Clinical Track, National Rx Drug Abuse Summit, April 2-4, 2013. The Innocent Victims: Neonatal Abstinence Syndrome (NAS) presentation by Dr. Michael Hokenson and Carla Saunders
Overview of Neonatal Abstinence Syndrome (NAS), a drug withdrawal syndrome resulting from sudden discontinuation of prolonged fetal exposure in utero. Topics include epidemiology, health care expenditures, pathophysiology, clinical presentation, management, and long-term outcomes.
This 3-year-old male child presented with episodes of unconsciousness not associated with tonic-clonic seizures. Prior investigations including EEG and treatment with anti-epileptic drugs did not reveal a clear diagnosis. After further examination, the child was diagnosed with Panayiotopoulos syndrome based on autonomic symptoms during episodes and EEG findings. Panayiotopoulos syndrome is an early-onset childhood occipital epilepsy characterized by emesis, other autonomic symptoms and abnormal EEG patterns, with seizures typically remitting after 1-2 years.
This case report describes a 13-year-old girl who presented with repeated episodes of vomiting, palpitations, tremors, fearfulness, sweating, and loss of awareness. Investigations including blood tests, CT brain scan, and EEG were normal except for EEG spikes in the occipital lobes. She was diagnosed with Panayiotopoulos syndrome, a rare idiopathic focal seizure disorder occurring in childhood, and treated successfully with antiepileptic medications.
Neonatal abstinence syndrome is a growing problem in Tennessee. NAS happens when babies are in contact with
medications or illegal drugs in the womb. These babies form a physical dependence on the drug used by their mother
during pregnancy. After birth, they experience withdrawal just like adults. Withdrawal symptoms vary, but can include high-pitched crying, tremors, hyperactive reflexes and inconsolability. In some cases, drug dependent babies suffer seizures as well.
Neonatal Abstinence Syndrome (NAS) occurs when newborn babies experience withdrawal symptoms from exposure to addictive drugs in the womb or prescription drugs administered to the baby. NAS is most commonly caused by opioids, methadone, barbiturates, or other narcotics used by the mother during pregnancy. Symptoms of NAS include tremors, difficulty feeding, and problems sleeping. Diagnosis involves scoring systems to assess symptoms and drug testing of meconium, urine, or hair. Treatment focuses on nutrition, calming techniques, and drug therapy with morphine or methadone if needed.
This document discusses neonatal abstinence syndrome (NAS) and a standardized protocol developed at Children's Mercy Hospital to improve care for infants at risk for NAS. The protocol allows more infants to be cared for in the Mother-Baby unit instead of the NICU, using standardized NAS scoring by nurses. Education was provided to nurses on NAS scoring and a family education program was developed to inform families prior to delivery about NAS. Outcome measures track locations of care and the number of families receiving education. The protocol aims to standardize NAS care while keeping more infants with their mothers when possible.
This document contains information from a pediatric neurology department including goals, common exam questions, topics related to relationships and neuroanatomy/neurochemistry, exam answers, clinical cases, imaging findings, and treatment guidelines. It discusses various pediatric neurological conditions like seizures, meningitis, hydrocephalus, neurocutaneous syndromes, and more. The document is intended as a study aid and reference for a pediatric neurology exam.
Neonatal abstinence syndrome (NAS) refers to withdrawal symptoms in newborns exposed to drugs in utero. NAS is most commonly associated with opioid exposure and presents as central nervous system disturbances, gastrointestinal issues, and autonomic dysfunction. Diagnosis is based on clinical history and signs, with supportive care as first-line treatment and pharmacotherapy with morphine or other drugs as needed. Proper management aims to stabilize the newborn and facilitate healthy development.
Overview of Neonatal Abstinence Syndrome (NAS), a drug withdrawal syndrome resulting from sudden discontinuation of prolonged fetal exposure in utero. Topics include epidemiology, health care expenditures, pathophysiology, clinical presentation, management, and long-term outcomes.
This 3-year-old male child presented with episodes of unconsciousness not associated with tonic-clonic seizures. Prior investigations including EEG and treatment with anti-epileptic drugs did not reveal a clear diagnosis. After further examination, the child was diagnosed with Panayiotopoulos syndrome based on autonomic symptoms during episodes and EEG findings. Panayiotopoulos syndrome is an early-onset childhood occipital epilepsy characterized by emesis, other autonomic symptoms and abnormal EEG patterns, with seizures typically remitting after 1-2 years.
This case report describes a 13-year-old girl who presented with repeated episodes of vomiting, palpitations, tremors, fearfulness, sweating, and loss of awareness. Investigations including blood tests, CT brain scan, and EEG were normal except for EEG spikes in the occipital lobes. She was diagnosed with Panayiotopoulos syndrome, a rare idiopathic focal seizure disorder occurring in childhood, and treated successfully with antiepileptic medications.
Neonatal abstinence syndrome is a growing problem in Tennessee. NAS happens when babies are in contact with
medications or illegal drugs in the womb. These babies form a physical dependence on the drug used by their mother
during pregnancy. After birth, they experience withdrawal just like adults. Withdrawal symptoms vary, but can include high-pitched crying, tremors, hyperactive reflexes and inconsolability. In some cases, drug dependent babies suffer seizures as well.
Neonatal Abstinence Syndrome (NAS) occurs when newborn babies experience withdrawal symptoms from exposure to addictive drugs in the womb or prescription drugs administered to the baby. NAS is most commonly caused by opioids, methadone, barbiturates, or other narcotics used by the mother during pregnancy. Symptoms of NAS include tremors, difficulty feeding, and problems sleeping. Diagnosis involves scoring systems to assess symptoms and drug testing of meconium, urine, or hair. Treatment focuses on nutrition, calming techniques, and drug therapy with morphine or methadone if needed.
This document discusses neonatal abstinence syndrome (NAS) and a standardized protocol developed at Children's Mercy Hospital to improve care for infants at risk for NAS. The protocol allows more infants to be cared for in the Mother-Baby unit instead of the NICU, using standardized NAS scoring by nurses. Education was provided to nurses on NAS scoring and a family education program was developed to inform families prior to delivery about NAS. Outcome measures track locations of care and the number of families receiving education. The protocol aims to standardize NAS care while keeping more infants with their mothers when possible.
This document contains information from a pediatric neurology department including goals, common exam questions, topics related to relationships and neuroanatomy/neurochemistry, exam answers, clinical cases, imaging findings, and treatment guidelines. It discusses various pediatric neurological conditions like seizures, meningitis, hydrocephalus, neurocutaneous syndromes, and more. The document is intended as a study aid and reference for a pediatric neurology exam.
Neonatal abstinence syndrome (NAS) refers to withdrawal symptoms in newborns exposed to drugs in utero. NAS is most commonly associated with opioid exposure and presents as central nervous system disturbances, gastrointestinal issues, and autonomic dysfunction. Diagnosis is based on clinical history and signs, with supportive care as first-line treatment and pharmacotherapy with morphine or other drugs as needed. Proper management aims to stabilize the newborn and facilitate healthy development.
This presentation discusses neonatal abstinence syndrome, which occurs when a newborn experiences withdrawal symptoms from exposure to addictive drugs in the womb. The presenter outlines the incidence, types, etiology, symptoms, exams/tests used for diagnosis, and management approaches for NAS. Regarding management, non-pharmacological interventions like swaddling and minimal stimulation are recommended initially. If symptoms are severe, pharmacological therapy using morphine, methadone or clonidine may be used. The roles of nurses in assessing exposed newborns, monitoring withdrawal, and coordinating multidisciplinary care are also reviewed. The presenter emphasizes the importance of prevention through screening, education, and treatment programs for pregnant women with substance use
Neonatal Abstinence Syndrome - Tennessee's Epidemic and The State's ResponseHealth Easy Peasy
This document discusses neonatal abstinence syndrome (NAS) in Tennessee. It defines NAS as withdrawal symptoms in newborns exposed to drugs like opioids prenatally. The rate of NAS hospitalizations in Tennessee increased dramatically from 1999-2012, mirroring the rise in prescription opioid use. In 2012, Tennessee had the second highest rate of prescription painkillers sold and the highest number of opioid prescriptions per capita nationally. The document outlines Tennessee's efforts to address NAS through a cabinet-level working group and legislative actions focused on prevention, treatment, and monitoring of prescription drug use and opioid-exposed pregnancies.
This document presents a case study of 16-year-old Soumya who was brought to the hospital with fever, shortness of breath, and vomiting. After examination, she was diagnosed with progeria. Progeria is an extremely rare genetic condition where children exhibit rapid aging symptoms. It is caused by a genetic mutation that prevents prelamin A from being properly processed. Children with progeria have short stature, loss of hair and body fat, stiff joints, heart disease, and typically die in their early teens. While currently incurable, research is ongoing to develop treatments to target the underlying genetic cause.
- Approximately 17% of children and 30% of adults in the US are obese. Many obese children become obese adults.
- Obesity is associated with excessive television watching, dietary intake, urban areas, and maternal obesity during pregnancy which increases childhood obesity risk.
- Sara, a 7 year old girl, is progressively gaining weight. Her grandmother encourages sweets while her parents are worried about her health and future obesity risks like diabetes and heart disease.
This document presents a case report of a 2 year old Malay girl admitted to the hospital due to fever and vomiting for 2 days prior to admission and 3 episodes of seizures on the day of admission. Upon examination and investigation, she was diagnosed with complex febrile seizures presumed to be caused by meningitis. She was treated with antibiotics and anticonvulsants and discharged after 5 days with no further seizures and good response to treatment.
