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Caring for infants with short- and long-term effects of in-utero opioid exposure

Caring for infants with short- and long-term effects of in-utero opioid exposure. Bonny Whalen, MD Medical Director / Newborn Pediatrician CHaD /DHMC Newborn Nursery June 5, 2013. OBJECTIVES.

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Caring for infants with short- and long-term effects of in-utero opioid exposure

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  1. Caring for infants with short- and long-term effects of in-utero opioid exposure Bonny Whalen, MD Medical Director / Newborn Pediatrician CHaD/DHMC Newborn Nursery June 5, 2013

  2. OBJECTIVES • Demonstrate an understanding of short- and long-term effects of in-utero opioid exposure on the developing fetus / neonate • Discuss the importance of multi-disciplinary, family-centered care for these infants in the newborn period • Help families best prepare for the birth of their at-risk infant including how to provide calm, nurturing environments, limiting visitors, etc.

  3. Illicit Drug Use in U.S. Women • ~ 11% illicit drug use in past month in women 15-44 yr • 15-17 yr: 13% 18-25 yr: 16.8% 26-44 yr: 7.6% • 4.4%illicit drug use in past month in known pregnancy • 15-17 yr: 16.2% 18-25 yr: 7.4% 26-44 yr: 1.9% • Most commonly reported illicit drugs used by women: • Marijuana • Psychotherapeutics (e.g., opioids) 2009 & 2010 National Surveys on Drug Use and Health https://nsduhweb.rti.org/

  4. In-utero opiate exposure and its effects • Growth restriction • Prematurity • Developmental abnormalities / long-term effects? • Opioid system mediates developmental events • FaridWO, et al. CurrNeuropharmacol. 2008. • Motor delays? Cognitive delays? ADHD? • Review of available studies reveals no adverse effects on development for opiate-exposed infants • Jones HE, et al. Early Hum Dev. 2009. * P < 0.05 for heroin vs. substitution agent Binder T and Vavrinkova B. NeuroendocrinolLett. 2008.

  5. Neonatal Abstinence Syndrome (NAS) • CNS hyperirritability • Autonomic hyperfunction • GI dysfunction

  6. CNS HYPERIRRITABILITY • High-pitched crying • Sleeplessness • Hyperactive moro reflex • Tremors • Increased muscle tone • Myoclonic jerks • Seizures http://newborns.stanford.edu/PhotoGallery/Jittery3.html

  7. AUTONOMIC HYPERFUNCTION Metabolic / Vasomotor / Respiratory Disturbances • Fever • Sweating • Yawning • Mottling • Nasal stuffiness • Sneezing • Nasal flaring • Tachypnea • Retractions

  8. GI DYSFUNCTION • Excessive sucking • Poor feeding • Regurgitation • Projectile vomiting • Loose stools • Watery stools

  9. NAS: What to Expect • 2/3 - 3/4 infants develop some degree of NAS • Symptoms from long-acting opioids start on DOL 2 • May see symptoms earlier if: • Mom missed dose the day prior • Baby has early rapid withdrawal phase of buprenorphine • Mom using other substances / meds / nicotine • Symptoms usually peak DOL 3-4 • May depend on med, mom’s other meds, baby’s metabolism ... • ≥ 1/2 infants require Rx for NAS • No relationship b/w dose of substitution agent and NAS severity or duration of Rx Lejeuneet al. Drug Alcohol Depend. 2006. Sigmanet al. J Peds. 2010

  10. Minimum Recommend Monitoring Times for opioid-exposed infants • 2 days • Short-acting opioids • e.g., morphine, oxycodone, Percocet • 4 days • Heroin • Long-acting opioids • e.g., buprenorphine, methadone

