the pregnancy to prevent addiction by the baby. Early pre-natal care can identify addictive behaviors in the mother and family system.[citation needed] Referrals to treatment centers is appropriate.[19] Some prescribed medicines should not be stopped without medical supervision, or harm may result. Women can discuss all medicines, and alcohol and tobacco use with their health care provider and get assistance to help stop drug use as soon as possible. Indications that a woman needs help if she is:

  • Using drugs non-medically
  • Using drugs not prescribed to her
  • Using alcohol or tobacco[1]

If she is already pregnant and takes medicines or drugs not prescribed to her, she can talk to a health care provider about the best way to keep the baby safe. Some medicines should not be stopped without medical supervision, or harm may result. Your health care provider will know how best to manage the risks.[1]

TreatmentEdit

Treatment depends on the drug involved, the infant's overall health, abstinence scores and whether the baby was born full-term or premature. Clinicians will watch the newborn carefully for up to a week after birth for signs of withdrawal, feeding problems, and weight gain. Babies who vomit or who are very dehydrated may need to get fluids through a vein (IV).

Some babies with severe symptoms need medicines such as methadone and morphine to treat withdrawal symptoms. Buprenorphine may also be effective.[20]

These babies may need to stay in the hospital for weeks or months after birth. The goal of treatment is to prescribe the infant a drug similar to the one the mother used during pregnancy and slowly decrease the dose over time. This helps wean the baby off the drug and relieves some withdrawal symptoms.

If the symptoms are severe, especially if other drugs were used, a second medicine such as phenobarbital or clonidine may be added. Breastfeeding may also be helpful if the mother is in a methadone or buprenorphine treatment program without other drug use.

Babies with this condition often have severe diaper rash or other areas of skin breakdown. This requires treatment with special ointment or cream. Babies may also have problems with feeding or slow growth. These problems may require higher-calorie feedings that provide greater nutrition and smaller portions given more often.[1] Objectives of management are to minimize negative outcomes and promote normal development.[21]

SupportiveEdit

Non-medication based approaches to treat neonatal symptoms include swaddling the infant in a blanket, minimizing environmental stimuli, and monitoring sleeping and feeding patterns.[1] Breastfeeding promotes infant attachment and bonding and is associated with a decreased need for medication. These approaches may lessen the severity of NAS and lead to shorter hospital stays.[22]

MedicationEdit

Medication is used to relieve fever, seizures, and weight loss or dehydration.[21] When medication use for opiate withdrawal in newborn babies is deemed necessary, opiates are the treatment of choice; they are slowly tapered down to wean the baby off opiates.[23] Phenobarbital is sometimes used as an alternative but is less effective in suppressing seizures; however, phenobarbital is superior to diazepam for neonatal opiate withdrawal symptoms. In the case of sedative-hypnotic neonatal withdrawal, phenobarbital is the treatment of choice.[24][25] Clonidine is an emerging add-on therapy.[26]

Opioids such as neonatal morphine solution and methadone are commonly used to treat clinical symptoms of opiate withdrawal, but may prolong neonatal drug exposure and duration of hospitalization.[27] A study demonstrated a shorter wean duration in infants treated with methadone compared to those treated with diluted tincture of opium. When compared to morphine, methadone has a longer half-life in children, which allows for less frequent dosing intervals and steady serum concentrations to prevent neonatal withdrawal symptoms.[28]

EpidemiologyEdit

A 2012 study from the University of Michigan and the University of Pittsburgh published in the Journal of the American Medical Association analyzed information on 7.4 million discharges from 4,121 hospitals in 44 states, to measure trends and costs associated with NAS over the past decade. The study indicated that between 2000 and 2009, the number of mothers using opiates increased from 1.19 to 5.63 per 1,000 hospital births per year. Newborns with NAS were 19% more likely than all other hospital births to have low birthweight and 30% more like to have respiratory complications. Between 2000 and 2009, total hospital charges for NAS cases, adjusted for inflation, are estimated to have increased from $190 million to $720 million.[29]

Neonatal abstinence syndrome in Canada are significant.[30][31]

