Case Study XVI

1. Case Study XVI Brittney Spengler, SPT Wayne Strube, SPT

2. Patient Background • Mother was incoherent when arrived to ER in last stage of labor • Both mother and pt tested positive for methamphetamine and cocaine • Pt estimated 28 weeks gestation when born • Significant respiratory issues

3. Patient Background • Mother reports no prenatal care • Pt discharged to maternal aunt who already has custody of other two siblings • 4 & 2 y/o • Currently 40 weeks gestational age/12 wks chronological age • Home care PT ordered to assess infant

4. Physical Examination1,2 • Alert & active • Shrill crying • RR slightly elevated with nml BP& HR • Temperature of 98.8°F • Peripheral pulses in tact • Frequent sneezing & yawning • Sweating

5. Neurological Examination1,2 • Awake • Hyperactive • Irritable • Increased mm tone with mild tremor • Pt’s inability to sleep and eat • *noted by caregiver

6. Any guesses as to what this patients diagnosis is?

7. Differential Diagnosis • Neonatal Abstinence Syndrome (NAS)/ Neonatal Withdrawal Syndrome (NWS) • Prenatal Drug Exposure

8. Etiology3,4 • Mothers who use substances during pregnancy are at risk for their child having neonatal withdrawal syndrome and poor birth outcomes. • Opioid use near term commonly leads to neonatal withdrawal syndrome. • The use of cocaine, methamphetamine, and other stimulants has been associated with increased risk for adverse intrauterine effects including growth restrictions and placental abruption. • Problem: It has been hard to tell why the neonate is affected because many of the drugs half-life’s are short enough for the mother not to get caught . but… now the pros are using hair sample and meconium to test.

9. Prevalence3,5,6 • Prevalence of neonatal withdrawal syndrome increased from 0.97 to a high of 42.2 per 10,000 live births in Australia. • NAS occurs in 55% to 94% of infants who are born to opioid-dependent mothers. • A survey of combined data from 2005 and 2006 reported that 10% of women of child-bearing age used illicit drugs.

10. Characteristics of NAS5,6 • Cardinal manifestations include: • Increased muscle tone • Autonomic instability • Poor sucking reflex • Impaired weight gain • Gastrointestinal dysfunction • Language delays • Cognitive differences • Irritability

11. Mental impairments6 • Infants • Language delay • Toddlers and grade school children • Differences in task persistence and sustained attention • Problems with impulse control • Temperamental differences • Aggressive/Hyperactive

12. Timeline of NAS 5 • A condition that is associated with prolonged hospitalization • Lengths of treatment of 8 to 79 days • Consensus duration is about 30 days

13. NCMRR Model: Pathophysiology • Neonatal Abstinence Syndrome (NAS)1 • Maternal use of narcotics during pregnancy leads to fetal dependency of that drug • aka Prenatal drug exposure • Methamphetamine and cocaine

14. NCMRR Model: Impairments • Abnormally increased sweating • Increased respiration • Increased mm tone • Withdrawal symptoms

15. NCMRR Model: Functional Limitations • Excessive tearing of skin • Breathing irregularities • Unable to sleep • Unable to eat

16. NCMRR Model: Disability1 • Difficulty performing self-care activities • Early bonding and attachment issues • Unable to independently perform ADL’s

17. NCMRR Model: Societal Limitations7,8 • CPS • Loss of birth mother • Psychological and psychosocial issues

18. APTA Practice Patterns9 • 5B: Impaired Neuromotor Development • 5C: Impaired Motor Function and Sensory Integrity Associated With Nonporgressive Disorders of the CNS-Congenital Origin • 6G: Impaired Ventilation, Respiration/Gas Exchange and Aerobic Capacity/ Endurance Associated With Respiratory Failure in the Neonate • 7B: Impaired Integumentary Integrity Associated With Superficial Skin Involvement

19. Prognosis2,7,8,10,11 • Good prognosis • Disease itself tends to resolve overtime as long as there are no complications • Treatment helps relieve symptoms of withdrawal • How well baby does depends on whether the mother (or father) continues to use drugs and the type of maternal drug used during pregnancy • Multidisciplinary approach • PT, OT, MD, CPS, family, & pt

20. Prognosis11 Maternal Drug Use and Length of Neonatal Unit Stay Objectives: Test hypothesis that the duration of neonatal stay would be influenced by type of maternal drug and is particularly prolonged for infants whose mothers had taken methadone with other substances.

21. Prognosis11 Methods Medical records of infants admitted to a neonatal unit because of NAS were reviewed. Subjects: 41 infants with a median GA of 39 weeks Range 37-42 weeks Data was collected regarding antenatal and neonatal factors likely to affect neonatal stay

22. Prognosis11 Methods cont. Comparisons were made between 3 groups: Methadone alone- 14 Methadone plus other drugs- 17 Heroin Cocaine Benzodiazapines Amphetamines Barbiturates Non-methadone opiods- 10 Heroin Dihydrocodeine

23. Prognosis11

24. Prognosis11

25. Prognosis11 Conclusion Women in the methadone and methadone plus groups were significantly more likely to have received antenatal care The duration of stay and requirement for treatment were greater in infants exposed to methadone and other drugs

26. Prognosis11 Take Home Message Prolonged treatment, prognosis, and neonatal unit stay are influenced by the type of maternal drug abused.

