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The Impact of Neonatal Abstinence
Syndrome on one West Virginia
Community
Sean Loudin MD
Disclosures
 I have no financial disclosures
Objectives
 Discuss the epidemiology of Neonatal Abstinence Syndrome
(NAS) both nationally and regionally
 Understand th...
How big is the problem?
0
0.5
1
1.5
2
2.5
3
3.5
2000 2003 2006 2009
NASper1000deliveries
Rate of NAS per 1000 births
US De...
How big is the problem?
Increasing incidence and geographic distribution of neonatal
abstinence syndrome: United States 20...
How big is the problem?
0
5
10
15
20
25
30
2000 2003 2006 2009
NASper1000deliveries
AHRQ
CHH
How big is the problem?
0
20
40
60
80
100
120
2000 2003 2006 2009 2012 2013
NASper1000deliveries
AHRQ
CHH
Drugs Causing Withdrawal
 Classic NAS due to opiates
 Nicotine withdrawal from maternal tobacco exposure
 Alcohol withd...
Drugs in WV
Prevalence of Drug Use in Pregnant West Virginia Patients
Chaffin et al. 2009
 During 1 month period (August ...
Drugs in WV
 Buprenorphine now very prominent
 Methadone decreasing in frequency
 Marijuana still continues to be used ...
Neonatal Abstinence Syndrome
 Passive exposure of the newborn occurs when a mother
uses a neuroactive drug during her pre...
Neonatal Abstinence Syndrome
 Classic NAS consists of a wide variety of CNS signs of
irritability, GI problems, autonomic...
Neonatal Abstinence Syndrome
 Autonomic over-reactivity is typically exhibited by yawning,
sneezing, mottling and fever
...
Pathogenesis of NAS
Pathogenesis of NAS
 Endogenous opiates (endorphins, enkephalins and
dynorphins)
 Complex interactions between endogenou...
Pathogenesis of NAS
Pathogenesis of NAS
 When the opiate is withdrawn, the inhibiting effect gone
 This results in a supranormal increase in...
Pathogenesis of NAS
Disuse Hypersensitivity
 A drug may depress certain neural systems
 Render the targets hypersensitiv...
Pathogenesis of NAS
Alternate Pathways
 Drug may depress a primary neural pathway
 An alternate pathway, usually of mino...
Pathogenesis of NAS
Alternative
Pathway
Disuse
Hypersensitivity
Identifying Withdrawal
Identifying Withdrawal
2012 AAP Clinical Report: Neonatal Drug Withdrawal
 Screening for maternal substance abuse is best...
Identifying Withdrawal
2012 AAP Clinical Report: Neonatal Drug Withdrawal
 Although newborn meconium screening also may y...
Identifying Withdrawal
13 Panel USDTL Umbilical Cord Testing
• Amphetamines (amphetamine, MDA, MDEA, MDMA, methamphetamine...
Identifying Withdrawal
2012 AAP Clinical Report: Neonatal Drug Withdrawal
 Signs of drug withdrawal can be scored by usin...
Modified Finnegan Scoring System
Identifying Withdrawal
 NAS symptoms in neonates
 Tremors
 Increased Tone
 Autonomic dysregulation
Treatment of NAS
Treatment of NAS
 No established optimal treatment
 2005 Cochrane reviews suggest lack of high-quality evidence
for any ...
Treatment of NAS
2012 AAP Clinical Report: Neonatal Drug Withdrawal
 The optimal threshold score for beginning pharmacolo...
Treatment of NAS
 Opioid agents used
 Morphine sulfate
 Neonatal opium solution
 Methadone
 Buprenorphine ???
 Adjun...
Treatment of NAS
Cabell Huntington Hospital
 Methadone inpatient weaning protocol
 Clonidine is used for adjunct agent
...
Before Meds Consider This
2012 AAP Clinical Report: Neonatal Drug Withdrawal
 Nonpharmacologic supportive measures that i...
Therapeutic Handling
 Reducing Stimuli
 Infants react to light, noise, touch, movement, and those
individuals around them
 Need quiet and ca...
 Swaddling
 Calms infants by controlling their bodies
Therapeutic Handling
 C position
 Bring swaddled baby’s knees up toward chest and chin slightly
down
 Use this position when feeding and cal...
 Sway and clap
 Stand and rock side to side, the baby will sense head to toe
movement
 Don’t bounce up and down
 Rhyth...
