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Improving Breastfeeding Rates in Neonatal Abstinence Syndrome Infants in the NICU

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Improving Breastfeeding Rates in Neonatal Abstinence Syndrome Infants in the NICU Improving breastfeeding rates in Neonatal Abstinence Syndrome infants in the NICU Donna Garey MD MPH Lisa Stellwagen MD UC San Diego Medical Center Division of Neonatology January 2015 FACULTY DISCLOSURE INFORMATION Lisa Stellwagen MD I have a relevant financial relationship to disclose: Medela, Inc: speaker Donna Garey MD MPH I have a relevant financial relationship to disclose: none Objectives • Identify current evidence based reasons to encourage breastfeeding of the Neonatal Abstinence Syndrome (NAS) infant • Identify what concrete steps can be implemented to improve breastfeeding rates at discharge in the NAS infant • Learn the what is currently known about the effects of Marijuana during pregnancy and lactation, and then be able to accurately counsel mothers on this issue Neonatal Abstinence Syndrome (NAS) • Due to abrupt discontinuation of chronic exposure to opioids in utero • Generalized multi-system disorder • Incidence of NAS increasing around the US From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 Figure Legend: Error bars indicate 95% CI. P for trend < .001 over the study period. The unweighted sample sizes for mothers diagnosed with and without antepartum opiate use are 987 and 833 494 in 2000; 1058 and 849 133 in 2003; 2160 and 879 910 in 2006; and 4563 and 816 554 in 2009; respectively. Copyright © 2015 American Medical Date of download: 1/27/2015 Association. All rights reserved. From: Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951 Figure Legend: NAS indicates neonatal abstinence syndrome. Error bars indicate 95% CI. P for trend < .001 over the study period. The unweighted sample sizes for rates of NAS and for all other US hospital births are 2920 and 784 191 in 2000; 3761 and 890 582 in 2003; 5200 and 1 000 203 in 2006; and 9674 and 1 113 123 in 2009; respectively. Copyright © 2015 American Medical Date of download: 1/27/2015 Association. All rights reserved. NAS Timeline NAS. Pediatrics. Kocherlakota. 2014 Opiates • Mimic natural endogenous endorphins at and receptors on the neuronal cell membrane • Block transmission of noxious stimuli from the periphery to the spinal cord • Develop tolerance to analgesia, sedation, and euphoria • Cross the placenta – Lipophilic, low molecular weight compounds Heroin • -opioid receptor agonist • Approx 40-80% of infants have NAS • Earlier onset and shorter withdrawal – Onset of withdrawal symptoms at 24 to 48 hours – Duration of withdrawal is 8-10 days Prescription Narcotics • Frequency of NAS • Long-Acting Opioids depends on amount – Fentanyl Transdermal Patch and duration of – Oxymorphone or Oxycodone hydrochloride extended-release maternal use – Morphine sulfate extended-release • Onset and duration of • Short-Acting Opioids withdrawal depends on – Hydrocodone – Oxycodone half-life of the drug – Tramadol • Approx 5-20% – Fentanyl (IV) or Morphine (IV) – Codeine experience NAS – Hydromorphone Treatment for opioid addiction Methadone Buprenorphine • -opioid receptor agonist • partial -opioid agonist • Half Life 23-48 hours • Half-life 26-34 hours • Typical dose is 20 to 120 • Mean hospital stay for NAS mg per day – 10 days • Mean hospital stay for NAS • Later onset and longer – 17.5 days withdrawal • Later onset and longer withdrawal Minimal relationship between maternal opioid dose and NAS. Buprenorphine +/- Naloxone • Synthetic opioid receptor agonist • Prescribed in a doctor’s office by qualified MD • Available formulations: – Tablets - 2 and 8 mg tablets – Sublingual film - 2-4-8-12 mg – Patch form for chronic pain • Less respiratory depression than other narcotics – Can cause coma/death if combined with benzos, alcohol, other respiratory depressants • Shorter duration of NAS Onset, Duration, and Frequency of NAS Opioids Onset Frequency Duration (hours) (%) (days) Heroin 24-48 40-80 8-10 Prescription 36-72 5-20 10-30 Opioids Buprenorphine 36-60 22-67 Up to 28 or more Methadone 48-72 13-94 Up to 30 or more Infants Admitted for Observation for Neonatal Abstinence Syndrome Observation Period: • Short acting Observation and Admit to NICU: Monitoring: prescription narcotics: 4 days NAS (Finnegan NAS < 8 continue to score) q 4 hr. monitor until safe for • Benzo + opiates: Implement non- discharge pharmacologic 4-7 days therapies NAS >8 times 2 • Heroin/methadone: implement therapy 5-7 days • Suboxone: 5-6 days Why treat maternal drug abuse and neonatal withdrawal? • Decreases illicit drug use • When combined with good obstetrical care improves fetal outcomes • Avoids complications of NAS such as seizures and dehydration due to poor feeding, vomiting, and diarrhea. • Allows infant to have normal feeding and infant interactions. Risk Factors for Increased Severity/Intensity of NAS • Term • Polydrug abuse • Combination with benzodiazepines • Specific gene polymorphisms of the -opioid receptor (OPRM1) and catechol-O-methyltransferase (COMT) • Smoking • Methadone • Combination with SSRIs Withdrawal in Preterm Infants • Decreased intensity and severity – Decreased cumulative exposure – Decreased transmission across placenta in early gestation – Decreased receptor development and sensitivity – Decreased fatty tissues • Methadone accumulates in fatty tissues Modified Finnegan Zimmerman-Baer U, et al. Addiction. 