27. Goals12 • LTG : • Pt to successfully consume 4oz of formula per feeding with proper feeding technique in 4 wks • Pt to take 2 naps, 2 hours each, without startling to full arousal in 4 wks • Pt to sleep 10 hours at night without startling to full arousal in 6 wks • STG : • Caregiver to demonstrate proper swaddling technique at next visit • Caregiver to verbalize safety precautions for swaddling and skin care at next visit • Pt to successfully consume 2oz of formula per feeding with proper feeding technique in 2 wks

28. Intervention13,14 • Reduce the degree of ambient light exposure • Minimize excessive noise • Avoid unnecessary handling • Provide swaddling, holding, rocking • Oscillating cribs • Avoidance of abrupt changes in the infant’s environment can be helpful. • Feeding high-caloric formula • If infant does not respond to these interventions they will require additional medical intervention.

29. Swaddling12 • Not just one method of swaddling but many variations • In start and duration • Tightness of wrapping • Effects • Sleep and Arousal • Temperature Control • Motor Development • Sudden Infant Death Syndrome (SIDS) • Respiratory Infections • Rickets and DDH • Pain Control • Crying Behavior • Breastfeeding and Postnatal weight

30. Intervention5 • Cochrane reviews suggest lack of high-quality evidence to support any specific treatment • Although expert opinion places opioids as the class of agents that possesses the greatest efficacy

31. Intervention5 • Sublingual Buprenorphine for Treatment of NeonatalAbstinence Syndrome: A Randomized Trial • Objectives • Opioid replacement with morphine is the present preferred treatment. Improved treatment options would be a therapeutic advance. • Morphine in the form of neonatal opium solution (NOS) • Buprenorphine is a partial opioid agonist that is finding increasing use in adult abstinence but has never been used for neonatal abstinence syndrome. • Could this help?

32. Intervention5 • Methods • A single-site, randomized, open-label trial • 26 neonates were randomly assigned to treatment with either sublingual buprenorphine or NOS in a 1:1 ratio. • Inclusion Criteria: • ≥ 37 weeks’ gestation, exposure to opioids in utero, and demonstration of signs and symptoms of NAS that required treatment.

33. Intervention5

34. Intervention5 • Exclusion Criteria: • Major congenital malformations • Intrauterine growth retardation • Medical illness that required intensification of medical therapy • Concomitant maternal benzodiazepine or severe alcohol abuse • Maternal use of alcohol or of benzodiazepines in the 30 days before enrolment • Concomitant maternal benzodiazepine or severe alcohol abuse • Seizure activity or other neurologic abnormality • Breastfeeding • Inability of mother to give conformed consent 2˚ psychiatric diagnosis

35. Intervention5

36. Interventions5

37. Intervention5 • Conclusion • The treatment of NAS with sublingual buprenorphine is feasible and has an acceptable safety margin. • Confirmation of safety will require additional study • Suggestion of improved efficacy in terms of length of stay and length of treatment • But will need to be confirmed in a larger, double-blind, properly powered clinical trial. • This project was supported by the Commonwealth of Pennsylvania Tobacco Fund and National Institute on Drug Abuse

38. Embedded Issue • Neonatal abuse and CPS • Abuse definition by CPS: • The current use by a person of a controlled substance as defined by the Health and Safety Code, in a manner or to the extent that the use results in physical, mental, or emotional injury to a child • Contact • Texas Abuse Hotline • 1-800-252-5400 • In hospital • Social Services

39. Embedded Issue • Dealt with on a case by case basis • Many things taken into consideration • Separation from mother • Placement of child in foster / protective care. • How will this effect the growth and development of the child? • Not all care givers are created equal

40. Video’s • http://newborns.stanford.edu/PhotoGallery/Jittery3.html

41. References 1. Campbell S, Vander Linden DW, Palisano RJ. Physical Therapy for Children. 3rd ed. St. Louis, Missouri: Saunders Elsevier; 2006. 2. Lall, A. Neonatal abstinence syndrome. British Journal of Midwifery. 2008;16: 220-223. 3. O’Donnell, M. et al. Increasing Prevalence of Neonatal Withdrawal Syndrome: Population Study of Maternal Factors and Child Protection Involvement. Pediatrics. 2009; 123, e614-e621 4. Koren G, Hutson J, Gareri J. Novel Methods for the Detection of Drug and Alcohol Exposure During Pregnancy: Implications for Maternal and Child Health. Clin Pharmacol Ther. 2008; 83: 631-634 5. Kraft K. et al. Sublingual Buprenorphine for Treatment of Neonatal Abstinence Syndrome: A Randomized Trial. Pediatrics. 2008; 122: 601-607. 6. Seligman, NS. et al. Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates. Am J Obstet Gynecol. 2008; 199: 396-397. 7. Marcellus, L. Neonatal abstinence syndrome: reconstructing the evidence. Neonatal Network. 2007; 26: 33-40. 8. Oei, J. et al. Management of the newborn infant affected by maternal opiates and other drugs of dependency. Journal of Pediatrics and Child Health. 2007; 43: 9-18.

42. References 9. APTA. Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001; 81:9-744. 10. King, TA. et al. Neurological manifestations of in utero cocaine exposure in near-term and term infants. Pediatrics. 1995; 96: 259-264. 11. Johnson, K. et al. Maternal drug use and length of neonatal unit stay. Addiction. 2003; 98: 785-789. 12. Sleuwen, AC. et al. Swaddling: A Systematic Review. Pediatrics. 2007; 120: 1097-1106. 13. Neonatal Abstinence Syndrome: Treatment & Medication. The eMedicine page. Available at: http://emedicine.medscape.com/article/978763-treatment. Accessed August 6, 2008. 14. Tecklin JS. Pediatric Physical Therapy. 4th ed. Lippincott Williams & Wilkins, 2007.

43. Questions?