Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_37_библиотеки_им_акад_М_И_Перельмана
.pdf
CHAPTER 11 Drug Withdrawal in the Neonate
https://t.me/medicina_free
259
SSRI who desires to breastfeed her infant should be
counseled about the benefits of breastfeeding as well
as the potential risk that her infant may continue to
be exposed to a measurable level of the SSRI with
unknown long-term effects.46 There has been some
suggestion of possible link of SSRIs with congenital
malformations.
85
*PREVENTION
Neonatal drug withdrawal is preventable if
women do not use dependence-producing substances, licit or illicit, during pregnancy. Through
intense educational efforts, the desirability and availability of drugs may be thwarted. Unfortunately, the
psychosocial and socioeconomic milieu of modern
society continues to propagate dysfunctional families, victimization of women, and an intergenerational cycle of substance abuse.
Therefore, our goals must be to provide prenatal
care for the pregnant drug-dependent woman and
her fetus to diminish or eliminate the sequelae of
NAS. The health care community is challenged
to become more astute in its assessment and
intervention for the problems of drug-dependent
parturients. More treatment options are necessary
for women with opioid use disorder and their
neonates through inpatient residential care and
outpatient interdisciplinary clinics that focus on
the elimination, as well as the consequences, of
addiction. Despite recent discussion in the press
and some literature regarding medically supervised
withdrawal during pregnancy, studies continue
to demonstrate, and the American College of
Obstetricians and Gynecologists (ACOG) states,
“that for women with an opioid use disorder,
opioid agonist pharmacotherapy is the recommended therapy.” The ACOG document also
states that pharmocotherapy is preferable to medically supervised withdrawal because withdrawal
is associated with high relapse rates, which lead to
unfavorable outcomes.
is now recognized that to achieve lasting results
from treatment of opioid use disorder in any
population, treatment must be family centered
and trauma informed.
For iatrogenic NAS, there is a need for guidelines for effective weaning of neonates from opiate
analgesics and sedatives.8 Investigators encourage
dose reductions of 10% to 20% per day. For the
4,10,16,40,117
70,90
Additionally, it
prevention of iatrogenic NAS, discussions in recent
literature include limiting total doses of fentanyl
during ECMO therapy by administering morphine
boluses or using continuous morphine infusions to
replace fentanyl, substituting enteral methadone for
morphine, or using sublingual buprenorphine.
64,77
DIAGNOSIS
History
A comprehensive prenatal medical and drug history, especially with respect to poly-drug abuse,
is of prime importance. All pregnant patients who
are substance abusers, regardless of the drug used,
are considered high risk because of the effects of
the drug, as well as complications arising from concomitant infections and lifestyle.26 Fear of referral to
child welfare agencies or the legal system in recent
years has prompted women to conceal their drug
abuse and/or pregnancy. This fear and denial may
prevent the pregnant woman from seeking prenatal
care. Thus, she may appear in the emergency department of the hospital either in crisis or ready to
deliver. In this instance, a prenatal history is absent,
making neonatal assessment more difficult.
4
Signs and Symptoms of Neonatal
Abstinence Syndrome
At birth, most infants exposed to opioids appear
physically and behaviorally normal with symptoms
of withdrawal beginning shortly after birth and
up to 2 weeks of age, but the majority are
exhibited within 72 hours.
toms may persist for several weeks, whereas
subacute symptoms (e.g., irritability, sleep problems, hyperactivity, feeding problems, hypertonia) may persist for 4 to 6 months.
The most common signs and symptoms
of NAS are listed in Box 11.6. A standardized
NAS scoring system is recommended for assessing
infants.46 Caregivers should have extensive training
on this scoring system with ongoing competencies
and second-scorer validation for high scores to
ensure as objective a measure as possible. For the
convenience of referencing, the signs and symptoms
discussed here are in the order in which they appear
on the assessment sheet reviewed within this chapter, as shown in Fig. 11.2.
33,46,61
Acute symp-
15
UNIT TWO Support of the Neonate260
https://t.me/medicina_free
BOX
11.6
• Signs and symptoms of neonatal abstinence syndrome may not be
• Most common signs and symptoms of neonatal abstinence syndrome
• Acute signs and symptoms that may persist for several weeks:
• Restlessness
• Tremors (disturbed at first to undisturbed)
• High-pitched cry
• Increased muscle tone
• Irritability and inconsolability
• Increased deep tendon reflexes
• Exaggerated Moro reflex
• Seizures in approximately 1% to 2% of heroin-exposed neonates
• Subacute signs and symptoms that may persist for 4 to 6 months:
• Irritability
• Sleep pattern disturbance
• Hyperactivity
• Feeding problems
• Hypertonia
CRITICAL FINDINGS
NEONATAL ABSTINENCE
SYNDROME
exhibited for up to 72 hours.
are central nervous system hyperirritability, gastrointestinal dysfunction, respiratory distress, and autonomic instability.
and approximately 7% of methadone-exposed neonates
29,32
Initially, the infants appear only to be restless.