The Integrative Medicine Treatment of SchizophreniaLouis Cady, MD
This is the third of three lectures that Dr. Cady did in Sao Paulo, Brazil, for Laboratorio Great Plains. Dr. Cady dispenses with the "Dopamine hypothesis of schizophrenia" quickly, and notes that the most powerful drug for schizophrenia, clozapine, is actually only a weak blocker at that receptor. Using the concepts of Dale Bredesen, MD, Dr. Cady advances the idea that there is no "one magic bullet" approach to the treatment of schizophrenia, but that, rather, multiple possibile causes of schizophrenia exist, multiple nutritional laboratory values exist, multiple other physiological perturbations exist (including gluten sensitivyt), and that the thoughtful practitioner's approach should be to attempt to identify, integrate, and address all possible causes and exacerbating influences on the causes, and treatments of schizophrenia. Obviously, this is not a comprehensive treatment on the subject - which would take days - but does scratch the surface at other ways to look at schizophrenia and approach its treatment.
Approach to a child with failure to thriveSingaram_Paed
This document discusses failure to thrive (FTT) in children. It defines FTT as inadequate physical growth compared to peers. FTT can be caused by inadequate calorie intake, absorption, increased needs, or utilization. It affects 5-10% of young children. Causes include psychosocial factors, infections, gastrointestinal issues, and neurological problems. Evaluation of a child with FTT involves medical history, physical exam, lab tests, and assessing nutrition. Treatment focuses on improving the child's diet and development stimulation, caregiver skills, and treating any underlying medical issues. Regular follow up is also important.
1. A 3-year old girl experienced acute cognitive and behavioral changes including exaggerated emotions, aggression, hallucinations, and mood swings for 2 hours after being given 1% cyclopentolate eye drops during an eye exam.
2. The eye drops are meant to dilate the pupils but can be absorbed into the bloodstream, especially in young children, and affect the central nervous system.
3. The behaviors observed in this case are thought to be caused by the cyclopentolate inhibiting the child's conscious mind and allowing repressed emotions from her unconscious mind to emerge, consistent with psychoanalytic theories of the mind.
This document discusses several epilepsy syndromes categorized by age of onset:
- Neonatal onset syndromes include benign neonatal seizures and early infantile epileptic encephalopathy.
- Infantile onset syndromes include Dravet syndrome, West syndrome, and myoclonic epilepsy in infancy.
- Childhood syndromes include Panayiotopoulos syndrome, Lennox-Gastaut syndrome, and benign epilepsy with centrotemporal spikes.
- Later onset syndromes extending into adolescence and adulthood include juvenile absence epilepsy and juvenile myoclonic epilepsy.
Progeria, also known as Hutchinson-Gilford Progeria Syndrome, is a rare genetic condition that causes rapid aging in children. It is caused by a mutation in the LMNA gene which produces lamin A protein that holds the nucleus of cells together. Children with progeria appear healthy at birth but start displaying signs of aging between 1-2 years old, such as hair loss, failure to grow, and cardiovascular issues. There is no cure for progeria and affected children typically live into their late teens or early twenties, most commonly dying from heart disease. While research continues for a cure, current treatment focuses on alleviating joint issues and maintaining mobility and quality of life.
The document summarizes research on progeria, a rare premature aging disease. It discusses how the Progeria Research Foundation was established in 1999 to address the lack of research, information, and treatment options. Through the foundation's efforts like establishing a patient registry and funding research, the understanding of progeria increased and a gene was identified. This led to the first-ever progeria treatment trial in 2007 testing drugs that target the abnormal protein produced in progeria cells. The research on progeria also provides insights into normal aging and age-related diseases.
Pediatric Genetics: What the Primary Provider Needs to KnowCHC Connecticut
This document provides information from a presentation on pediatric genetics for primary care providers. It discusses when genetic or metabolic diseases should be considered, such as in cases with multi-system involvement, seemingly unconnected symptoms, or progressive disease courses. It emphasizes that descriptive or idiopathic diagnoses can miss underlying causes and outlines examples of conditions that present with episodic clinical or biochemical decompensation. The document also notes challenges in making a diagnosis and potential issues with clinical diagnoses, and discusses considerations around patients obtaining genetic testing directly from commercial companies.
In collaboration with the New England Regional Genetics Network, the Weitzman Institute aims to improve access to genetics services for underserved populations by offering primary care provider educational support through a free five-part webinar series that aims to enhance provider knowledge, practice, and attitudes regarding genetic services.
The document discusses several topics related to newborn screening:
1) It reviews important aspects of newborn screening discussed in previous sessions, including resources for information and the roles of primary care providers and specialists.
2) It discusses diseases recently added to newborn screens including SCID, MPS I, Pompe disease, X-ALD, and SMA, outlining their characteristics, inheritance, newborn screening protocols, and treatment options.
3) It emphasizes the need to facilitate urgent referrals for conditions like SCID given the time-sensitive nature of diagnosis and treatment for better outcomes.
- Drug therapy in pediatric patients presents unique challenges due to physiological differences compared to adults that influence pharmacokinetics. Organs such as the liver and kidneys are immature at birth and do not reach adult functionality until approximately 1 year of age. This results in altered absorption, distribution, metabolism, and excretion of drugs in neonates and infants.
- Due to organ immaturity, neonates and infants experience more intense and prolonged responses to drugs. They are at higher risk for adverse effects from drugs cleared primarily by the liver or kidneys. Careful monitoring is needed when dosing pediatric patients.
- Initial pediatric doses are approximations, often based on body surface area calculations. Frequent assessment and potential dose adjustments are
This document discusses the neurobiology of schizophrenia. It covers several key points:
- Schizophrenia is a disruptive psychopathology involving cognition, emotion, perception and behavior that typically emerges before age 25.
- Positive symptoms include delusions and hallucinations, while negative symptoms include anhedonia and avolition.
- Genetic and biochemical factors like dopamine imbalance are implicated in schizophrenia. Brain structures like the prefrontal cortex and hippocampus also show abnormalities.
- Multiple neurotransmitter systems may be involved including dopamine, serotonin, glutamate, GABA, acetylcholine, and norepinephrine.
Alzheimer's disease is a degenerative brain disease that results in cognitive and behavioral impairment. It accounts for around 70% of dementia cases. The hallmarks of the disease are amyloid plaques and neurofibrillary tangles in the brain. Symptoms include memory loss, confusion, changes in personality and behavior, and problems with language and visual-spatial skills. Treatment focuses on acetylcholinesterase inhibitors and memantine to manage symptoms, as well as non-pharmacological approaches to improve quality of life. The disease is progressive and currently has no cure.
In his third of five lectures, Dr. Cady reviews the concepts of food allergy testing with IgG and IgE antibodies, traces the development of this body of knowledge from the 1960's, and reviews two illustrative cases.
Progeria (HGPS), also known as Hutchinson-Gilford syndrome, is a progressive genetic disorder that causes children to age rapidly, beginning in their first two years.
ELIMINATION DISORDER AND EATING DISORDER.pptxNimish Savaliya
1) Elimination disorders like encopresis and enuresis are common in children and involve repeated soiling or bed-wetting past the age when continence is expected. Encopresis is often caused by chronic constipation while enuresis has genetic and developmental factors.
2) Feeding and eating disorders in children include pica, rumination disorder, and avoidant/restrictive food intake disorder. Pica involves eating non-food items and rumination involves regurgitating and rechewing food. These disorders can be caused by nutritional deficiencies, neurological issues, or psychosocial factors.
3) Treatments for these disorders include behavioral, educational, and pharmacological approaches. Behavioral treatments
Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Neonatal Abstinence Syndrome: Treating Pregnant Women presentation by Dr. Rick McClead, Mona Prasad, Jacqueline Magers and Gail A. Bagwell
This presentation discusses neonatal abstinence syndrome, which occurs when a newborn experiences withdrawal symptoms from exposure to addictive drugs in the womb. The presenter outlines the incidence, types, etiology, symptoms, exams/tests used for diagnosis, and management approaches for NAS. Regarding management, non-pharmacological interventions like swaddling and minimal stimulation are recommended initially. If symptoms are severe, pharmacological therapy using morphine, methadone or clonidine may be used. The roles of nurses in assessing exposed newborns, monitoring withdrawal, and coordinating multidisciplinary care are also reviewed. The presenter emphasizes the importance of prevention through screening, education, and treatment programs for pregnant women with substance use
Neonatal Abstinence Syndrome - Tennessee's Epidemic and The State's ResponseHealth Easy Peasy
This document discusses neonatal abstinence syndrome (NAS) in Tennessee. It defines NAS as withdrawal symptoms in newborns exposed to drugs like opioids prenatally. The rate of NAS hospitalizations in Tennessee increased dramatically from 1999-2012, mirroring the rise in prescription opioid use. In 2012, Tennessee had the second highest rate of prescription painkillers sold and the highest number of opioid prescriptions per capita nationally. The document outlines Tennessee's efforts to address NAS through a cabinet-level working group and legislative actions focused on prevention, treatment, and monitoring of prescription drug use and opioid-exposed pregnancies.
This document presents a case study of 16-year-old Soumya who was brought to the hospital with fever, shortness of breath, and vomiting. After examination, she was diagnosed with progeria. Progeria is an extremely rare genetic condition where children exhibit rapid aging symptoms. It is caused by a genetic mutation that prevents prelamin A from being properly processed. Children with progeria have short stature, loss of hair and body fat, stiff joints, heart disease, and typically die in their early teens. While currently incurable, research is ongoing to develop treatments to target the underlying genetic cause.