 Vertical Rock
 Seeing the caregivers face may be too stimulating
 Turn infant away from you, hold in the C position, a...
 Feeding
 Always feed in a calm, quiet environment
 Hold in the C position
 Middle finger under chin for support may b...
System of Care
System of Care
Increasing incidence of the neonatal abstinence syndrome in
U.S. neonatal ICUs
Tolia et al. NEJM May 2015
...
System of Care
 Different environments for different roles
 NICU
 Neonatal Therapeutic Unit
 Lily’s Place
Places For Treatment
Places For Treatment
 Neonatal Therapeutic Unit
 Locked unit
 Unit clerk controls
visitors
Places For Treatment
 5 rooms
 3-4 beds per room
 Visiting hours
10 am-4 pm
Places For Treatment
 Keep room lights dimmed
 Natural light from window
Places For Treatment
Places For Treatment
Lily’s Place
 Established as 501c3
 Community support from day 1
 Building donated and renovated
 Nurseries were spons...
Lily’s Place
Licensed
 WV DHHR
 DEA
 City of Huntington
West Virginia HB 2999
Lily’s Place
Lily’s Place
Lily’s Place
Future Directions
Future Directions
 Increase access to substance abuse resources for adults
 Educate various populations about the conseq...
Thank You
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The Impact of Neonatal Abstinence Syndrome on One West Virginia Community

This session will center on Neonatal Abstinence Syndrome (NAS). We will discuss the epidemiology of NAS, the clinical presentation of and management of infants affected by withdrawal. We will also introduce innovative alternatives to hospital care for these babies that allows for a smooth transition into society.
Objectives:
•Discuss the epidemiology of NAS both nationally and regionally
•Discuss the management of infants with NAS
•Discuss our systems of care surrounding NAS
Dr. Loudin is a member of the Division of Neonatal-Perinatal Medicine at Marshall University and an Assistant Professor of Pediatrics at the Joan C. Edwards School of Medicine. He received his medical degree and completed his Pediatric residency at Marshall University. Dr. Loudin continued his training with a three-year fellowship in Neonatal/Perinatal Medicine at the Medical University of South Carolina in Charleston, SC. His research and clinical interests focus on neonatal abstinence syndrome, prevention of bronchopulmonary dysplasia, ventilator support of extremely low birth weight infants, and pain management. Dr. Loudin is a Board-certified pediatrician, Board-certified in Neonatology subspecialty and a member of the American Academy of Pediatrics.

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The Impact of Neonatal Abstinence Syndrome on One West Virginia Community

  1. 1. The Impact of Neonatal Abstinence Syndrome on one West Virginia Community Sean Loudin MD
  2. 2. Disclosures  I have no financial disclosures
  3. 3. Objectives  Discuss the epidemiology of Neonatal Abstinence Syndrome (NAS) both nationally and regionally  Understand the mechanism of withdrawal  Discuss the management of infants with NAS  Describe our system of care surrounding NAS
  4. 4. How big is the problem? 0 0.5 1 1.5 2 2.5 3 3.5 2000 2003 2006 2009 NASper1000deliveries Rate of NAS per 1000 births US Department of Health and Human Services, Agency for Healthcare Research and Quality
  5. 5. How big is the problem? Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012 Patrick et al. J Perinatology April 2015  Incidence increased from 3.4 to 5.8 per 1000 live births  Geographical variation  East South Central Division (Kentucky, Tennessee, Mississippi and Alabama) showed 16.2 per 1000 live births  West South Central Division (Oklahoma, Texas, Arkansas and Louisiana) showed 2.6 per 1000 live births
  6. 6. How big is the problem? 0 5 10 15 20 25 30 2000 2003 2006 2009 NASper1000deliveries AHRQ CHH
  7. 7. How big is the problem? 0 20 40 60 80 100 120 2000 2003 2006 2009 2012 2013 NASper1000deliveries AHRQ CHH
  8. 8. Drugs Causing Withdrawal  Classic NAS due to opiates  Nicotine withdrawal from maternal tobacco exposure  Alcohol withdrawal and birth defects  Delayed withdrawal secondary to maternal benzodiazepine or psychotropic medications
  9. 9. Drugs in WV Prevalence of Drug Use in Pregnant West Virginia Patients Chaffin et al. 2009  During 1 month period (August 2009) all cords at 8 hospitals were tested  759 total samples collected, 146 (19.2%) were positive for drugs and/or alcohol  Of the positives 40% marijuana, 28% opiates, 27% alcohol, 12% bezos, 10% methadone, <1% amphetamines and 0% were positive for cocaine or buprenorphine