Tremors develop, which are mild and occur
only when the infant is disturbed, but these
progress until they occur spontaneously without external stimulation of the infant. One of
the most serious but rare consequences of neonatal
opioid abstinence is the development of seizures.
No relationship between maternal methadone
dosage and the frequency or severity of neonatal seizures has been established. In addition, no
significant differences have been found between
neonates with seizures and those without seizures
in birth weight, gestational age, occurrence of their
withdrawal symptoms, day of onset of withdrawal
symptoms, or the need for specific pharmacologic treatment.46 The short-term prognosis
for abstinence-associated seizures is favorable
compared with the prognosis after seizures
associated with other causes. This observed
improvement in neurologic function may be based
on the replenishment of neurotransmitters after
transient depletion in the neonatal period.
72,109
The risk for SIDS should be considered when
the neonate has an especially difficult course of
NAS, when the mother uses multiple agents
(poly-pharmacy: opioids and stimulants such as
cocaine or amphetamine, nicotine), and when
a combination of therapeutic agents is used for
treatment. The rate of SIDS in these infants has
been demonstrated to be 5 to 10 times over
that in the general population. Research reports
that the risk for SIDS is increased in opiate-exposed
infants and varies from 2.5% to 4%.47 Wingkun and
other investigators studied carbon dioxide sensitivity
in infants of substance-abusing mothers and found
that these infants have abnormal sleep ventilatory
patterns and “an impaired repertoire” of protective
responses to hypoxia and hypercapnia during sleep
125
cycles.
In addition to having disturbed sleep patterns, infants undergoing withdrawal from narcotics exhibit excessive spontaneous generalized
sweating. Other autonomic nervous system signs
include yawning, elevation of temperature, sneezing,
and skin mottling. The rooting reflex is exagger-
ated, and these infants frequently suck their fists
or thumbs; yet when fed, their suck-and-swallow reflexes are uncoordinated and ineffectual.
Therefore they tend to regurgitate or vomit in a
projectile manner. The infant also may develop
loose stools and is susceptible to dehydration and
electrolyte imbalance.
5,33,46
These symptoms are
exhibited as a result of exposure to opioids, as well
as to nonopioid CNS depressants. However, with
nonopioid CNS depressant exposure, symptoms
tend to begin at a later age, with malnourishment at birth an unusual feature. Because barbi-
turate withdrawal may not develop until an infant
has been discharged from the nursery, it may not
be treated unless suspicion has been aroused by the
mother’s symptoms or actions. Furthermore, there
is a greater risk for seizure activity in neonates
withdrawing from barbiturates than in those
withdrawing from opioids.
5,30,46
Symptoms exhibited by stimulant-exposed
newborns are manifestation of drug toxicity
(drug effect or toxidrome) rather than withdrawal.46 The symptoms usually decrease with
time rather than increase as is seen with true
withdrawal. The literature describes cocaine-ex-
posed infants as tremulous, irritable, lethargic, unable
to respond appropriately to stimuli, and having
abnormal state control and cry patterns.
5,7,46,61,106
CHAPTER 11 Drug Withdrawal in the Neonate
https://t.me/medicina_free
261
Also described are abnormalities in orientation, motor ability, state regulation, muscular
hypertonia, and abnormal reflexes. Infants may
show symptoms of lethargy intermittently with
irritability, poor sucking patterns, and sleep disturbances. When cocaine has been the primary
drug of abuse, most clinicians have not seen
symptoms severe enough to treat the infant
pharmacologically.
31,46,61
Laboratory Data and Differential
Diagnosis
Before initiating medication for treatment of
NAS, common neonatal metabolic alterations
that can mimic or compound withdrawal, such
as hypocalcemia, hypomagnesemia, hypoglycemia, and hypothermia must be ruled out.
Serum glucose and calcium tests may be indicated. If the mother has had no prenatal care,
it would be prudent to thoroughly assess the
infant at birth, including testing for occult disease, sepsis, and intracranial bleeding. A urine
and meconium test for toxicology should also
be obtained. Meconium is more accurate and can
detect a longer period of drug exposure. Umbilical
cord testing has the benefit of being obtained even
before drug exposure is suspected, but may not be as
sensitive a test as meconium, and can be logistically
more difficult.