- Approximately 17% of children and 30% of adults in the US are obese. Many obese children become obese adults.
- Obesity is associated with excessive television watching, dietary intake, urban areas, and maternal obesity during pregnancy which increases childhood obesity risk.
- Sara, a 7 year old girl, is progressively gaining weight. Her grandmother encourages sweets while her parents are worried about her health and future obesity risks like diabetes and heart disease.
This document presents a case report of a 2 year old Malay girl admitted to the hospital due to fever and vomiting for 2 days prior to admission and 3 episodes of seizures on the day of admission. Upon examination and investigation, she was diagnosed with complex febrile seizures presumed to be caused by meningitis. She was treated with antibiotics and anticonvulsants and discharged after 5 days with no further seizures and good response to treatment.
The Integrative Medicine Treatment of SchizophreniaLouis Cady, MD
This is the third of three lectures that Dr. Cady did in Sao Paulo, Brazil, for Laboratorio Great Plains. Dr. Cady dispenses with the "Dopamine hypothesis of schizophrenia" quickly, and notes that the most powerful drug for schizophrenia, clozapine, is actually only a weak blocker at that receptor. Using the concepts of Dale Bredesen, MD, Dr. Cady advances the idea that there is no "one magic bullet" approach to the treatment of schizophrenia, but that, rather, multiple possibile causes of schizophrenia exist, multiple nutritional laboratory values exist, multiple other physiological perturbations exist (including gluten sensitivyt), and that the thoughtful practitioner's approach should be to attempt to identify, integrate, and address all possible causes and exacerbating influences on the causes, and treatments of schizophrenia. Obviously, this is not a comprehensive treatment on the subject - which would take days - but does scratch the surface at other ways to look at schizophrenia and approach its treatment.
Approach to a child with failure to thriveSingaram_Paed
This document discusses failure to thrive (FTT) in children. It defines FTT as inadequate physical growth compared to peers. FTT can be caused by inadequate calorie intake, absorption, increased needs, or utilization. It affects 5-10% of young children. Causes include psychosocial factors, infections, gastrointestinal issues, and neurological problems. Evaluation of a child with FTT involves medical history, physical exam, lab tests, and assessing nutrition. Treatment focuses on improving the child's diet and development stimulation, caregiver skills, and treating any underlying medical issues. Regular follow up is also important.
1. A 3-year old girl experienced acute cognitive and behavioral changes including exaggerated emotions, aggression, hallucinations, and mood swings for 2 hours after being given 1% cyclopentolate eye drops during an eye exam.
2. The eye drops are meant to dilate the pupils but can be absorbed into the bloodstream, especially in young children, and affect the central nervous system.
3. The behaviors observed in this case are thought to be caused by the cyclopentolate inhibiting the child's conscious mind and allowing repressed emotions from her unconscious mind to emerge, consistent with psychoanalytic theories of the mind.
This document discusses several epilepsy syndromes categorized by age of onset:
- Neonatal onset syndromes include benign neonatal seizures and early infantile epileptic encephalopathy.
- Infantile onset syndromes include Dravet syndrome, West syndrome, and myoclonic epilepsy in infancy.
- Childhood syndromes include Panayiotopoulos syndrome, Lennox-Gastaut syndrome, and benign epilepsy with centrotemporal spikes.
- Later onset syndromes extending into adolescence and adulthood include juvenile absence epilepsy and juvenile myoclonic epilepsy.
Progeria, also known as Hutchinson-Gilford Progeria Syndrome, is a rare genetic condition that causes rapid aging in children. It is caused by a mutation in the LMNA gene which produces lamin A protein that holds the nucleus of cells together. Children with progeria appear healthy at birth but start displaying signs of aging between 1-2 years old, such as hair loss, failure to grow, and cardiovascular issues. There is no cure for progeria and affected children typically live into their late teens or early twenties, most commonly dying from heart disease. While research continues for a cure, current treatment focuses on alleviating joint issues and maintaining mobility and quality of life.
The document summarizes research on progeria, a rare premature aging disease. It discusses how the Progeria Research Foundation was established in 1999 to address the lack of research, information, and treatment options. Through the foundation's efforts like establishing a patient registry and funding research, the understanding of progeria increased and a gene was identified. This led to the first-ever progeria treatment trial in 2007 testing drugs that target the abnormal protein produced in progeria cells. The research on progeria also provides insights into normal aging and age-related diseases.
Pediatric Genetics: What the Primary Provider Needs to KnowCHC Connecticut
This document provides information from a presentation on pediatric genetics for primary care providers. It discusses when genetic or metabolic diseases should be considered, such as in cases with multi-system involvement, seemingly unconnected symptoms, or progressive disease courses. It emphasizes that descriptive or idiopathic diagnoses can miss underlying causes and outlines examples of conditions that present with episodic clinical or biochemical decompensation. The document also notes challenges in making a diagnosis and potential issues with clinical diagnoses, and discusses considerations around patients obtaining genetic testing directly from commercial companies.
In collaboration with the New England Regional Genetics Network, the Weitzman Institute aims to improve access to genetics services for underserved populations by offering primary care provider educational support through a free five-part webinar series that aims to enhance provider knowledge, practice, and attitudes regarding genetic services.
The document discusses several topics related to newborn screening:
1) It reviews important aspects of newborn screening discussed in previous sessions, including resources for information and the roles of primary care providers and specialists.
2) It discusses diseases recently added to newborn screens including SCID, MPS I, Pompe disease, X-ALD, and SMA, outlining their characteristics, inheritance, newborn screening protocols, and treatment options.
3) It emphasizes the need to facilitate urgent referrals for conditions like SCID given the time-sensitive nature of diagnosis and treatment for better outcomes.
- Drug therapy in pediatric patients presents unique challenges due to physiological differences compared to adults that influence pharmacokinetics. Organs such as the liver and kidneys are immature at birth and do not reach adult functionality until approximately 1 year of age. This results in altered absorption, distribution, metabolism, and excretion of drugs in neonates and infants.
- Due to organ immaturity, neonates and infants experience more intense and prolonged responses to drugs. They are at higher risk for adverse effects from drugs cleared primarily by the liver or kidneys. Careful monitoring is needed when dosing pediatric patients.
- Initial pediatric doses are approximations, often based on body surface area calculations. Frequent assessment and potential dose adjustments are
This document discusses the neurobiology of schizophrenia. It covers several key points:
- Schizophrenia is a disruptive psychopathology involving cognition, emotion, perception and behavior that typically emerges before age 25.
- Positive symptoms include delusions and hallucinations, while negative symptoms include anhedonia and avolition.
- Genetic and biochemical factors like dopamine imbalance are implicated in schizophrenia. Brain structures like the prefrontal cortex and hippocampus also show abnormalities.
- Multiple neurotransmitter systems may be involved including dopamine, serotonin, glutamate, GABA, acetylcholine, and norepinephrine.
Alzheimer's disease is a degenerative brain disease that results in cognitive and behavioral impairment. It accounts for around 70% of dementia cases. The hallmarks of the disease are amyloid plaques and neurofibrillary tangles in the brain. Symptoms include memory loss, confusion, changes in personality and behavior, and problems with language and visual-spatial skills. Treatment focuses on acetylcholinesterase inhibitors and memantine to manage symptoms, as well as non-pharmacological approaches to improve quality of life. The disease is progressive and currently has no cure.
In his third of five lectures, Dr. Cady reviews the concepts of food allergy testing with IgG and IgE antibodies, traces the development of this body of knowledge from the 1960's, and reviews two illustrative cases.
Progeria (HGPS), also known as Hutchinson-Gilford syndrome, is a progressive genetic disorder that causes children to age rapidly, beginning in their first two years.
ELIMINATION DISORDER AND EATING DISORDER.pptxNimish Savaliya
1) Elimination disorders like encopresis and enuresis are common in children and involve repeated soiling or bed-wetting past the age when continence is expected. Encopresis is often caused by chronic constipation while enuresis has genetic and developmental factors.
2) Feeding and eating disorders in children include pica, rumination disorder, and avoidant/restrictive food intake disorder. Pica involves eating non-food items and rumination involves regurgitating and rechewing food. These disorders can be caused by nutritional deficiencies, neurological issues, or psychosocial factors.
3) Treatments for these disorders include behavioral, educational, and pharmacological approaches. Behavioral treatments
Treatment Track, National Rx Drug Abuse Summit, April 2-4, 2013. Neonatal Abstinence Syndrome: Treating Pregnant Women presentation by Dr. Rick McClead, Mona Prasad, Jacqueline Magers and Gail A. Bagwell
This document provides information on common behavioral problems in children. It discusses causes of behavioral disorders like faulty parental attitudes, inadequate family environment, and influence of social relationships. It describes types of behavioral problems stemming from emotional, physical, and social deprivation including temper tantrums, bedwetting, thumb sucking, and more. Assessment and management strategies are outlined for each condition. The document emphasizes the importance of parental support, clear communication, and developing a child's independence and social skills to address behavioral issues.
This document provides an overview of Prader-Willi Syndrome (PWS), including:
1. PWS is caused by abnormalities on chromosome 15 that result in problems with feeding, motor skills, cognition and behavior as well as obesity.
2. Clinical features include neonatal hypotonia, poor feeding, developmental delays, hyperphagia leading to obesity, and characteristic facial features.
3. Diagnosis involves genetic testing to identify deletions, disomy or mutations on chromosome 15; treatment aims to manage feeding, obesity, endocrine issues, and behavioral challenges through a multidisciplinary approach.