  10. 10. Drugs in WV  Buprenorphine now very prominent  Methadone decreasing in frequency  Marijuana still continues to be used at high rates  Prescription opiates decreasing at time of delivery  Heroin use on the rise
  11. 11. Neonatal Abstinence Syndrome  Passive exposure of the newborn occurs when a mother uses a neuroactive drug during her pregnancy  When the infant is deprived of these substances through the birthing process, a withdrawal syndrome may develop
  12. 12. Neonatal Abstinence Syndrome  Classic NAS consists of a wide variety of CNS signs of irritability, GI problems, autonomic signs of dysfunction, and respiratory symptoms  The hallmark of neonatal withdrawal is a striking disorder of movement, most aptly termed “jitteriness” ~Volpe 2008
  13. 13. Neonatal Abstinence Syndrome  Autonomic over-reactivity is typically exhibited by yawning, sneezing, mottling and fever  Cerebral irritation results in an irritable and hypertonic infant ~Oei and Lui 2007
  14. 14. Pathogenesis of NAS
  15. 15. Pathogenesis of NAS  Endogenous opiates (endorphins, enkephalins and dynorphins)  Complex interactions between endogenous opiates and their receptors are important in the developing brain  Locus ceruleus is a nucleus in the brain stem involved with physiological response to stress and panic
  16. 16. Pathogenesis of NAS
  17. 17. Pathogenesis of NAS  When the opiate is withdrawn, the inhibiting effect gone  This results in a supranormal increase in norepinephrine levels, which are the likely cause of the signs and symptoms of NAS
  18. 18. Pathogenesis of NAS Disuse Hypersensitivity  A drug may depress certain neural systems  Render the targets hypersensitive to their usual stimuli  Removal of the depressing drug results in a rebound hypersensitivity of the affected targets  May be caused in part by an increase in synthesis of certain receptors ~Volpe 2008
  19. 19. Pathogenesis of NAS Alternate Pathways  Drug may depress a primary neural pathway  An alternate pathway, usually of minor activity, may become more prominent in attempt to compensate  When the drug is removed, both pathways may operate in an additive fashion ~Volpe 2008
  20. 20. Pathogenesis of NAS Alternative Pathway Disuse Hypersensitivity
  21. 21. Identifying Withdrawal
  22. 22. Identifying Withdrawal 2012 AAP Clinical Report: Neonatal Drug Withdrawal  Screening for maternal substance abuse is best accomplished by using multiple methods, including maternal history, maternal urine testing, and testing of newborn urine and/or meconium specimens that are in compliance with local laws.  The duration of urinary excretion of most drugs is relatively short, and maternal or neonatal urinary screening only addresses drug exposure in the hours immediately before urine collection. Thus, false-negative urine results may occur in the presence of significant intrauterine drug exposure.
  23. 23. Identifying Withdrawal 2012 AAP Clinical Report: Neonatal Drug Withdrawal  Although newborn meconium screening also may yield false- negative results, the likelihood is lower than with urinary screening.  The more recent availability of testing of umbilical cord samples may be considered a viable screening tool, because it appears to reflect in utero exposures comparable to meconium screening.
  24. 24. Identifying Withdrawal 13 Panel USDTL Umbilical Cord Testing • Amphetamines (amphetamine, MDA, MDEA, MDMA, methamphetamine) • Cannabinoids (carboxy-THC) • Cocaine (benzoylecgonine) • Opiates (6-MAM, meconin, codeine, hydrocodone, hydromorphone, morphine) • Phencyclidine (phencyclindine) (PCP) • Methadone (EDDP, methadone) • Barbiturates (amobarbital, butalbital, pentobarbital, phenobarbital, secobarbital) • Benzodiazepines (alprazolam, diazepam, midazolam, nordiazepam, oxazepam, temazepam) • Propoxyphene (propoxyphene, norpropoxyphene) • Oxycodone (oxycodone, oxymorphone) • Meperidine (meperidine, normeperidine) • Tramadol (tramadol) • Buprenorphine
  25. 25. Identifying Withdrawal 2012 AAP Clinical Report: Neonatal Drug Withdrawal  Signs of drug withdrawal can be scored by using a published abstinence assessment tool.  Together with individualized clinical assessment, the serial and accurate use of a withdrawal assessment tool may facilitate a decision about the institution of pharmacologic therapy and thereafter can provide a quantitative measurement that can be used to adjust drug dosing.