20,28,74,121
TREATMENT AND
INTERVENTION
Infants at risk for NAS should be monitored
closely for signs and symptoms of withdrawal.
The appropriate duration of observation should
be dependent on careful assessment of maternal
substance history. Infants born to mothers requir-
ing or taking an opiate with a short half-life
(hydrocodone) may be discharged after 72 hours
if without signs of withdrawal. Infants exposed
to maternal opiates with a long half-life (methadone, buprenorphine) should be monitored
for 5 to 7 days.46 Fifty-five percent to 94% of
infants with maternal opiate exposure will have
some signs or symptoms of withdrawal. While there
is clear literature to support nonpharmacologic
management as the initial treatment for infants
at risk for NAS or experiencing symptoms of
NAS, there is no literature-based standard for
pharmacologic treatment.46 A randomized control
trial showed that implementation and adherence to
a formalized NAS protocol with set initiation, escalation, and weaning parameters was key to improving pediatric outcomes.42 Nonpharmacologic care
should be implemented after birth to help abate
symptoms of withdrawal and to help control
symptoms if pharmacologic treatment becomes
necessary.
41,42,46,121
To best monitor an infant, each nursery
should adopt a protocol for the evaluation and
management of NAS. Staff should be trained
on the use of an abstinence assessment tool.46
Institutions may increase the reliability of NAS
assessment through competency requirements and
second-scorer validation of elevated scores. The
most predominantly used assessment tool is the
Finnegan Neonatal Abstinence Scoring System
(FNASS). The Lipsitz Tool, initially endorsed by the
American Academy of Pediatrics in 1998, is still in
use in some institutions.
74
With the increased focus on NAS monitoring
and treatment, many centers have moved attention to not only modifying the Finnegan Scoring
System, but also creating whole new systems that
emphasize physiologic behaviors, comfort care,
and team-approach scoring.39 For example, the
Eat, Sleep, Console model is a comprehensive
nonpharmacologic approach on which infants
are assessed on three key aspects: how well the
infant is eating, how well the infant is sleeping,
and consolability of the infant. Pharmacologic
treatment is based on infant function and comfort
versus reducing all signs of opioid withdrawal.
Medication treatment is initiated only when
an infant fails to eat, sleep, or console because
of symptoms from NAS after assuring nonpharmacologic treatment has been maximized.
Although this model of care has not been validated, the initial study showed a decreased length
of hospitalization in infants with NAS from 22.5
to 5.9 days with the initiation of the Eat, Sleep,
Console model’s launch in 2011.39 Presently, further validation and evaluation of this system is
taking place.
The FNASS, developed in 1975, is used in 95%
of US hospitals, although the tool has been modified frequently. Centers now allow for comfort
care, clustering of care, assessing after feedings,
and not waking an infant simply for scoring.39
UNIT TWO Support of the Neonate262
CLINICAL STATUS
STATE OF AROUSAL
https://t.me/medicina_free
This system allows for assessment of the onset, progression, and resolution of symptoms, as well as the
infant’s clinical response to pharmacotherapy for the
control of NAS symptoms. Titration of therapeutic
agents is thus based on the degree of withdrawal
symptoms that correspond to a specific score (Fig.
11.1). Although a number of scoring tools have
been used in both clinical and research settings,
the modified 21-item Finnegan neonatal abstinence score has remained useful. The nurse and
multidisciplinary team are vital in the assessment
of withdrawal in an infant. It is vital that interrater
reliability be developed among all nursing staff and
anyone responsible for scoring and assessment of
the infant.
The Finnegan Abstinence Score sheet (see Fig.
11.2) uses a weighted scoring of 21 actual items
that are most commonly observed in an opioid-exposed neonate.
31,46,74
Signs and symptoms
are recorded as single entities, or in several
categories if they occur in varying degrees
of severity. Each symptom, with its associated
degree of severity, has been assigned a score.
Higher scores are assigned to symptoms found
in infants with more severe withdrawal. The
total score is determined by adding the scores
assigned to each symptom observed throughout the entire scoring interval. The scoring
system is dynamic rather than static; all signs
and symptoms observed during the 3- to 4-hour
intervals at which infant symptoms are monitored
are point-totaled for that interval. Most institutions
now use intervals from one feeding to the next to
ensure the implementation of nonpharmacologic
comfort care.
Fig. 11.2 shows the NAS scoring system.