2010. Infants Admitted for Observation for Neonatal Abstinence Syndrome Observation and Observation Period: Monitoring: • Short acting Admit to NICU: NAS < 8 continue prescription NAS (Finnegan score) q narcotics: 4 days 4 hr. to monitor until • Benzo + opiates: Implement non- safe for discharge 4-7 days pharmacologic therapies • Heroin/methadone: NAS >8 times 2 5-7 days implement therapy • Suboxone: 5-6 days CNS Signs and Symptoms Scored infants 30 – 60 minutes after a feed. If the infant requires rocking to quiet during this time. Their cry is considered prolonged. If infant’s cry is high pitched at its peak even though it is not prolonged – score 2. If cry is high pitched throughout, or if crying is prolonged, even if not high pitched – score 3. Excessive High Pitched Cry Increased muscle tone Score if excessive or above-normal muscle tone. For instance: no head lag when being pulled to a sitting position or tight flexion of the infant’s arms and legs. Moro Reflex If the infant exhibits pronounced jitteriness (rhythmic tremors that are symmetrical and involuntary) of the hands during or at the end of a Moro reflex – score 2. If jitteriness and clonus (repetitive involuntary jerks) of the hands and/or arms are present during or after a Moro – score 3. Myoclonic jerks Score if involuntary muscular contractions which are irregular and exceedingly abrupt (usually involving a single muscle group) are observed. Tremors Mild, Moderate, and Severe Disturbed or Undisturbed Undisturbed means that the baby is either sleeping or at rest in its bed. Seizures Most commonly seen as tonic extensions of all limbs. Unusual limb movements may accompany a seizure. In the upper limbs these often resemble swimming or rowing in the lower limbs, they resemble pedaling or bicycling. Other subtle signs may include staring, rapid involuntary eye movement, chewing, back arching, and fist clenching. Occurs in 2-11% of infants with NAS Gastrointestinal Signs and Symptoms Excessive Sucking Score if hyperactive or disorganized sucking, increased rooting reflex. Loose/watery Vomiting stools Score if at least one episode of regurgitation is observed. Score if loose (curds/seedy appearance) or watery stools (water ring on nappy around stool) are observed. Poor Feeding Score if the infant demonstrates excessive sucking prior to feeding, yet sucks infrequently during a feeding, taking a small amount; and/or demonstrates an uncoordinated sucking reflex. Respiratory and Vasomotor Signs and Symptoms Respiratory Rate Score 1 only if respirations are >60/min in the absence of lung or airway disease. Score 2 only if respirations are >60/min and retractions are present in the absence of lung or airway disease Nasal Stuffiness Score if the infant sounds congested; mucous may be visible Sneezing Score if more than three sneezes are noted within the scoring interval Yawning Score if more than 3 yawns are observed within the scoring interval. Sweating Score if sweating is spontaneous and not due to excessive clothing or high room temperature. Hyperthermia Temperature should be taken per axilla. Mild pyrexia is an early indication of heat produced by increased muscle tone and tremors. Usually less than 102 Frequent low grade temp Mottling Score if mottling is present on the infant’s chest, trunk, arms, or legs. Non-pharmacologic Adjunct Therapy • Swaddling • Settling • Rocking • Decrease outside stimulation/white noise • Massage • Relaxation Baths • Pacifiers Pharmacologic Treatment Half-life Advantages Disadvantages (hours) Morphine 9 Shorter weaning Frequent doses course Constipation Methadone 26 Long half-life Longer weaning course Phenobarbital 45-100 Long half-life Sedation Possible apoptosis Clonidine 44-72 No sedation Hypotension, Rebound hypertension Adjunct Pharmacotherapy • Phenobarbital – Binds to the GABA receptor, improving the effect of GABA by extending GABA-mediated chloride channel openings which permits an increasing flow of chloride ions across the membrane, causing neuronal hyperpolarization (e.g., membrane inhibition to depolarization). – Does not treat gastrointestinal symptoms
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