  11. METHADONE VS. BUPRENORPHINEJones et al. N Engl J Med. 2010; 363:2320-2331. • Multi-center RCT (n = 7) comparing MTD vs. BUP Rx in 175 pregnant women with opioid dependency (89 MTD, 86 BUP) • Double-blind, double-dummy, flexible-dosing • Comparison of 131 neonates whose mothers were followed to end of pregnancy • 33% BUP vs. 18% MTD discontinued Rx (P > 0.02) - Most commonly due to maternal dissatisfaction with Rx • Unclear if pts with more severe dependence more likely to leave BUP group, therefore skewing towards better outcomes in BUP neonates; however post-hoc analyses remained significant when excluded moms on ≥ 100 mg methadone

  12. Significant Predictors related to NAS Need for Rx for NAS • Maternal cigarette smoking • Higher birthweight Higher peak NAS score prior to Rx • Lower maternal weight • Maternal SSRI use • Higher birthweight • Lower gestational age • Vaginal delivery Longer duration of Rx • Maternal use of SSRIs, antidepressants, or antipsychotics Higher dose of morphine required for Rx • Maternal use of SSRIs, antidepressants, or antipsychotics • SSRIs independently • Lower # days of maternal receipt of study medication • Greater # of cigarettes smoked 24 hr prior to delivery Kaltenbach, et al. Addiction. 2012;107:45-52.

  13. Significant Differences in NAS Profiles Methadone-exposed • Higher incidence of: • Undisturbed tremors • Hyperactive Moro • Greater mean severity score: • Total NAS score • Disturbed tremors • Undisturbed tremors • Hyperactive Moro • Excessive irritability • Failure to thrive • Shorter time to Rx initiation • 36 hr (compared with 59 hr for buprenorphine) Buprenoropine-exposed • Higher incidence of: • Nasal stuffiness • Sneezing • Loose stools • Greater mean severity score: • Sneezing Limitation = Data from neonates requiring Rx were excluded from analyses once Rx was initiated → may underestimate measures of incidence / severity Gaalema, et al. Addiction. 2012;107:53-62.

  14. How to Assess for NAS: Finnegan scoring tool

  15. development of the finnegan scoring tool • Developed to: • monitor full spectrum of abstinence sx due to narcotic withdrawal • monitor response to Rx • Determined prevalence of 20 most common sx seen in infants with narcotic withdrawal • Ranked sx based on potential for greatest harm to infant Finnegan LP, at al. Int J Clin PharmacolBiopharm. 1975.

  16. Assigned score of “5” to sx with greatest potential to harm infant and “1” to sx with least pathological significance • Scored q 1 hr in 1st 24 hr, q 2 hr x 24 hr, then q 4 hr corresponding to “Nursery feedings” • Good inter-rater reliability Finnegan LP, et al. Int J Clin PharmacolBiopharm. 1975 • Modified in 1986 - Score q 4 hr - Allow to feed q 2-3 hr

  17. LIMITATIONS OF FINNEGAN TOOL Designed for term infants At times, difficult to interpret sx of ‘normal newborn’ vs NAS • Study of 102 non-addicted infants • DOL 1-3: Median score = 2 • Variability increased on DOL 1-2 • DOL 1: 95th percentile = 5.5 • DOL 2: 95th percentile = 7 Zimmermann-Baer et al. Addiction. 2010. Can be prone to subjectivity Not to be used for a “one point in time” quick assessment Lacks specificity • DDx: hunger, nicotine or benzo withdrawal, SSRI toxicity vs withdrawal, hypoglycemia, infection, CNS injury, hypocalcemia, hyperthyroidism

  18. Co-morbidities • Nicotine withdrawal • Tobacco use in pregnancy ~85% Lejeuneet al. Drug Alcohol Depend. 2006. Zimmermann-Baer et al. Addiction. 2010. • SSRI withdrawal / toxicity • 13% maternal SSRI use in pregnancy Zimmermann-Baer et al. Addiction. 2010. • Other substance / med toxicity • 12% benzodiazepine Rx in pregnancy Zimmermann-Baer et al. Addiction. 2010. • Difficulties feeding • Increased weight loss