Symptoms are listed on the left and scores on the
right. Times of each evaluation are listed at the top,
and the total score is listed for each evaluation. A
new sheet should be started at the beginning of
each day. A “Comments” column is provided for
nursing and medical staff to record important notes
about the infant’s progress.
The first score should be recorded approximately 2 to 4 hours after the neonate’s admission. This score reflects all infant behaviors from
admission to the first point in time when the
scoring interval is complete. The times designating the end of the scoring intervals have been left
blank to permit the health care team or nursing
staff to choose appropriate times for scoring. Most
institutions now center scoring around or after
feedings.
The need for medication is indicated when
the total score is 8 or higher for three consecutive scorings (e.g., 9, 8, 10). Medication treatment is also warranted when the infant’s total
is 12 or higher for two consecutive intervals.
INTERVENTION
Subtle symptoms of decreased
activity should alert one to
the (1) possibility of underlying
or developing medical problems
or (2) early signs of oversedation
from therapeutic detoxification
Very close monitoring of vital
signs and state of CNS arousal
FIGURE 11.1 Management of neonatal abstinence syndrome. CNS, Central nervous system. (From Finnegan LP. Neonatal abstinence
syndrome. In: Nelson N, ed. Current Therapy in Neonatal-Perinatal Medicine. 2nd ed. Ontario: Decker; 1990.)
NARCOSIS
NORMALITY
“LOSS OF CONTROL” “CONTROL”
ABSTINENCE SCORE
0
1 - 3
4 - 7
8 - 10
11 - 13
14 - 16
17
AGITATION
INTERVENTION
Point of optimal behavior and
neurologic state in which the infant
should be maintained
Need for conservative measures to
limit withdrawal symptomatology
Need for pharmacologic intervention
to control withdrawal symptomatology
Ranges of increasing total abstinence
scores that dictate the need for
increasing doses of each therapeutic
detoxicant
Date:
eC
https://t.me/medicina_free
System
Central nervous
system disturbances
Metabolic/vasomotor/
respiratory disturbances
disturbances
Gastrointestinal
Signs and Symptoms ScoreTim
Excessive high-pitched cry
Continuous high-pitched cry
Sleeps 1 hour after feeding
Sleeps 2 hours after feeding
Sleeps 3 hours after feeding
Hyperactive Moro reflex
Markedly hyperactive Moro reflex
Mild tremors when disturbed
Moderate - severe tremors disturbed
Mild tremors when undisturbed
Moderate - severe tremors undisturbed
Increased muscle tone
Excoriation (specific area)
Myoclonic jerks
Generalized convulsions
Sweating
Fever 101° F (37.2° - 38.2° C)
Fever 38.4° C and higher
Frequent yawning (3 - 4 times/interval)
Mottling
Nasal stuffiness
Sneezing (3 - 4 times/interval)
Nasal flaring
Respiratory rate 60/min
Respiratory rate 60/min with retractions
Excessive sucking
Poor feeding
Regurgitation
Projectile vomiting
Loose stools
Watery stools
TOTAL SCORE
Initials of Scorer
NEONATA L ABSTINENCE SCORE
Weight:
AM PM
2
3
3
2
1
2
3
1
2
3
4
2
1
3
5
1
1
2
1
1
1
1
2
1
2
1
2
2
3
2
3
CHAPTER 11 Drug Withdrawal in the Neonate
omments
263
FIGURE 11.2 Neonatal abstinence score sheet. Check sign or symptom observed at various time intervals, and add scores for a total
at each evaluation. (Modified from Finnegan LP, Kaltenbach K. The assessment and management of neonatal abstinence syndrome. In
Hoekelman RA, Nelson N, eds. Primary Pediatric Care. 3rd ed. St Louis, MO: Mosby; 1992.)
Some simply refer to the threshold for medical
treatment as the “rule of 24.” When two to three
consecutive scores add up to 24 or greater, then
pharmacologic treatment should be considered.
Once an infant’s score is 8 or higher, one must
ensure nonpharmacologic measures (comfort
measures) are maximized, and scoring intervals
should be changed to hourly to closely monitor the infant’s symptoms, the efficacy of the
comfort measures employed, and the potential
need for pharmacologic treatment. Many centers
now use a second scorer to validate (“second-scorer
validation”) scores greater than 8 to allow more
objectivity in scoring. This is important because the
decision to treat medically relies on this measure.
Table 11.2 describes the symptoms of withdrawal,
appropriate observations, and nonpharmacologic
interventions (comfort care).