This document discusses issues related to drug exposed infants. It provides information on an upcoming conference on drug exposed infants including accepted learning objectives, disclosure statements, and trends in drug use during pregnancy. Specific drugs discussed include nicotine, alcohol, benzodiazepines, marijuana, stimulants, cocaine, and opiates. Information is presented on trends in neonatal abstinence syndrome, mechanisms of action and effects of various opioids including methadone and buprenorphine. The document also discusses complications of chronic opiate use for both mother and fetus, and recommendations for screening, treatment and recognizing neonatal withdrawal.
This slide contains information regarding Childhood Psychiatric Disorders (Enuresis, Encopresis and Pica). This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated. Thank you!
This document discusses feeding and eating disorders that can occur in infancy and early childhood. It describes disorders such as pica, rumination disorder, and feeding disorder of infancy. Pica involves recurrent ingestion of non-nutritive substances. Rumination disorder involves regurgitation and rechewing of food. Feeding disorder of infancy is a persistent failure to eat adequately resulting in failure to gain weight. The document provides diagnostic criteria and discusses epidemiology, etiology, treatment and differential diagnosis of these disorders.
The document discusses the field of pharmacogenomics and its applications in psychiatry. Specifically, it focuses on how genetic variations, such as single nucleotide polymorphisms (SNPs), affect individual responses to psychiatric medications by influencing pharmacokinetic and pharmacodynamic pathways. It provides examples of how testing for genetic polymorphisms in cytochrome P450 enzyme genes, such as CYP2D6 and CYP2C19, can help predict drug metabolism and avoid adverse reactions. The document cautions that clinical applications are still limited but genetic testing may help medication selection for some patients.
Schizophrenia is a disorder that affects approximately 1% of the population. It has genetic influences and possible causes include abnormalities in brain functioning and chemical imbalances. Treatment involves psychotherapy, group therapy, family therapy, and medications. Antipsychotic medications help normalize biochemical imbalances and reduce relapse risk, though they can cause side effects ranging from mild to serious.
Fetal alcohol syndrome is caused when a woman drinks alcohol during pregnancy. It can cause growth delays, physical abnormalities, and cognitive impairments in the baby. The risks are highest when alcohol is consumed during the first trimester. There is no known safe amount of alcohol during pregnancy. Diagnosis involves assessing physical features and developmental delays. Prevention focuses on educating women not to drink during pregnancy.
This document discusses neonatal seizures, including their causes, types, diagnosis, treatment, and nursing management. Neonatal seizures are a medical emergency that can cause irreversible brain damage. They are most commonly caused by perinatal complications, developmental neurological problems, perinatal infections, or metabolic problems. The main types of neonatal seizures are subtle, tonic, clonic, and myoclonic. Diagnosis involves history, physical exam, laboratory tests, imaging, and EEG. Treatment focuses on controlling seizures, stabilizing vital functions, treating the underlying cause, and providing supportive care. This includes anticonvulsant medication, treating hypoglycemia, hypocalcemia, or other metabolic abnormalities, and ensuring proper nursing observation
The document discusses the evolution of eating disorder definitions and classifications in diagnostic manuals like the DSM. It notes that definitions and diagnoses have changed frequently over decades as understanding has grown. This has led to inconsistencies and difficulties in research. The text advocates classifying eating disorders based on behaviors and their impact on the individual, rather than rigid criteria, in order to distinguish pathology from normative behaviors influenced by social pressures.
This document discusses neonatal seizures, beginning with an introduction stating they are not uncommon and often the first sign of neurological disorders. It then covers the pathophysiology, incidence, patterns, etiology, diagnosis, management, treatment including anticonvulsants, and prognosis of neonatal seizures over multiple pages with headings and subheadings. Key points include seizures occurring in 1 in 200 healthy newborns, various possible causes like hypoglycemia or infections, treatments involving anticonvulsants like phenobarbital or midazolam, and prognosis varying from normal outcome to neurological sequelae depending on factors like etiology and examination findings.
This OSCE document describes 12 clinical spots or cases presented to a pediatric resident. For each spot, key details are provided such as the patient's history, examination findings, and any relevant investigations. The resident is asked to identify diagnoses, interpretations, treatment plans, and other clinical information. This OSCE evaluates the resident's ability to synthesize clinical data and demonstrate sound medical knowledge and reasoning for various common and important pediatric presentations.
Use of prescribed psychotropics during pregnancyRiaz Marakkar
This document discusses the use of prescribed psychotropic medications during pregnancy. It begins by providing context on global pharmaceutical consumption patterns. It then discusses the prevalence of maternal mental health problems and the need for more research on risks of psychotropic medication use during pregnancy. The document categorizes medications from A to X based on risks in pregnancy. It discusses specific risks of various antidepressants, mood stabilizers, antipsychotics and other drug classes. It also addresses considerations for pharmacotherapy in pregnancy, balancing severity of the condition with risks. The document concludes by discussing risks and guidelines regarding breastfeeding while taking psychiatric medications.
Unit 1_ Genetic Disorders, Part 2, Educational Platform.pptuk581147
Down syndrome is a chromosomal disorder caused by an extra 21st chromosome. It leads to cognitive and physical impairments ranging from mild to moderate. The document discusses Down syndrome, including its definition, background, etiology, pathophysiology, potential problems, signs and symptoms, screening tests, nursing diagnoses, interventions, and management. It is intended to educate nursing students on Down syndrome.
This document discusses the relationship between food allergies/sensitivities and behavioral/developmental disorders in children. It presents two case studies of children whose symptoms of ADHD, autism, and other CNS issues were linked to specific food allergens and additives through elimination diets. The author argues that foods can affect the CNS through various mechanisms beyond IgE-mediated allergies. Studies show links between conditions like asthma, depression, and anxiety, suggesting shared genetic or environmental factors rather than direct causation. Careful dietary management can effectively treat CNS issues in children with food sensitivities.
Poisoning in children is common and can be life-threatening. The document discusses poisoning in children, including common causes, clinical presentations, management principles, and prevention. It defines poisoning, identifies common toxidromes like anticholinergic and sympathomimetic, and outlines the history, exam, decontamination procedures, and management of specific poisonings from substances like acetaminophen, iron, salicylates, and hydrocarbons. Prevention strategies are also discussed, emphasizing the effectiveness of child-resistant containers and safe storage of household products.
Dr. Tom Frieden, Director of the Centers for Disease Control and Prevention, keynote presentation at the National Rx Drug Abuse & Heroin Summit on March 30, 2016.
Kana Enomoto, Acting Administrator, Substance Abuse and Mental Health Services Administration, keynote presentation at the National Rx Drug Abuse & Heroin Summit March 29, 2016
This document summarizes a presentation on managing morphine equivalent dose (MED) and identifying high-risk opioid use through "red flagging." It discusses how calculating MED at the point of sale can help identify unsafe dosages and decrease opioid prescriptions. It also evaluates different methods to screen for overdose risk, finding that simple opioid use thresholds to flag patients may not accurately target those most likely to experience preventable overdoses. The presentation aims to explain MED management, describe payer solutions that reduced opioid use, and identify more precise ways to intervene with highest-risk patients.
Web rx16 prev_tues_330_1_lawal_2warren_3huddleston_4pershingOPUNITE
This document discusses the role of health departments in preventing neonatal abstinence syndrome (NAS). It notes that NAS rates have increased significantly in recent years, disproportionately affecting women. Health departments engage in surveillance to monitor NAS trends, partner with other organizations, support treatment and recovery programs, and provide education to prevent NAS, which is entirely preventable. The document outlines specific strategies health departments use across these areas to address the opioid epidemic and protect maternal and infant health.
The document discusses the opioid crisis in the United States, including rising rates of prescription opioid misuse and abuse, as well as heroin use and overdose deaths. It outlines how research can help address this crisis through developing less abusable analgesics, expanding access to treatment medications like naloxone and buprenorphine, and exploring new treatment approaches such as immunotherapies and precision medicine targeting genetic factors. The National Institute on Drug Abuse is supporting these research efforts and working to disseminate findings to improve prevention and intervention programs.
This document summarizes the opioid crisis in the United States from 2000 to 2014. It shows that the number of opioid-related overdose deaths more than tripled during this period, increasing from about 8,000 to over 28,000. Additionally, 7.9 million Americans aged 12 or older met the criteria for an illicit drug use disorder in 2013-2014 but only 20% received treatment. The document outlines actions by the Obama administration to address the crisis and increase funding for treatment. It emphasizes that stories can help reduce stigma and that recovery is possible through working together.
Web rx16 prev_tues_200_1_bretthaude-mueller_2scott_3debenedittis_4cairnes copyOPUNITE
This presentation covered multi-media prevention strategies for issues like prescription drug overdoses. It discussed the CDC's digital Rx drug prevention campaign, best practices for digital messaging, and programs using expectancy challenge theory and media literacy education in schools. Presenters included representatives from the CDC, Media Literacy for Prevention, and the Hanley Center Foundation who discussed their work developing and implementing digital communications and single-session prevention programs.
This document discusses strategies for reducing buprenorphine diversion and pill mills while improving access to treatment. It notes that limiting access to buprenorphine treatment is associated with increased diversion, while expanded access to quality treatment decreases diversion and overdose deaths. The document recommends educating prescribers, using medically-derived prescribing standards, ensuring adequate insurance coverage of safe prescribing practices, and addressing diversion risks for other controlled medications. It argues against onerous new regulations that could limit treatment access. The goal is to identify and support high-quality treatment while prosecuting criminal operations.