  19. NAS SCORING TIPS • Teach parents how NAS scoring is performed • Teach parents how to help monitor infant • e.g., watch for decreased sleep, yawning, sneezing, excessive sucking • Score within 2 hr of birth, then q 3 - 4 hr • Score baby when awake to elicit reflexes & behaviors Do not awaken unless asleep for > 3 hr • Allow infant to calm first • e.g., allow infant to feed before scoring, place skin-to-skin with mother • especially important for muscle tone & RR • Score all symptoms that occur within interval • If score ≥ 8, score NAS q 2 hr until < 8 x 24 hr

  20. SUPPORTIVE CARE FOR NEWBORNS • Rooming-in Allows family to respond to infant at early feeding / stress cues, empowers family to care for their infant independently, and provides opportunity for calmer environment for infant • Decreased need for NAS Rx • Shorter length of stay • More likely to be discharged into custody of mother Abrahams R et al. Can Fam Physician. 2007.

  21. SUPPORTIVE CARE FOR NEWBORNS • Feed baby at early feeding cues, till content • Frequent skin-to-skin contact • Use calming techniques • C-position • Swaddling • Gentle jiggling • Slow, rhythmic up & down movements* • Clap baby’s bottom with cupped hand* • Shooshing • Non-nutritive sucking *May not work for some babies

  22. SUPPORTIVE CARE FOR NEWBORNS • Provide undisturbed periods of sleep / rest • Cluster care • Decrease environmental stimuli • Low lights • Quiet room • Limit visitors / # caregivers • Avoid “excessive handling” of baby • Introduce stimuli as baby able to tolerate • Infant touch / massage

  23. BREASTFEEDING AND OPIATE REPLACEMENT Rx Methadone and buprenorphine considered safe Breastfed infants may experience decreased NAS severity Faridet al. CurrNeuropharmacol. 2008. Ensure no active illicit drug use- see ABM guidelines Provide lactation support Promote calm, organized environment Frequent, ad lib feedings Provide emotional support Teach ways to help baby if NAS present Skin-to-skin Hand expression / breast massage during feeding Organize baby’s suck on finger first if suck disorganized Feed small amount of colostrum first C-hold in cross cradle / football positions May require caloric supplementation for increased metabolic needs

  24. ABM’s Breastfeeding Guidelines • Consistent prenatal care • Abstinent from illicit drug use or licit drug abuse for 90 days prior to delivery & able to maintain sobriety in outpt setting • Women engaged in substance abuse Rx who have provided consent to discuss progress with Rx & postpartum plans with substance abuse Rx counselor • Negative urine toxicology testing at delivery • No medical contraindications • e.g., HIV, contraindicated antipscyh med The Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #21: Guidelines for breastfeeding and the drug-dependent woman. Breastfeeding Medicine. 2009;4:225-228.

  25. DRUG OF ABUSE SCREENING • Obtain specimens within 24 - 48 hr of delivery to help: • Anticipate timing and type of withdrawal symptoms • Inform DCF / DCYF of exposure, when clinically indicated • Make recommendations re: safety of breastfeeding • Urine drug of abuse screen • Urine confirmatory testing • Meconium drug of abuse screen

  26. WHEN TO CONSIDER RX / ICN TRANSFER • Apnea • Seizures • 3 consecutive scores (or average of) ≥ 8 • 2 consecutive scores (or average of) ≥ 12 • Inability to feed orally due to NAS sx

  27. PHARMACOLOGIC RX FOR NAS Capture Phase • Oral morphine*§ q 4 hr, dose increased until NAS sx controlled • Phenobarbital added if difficult to capture or wean Maintenance Phase • Find smallest dose that adequately controls baby’s sx • Goal of Rx = NAS scores < 8 Weaning Phase • Begin wean when scores < 8 x 48 hr & baby clinically stable • Wean by 10% daily when following present: • NAS scores < 8 • Baby clinically stable *Agent of choice at DHMC, alternative agents sometimes preferred at other institutions (e.g., methadone) §2010 Cochrane Systematic Review on Opiate Rx for opiate withdrawal in newborn infants: “There is insufficient data to determine safety or efficacy of any specific opiate compared to another opiate.”