Pharmacologic Treatment of
Neonatal Abstinence Syndrome
Even though there is a plethora of evidence to support nonpharmacologic (comfort)
approaches for NAS, no single evidence-based
best practice concerning pharmacologic treatment exists.
approaches, all varying in choice of drug and
dose, as well as approaches to escalation of dosing and weaning have been suggested.
In the past decade and in the latest study
of 199 US NICUs in the Vermont Oxford
Network,96 morphine is the most commonly
used medication for pharmacologic treatment
of NAS. However, in recent years there is
increasing research about the use of methadone
or buprenorphine.
45,46,94,121
23,46,61,96,121
Many pharmacologic
46,60,61,74,121
Table 11.3 lists
UNIT TWO Support of the Neonate264
https://t.me/medicina_free
TABLE
11.2
INFANT BEHAVIOR OBSERVATIONS INTERVENTIONS (COMFORT CARE)
High-pitched cry Note onset.
Inability to sleep Note how long infant sleeps after feeding.
Frantic sucking of fists Note onset and amount of fist sucking. Use infant shirts with sewn-in sleeves for mitts to prevent skin
Yawning Note onset and frequency. None
Sneezing Note onset and frequency. Wipe secretions with cloth
Nasal stuffiness Note severity of nasal stuffiness, and determine
Poor feeding Note sucking pattern: Is infant uncoordinated in attempt
Regurgitation Note when regurgitation or vomiting occurs: Is there
Hyperactive Moro
reflex
CREATING A SUPPORTIVE ENVIRONMENT FOR THE DRUG-EXPOSED NEONATE
Nonnutritive sucking
Note length of time the cry persists: Is it continuous?
Is it high pitched and piercing as though infant were
in pain?
Note general sleep-wake patterns.
If drug therapy has been initiated, note changes in
sleep patterns, ability to rest, and any decreased
activity indicative of drug overdose.
whether it hinders breathing and feeding.
to suck, swallow, and breathe?
a precipitating factor (e.g., medication, handling,
manipulation, position)?
Is reflex moderately or markedly exaggerated?
If drug therapy has been started, is Moro reflex
diminished or absent?
Swaddle infant
Soothe with slow, rhythmic swaying
Skin-to-skin contact with parent
Feed on demand
Decrease environmental stimuli (low noise, low light, limit
visitors)
Organize care to minimize handling
Decrease environmental stimuli (low noise, low light, limit
visitors)
Feed on demand, or small amounts at frequent intervals
Organize care to minimize handling
Swaddle infant
Skin-to-skin contact with parent
Soothe with slow, rhythmic swaying
trauma
Offer pacifier for nonnutritive sucking
Allow more time for feeding with rest between sucking
Check rate and character of respirations frequently
Weigh daily
Decrease environmental stimuli (low lights, low noise, limit
visitors)
Feed small amounts at close intervals
Swaddle infant
Maintain fluid and caloric intake required for infant’s weight
Feed on demand
Use alternative feeding methods (e.g., gavage)
Consider higher-calorie formula
Organize care to minimize handling to ensure adequate rest
between feedings
Measure intake and output closely
Burp infant each time he or she has a long pause in sucking
during a feeding
Hold infant upright for 15–20
minutes after feeding
Monitor weight closely
Feed small amounts at close intervals
None
Continued
CHAPTER 11 Drug Withdrawal in the Neonate
https://t.me/medicina_free
TABLE
11.2
INFANT BEHAVIOR OBSERVATIONS INTERVENTIONS (COMFORT CARE)
Hypertonicity Note degree (mild, moderate, or severe) of increased
Tremors Note whether tremors occur when infant is disturbed or
Seizures Observe for seizures; if they occur, note onset, length,
CREATING A SUPPORTIVE ENVIRONMENT FOR THE DRUG-EXPOSED NEONATE—CONT’D
Swaddle infant
muscle tone by:
• Attempting to straighten arms and legs and
recording degree of resistance
• Picking up infant by hands and noting body rigidity
with degree of head lag (a withdrawing infant often
exhibits trunk rigidity and holds the head on a plane
with the body for a prolonged time)
• Raising infant by arms and letting baby stand (a
withdrawing neonate exhibits marked leg rigidity
and can support body weight for considerable
periods)
undisturbed.
Note location of tremors:
• Note whether degree of tremors is mild, moderate,
or severe.
origin, body involvement, type (tonic, clonic, or both),
eye deviation, and infant’s color.
