NAS.txt

• Self reporting – unreliable
• National survey of drug use and health
• Maternal lifestyle study

• 8% of population >12 are current drug users
• 75% of murders, assaults and child abuse are r/t drugs/alcohol
• 1/3 of the addicted population is women
• 15% of childbearing women are drug users
• 3-8% drug abuse during pregnancy
• 10-11% of all newborns are prenatally exposed to alcohol or drugs
• 75-90% of substance exposed infants are undetected and go home

• Methods for defining drug use are not clearly defined
• Multiple confounding variables make it difficulty to study cause and affect relationships of a single drug on child outcomes
• Multiple factors that can play a role in child growth and development (SES)

75% of pregnancies

• Increased respirations and heart rate
• Low birth weight
• Altered sleep pattern

• Increased HR
• Still birth

A small amount crosses but the AAP considers it safe to breastfeed and consume caffeine

Cigarettes but it has declined over the last 2 decades, 10-20% of pregnant women smoke

Exact mechanism is unknown but the nicotine and carbon monoxide play a role- they have a direct cytotoxic effect (cigarettes contain >2500 toxic chemicals)

• Spontaneous abortion and stillbirth
• 2x risk of placenta previa
• PROM
• IUGR
• CHD

• Withdrawal like symptoms
• SIDS, otitis media
• ashthma

Decreased stillbirth and decreased neonatal death

Yes

• Smoking is independently associated with an increased risk
• There is a dose dependent relationship
• Smoking may cause altered lung function and altered CNS control pr arousal of respiration or both
• There is a loss of neonatal hypoxia tolerance after prenatal exposure – so infant stops breathing and doesn’t recognize the decreased oxygen levels since they were used to it in utero

Alcohol

• Analgesic that depresses the CNS, low doses act as a stimulant and relaxant causing sensations of euphoria
• Lipid and water soluble and easily passes through cell membrance
• Alcohol and its metabolite are toxic and fetus lacks the enzymes necessary to break the alcohol down
• The amniotic fluid becomes a reservoir for the alcohol and metabolites
• Major cause of MR today
• It is the only abusing drug that is well associated with teratogenic effects

• Abnormal facial features
• Prenatal and postnatal growth deficiencies
• CNS problems

• Umbrella term to describe a spectrum of effects resulting from maternal alcohol use during pregnancy
• It is not a medical dx
• What is the incidence of FAS
• .2-1.5/1000 births
• FASD may occur 3x more than FAS

• Poverty
• Advanced maternal age
• Nonwhite race

• Interrupts the normal accumulation and organization of protein
• Interferes with the primary function of the placenta to transport nutrients
• Has a direct effect on cell maturation, migration growth and division

• The exact amount is unknown
• Number of binge drinking days has the strongest effect
• Effects are r/t the GA of exposure, amount ingested, frequency of exposure, peak blood concentrations, maternal alcohol metabolism and susceptibility of the infant

• Microcephaly
• Dysgenesis corpus collosum (left brain –logic, right brain-impulse/feelings)
• Hypoplasia of basal ganglia – special memor, perception of time
• Hypoplasia of the cerebellum – coordination, movement, behavior, memory
• Prefrontal cortex – executive function
• Neurosensory hearing loss

• Midface hypoplasia
• Broad,flat nasal bridge
• Poorly developed philtrum
• Thin upper lip
• Short palpable fissures
• Strabismus
• Ptosis and low set dysplastic ears

• Occurs shortly after birth with peak effects at 48 hours
• 72 hours period of hyperactivity, crying, tremors, irritability, seizures, poor sleep patterns, hyperphagia and diaphoresis followed by 48 hours phase of lethargy and return to baseline

• Continued growth restriction
• Lower Bayley scores
• Learning difficulties, poor memory, poor language comprehension, and poor problem solving skills
• Inability to understand concepts such as time and money
• Poor coordination
• Poor socialization skills
• Lack of imagination or curiositybahavioral problems- hyperactive, social withdrawal, stubbornness, impulsiveness and anxity

2nd or 3rd grade level

THC

• Growth retardation
• Mild withdrawal syndrome
• No documented long term effects but may potentiate risk of prematurity, low birth weight and teratogenic effects of other drugs used during pregnancy