This document summarizes a presentation on linking and mapping prescription drug monitoring program (PDMP) data. It discusses the benefits of linking PDMP data to clinical data, including improving patient safety, evaluating prescribing decisions, and assessing the impact of PDMP interventions. It describes challenges with linking data, such as obtaining consent and negotiating data use agreements. It also discusses Washington State's MAPPING OPIOID AND OTHER DRUG ISSUES (MOODI) tool, which integrates PDMP data with other databases to map and target treatment and overdose prevention efforts at the community level.
Rx16 prev wed_330_workplace issues and strategiesOPUNITE
This document discusses workplace issues related to prescription drug abuse and strategies for prevention. It begins with introductions of the presenters and moderators. The learning objectives are then outlined as understanding challenges of prescription drug abuse in the workplace, identifying prevention strategies, and describing programs available through SAMHSA. The document then covers topics such as the scope of prescription drug misuse among workers, risks to the workplace, prevention strategies employers can consider, and available resources from SAMHSA.
Web only rx16 pharma-wed_330_1_shelley_2atwood-harlessOPUNITE
This document discusses a presentation on pharmacy burglary, robbery, and diversion of prescription drugs. The presentation covers trends in prescription drug diversion, particularly those involving robbery and burglary of pharmacies. It identifies preventative measures to enhance pharmacy security and safety. Strategies to reduce pharmacy crimes are outlined. The offender perspective is examined based on interviews with convicted offenders. Routine activities theory is discussed as relating to suitable targets, capable guardians, and motivated offenders. Partnerships between regulatory agencies and law enforcement are emphasized as key to prevention efforts.
Linking and mapping PDMP data can provide several benefits but also faces challenges. Linking PDMP and clinical data allows for evaluating the impact of PDMP interventions on outcomes and prescribing decisions. However, obtaining permissions and data is difficult due to legal and resource barriers. Mapping PDMP data using GIS tools in Washington identified areas for targeting overdose prevention efforts by visualizing patterns in prescribing risks, treatment availability, and overdoses. Stakeholders used these maps to guide education and funding decisions. Sustaining these tools requires ongoing funding and expanding included data sources.
This document discusses drug court models and the role of law enforcement in drug courts. It begins with introductions from presenters and outlines learning objectives about explaining drug court operations and benefits, how law enforcement can utilize drug courts, and identifying best practices. The following sections provide details on drug court models, including how they integrate treatment into the justice system using a non-adversarial approach. Key components of drug courts are outlined, and presenters discuss issues like prescription drug and heroin abuse as well as outcomes from drug courts in reducing recidivism and saving money. Law enforcement can play roles in prevention, addressing domestic violence, and targeting the right populations for drug court involvement through assessment.
This document summarizes presentations from two communities - Huntington, WV and Camden County, NJ - on their responses to heroin crises. It outlines programs implemented in Huntington, including a harm reduction program, centralized information system, and drug court expansion. It also discusses the region's history with prescription drug abuse and rise in heroin and associated issues like hepatitis and neonatal abstinence syndrome. Long-term strategies proposed include expanding treatment services, promoting career opportunities for those in recovery, and preventing relapse through environmental design changes.
This document discusses neonatal abstinence syndrome (NAS) and universal maternal drug testing. It provides background information on NAS including trends showing large increases in incidence and costs associated with NAS. It outlines objectives related to describing NAS trends, identifying legislative activities impacting NAS, describing family planning for women in substance abuse treatment, and explaining a hospital program using universal drug testing. The document then covers topics including NAS symptoms, incidence and geographic trends, costs of NAS, opioid use in women of childbearing age, unintended pregnancy rates, contraceptive use among opioid users, and maternal drug exposure sources.
Web only rx16-adv_tues_330_1_elliott_2brunson_3willis_4deanOPUNITE
This document outlines an advocacy track presentation on activating communities to address prescription drug abuse. It provides biographies of the presenters and moderators and discloses any conflicts of interest. The learning objectives are to identify best practices for implementing CADCA's seven strategies for community change to impact prescription drug issues. It then provides examples of how various coalitions across the country are utilizing each of the seven strategies, such as providing education, enhancing skills, supporting communities, and changing policies.
This document discusses recovery ready ecosystems and recovery community organizations. It introduces presenters from Young People in Recovery and Hope House Treatment Track who will discuss interventions, prevention, and recovery programs. Examples of Young People in Recovery chapters, programs, and services are provided, including employment workshops, education workshops, housing workshops, and recovery support services. The document also discusses recovery community organizations and initiatives in Texas and Georgia, such as the Association of Persons Affected by Addiction in Dallas and the Georgia Council on Substance Abuse.
This document summarizes a presentation on health plan involvement in safe prescribing. It includes:
1) Presentations from medical experts on prescription drug abuse trends from medical examiner data and a tribal health system's safe prescribing program.
2) A discussion of health plan policies to reduce "red flag" medication combinations like opioids plus benzodiazepines through prior authorization, formulary changes, and provider restrictions.
3) Examples of one health plan's implementation of policies like restricting methadone prescriptions to pain specialists and removing carisoprodol from its formulary.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
1. The
Innocent
Vic,ms:
Neonatal
Abs,nence
Syndrome
Michael
Hokenson,
MD
Assistant
Professor
of
Pediatrics;
Division
of
Neonatology
Carla
Saunders,
NNP-‐BC
Advanced
Prac@ce
Coordinator,
East
Tennessee
Children’s
Hospital
2. Learning
Objec,ves
•
Iden@fy
the
scope
of
babies
affected
by
NAS
with
sta@s@cs
and
research.
•
Evaluate
treatment
programs
around
the
country
that
work
to
care
for
babies
with
NAS.
•
Build
solu@ons
for
clinicians
to
treat
babies
with
NAS.
3. Disclosure
Statement
• Michael
Hokenson
has
no
financial
rela@onships
with
proprietary
en@@es
that
produce
health
care
goods
and
services.
• Carla
Saunders
has
no
financial
rela@onships
with
proprietary
en@@es
that
produce
health
care
goods
and
services.
An
off-‐label
discussion
will
take
place.
4. Background
• Despite
growing
knowledge,
NAS
con@nues
to
challenge
us
– Es@mated
4.5%
of
mothers
14
to
45
yrs/old
use
illicit
drugs
– ORen
overlap
with
medica@ons
for
chronic
pain
and
mental
illness
– 50-‐90%
of
neonates
exposed
to
heroin
in
utero
may
develop
signs
of
withdrawal
1
• Signs/Symptoms
may
be
non-‐specific
1.
Schuckit
Marc
A.
Opioid
drug
abuse
and
dependence.
Harrison's
Principles
of
Internal
Medicine.
17th
edn,
McGraw-‐Hill:
New
York,
2008
5. Challenges
• The
number
of
infants
coded
as
(NAS)
at
d/c
are
on
the
rise
– Na@onally
• 1995-‐
7,654
infants
• 2008-‐
11,937
infants
– In
Florida;
• 1995-‐
0.4/1000
live
births
• 2008-‐
4.4/1000
live
births
– Possibly
increased
awareness,
but
also
prescrip@on
pain
relief
2
2.
Kellogg
A,
Rose
CH,
Harms
RH,
Watson
WJ
.
Current
trends
in
narco@c
use
in
pregnancy
and
neonatal
outcomes.
Am
J
Obstet
Gynecol.
2011;204:259
6. Clinical
Presenta,on
• A
wide
variety
of
drugs
in
utero
may
have
an
effect
on
infant
• Overlap
between
acute
effect
and
withdrawal
of
substance
• The
classic
findings
associated
with
opioid
withdrawal
are
coined
(NAS)
7. Clinical
Presenta,on
• Infants
exposed
to
opioids
in
utero
– Anywhere
from
55-‐94%
may
exhibit
signs
of
withdrawal
3
• Infants
may
also
display
signs
of
withdrawal
if
exposed
to:
– Benzodiazepines
– Barbiturates
– Alcohol
3.
Fricker
HS,
Segal
S
.
Narco@c
addic@on,
pregnancy,
and
the
newborn.
Am
J
Dis
Child.
1978;132(4):360–366
8. Clinical
Presenta,on
• Signs
and
symptoms
• Narco@cs
are
s@ll
the
vary
in
each
infant
most
frequent
cause
– Will
depend
on
specific
and
include:
maternal
drug(s)
– Heroin
– Severity
of
withdrawal
may
– Methadone
not
correlate
with
dose
or
– Morphine
dura@on
of
exposure
– Oxycodone
– Codeine
– Buprenorphine
9. Clinical
Presenta,on
• Narco@cs
and
Barbiturates
– The
@me
frame
for
signs
of
withdrawal
from
narco@cs
may
vary
greatly
• May
be
present
at
birth
and
peak
at
3
to
4
days
• May
not
appear
for
up
to
two
weeks
• Subacute
withdrawal
may
occur
for
4
to
6
months
• Neurologic
irritability
with
abnormal
Moro
has
been
reported
at
7
and
8
months
of
age
10. Clinical
Presenta,on
• Many
systems
can
be
• Common
signs
include:
affected
– Hypertonia
• The
most
common
are:
– Tremors
– CNS
– Hyperreflexia
– Gastrointes@nal
– High-‐pitched
cry
– Autonomic
nervous
– Sleep
disturbances
system
– Occasionally
seizures
11. Clinical
Presenta,on
• Autonomic
dysfunc@on
• GI
symptoms
may
may
include:
include:
– Swea@ng
– Diarrhea
– Low
grade
fever
– Vomi@ng
– Nasal
conges@on
– Poor
feeding
– Sneezing
– Poor
swallowing
– Yawning
– Failure
to
thrive
– Skin
mokling
• Respiratory
signs
may
also
be
present
– Tachypnea
– Apnea
12. S,mulants
• Methamphetamine
and
cocaine
are
less
common
causes
– Withdrawal
signs
have
been
observed
in
as
few
as
4%
of
infants
– Tend
to
be
much
less
severe
than
seen
in
opioid
exposed
infants
– Generally,
only
6%
of
infants
exposed
to
cocaine
will
require
pharmacologic
therapy
4
4.