Skin-to-skin contact with parent
Decrease environmental stimuli (low lights, low noise, limit
visitors)
Organize care to minimize handling
Avoid overdressing or overswaddling because of the risk for
increased body temperature with hypertonicity
Decrease environmental stimuli (low lights, low noise, limit
visitors)
Organize care to decrease handling
Support movements during caregiving
Swaddle infant as much as possible during caregiving
Swaddle when sleeping in crib
Monitor respiratory rate, heart rate (sign of apnea or bradycardia)
Initiate resuscitation as indicated
265
Modified from Finnegan LP, MacNew BA. Care of the addicted infant. Am J Nurs. 1974;74:685.
first-line and adjunctive pharmacologic treatment
for NAS. Although preliminary data suggest methadone and buprenorphine are both viable options
in the pharmacologic treatment of NAS, there are
presently no neonatal formulations of these medications commercially available for use, and studies
have used formulations specifically designed for the
study.23 Additionally, in former eras of NAS care,
the longer-acting opioid choices had fallen out of
favor because of a prolonged half-life and difficultly
weaning effectively in a short period. Both phe-
nobarbital and clonidine are used for adjunct
therapy when first-line treatment does not control symptoms.
46,96,121
are needed to support a specific treatment drug
choice or protocol, standardized, evidence-based
practice is essential. Within a specific unit or system,
the following must be clearly defined: (1) medication to be used, (2) initial dosing (can be symptom
based, weight based, or both), (3) parameters for
Although continued data
escalation of dosing, (4) parameters for weaning of
dosing, and (5) second-line therapy with all of the
previously mentioned specifications. The development and use of a standardized NAS treatment
protocol has been shown to improve neonatal
response and decrease length of stay.
17,41
Although
a standard pharmacologic approach to NAS
is important, expert clinical judgment is also
necessary to individualize care when necessary.
If there are some unappreciated clinical findings
that seem to confound scoring, this must be fully
examined before starting treatment “per protocol.”
Likewise, if an infant becomes excessively sleepy or
less responsive, the dosing protocol must be put on
hold while the infant is thoroughly assessed by the
provider. Although the standard medication dosing
dictated by a protocol may be appropriate for most
infants, there may be cases in which the starting
dose is in excess of that required by an individual
infant so that care individualization is necessary.
UNIT TWO Support of the Neonate266
https://t.me/medicina_free
TABLE
11.3
PHARMACOLOGIC TREATMENT FOR NEONATAL ABSTINENCE SYNDROME
DRUG DOSAGE COMMENTS
Oral
buprenorphine
62–64
Initial dose: 5.3 mcg/kg every 8 hours sublingually;
give pacifier and administer under tongue while
neonate sucks on pacifier
Total dose per day:
15.9 mcg/kg/day divided in three doses
Three RCTs comparing oral buprenorphine and morphine found
advantages to buprenorphine use.
The most recent RCT found fewer days of treatment (15 days
vs. 28 days), shorter LOS (21 days vs. 33 days), and fewer
babies requiring adjunctive phenobarbital in the buprenorphine-treated group.
Longer duration of action than methadone
Oral methadone: used in
20% of participating VON
96
US NICUs
Oral morphine: used in 80%
of participating VON US
96
NICUs
Initial dose: 0.05–0.1mg/kg every 6 hours
Increment: 0.05 mg/kg/dose
Maximum dose: to effect
Initial dose: 0.04 mg/kg every 3–4 hours
Increment: 0.04 mg/kg/dose
Maximum dose: 0.2 mg/kg/dose
46
Use a 0.4-mg/mL dilution: 1 mL of the 4 mg/mL
injectable solution added to 9 mL preservative-free
normal saline solution.
Protect from light; stable for 7 days, refrigerated.
Long half-life of 8–59 hours
Control is evidenced by an NAS average score <8, rhythmic
feeding/sleep cycles, optimal weight gain, same opium dose
for 72 hours, and pharmacologic weaning.
Continue to score for NAS.
Scores must remain <8.
Advantages: Diminishes bowel motility and loose stools; 20%
to 40% bioavailability when administered orally; lower doses
and shorter dosing interval are associated with shorter hospital
stay in infants with NAS resulting from maternal methadone
treatment.
Disadvantages: Respiratory depression, hypotension, delayed
gastric emptying, ileus, urine retention.
62–64
62
101
Adjunctive Pharmacologic Therapy
Oral clonidine46: used in
less than 10% of participating VON US NICUs
96
Phenobarbital: used in 24%
of participating VON US
96
NICUs
LOS, Length of stay; NAS, neonatal abstinence syndrome; PO, by mouth; RCT, randomized controlled trial; VON, Vermont Oxford Network.
