Managing infants born to mothers who have used opioids

Question 1

Opioid use during pregnancy risks

Answer 1

• prematurity
• low birth weight
• increased risk spont. abortion
• SIDS
• infant neurobehavioural abnormalities

Other risks:
infections (hep B, C, syphilis, HIV), insufficient maternal nutrition or access to antenatal care, social risk factors (screen and manage)

Question 2

Timing of withdrawal symptoms in neonates with NAS from opioids?

Answer 2

• usually within 48-72 hr
• might be later: 5-7 days post birth for methadone or buprenorphine
• initial acute symptoms for 10-30 days
• milder symptoms 4-6 mo (irritability, sleep disorders, feeding problems )

Question 3

Why are premature infants at lower risk of opioid withdrawal?

Answer 3

• shorter in utero exposure time
• decreased placental transmission
• inability to fully excrete drugs by immature kidneys and liver
• minimal fat stores leading to lower opioid deposition and activity
• limited capacity to express classic NAS symptoms by immature brain

Question 4

How long do you do Finnegan scores for babies with exposure to maternal opioids?

Answer 4

• within 1-2 hr post delivery then q3-4 hrs
• minimum 72-120h of scoring should be done if infant exposed to long acting morphine (methadone or buprenorphine)

Babies must be observed for a minimum of 72 hours

Question 5

How do you treat babies with exposure to maternal opioids (nonpharmacological)

Answer 5

• Avoid naloxone (as per NRP) —> associated with seizures in newborns
• rooming-in model of care
• Nonpharmacological interventions
  * skin-to-skin contact
  * safe swaddling
  * gentle waking
  * quiet environment
  * minimal stimulation
  * lower lighting
  * developmental positioning
  * music
  * massage therapy
• Breastfeed (HIV-negative who are stable on opioid maintenance with morphine or buprenorphine)
• Supplement with concentrate or increase caloric intake if poor wt gain

Question 6

What are benefits of the rooming-in model of care for infants with opioid exposure?

Answer 6

(lower NICU admission rate, higher breastfeeding initiation rates, less need for medications, shorter hospital stays)

Question 7

Pharmacological interventions for NAS?

Answer 7

First line: Morphine & methadone, can use sublingual buprenorphine

• Start morphine if score >= 8 on 3 or >=12 on 2 consecutive measures. Start 0.32 mg/kg/day divided q4-6 hr
• increase by 0.16 mg/kg/day q4-6 h if scores >= 8 on 3 evals
• taper by 10% of total daily dose q48-72 hr

Adjunct: phenobarb, clonidine

• clonidine effective if autonomic symptoms present
• phenobarb may have GI side effects

Question 8

Discharge considerations for neonatal abstinence syndrome?

Answer 8

• observe minimum 72 hours
• Can discharge home on pharmacological support in some cases
  
  • before DC, should tolerate pharmacological tapering and withdrawal scores <8

Question 9

What is the recommended medication for opioid-dependent pregnant women?

Answer 9

methadone
buprenorphine as alternative

• Opioid substitution in pregnancy can lessen use of other opioids and ilict drugs, improve prenatal care (access to education, counselling and community supportive services)
• antenatal consult by perinatology, pediatrics and/or neo

Question 10

What is the differential diagnosis for a baby with NAS?

Answer 10

hypoglycemia, hypocalcemia, CNS injury, hyperthyroidism, bacterial sepsis, infection