Fulroth
R,
Phillips
B,
Durand
DJ.
Perinatal
outcome
of
infants
exposed
to
cocaine
and/or
heroin
in
utero.
Am
J
Dis
Child.
1989;143
:905
–910
13. S,mulants
• Signs
may
include:
– Tremors
– High-‐pitched
cry
– Irritability
– Hyper-‐alertness
– Apnea
– Tachycardia
• Most
commonly
seen
around
72
hours
of
age
14. S,mulants
• Infants
exposed
to
methamphetamine
or
cocaine
also
may
exhibit:
5
– Higher
rates
of
prematurity
– IUGR
– Asphyxia
secondary
to
placental
abrup@on
• Mul@ple
drug
use
is
common
in
this
group
– Which
will
oRen
complicate
the
clinical
picture
5.
Eyler
FD,
Behnke
M,
Garvan
CW,
Woods
NS,
Wobie
K,
Conlon
M
.
Newborn
evalua@ons
of
toxicity
and
withdrawal
related
to
prenatal
cocaine
exposure.
Neurotoxicol
Teratol.
2001;23(5):399–411
15. Depressants
and
Seda,ves
• Ethanol
withdrawal
may
be
seen
as
early
as
3
to
12
hours
of
life
– Physical
findings
of
FAS
may
be
superimposed
• Classic
signs
of
NAS
(irritability,
poor
feeding,
crying)
may
be
seen
– Although
the
severity
is
much
less
compared
to
infants
exposed
to
opioids
16. SSRI’s
• Selec@ve
Serotonin
• Poten@al
effects
seen
in
Reuptake
Inhibitors:
infants
exposed
are:
7
– Most
commonly
– Con@nuous
crying
prescribed
medica@on
– Irritability
for
depression
6
– Fever
– Tachypnea
– Tremors
– Hypoglycemia
– Seizures
6.
Alwan
S,
Friedman
JM
.
Safety
of
selec@ve
serotonin
reuptake
inhibitors
in
pregnancy.
CNS
Drugs.
2009;23(6):493–509
7.
Haddad
PM,
Pal
BR,
Clarke
P,
Wieck
A,
Sridhiran
S
.
Neonatal
symptoms
following
maternal
paroxe@ne
treatment:
serotonin
toxicity
or
paroxe@ne
discon@nua@on
syndrome?
J
Psychopharmacol.
2005;19(5):554–557
17. SSRI’s
• Debate
over
source
of
signs
and
symptoms
– Excess
serotonin
(drug
itself)
– Low
serotonin
(withdrawal
of
drug)
• SSRI’s
seem
to
be
safe
in
pregnancy
– Many
reviews
have
not
shown
long
term
neurodevelopmental
impairment
8
8.
Mark
L.
Hudak,
MD,
Rosemarie
C.
Tan,
MD,
PhD,
THE
COMMITTEE
ON
DRUGS,
and
THE
COMMITTEE
ON
FETUS
AND
NEWBORN.
Neonatal
Drug
Withdrawal.
Pediatrics
Vol.
129
No.
2
February
1,
2012
18. Abs,nence
scoring
systems
• Many
scoring
systems
exist
– No
par@cular
one
has
been
adopted
as
“the
standard”
• The
most
comprehensive
and
widely
used
is
the
Finnegan
scoring
system
9
• The
Finnegan
scoring
system
takes
20
of
the
most
common
signs
and
groups
them
into:
– CNS
disturbances
– Metabolic/Vasomotor/Respiratory
disturbances
– GI
disturbances
9.
Finnegan
LP,
Connaughton
JF
Jr,
Kron
RE,
Emich
JP.
Neonatal
abs@nence
syndrome:
assessment
and
management.
Addict
Dis.
1975;2
:141
–158
19. Finnegan
Scores
• The
signs
were
ranked
according
to
pathologic
significance
– Those
with
the
least
poten@al
for
adverse
affects
were
given
a
“1”
– Those
with
the
most
poten@al
for
adverse
affects
were
given
a
“5”
– A
score
of
7
or
less
is
considered
mild
and
babies
do
well
with
nonpharmacologic
comfort
measures
– A
score
of
8
or
greater
generally
indicates
that
infants
may
need
pharmacologic
therapy
20.
21. Opioid
Withdrawal
Recap
• Mostly
affects:
– CNS
– Autonomic
nervous
system
– Gastrointes@nal
system
• Other
things
to
keep
in
mind:
– Presenta@on
will
vary
depending
upon:
• Maternal
dose
• Placental
metabolism
• Maternal
drug
history
• Polysubstance
abuse
22. Prematurity
• Some
studies
suggest
a
lower
risk
for
withdrawal
10
• However,
the
classic
signs
may
not
be
present
– Scoring
systems
developed
around
Term
infants
– Decreased
maturity
of
CNS
system
– Less
adipose
@ssue
• Good
maternal
history
and
general
assessment
of
infants
status
is
key
10.
Liu
AJ,
Jones
MP,
Murray
H,
Cook
CM,
Nanan
R
.
Perinatal
risk
factors
for
the
neonatal
abs@nence
syndrome
in
infants
born
to
women
on
methadone
maintenance
therapy.
Aust
N
Z
J
Obstet
Gynaecol.
2010;50(3):253–258.
23. Prenatal
Screening
• Consider
prenatal
screening
if
certain
risk
factors
present
– Absent/Late
prenatal
care
– Unexplained
fetal
demise
– Placental
abrup@on
– Large
swings
in
cardiovascular
status
– Prior
history
of
drug
abuse
• Can
be
a
delicate
issue
24. Is
it
NAS?
• Be
aware
of
other
systemic
disorders
that
may
have
similar
symptoms
– Hypoglycemia
– Inborn
errors
metabolism
– Calcium
dysregula@on
– Intracranial
process
(HIE,
hemorrhage)
– Uncommon
neuromuscular
disorders
25. What
to
Expect?
11,12
Heroin
Methadone
Buprenorphine
Onset
of
Usually
by
24
Usually
1-‐3
Usually
2-‐3
Symptoms
hours
days
days
• However,
some
infants
may
not
display
signs
un@l
5-‐7
days
11.
Zelson
C,
Rubio
E,
Wasserman
E
.
Neonatal
narco@c
addic@on:
10
year
observa@on.
Pediatrics.
1971;48(2):
12.
Kandall
SR,
Gartner
LM
.
Late
presenta@on
of
drug
withdrawal
symptoms
in
newborns.
Am
J
Dis
Child.
1974;127(1):58–61
26. Treatment
• The
treatment
should
begin
with
non-‐
pharmacologic
measures
– Gentle
handling
– Ambient
noise
control
– Swaddling
– On
demand
feeding
• Be
mindful
of
infants
needs
– Caloric
requirement,
sleep..etc
27. Pharmacologic
Treatment
• Pharmacotherapy
may
be
helpful
if…
– Seizures
are
present
– Weight
loss/Dehydra@on
• Secondary
to
vomi@ng
and
diarrhea
– Poor
feeding
skills
• Opioids
(morphine/methadone)
– Reduce
excessive
bowel
mo@lity
– Reduc@on
of
seizures
28. Pharmacologic
Treatment
• What
is
a
concerning
score?
(Finnegan)
– Usually
8
or
higher
• Goal
of
therapy?
– Allow
gradual
withdrawal
– Absence
of
excessive
excita@on
• The
length
of
the
weaning
process
may
vary
29. Morphine
vs.
Methadone
• Morphine
– Shorter
half
life
(4-‐16
hours)
– Poten@al
to
“capture”
quicker
• Methadone
– Longer
half
life
(16-‐25
hours)
– Less
frequent
dosing
30. Na,onwide
Children’s
Protocol
• Enteral
morphine
based
• Ini@ate
protocol
if
– 2
consecu@ve
scores
above
8
– 1
score
above
12
• Both
within
a
24
hour
period
• Star@ng
dose
– Morphine
0.05
mg/kg/dose
PO
q
3
hours
• IV
would
be
0.02
mg/kg/dose
31. NCH
Protocol
Cont.
• Escala@on
– Increase
Morphine
by
0.025-‐0.04
mg/kg/dose
every
3
hours
un@l
scores
<
8
– If
IV,
increase
by
0.01
mg/kg/dose
• Rescue
dose
– If
scores
are
s@ll
above
12
• Double
the
previous
dose
x
1
• If
s@ll
above
12,
increase
dose
by
50%
– Un@l
captured
• Rescue
dose
only
in
ini@al
phase
32. NCH
Protocol
Cont.
• Stabiliza@on
– Once
captured
(scores
<8)
con@nue
maintenance
dose
for
72-‐96
hours
• Weaning
– Following
the
above,
wean
by
10%
every
24
to
48
hours
– Do
not
rou@nely
weight
adjust
meds
– Drug
may
be
d/c’ed
when
a
single
dose
is
<
0.02
mg/kg/dose
q
3
hours
33. NCH
Protocol
Cont.