Initial dose: 0.5–1 mcg/kg every 6 hours
Increment: not studied
Maximum dose: 1 mcg/kg every 3 hours
Loading dose: 20 mg/kg to achieve an expected
therapeutic level in a single dose.
If score is ≥8, give 10 mg/kg every 12 hours
until control or signs of toxicity appear.
Maintenance dose (once under control):
2–6 mg/kg/day for 3–4 days. Decrease dose to
3 mg/kg/day.
Discontinue: serum levels <15 mcg/mL.
Reduces CNS sympathetic outflow and palliates symptoms
of autonomic overactivity, such a tachycardia, hypertension,
diaphoresis, restlessness, and diarrhea. Cessation of clonidine
treatment can result in a rebound of autonomic activity.
Reported experience with clonidine as a primary or adjunctive
treatment of NAS is limited but promising.
46
Daily serum levels can be obtained.
Advantages: Drug of choice for poly-drug use; especially
effective in controlling irritability and insomnia; controls
symptoms in 50% of infants.
Disadvantages: Does not prevent loose stools.
Infant should be in a nursery where he or she can be
monitored closely.
CHAPTER 11 Drug Withdrawal in the Neonate
https://t.me/medicina_free
267
Complications of excessive pharmacologic
treatment are listed in Box 11.7. Alternatively,
these neonatal symptoms may represent another
underlying issue (e.g., hypoglycemia, sepsis,
meningitis) unrelated to NAS that requires
investigation and treatment. Detection of underlying medical problems may be difficult, because
poorly controlled abstinence may mimic and/or
disguise many common neonatal conditions.
Breastfeeding the Infant With
Neonatal Abstinence Syndrome
All drugs of abuse pass through the breast milk.
However, breastfeeding for women in medically
supervised treatment programs with nontoxic
agents need not be discouraged.
trast, women using stimulants and other potentially
toxic drugs, as well as those who are infected with HIV,
should be discouraged from breastfeeding because of
the potential toxic and negative effects on the neonate.
Both methadone and buprenorphine are
found in breast milk. Methadone appears in low
levels in breast milk, but absolute levels depends on
maternal dosing.30 Buprenorphine is excreted into
breast milk approximately 2 hours after maternal ingestion. The concentrations of buprenor-
phine and norbuprenorphine in breast milk are
highly variable because of differences in breast milk
BOX
11.7
• Diminished or absent reflexes: Moro, sucking, swallowing, Galant,
• Truncal (central) or circumoral cyanosis or persistent mottling not
• Decreased muscle tone with passive resistance to extension of
• Altered state of arousal (e.g., obtunded, comatose)
• Diminished response to painful stimuli
• Failure of visual following
• Hypothermia
• Altered respirations: irregular (periodic breathing in full-term infants),
• Cardiac alterations: irregular rate, distant heart sounds with weak
COMPLICATIONS OF EXCESSIVE
PHARMACOLOGIC TREATMENT
Perez, tonic neck, corneal, grasp (palmar, plantar)
associated with ambient temperature decreases
extremities, or decreased neck or trunk tone
shallow (decreased air entry), decreased respiratory rate (<20/
min), apnea
peripheral pulses, heart rate of 80 to 100 beats/min, poor peripheral perfusion (pale, gray, mottled skin), cardiac arrest
1,30,46,61,84
In con-
protein and fat. However, neither concentrations
of buprenorphine and norbuprenorphine exceed
plasma concentrations.51 One study comparing
breastfeeding rates and the relationship between
breastfeeding and NAS in buprenorphine-exposed
neonates found the following:
51
• 76% or (65 of 85 participants) in the study chose
to breastfeed.
• 66% were still breastfeeding at 6 to 8 weeks
postpartum.
• NAS was less severe with the breastfeeding
group (mean peak NAS scores of 8.83 vs. 9.65
on the Finnegan scoring system).
• Breastfed infants were less likely to require
pharmacologic treatment (23.1% vs. 30%) than
infants who were not breastfed.
The Norwegian National Cohort Study of
124 women treated with either methadone or
buprenorphine found that 77% of the women chose
to breastfeed. Methadone-exposed infants had a
lower incidence of NAS requiring pharmacologic treatment (53% vs. 80%). Breastfed infants
exposed to both methadone and buprenorphine
needed less medication for a shorter period.
69
In summary, the limited published research
(barring other complications and contraindications,
such as an HIV-positive mother) support current
guidelines that recommend breastfeeding for
mothers who are stabilized on either methadone or buprenorphine.
2,51
Likewise, it is rec-
ommended that women who are stable on any
medically supervised opioid agonist treatment
program are supported in their breastfeeding
efforts.4 Marijuana is the most commonly used
recreational drug among breastfeeding women.