  26. 26. Modified Finnegan Scoring System
  27. 27. Identifying Withdrawal  NAS symptoms in neonates  Tremors  Increased Tone  Autonomic dysregulation
  28. 28. Treatment of NAS
  29. 29. Treatment of NAS  No established optimal treatment  2005 Cochrane reviews suggest lack of high-quality evidence for any specific treatment  Expert opinion suggest opioids as the class of agents with the greatest efficacy
  30. 30. Treatment of NAS 2012 AAP Clinical Report: Neonatal Drug Withdrawal  The optimal threshold score for beginning pharmacologic therapy is unknown  Vomiting, diarrhea, dehydration, and poor weight gain are reasons to initiate treatment  Limited evidence as to which medication is the preferred treatment for NAS
  31. 31. Treatment of NAS  Opioid agents used  Morphine sulfate  Neonatal opium solution  Methadone  Buprenorphine ???  Adjunct agents  Phenobarbital  Clonidine
  32. 32. Treatment of NAS Cabell Huntington Hospital  Methadone inpatient weaning protocol  Clonidine is used for adjunct agent  Weight based-symptom driven 9 step wean  Average length of stay 27-29 days  Utilize the NICU and the Neonatal Therapeutic Unit  Dedicated nursing staff
  33. 33. Before Meds Consider This 2012 AAP Clinical Report: Neonatal Drug Withdrawal  Nonpharmacologic supportive measures that include minimizing environmental stimuli, promoting adequate rest and sleep, and providing sufficient caloric intake to establish weight gain should constitute the initial approach to therapy.
  34. 34. Therapeutic Handling
  35. 35.  Reducing Stimuli  Infants react to light, noise, touch, movement, and those individuals around them  Need quiet and calm environment  Attempt to only handle infant for feeding and cluster care Therapeutic Handling
  36. 36.  Swaddling  Calms infants by controlling their bodies Therapeutic Handling
  37. 37.  C position  Bring swaddled baby’s knees up toward chest and chin slightly down  Use this position when feeding and calming infant Therapeutic Handling
  38. 38.  Sway and clap  Stand and rock side to side, the baby will sense head to toe movement  Don’t bounce up and down  Rhythmic patting the infants bottom may aid in relaxation Therapeutic Handling
  39. 39.  Vertical Rock  Seeing the caregivers face may be too stimulating  Turn infant away from you, hold in the C position, and alternate infant slowly up and down Therapeutic Handling
  40. 40.  Feeding  Always feed in a calm, quiet environment  Hold in the C position  Middle finger under chin for support may be necessary Therapeutic Handling
  41. 41. System of Care
  42. 42. System of Care Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs Tolia et al. NEJM May 2015  NICU admissions from 2004-2013 across the Pediatrix hospital database  7 cases per 1000 admissions to 27 cases per 1000 admissions  length of stay increased from 13 days to 19 days  total percentage of NICU days attributed to NAS increased from 0.6% to 4.0%  Infants increasingly received pharmacotherapy (74% in 2004– 2005 vs. 87% in 2012–2013)
  43. 43. System of Care  Different environments for different roles  NICU  Neonatal Therapeutic Unit  Lily’s Place
  44. 44. Places For Treatment
  45. 45. Places For Treatment
  46. 46.  Neonatal Therapeutic Unit  Locked unit  Unit clerk controls visitors Places For Treatment
  47. 47.  5 rooms  3-4 beds per room  Visiting hours 10 am-4 pm Places For Treatment
  48. 48.  Keep room lights dimmed  Natural light from window Places For Treatment
  49. 49. Places For Treatment
  50. 50. Lily’s Place  Established as 501c3  Community support from day 1  Building donated and renovated  Nurseries were sponsored  Building brought up to code
  51. 51. Lily’s Place Licensed  WV DHHR  DEA  City of Huntington West Virginia HB 2999
  52. 52. Lily’s Place
  53. 53. Lily’s Place
  54. 54. Lily’s Place
  55. 55. Future Directions
  56. 56. Future Directions  Increase access to substance abuse resources for adults  Educate various populations about the consequences of substance abuse  Continue to develop innovative ways to treat patients of all ages  Expand research in the field of neonatal abstinence syndrome
  57. 57. Thank You

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