• Powerful addictive CNS stimulant
• Derived from the erythroxylon cocoa plant
• Chewed or made into tea for centuries
• Freud recommended it for alcohol and morphine addiction

Cocaine

• Low molecular weight
• Water and lipid soluble
• Prevents reuptake of dopamine, norepi, and serotonin
• Results in intensified neurochemical responses
• Accumulation of neurotransmitters
• Causes the release of dopamine from the brain resulting in euphoria and cycle of sddiction
• Tryptophan uptake is inhibited so have more energy
• Blocks Na ion channels – anesthetic effect

• 5-10 minutes – smoking and injecting
• 15-20 – snorting
• ½ life is 16-90 minutes depending on dose and route

• Teratogenic effects are controversial
• Sypathomimetic effects on CNS
• Vasoconstriction decreased placental blood flow fetal hypoxia, IUGR
• Decreased vascular tone and perfusion increase chance of NEC, bowel perforation, HT, MI in newborn
• Maternal HT and fetal hypoxia increased risk of abrutipn
• GU anomalies (4x more)
• Midline defects (agenesis corpus colossum, ocular abnormalities)
• Vascular disruption (forearm defects, intestinal atresia)
• Tachycardia

• Wide range of neurobahvioral abnormalities most likely due to acute intoxication vs withdrawal
• Onset of signs occur in 0-3 days, peaks at 1-4 days
• Duration is unknown
• Signs include hypertonic, tremulous, irritable, abnormal crying, feeding and sleeping patterns

• Increased r/o SIDS
• Most infants exhibit catch up growth by 12 months
• Studies agree that infants with small heads are at risk for intellectual and developmental problems

• CNS stimulant initially marketed for tx of obesity and narcolepsy but currently used for ADD
• Resemble effects of cocaine but duration is 2-12 hours

Methamphetamine

• Easily dissolves in water for injection (crystal)
• Readily goes from solid to gas (Ice)
• Cheap and easy to make
• Popular among teens and white women

Greater restrictions on cocaine importation

Poor growth, increased BP and stroke, birth defects (6x more): cleft lip and palate, CHD, kidney disease and gastroschesis

Escatsy and eve-there is just an alteration in the benzene ring

• Similar to methadone but less intense
• Onset is 48 to 72 hours
• ~10% will need medical intervention

• Intellectual capacity does not appear to be effected
• Hyperactive and aggressive
• Accelerated puberty in boys and delayed puberty in girls

• Heroin
• They tend to inhale it

Synthetic opiate drug that is highly addictive, it is made from morphine, which is a naturally occurring substance extracted from the Asian opium poppy plant

• Poor health, poor nutrition and multiple medical issues
• Less likely to seek PNC
• Higher rate of STDs, urinary and vaginal infections
• 5x higher rates of maternal hepatitis
• drug use is further complicated by HIV

• IUGR, small head circumference
• Increased Mec staining
• Low apgars
• Increased r/o syphilis and HIV
• Thrombocytosis
• 2-4x r/o SIDS
• NAS

• No major neuro deficits but “soft” signs are evident such as deviations in sensory, motor, and integrative functions that do not indicate localized brain injury
• Characteristics of ADD
• Aggressiveness and compulsiveness

Synthetic narcotic used to treat opium addiction

Heroin releases an excess of dopamine and causes users to need an opiate to continuously occupy the opiod receptors-meth occupies this captor and is a stabilizing factor that permits addicts on methadone to change their behavior

• Doesn’t impair function
• No adverse effects on mental capability, intelligence or employability
• Not sedating or intoxicating
• Doesn’t interfere with ordinary activities such as driving a car
• Pts are able to feel and experience emotional reactions
• Prevents opiate withdrawal
• Better PNC and medical care
• Improved growth of the fetus
• Decreased prematurity, decreased perinatal infections

Stabilized uterine environment

No dosing guidelines

• AAP states that it is compatible
• Some experts report that it is safe if the max dose is <120mg and no other medication

• Codeine, Talwin – less potent opiods
• Tranquilizers, sedatives, valium, serax – nonopiod CNS depressants