  28. CARE COORDINATION • Clinical Resource Coordinator • Assist in identifying and arranging postnatal supports • VNA, Good Beginnings, breast pump rental, etc. • Identify Primary Care Physician (PCP) • Social Worker • Perform initial assessment of mother and newborn • Assist in identifying and arranging postnatal supports • Review risk for postpartum depression / stress & identify coping mechanisms / supports • Mandated report to DCF/DCYF, when clinically indicated • Consider offering that mother make report herself • Review how report will help engage parenting/family supports

  29. KEEPING CHILDREN AND FAMILY SAFE ACT • As a condition of federal funds under Child Abuse Prevention and Treatment Act, each state must develop policies & procedures to address needs of infants born and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure • Notify CPS of substance-exposed newborns • Develop plan of safe care for infant • Law specifies that reports of prenatal substance exposure shall not be construed to be child abuse or require prosecution for any illegal action

  30. DHMC MANDATED REPORTING GUIDELINES • Mother continuing to use any of following substances during pregnancy, subsequent to documented teaching on potential dangers of substance(s) and resources offered for cessation: • Alcohol • Controlled medication not prescribed to the mother • Illicit substance • Mother who admits to prenatal use of illicit substance and use not previously disclosed • Baby tests positive for any of above substances • Baby with Fetal Alcohol Syndrome or Adverse Effects

  31. DISCHARGE READINESS • No apnea or respiratory compromise • Stable vital signs • Baby has completed appropriate observation period • No active concerns for significant sx of NAS • Feeding well with appropriate weight pattern • Parents demonstrate appropriate response to / care of baby • Home environment assessed as safe • Referrals to community resources in place

  32. COMMUNITY RESOURCES • Information and Referral • NH Resource 211 802-652-4636 • VT Resource 211 866-444-4211 • Support/Home-based programs (e.g., VNA, Good Beginnings, Parenting Programs) • Health and Mental Health / Treatment Programs • Child Protective Services • Domestic/Family Violence • Housing • Emergency Financial Assistance • Legal Assistance • Transportation • Long-term follow-up programs / interventions (e.g., Early Intervention)

  33. GOING HOME … • Communication with community supports • Identify known family challenges (domestic violence, mental health issues, homelessness) • Identify known family strengths and informal supports • Update state CPS agency, as clinically indicated • Known family challenges and strengths • Issues in the home which may pose risk for baby • Results of drug of abuse screening • Community supports recommended / accepted • Communication with baby’s PCP & 1st visit made • Update on medical course, social issues, community resources offered / accepted

  34. Prenatal preparation • Maintain abstinence • Engage social supports • Encourage breastfeeding (with abstinence) • Decrease / stop smoking • Educate families regarding what to anticipate • Likelihood of NAS symptoms / what sx look like • Need to stay in hospital for at least 4 days for monitoring • Possibility of needing Rx / duration of Rx if needed • Providing calm environments for baby / calming techniques • Limiting visitors, rooming-in, skin-to-skin, swaddling, etc. • Drug of abuse screening • Need for mandated reporting / referral to DCF/DCYF

  35. Resources for providers • “Parenting and Substance Abuse: Developmental Approaches to Intervention” - Book that explores issues of the substance exposed dyad pre- and post-partum • Edited by Nancy Suchman, MarjukkaPajulo and Linda Mayes (Oxford University Press, 2013). • “Highs and Lows” - Book about women and addiction. http://www.camh.ca/en/education/about/camh_publications/Pages/highs_lows.aspx

  36. QUESTIONS?

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