ReferencesEdit

  1. ^ a b c d e f g h i "Neonatal abstinence Syndrome". MedlinePlus. US Library of Medicine. 5 July 2017. Retrieved 27 July 2017.  This article incorporates text from this source, which is in the public domain.
  2. ^ Neonatal Abstinence Syndrome on eMedicine
  3. ^ Hall, RW.; Boyle, E.; Young, T. (Oct 2007). "Do ventilated neonates require pain management?". Semin Perinatol. 31 (5): 289–97. doi:10.1053/j.semperi.2007.07.002. PMID 17905183.
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  16. ^ Mercer, J (2009). "Claim 9: "Crack babies" can't be cured and will always have serious problems". Child Development: Myths and Misunderstandings. Thousand Oaks, Calif: Sage Publications, Inc. pp. 62–64. ISBN 978-1-4129-5646-8.
  17. ^ Hamdan, Ashraf (December 20, 2017). "Neonatal Abstinence Syndrome". Medscape. Archived from the original on September 14, 2017. Retrieved July 25, 2018.
  18. ^ a b "Neonatal Abstinence Syndrome Clinical Presentations". Medscape. 27 November 2016. Retrieved 28 July 2017.
  19. ^ a b Henry, p. 184.
  20. ^ Disher, T; Gullickson, C; Singh, B; Cameron, C; Boulos, L; Beaubien, L; Campbell-Yeo, M (22 January 2019). "Pharmacological Treatments for Neonatal Abstinence Syndrome: A Systematic Review and Network Meta-analysis". JAMA Pediatrics. doi:10.1001/jamapediatrics.2018.5044. PMC 6439896. PMID 30667476.
  21. ^ a b Longo, Dan L.; McQueen, Karen; Murphy-Oikonen, Jodie (22 December 2016). "Neonatal Abstinence Syndrome". New England Journal of Medicine. 375 (25): 2468–2479. doi:10.1056/NEJMra1600879. PMID 28002715.
  22. ^ Pritham, Ursula A.; Paul, Jonathan A.; Hayes, Marie J. (March 2012). "Opioid Dependency in Pregnancy and Length of Stay for Neonatal Abstinence Syndrome". Journal of Obstetric, Gynecologic, & Neonatal Nursing. 41 (2): 180–190. doi:10.1111/j.1552-6909.2011.01330.x. PMC 3407283. PMID 22375882.
  23. ^ Hudak, ML; Tan, R. C. (30 January 2012). "Neonatal Drug Withdrawal". Pediatrics. 129 (2): e540–e560. doi:10.1542/peds.2011-3212. PMID 22291123.
  24. ^ Osborn, DA; Jeffery, HE; Cole, M (2010). Osborn, David A (ed.). "Opiate treatment for opiate withdrawal in newborn infants". Cochrane Database Syst Rev (3): CD002059. doi:10.1002/14651858.CD002059.pub3. PMID 20927730.
  25. ^ Osborn, DA; Jeffery, HE; Cole, MJ (2010). Osborn, David A (ed.). "Sedatives for opiate withdrawal in newborn infants". Cochrane Database Syst Rev (3): CD002053. doi:10.1002/14651858.CD002053.pub3. PMID 20927729.
  26. ^ Kraft, WK; van den Anker, JN (Oct 2012). "Pharmacologic management of the opioid neonatal abstinence syndrome". Pediatric Clinics of North America. 59 (5): 1147–65. doi:10.1016/j.pcl.2012.07.006. PMC 4709246. PMID 23036249.
  27. ^ Logan, Beth A.; Brown, Mark S.; Hayes, Marie J. (March 2013). "Neonatal Abstinence Syndrome: Treatment and Pediatric Outcomes". Clinical Obstetrics and Gynecology. 56 (1): 186–192. doi:10.1097/GRF.0b013e31827feea4. PMC 3589586. PMID 23314720.
  28. ^ Johnson, Melissa R.; Nash, David R.; Martinez, Michael A. (July 2014). "Development and Implementation of a Pharmacist-Managed, Neonatal and Pediatric, Opioid-Weaning Protocol". The Journal of Pediatric Pharmacology and Therapeutics. 19 (3): 165–173. doi:10.5863/1551-6776-19.3.165 (inactive 2019-06-06). PMC 4187529. PMID 25309146.
  29. ^ Patrick, SW; Schumacher, RE; Benneyworth, BD; Krans, EE; McAllister, JM; Davis, MM (May 9, 2012). "Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009". JAMA: The Journal of the American Medical Association. 307 (18): 1934–40. doi:10.1001/jama.2012.3951. PMID 22546608.
  30. ^ Dow, Ordean (2012). "Neonatal Abstinence syndrome clinical practice guidelines for Ontatio" (PDF). Journal of Population Therapeutics and Clinical Pharmacology. 19: 488–506.
  31. ^ Leslie, K (2015). "Officials can't explain increase in North Bay babies born to addicted moms". CTV News.

BibliographyEdit

  • Henry, Norma (2016). RN Maternal Newborn Nursing. Stilwell, KS: Assessment Technologies Institute. ISBN 9781565335691.

External linksEdit