Authors of case reports have documented the
presence of marijuana metabolites in human milk.
Recently, one study measured variable quantities of
the primary psychoactive ingredient in marijuana,
Δ-9-tetrahydrocannabinol, in human milk up to
approximately 6 days after marijuana use.12 Similar
to marijuana use during pregnancy, there are insufficient data to evaluate the effects of marijuana
use on infants during lactation and breastfeeding,
and in the absence of such data, marijuana use is
discouraged.
16
Complications
Kocherlakota nicely summarized in a 2014 publication the recommendations for discharge and
UNIT TWO Support of the Neonate268
https://t.me/medicina_free
follow-up of babies who have exhibited signs
and symptoms of NAS61:
• Neurodevelopmental assessments to identify motor deficits, cognitive delays, or relative
microcephaly
• Psychobehavioral assessments to identify
hyperactivity, impulsivity, and attention-deficit/
hyperactivity disorder in preschool-age children,
as well as school absences, school failure, and
other behavioral problems in school-age children
• Ophthalmologic assessment to identify nystagmus, strabismus, refractive errors, and other visual
defects
• Growth and nutritional assessment to identify
failure to thrive and short stature
• Family support assessments to exclude continuous maternal substance abuse and child abuse
Depending on the substance to which the fetus was
exposed some expected long term effects may include
alterations in growth, behavior, cognition/ executive function, language and school achievement.9An
empiric evaluation of in utero drug exposure and
school performance also demonstrated poor and deteriorating school performance in children who were
diagnosed with NAS during the neonatal period.
86
irritable and less cuddly, exhibit more tremors, and
have increased tone (Box 11.8). These infants are
also less responsive to visual stimulation and are less
likely to maintain an alert state. Some symptoms
of withdrawal may persist for 2 to 6 months,
and the health care professional should discuss
this possibility with the family caregivers well
before discharge so they can begin building the
skills they will need under the watchful eye of
supportive staff. The infant may continue to feed
poorly and regurgitate, yet vigorously suck fists and
hands. Mothers and families frequently misread this
continued, exaggerated rooting reflex as hunger and
therefore may overfeed the infant, contributing to
emesis and continued loose stool.
These infants may have hyperacusis or are easily disturbed by normal household sounds and do
not sleep well. They sweat more than other infants
and, when crying, continue to have a high-pitched
cry. They may have poor tolerance of being held
or to abrupt changes in position. This, along with
BOX
11.8
PARENT/CAREGIVER TEACHING
CARING FOR AN INFANT
EXPOSED TO OPIOIDS
PARENT TEACHING
As soon as it is identified that an infant may be at
risk for NAS through maternal use of illicit or prescription drugs, whether in a structured program or
prescribed by an individual caregiver, education for
the family must begin. The education is best delivered
by health care providers who have been educated and
are well versed in the issues of NAS. Best practice
is to supply written material that is supportive
and nonjudgmental, describing the symptoms
of NAS; what families can do before, during,
and after birth; comfort measures; expectations
regarding time of observation; and details of scoring. Also essential is a discussion regarding the poten-
tial need for treatment and what to expect regarding
length of stay and location of care (family room vs.
separate location). When families are prepared with
knowledge and expectations before the birth,
they are better able to partner in the care of their
infant and comply with recommendations.
It is important for primary caretakers to understand that infants exposed to narcotics through
maternal drug use have been found to be more
46
Some symptoms may persist for 2 to 6 months.
• Infants exposed to narcotics in utero are more irritable, less cuddly,
and tremulous and have increased tone: Parent(s) may interpret
these behaviors as signs of rejection; the infant may not want to be
held or cuddled as other babies do.
• Less responsive to visual stimulation
• Less likely to maintain a quiet-alert state: Let parent know symptoms
are time-limited.
• Poor feeding habits: Continues to regurgitate yet shows vigorous
sucking of fists or pacifier: Constant sucking and exaggerated rooting
reflex may lead to overfeeding the infant.
• Continuation of loose stools: Important to stress good diaper hygiene
to prevent infection from excoriated skin.
• Infants easily disturbed by sounds: Parent may decrease stimuli in
house.
• Sweat more than other newborns: Dress infant appropriately to avoid
overheating.
• High-pitched cry: Not easily consoled, parents need someone to
share infant care and give them some rest from an irritable infant to
prevent neglect or abuse.
• Hypertonia
• Less eye-to-eye contact, which decreases social interaction
Соседние файлы в папке Библиотека им академика М.И. Перельмана