• Problems
with
weaning
– If
scores
following
a
wean
are
above
8
• Ensure
comfort
measures
– Maximize
swaddling
– Holding
– Decreased
s@muli
– Go
back
to
dose
where
infant
was
stable
– Do
not
use
rescue
dose
– Consider
weaning
at
longer
intervals
• 48
hours
vs
24
hours
– Monitor
for
48-‐72
hours
prior
to
d/c
34. Adjunct
Therapy
• Consider
a
second
agent
if:
– Infant
has
2
consecu@ve
weaning
failures
– No
progress
in
weaning
off
morphine
by
day
14
– May
be
added
earlier
• Based
on
infants
symptoms
• Maternal
history
35. Adjunct
Therapy
• Phenobarbital
– Binds
to
GABA
receptors
– Helps
with
CNS
issues
such
as
• Irritability,
sleeplessness
and
tone
– Has
been
shown
to
reduce
LOS,
and
severity
of
withdrawal
13
13.
Coyle
MG,
Ferguson
A,
Lagasse
L,
Oh
W,
Lester
B.
Diluted
@ncture
of
opium
(DTO)
and
phenobarbital
versus
DTO
alone
for
neonatal
opiate
withdrawal
in
term
infants.
J
Pediatr
2002;
140(5):
561–564
36. Adjunct
Therapy
• Phenobarbital
may
be
beneficial
if
– CNS
symptoms
predominate
• (Hyperac@ve
reflexes,
tremors,
increased
tone)
– History
of
polysubstance
abuse
37. Adjunct
Therapy
• Cau@ons
with
phenobarbital
– Poten@al
to
oversedate
– Impaired
feeding
– Drug
interac@ons
– Longer
half
life
(45-‐100hr)
– Alcohol
content
(15%)
38. Adjunct
Therapy
• Clonidine
– Alpha
2
adrenergic
receptor
agonist
• Ac@vates
inhibitory
neurons
• Reduced
sympathe@c
tone
– Has
been
shown
to
help
with
• Faster
stabiliza@on
• Decreased
dosing
requirements
of
opioid
therapy
14
14.
Agthe
AG,
Kim
GR,
Mathias
KB,
Hendrix
CW,
Chavez-‐Valdez
R,
Jansson
L
et
al.
Clonidine
as
an
adjunct
therapy
to
opioids
for
neonatal
abs@nence
syndrome:
a
randomized,
controlled
trial.
Pediatrics
2009;
123(5):
e849–e856
39. Adjunct
Therapy
• Clonidine
– May
be
useful
if
majority
of
symptoms
are
in
the
autonomic
category
• (swea@ng,
fever,
yawning,
mokling..etc)
– Monitor
for
hypotension
and
bradycardia
– Avoid
rapid
discon@nua@on
– Observe
for
48
hours
off
prior
to
d/c
• Do
not
recommend
treatment
as
outpa@ent
40. Prenatal
Counseling
• Many
mothers
feel
anxiety
and
guilt
– Clinicians
should
be
prepared
to
be
empathe@c
and
nonjudgmental
• Essen@al
components
to
prenatal
counseling
include:
– Poten@al
for
teratogenicity
– Expected
clinical
course
– Breasueeding
and
Lacta@on
– Social
considera@ons
41. Social
Considera,ons
• Be
empathe@c
and
nonjudgmental
• Be
aware
of
maternal
psychosocial
status
– Is
there
signs
of
postpartum
depression?
– Is
counseling
a
reasonable
resource?
• Always
be
honest
– Not
every
baby
follows
the
rules
– Updates
frequently
regarding
status
43. Epidemiology
NIDA
es@mates
$600
billion
is
spent
annually
on
costs
associated
with
substance
abuse
in
U.S.
American
Diabetes
Associa@on
es@mates
annual
costs
associated
with
diabetes
is
$174
billion
in
2007.
Na@onal
Cancer
Ins@tute
es@mates
$125
billion
in
annual
costs
for
cancer
care
in
2010.
• 2009
Na@onal
Survey
on
Drug
Use
and
Health:
• 4.5
percent
of
pregnant
women
aged
15
to
44
have
used
illicit
drugs
in
the
past
month.
• In
2008
there
were
9430
babies
born
in
Knox
County
according
to
Knox
County
hospitals
birth
records:
Es@mated
424
babies
born
annually
in
Knox
County
whose
mother
used
illicit
drugs
in
the
past
month.
• 2009
Key
Birth
Stats
from
CDC
report
4,131,019
births
in
U.S.
• Approximately
186,000
babies
born
to
mothers
who
used
illicit
drugs
in
past
month
1. NIDA
InfoFacts:
Understanding
Drug
Abuse
and
Addic@on.
Na@onal
Ins@tute
on
Drug
Abuse.
hkp://www.drugabuse.gov/infofacts/understand.html.
Accessed
May
28,
2011
2. Diabetes
Cost
Calculator.
American
Diabetes
Associa@on.
hkp://www.diabetesarchive.net/advocacy-‐and-‐legalresources/cost-‐of-‐diabetes.jsp.
Accessed
May
28,
2011.
3. The
Cost
of
Cancer.
Na@onal
Cancer
Ins@tute.
hkp://www.cancer.gov/aboutnci/servingpeople/cancer-‐sta@s@cs/costofcancer.
Accessed
May
28,
2011.
4. Substance
Abuse
and
Mental
Health
Services
Administra@on.
(2010).
Results
from
the
2009
NaMonal
Survey
on
Drug
Use
and
Health:
Volume
I.
Summary
of
NaMonal
Findings
(Office
of
Applied
Studies,
NSDUH
Series
H-‐38A,
HHS
Publica@on
No.
SMA
10-‐4856Findings).
Rockville,
MD.
5. Number
of
Babies
Born.
Kids
Count
Data
Center.
hkp://datacenter.kidscount.org/data/bystate/Rankings.aspx?state=TN&ind=2996.
Accessed
May
27,
2011.
44. 1999
Veterans
Health
Admin.
Ini,a,ve:
“Pain
as
the
5th
Vital
Sign”
JCAHO
ins,tute
pain
standards
in
2001
Cocaine
Heroin
46. Tolerance
–
Dependence
–
Addic@on
• Tolerance
– Our
body
develops
tolerance
to
a
drug’s
effect
so
that
an
increased
amount
of
drug
is
required
to
produce
effect.
• Dependence
– If
the
supply
of
the
drug
is
removed
then
the
person
will
exhibit
“withdrawal
symptoms”.
• Addic@on
– The
con@nuing,
compulsive
nature
of
the
drug
use
despite
physical
and/or
psychological
harm
to
the
user
and
society
47. Unique
Concerns
for
the
Substance
Abusing
woman
US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
48. Substance
Use
Treatment
among
Women
of
Childbearing
Age
Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
(October 4, 2007). The NSDUH Report: Substance Use Treatment among Women of
Childrearing Age. Rockville, MD.
49. Return
on
Investment
• For
every
$1
spent
on
addic@on
treatment
programs
– $4
to
$7
saved
in
reduced
drug-‐related
crime,
criminal
jus@ce,
and
theR
– Up
to
$12
saved
when
including
health-‐care
costs
– Other
considera@ons
• Neonatal
abs@nence
syndrome
might
be
reduced
NIDA. Principles of Drug Addiction Treatment, A research-based Guide. NIH Publication No. 09-4180. April 2009
• Greater
workplace
produc@vity
50. Incidence
of
Maternal
Opiate
Use
and
NAS
Maternal
Opiate
Use
increased
x
5
NAS
Incidence
tripled
Patrick, S. W. et al. JAMA 2012;307:1934-1940
51. Why
do
expectant
mothers
use
drugs?
Prior
injury
/
chronic
pain
Medical
need
for
pain
management
Appropriately
managed
Inappropriately
managed
In
a
substance
abuse
treatment
program
Confusion
between
symptoms
of
withdrawal
and
pregnancy.
52. Why
do
MDs
con@nue
to
prescribe?
• ACOG
Guidelines
and
SAMSHA
Guildelines
recommend
to
con@nue
methadone
(possibly
buprenorphine)
• “Lesser
of
two
evils”
– Risky
drug-‐seeking
behaviors
– Goals
of
quelling
cravings
– Prevent
mini-‐withdrawals
– Ceiling
effect
of
being
in
treatment
• Methadone,
suboxone,
subutex
– Reveal
danger
of
I.V.
suboxone
53. “Standard
of
care
for
pregnant
women
with
opioid
dependence:
referral
for
opioid-‐assisted
therapy
with
methadone…emerging
evidence
suggests
that
buprenorphine
also
should
be
considered.”
Abrupt
d/c
of
opioids
can
result
in
preterm
labor,
fetal
distress,
or
fetal
demise
During
intrapartum/postpartum
period,
special
considera@ons
are
needed…ensure
appropriate
pain
management,
prevent
postpartum
relapse,
prevent
risk
of
overdose,
ensure
adequate
contracep@on.
54. Prenatal
Care
is
Vital
• “Adequate
prenatal
care
oRen
defines
the
difference
between
rou@ne
and
high-‐risk
pregnancy
and
between
good
and
bad
pregnancy
outcomes.
Timely
ini@a@on
of
prenatal
care
remains
a
problem
na@onwide,
and
it
is
overrepresented
among
women
with
substance
use
disorders.
In
part,
the
threat
of
legal
consequences
for
using
during
pregnancy
and
limited
substance
abuse
treatment
facili@es
(only
14
percent)
that
offer
special
programs
for
pregnant
women
(SAMHSA
2007)
are
key
obstacles
to
care.”
