NAS -2.txt

Occurs in 60% of infants exposed to drugs in utero

• Marijuana
• Cigarettes
• Heroin (diamorphine)/methadone
• Cocaine/crack
• Opiates (ie. morphine, oxycodone)
• Barbiturates (ie. Phenobarbital, Seconal)
• Benzodiazepines (ie. Valium, Ativan)
• EtOH (alcohol)

• Hyperactivity
• Irritability
• Poor sucking
• Hyperphagia (> 190 ml/kg/day)
• Crying
• Tremors
• Poor sleeping patterns
• Sleep-wake abnormalities
• Vomiting/diarrhea
• Dehydration
• Poor weight gain
• Seizures
• Tone abnormalities

• Fetal alcohol syndrome: hypotonia
• Cocaine: hypertonia
• Cigarette smoking + cocaine: hypertonia

Hypertonia resolves by 2 yrs of age and does not seem to be a marker for cerebral palsy

Usually within 24-72 hrs following birth

• Type of drug used
• Methadone exposed infants may not present until 96 hrs after delivery
• Timing of last dose prior to delivery
• The closer to delivery the greater the delay of onset and the more severe the symptoms
• Amount & strength of drug

• Prematurity
• Low birthweight, length, and head circumference
• Abnormal neurologic exam

“an altered state of response to an agent in which increasing amounts of the agent are required to produce or maintain the same effect”

downregulation of receptor

induction of degradative enzymes

“a physiologic state produced by continued administration of an agent which results in an abstinence syndrome if the administration of the agent is discontinued”

physiologic need for a drug

desire for the euphoric effects of drugs, usually recreational use of benzodiazepines, narcotics, and amphetamines

A generalized disorder characterized by signs and symptoms of CNS hyperirritability, GI dysfunction, respiratory distress, and vague autonomic symptoms.

developed by Loretta Finnegan in 1974

• Assess the need for pharmacotherapy
• Monitor therapeutic efficacy
• Correlate drug-related neurodysfunction with eventual neurobehavioral outcome

• Symptom severity scales may be inadequate or inappropriate for preterm infants
• Scoring scales do not take into account differences for gestational age
• Published data on neurodevelopmental outcome is inconsistent

• Assess high-risk infants 2 hrs after birth, then q4h until 96 hrs of life if pharmacotherapy is not needed
• Notify NP/MD to assess for pharmacotherapy or need to change pharmacotherapy if infant :
• Scores 8 or greater on 3 consecutive assessments
• Scores 12 or greater on 2 consecutive assessments
• Has a seizure

• Preemies (< 35 wks) have less abstinence symptoms and CNS manifestations than term infants
• Signs of opioid abstinence are related to developmental maturity
• Preemies are less likely to require specific pharmacotherapy than term infants
• Peak severity of symptoms occurs 1-2 days later in preterm than term infants

• Autonomic symptoms: sweating, yawning, sneezing, dilated pupils, diarrhea, gooseflesh, rhinorrhea
• Tremor
• Irritability
• Insomnia
• Feeding intolerance
• Seizures

• Poor communication
• Agitation
• Visual hallucinations
• Facial grimacing
• Generalized seizures

• Peak withdrawal occurs 2 days after discontinuing drug
• Severity and duration of symptoms increase with duration of midazolam administration
• After 3 weeks of therapy , detoxification requires 7-10 days

• Seizures
• Vomiting and diarrhea
• Inability to sleep
• Fever unrelated to infection
• Severe hyperactivity and irritability

• Jitteriness
• Hyperreflexia
• Sneezing

• Calm, quiet, warm, dark environment
• Gentle handling; gentle rocking
• Swaddling to decrease sensory stimulation
• Non-nutritive sucking
• Frequent small feedings; gavage feeding if necessary to promote rest periods; high caloric feeds to meet metabolic demands

• Replacement therapy
• Blockade therapy
• Nonspecific supportive or symptomatic therapy

• Gradual tapering of the drug of choice
• Substitution of the drug of choice with a cross-tolerant medication
• Combination therapy

• Opiates - methadone
• Benzodiazepines - phenobarbital
• Heroin – paregoric/methadone
• Methadone-treated Moms – paregoric/methadone
• Barbiturates – phenobarbital
• Alcohol - benzodiazepines

• Controls symptoms associated with opiates and barbiturates
• Modifies hyperactive behavior due to sedative and anticonvulsant properties
• Dosage and therapeutic level necessary to control symptoms are not well established

• Goals of Therapy:
• Serum level = 20-30 mcg/ml
• Note: Each 1 mg/kg of phenobarbital will raise serum level 1-2 mcg/ml.

• Loading dose approach
• Score titration method

• Loading Dose: 20 mg/kg
• Maintenance Dose: 5-8 mg/kg/day divided q12h
• Dosage Increase: 10 mg/kg q12h until control is achieved or plasma level of 70 mcg/ml is reached or signs of clinical toxicity appear
• Control abstinence for 72 hours
• Initiate detoxification process

• What is the Goal of Detox:
• allow PB level to decrease 10% every 24 hours

• Dosage adjustment based on symptoms until NAS is less than 8:
• Phenobarb: q8h
• Paregoric: q4h
• Give dose on schedule (ex. Phenobarb: 8 hours from previous dose)

• Long-acting synthetic opiate agonist (t 1/2 = 12-24 hours)
• Good oral bioavailability (F = 90%)
• Causes respiratory depression and sedation
• Causes little euphoria and little constipation
• Dosage: 0.05-0.1 mg/kg/dose q12h/q8h
• Wean dose by 10-20% until discontinue therapy (may take 6 weeks)

• Anhydrous morphine 0.4 mg/ml
• Contains camphor (CNS stimulant), papaverine (antispasmodic), ethanol (~50%), benzoic acid
• Increase dosage in increments of 0.5 mls/dose q4h
• Detox by decreasing dose by 10% every 2-3 days
• Caution: Tincture of Opium is anhydrous morphine 10 mg/ml. Dilute to 0.4 mg/ml before administration!

• Controls tremulousness and irritability
• Eliminates abnormal sucking behavior
• No longer recommended for neonatal drug withdrawal

• Phenobarbital
• Benzodiazepines
• Morphine
• Paregoric