• Testing is done based on maternal indicators and should be done on infants with unexplained symptoms
• Based on drug specific assays
• Drugs tested are determined by frequency of use, illegality and potential for harm
• Conducted as a two tiered procedure
• Testing is based on institutional policy

National institute of drug abuse

High cut off levels underestimate the true scope of drug abuse in pregnancy

To know what the infant is withdrawing from

Urine tox- it represents the ultrafiltration of plasma

The kidneys ability to concentrate substances

Recent drug use

• Cocaine 72-96 hours
• Heroin – 24-48 hours
• Methadone – up to 10 days
• Alcohol – 8-16 hrs
• Amphetamines – 48 hours
• THC – 5-20 days

Meconium

Drug exposure as early as 20-24 weeks – drugs may be detected up to 3 days of age

• Distribution of drugs is not uniform
• Results aren’t readily available

Hair, nails, gastric aspirates

NAS

Documented recent drug use, positive screens, unexplained CNS/GI symptoms, iatrogenic cause

50%

60-90%

• Drug
• Last dose
• Metabolism (maternal and infant)
• excretion

If > 1 week since last exposure and delivery

• Occurs in varying degrees
• Most opiates are short acting and symptoms exhibit in the 1st 24-72 hours
• Heroin exposed infants exhibit s/s earlier than meth infants

• Acute s/s last for several weeks
• Subacute s/s ( irritability, hypertonia, sleep disturbances, hyperactivity, and feeding problems) persist for up to 6 months

Irritability, altered sleep patterns, tremors, increased tone, myoclonic jerks, seizures (2-111%), increased moro

Tacypnea, nasal stuffiness, sneezing, nasal flaring

Fever, sweating, mottling

• Excessive uncoordinated sucking
• Poor feeding
• Emesis
• Loose/watery stools

• To be objective but subjectivity is evident
• Used to guide management
• Important not to use the absolute score when evaluating pharmacological evaluation
• Should discuss the abnormal scores

Finnegan tool-it is based on nursing observation

• Non-opiod drugs
• When would you notify a MD/NNP of NAS scores
• 8 or higher over 3 consecutive assessments or 12 or higher over 2 assessments – will evaluate for need of meds

3 days after d/c therapy if there is no increase in s/s or if score is <8 – if the s/s begin again then the scoring is started for at least another 4 days

• There is a lower risk of withdrawal possibly r/t immaturity of CNS or decreased exposure time
• Need to focus less on respiratory distress syndromes, tremulous movements and poor feeding and place more emphasis on irritability, diarrhea, sneezing and yawning

• Maintain infant comfort
• Support the infants ability to sleep, feed and gain weight
• Standard medical practice incorporates both developmental and behavioral methods in conjuncture with pharmacologic agents to achieve above goals

• Provide relief of nasal stuffiness
• Small frequent feedings
• Non-pharmacologic interventions

• Swaddling.
Non-nutritive sucking.
Gentle rocking.
Reducing environmental stimuli at the patient's bedside.
Provide adequate pain management for painful procedures
• Assist infant with self-regulatory behaviors to decrease energy expenditure
• Provide good skin care
• Lactation consult
• Social work consult

• Rule out common neonatal metabolic imbalances that can mimic or potentiate withdrawal symptoms
• If pharmacologic intervention is initiated an assessment tool should be used to monitor the infant in an objective and consistent manner
• Tool is also used to monitor infants clinical response to pharmacotherapy
• Drug from same class as the drug causing withdrawal preferred
• Only drugs approved for the treatment of drug withdrawal are benzodiazepines for alcohol withdrawal and methadone for opioid withdrawal

AAP committee on Drugs (1998) recommends tincture of opium for opioid withdrawal and phenobarbital for sedative-hypnotic withdrawal

• Currently only SC holds prenatal substance abuse as a criminal act of child abuse and neglect
• Minnesota, South Dakota and Wisconsin have laws that enforce admission to an inpatient treatment program
• 2004 Texas made it a felony to smoke marijuana while pregnant with a prison sentence of 2-20 yrs
• Other states have laws that address prenatal substance abuse

• Not recommended during the initial steps of resuscitation
• Indications to give Narcan require both of the following according to NRP
• Continued resp depression after PPV has restored nml HR and color
• Hx of maternal narcotic administration within the last 4 hrs