US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
55.
56. Early
Interven@on
• Window
of
opportunity
– “Brief
interven@ons
can
provide
an
opening
to
engage
women
in
a
process
that
may
lead
toward
treatment
and
wellness.”
• Pregnancy
creates
a
sense
of
urgency
to
– Enter
treatment
– Become
abs@nent
– Eliminate
high-‐risk
behaviors
US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. Substance
Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
57. NAS
Incidence
in
the
U.S.
Patrick, S. W. et al. JAMA 2012;307:1934-1940
58. TennCare Office of Healthcare Informatics. Neonatal Abstinence Syndrome among TennCare enrollees. September,
2012.
59. American
Academy
of
Pediatrics
(AAP)
Guidelines
“Reported
rates
of
illicit
drug
use…underes@mate
true
rates…”
55
to
94%
of
neonates
exposed
to
opioids
in
utero
will
develop
withdrawal
signs.
Each
nursery
that
cares
for
infants
with
NAS
should
develop
protocol
for
screening
for
maternal
substance
abuse
Screening
is
best
accomplished
by
using
mul@ple
methods
Maternal
history
Maternal
urine
tes/ng
Tes@ng
of
newborn
urine/meconium
May
consider
umbilical
cord
samples
Hudak ML, Tan RC, The Committee on Drugs and The Committee on Fetus and Newborn. Neonatal Drug Withdrawal.
Pediatrics. 2012;129:e540e560.
60. AAP
Guidelines
-‐
Newborn
Observa@on
Risk
Factors
Recommenda,on
• No
prenatal
care
• Observe
in
the
hospital
• Limited
prenatal
care
for
4
to
7
days
• History
of
substance
use
• Early
outpa@ent
or
abuse
followup
• Any
posi@ve
screen
– Reinforce
caregiver
educa@on
about
late
during
pregnancy
withdrawal
signs
• Posi@ve
UDS
on
admission
Hudak
ML,
Tan
RC,
The
Commikee
on
Drugs
and
The
Commikee
on
Fetus
and
Newborn.
Neonatal
Drug
Withdrawal.
Pediatrics.
2012;129:e540e560.
61. American
Academy
of
Pediatrics
(AAP)
Guidelines
• Pharmacologic
interven@ons
include:
– oral
morphine
solu@on,
or
methadone
as
primary
therapy
– Increasing
evidence
for
clonidine
as
primary
or
adjunc@ve
therapy
– Buprenorphine
use
as
primary
or
adjunc@ve
therapy
is
also
increasing
– Treatment
for
polysubstance
exposure
may
include
opioid,
phenobarbital,
and
clonidine
in
combina@on.
Hudak
ML,
Tan
RC,
The
Commikee
on
Drugs
and
The
Commikee
on
Fetus
and
Newborn.
Neonatal
Drug
Withdrawal.
Pediatrics.
2012;129:e540e560.
62. ETCH
Haslam
Neonatal
Intensive
Care
•
Unit
152
beds
/
Level
III
NICU
–
60
beds
– About
30
%
of
our
NICU
admissions
primarily
for
NAS
treatment
– 135
admissions
for
2011
– 283
admissions
for
2012
• ProjecMng
315
for
2013
– Highest
daily
census:
37
in
September,
2012
Average
Daily
Census
for
NAS
babies
1st
Quarter
(JAN-‐MAR)
4th
Quarter
(OCT-‐DEC)
2011
8
18
2012
29
27
63. Our
rate
of
admissions
is
almost
1
baby
every
day…
65. Previous
Treatment
Plan
Goal:
Stabilize
on
meds
and
discharge
to
wean
Drugs:
Methadone
and
Phenobarbital
No
consistent
approach
to
ini@a@on
of
meds,
dosing,
or
weaning
or
criteria
for
discharge
Avg
LOS:
16
days
to
discharge
on
meds
Confusion
of
staff
and
families
about
treatment
and
expecta@ons
66. Discharge
Support
• Discharged
only
to
DCS
approved
caregivers
• Discharged
with
weaning
schedule
• Dedicated
pediatric
follow
up
• Physiatry
follow
up
• DCS
services
in
the
home
• Home
health
nursing
visits
with
social
work
support
67. Factors
for
Change
in
Treatment
Plan
Realiza,on
that
safety
plan
was
failing
Barriers
to
compliance
Caregiver
resistance
(biological/foster)
Caregiver
changes
Drug
diversion
Outpa@ent
management
issues
About
80%
of
discharged
NAS
infants
do
not
keep
follow-‐up
Pediatrician
refusal
to
manage
weans
Observa@ons
that
babies
were
not
receiving
meds
Issues
with
retail
pharmacy
comfort/availability
of
methadone
Former
NAS
infant,
D/C
on
methadone,
presents
DOA
at
ETCH-‐ED
68. ETCH
Mul@disciplinary
Team
Medical
team
(NNP
lead)
PT/OT
and
Speech
Pharmacy
Child
Life
Staff
nurses
Volunteer
Services
Administra@on
Security
Pa@ent
Care
Coordinator
Nutri@on
Services
Social
Work
PCAs
Lacta@on
Unit
Secretaries
Physiatry
Service
Excellence
69. Project
Objec@ves
Develop
a
treatment
plan
to
treat
NAS
that
will:
Iden@fy
neonates
at
risk
for
NAS
Consistently
evaluate
the
presence
and
severity
of
withdrawal
symptoms
Standardize
and
simplify
the
opioid
withdrawal
treatment
plan
Ini@ate
appropriate
non-‐pharmacological
interven@ons
and
pharmacotherapy
to
control
symptoms
Safely
minimize
length-‐of-‐stay:
Wean
the
opioid-‐dependent
infant
as
quickly
as
possible
while
providing
good
control
of
withdrawal
symptoms
Discharge
infant
weaned
from
NAS
pharmacotherapy
Will
not
require
outpaMent
management
of
methadone
71. Morphine
Algorithm
Literature
review
Goals
for
protocol
Safe
EffecMve
Quick
Iden@fied
treatment
plan
symptom-‐based
protocol
Dr.
Jansson
/Johns
Hopkins
Adapted
protocol
Simple
to
use
Standardize
treatment
decisions.
72. Typical
course
of
treatment
• 70
%
of
NAS
babies
• 30
%
of
NAS
babies
– Wean
in
20
days
– Wean
in
60
days
– No
adjunc@ve
meds
– Require
adjunc@ve
meds
• Phenobarbital
(27%)
– LOS
24
days
• Phenobarbital
+Clonidine
(7%)
– LOS
68
days
• (longest
LOS
=
155
days)
77. Unique
Challenges
Environment
Work
load
Nursing
Pharmacy
Social
Work
Rehabilita@on
Services
Volunteer
Services
Security
78. Emo@onal
Challenges
• A_tudes
/
PercepMons
• Family
/
Caregiver
Issues
• Preventable
nature
of
• Personal
addic@on
of
condi@on
parents
• Personal
prejudices
• Mental
health
issues
• Literacy
problems
• Feelings
• Comprehension/
• Confusion
/
fear
reten@on
issues
– HIPPA
concerns
– Ethical
Issues
• FaMgue/exhausMon/burnout
Educa/onal
deficit
regarding
the
science
of
addic/on
79. Public
Health
Issues
NICU
beds
taken
by
infants
whose
only
need
is
withdrawal
treatment
Behavioral
issues
in
childhood
Schools
–
teacher
retraining
Poten@al
long-‐term
public
health
issue
Genera@onal
addic@on
problems
2nd
and
3rd
genera@onal
behaviors
sustained
Gene@c
predisposi@on?
Does
intrauterine
exposure
ac@vate
gene
in
utero?
Does
NAS
treatment
complicate
addic@ve
tendencies?
80. Long-‐Term
Consequences
of
NAS
• At
risk
for:
– Aken@@on
deficit
disorder
– Hyperac@vity
– Difficulty
transi@oning
between
tasks
– Impulse-‐control
– Sleep
disorders
– Sensory
disorders
– Future
risk
of
addic@ve
behavior
81. Lessons
Learned
• Withdrawal
outpa@ent
is
unreliable
even
unsafe
• Withdrawal
is
not
linear
• Consistency
is
invaluable
• Data
drives
success
• Challenges
are
unique
to
this
pa@ent
popula@on
• Scoring
tools
are
not
designed
for
older
neonate
• Early
capture
may
lead
to
decreased
LOS
82. More
lessons….
• Not
all
drug
“screens”
are
created
equal
• Collect
meconium
from
first
stool
to
transi@on
• Maternal
histories
are
not
always
reliable
• Mother
can
be
posi@ve
and
baby
nega@ve
• Addic@on
knows
no
boundaries
• If
it
“quacks”….
You
will
likely
discover
it
IS
a
duck!
83. Summary
• The
impact
of
NAS
does
not
end
in
the
NICU.
• Long-‐term
benefits
to
both
the
healthcare
system
and
society
are
significant.
• Prenatal
care
in
the
otherwise
healthy
woman
is
widely
accepted
to
be
beneficial
to
mothers
and
babies.
• We
must
do
all
we
can
to
promote
prenatal
care
and
substance
abuse
treatment/counseling
in
this
high-‐risk
popula@on.
• Incen@ves
to
seek
help
may
allow
more
opportuni@es
for
the
woman
to
receive
successful
treatment
with
lifelong
benefits.
84. Shoot for the moon,
even if you miss
you’ll land among the
stars.