Here is the complete list of the Table Of Contents of the PedsCases website. On this page the site has organized all of the contents into two groups: Clinical Presentation and Specialty Area.
This post contains links to and excerpts from Management of infants born to mothers who have used Opioids during pregnancy – CPS Podcast [Link To The Podcast] [Link To The Transcript] of Jan 15, 2018 from PedsCases:
This podcast was made in conjunction with PedsCases and the Canadian Paediatric Society (CPS) to summarize the recently published 2017 CPS Practice Point: Management of Infants born to Mothers who have used Opioids during pregnancy.
The podcast was developed by Dr. Maya Dhahan, a second-year Paediatrics Resident, in collaboration with Dr. Thierry Lacaze, staff Neonatologist and Section Chief for the Department of Neonatology at the University of Calgary, and the lead author of the CPS statement.
Here are excerpts from the transcript:
Background:
Opioid use in pregnancy has been associated with spontaneous abortions, IUGR/low birth weight, prematurity, sudden infant death syndrome and infant neurobehavioral abnormalities. NAS (Neonatal Abstinence Syndrome] is the most common short term complication of maternal opioid use.
Presentation:
1. From a CNS perspective, infants suffering from NAS can present as
extremely irritable and inconsolable, have high pitched crying and are unable to sleep. On exam, they can have hyperactive reflexes, hypertonia, jitteriness or tremors, myoclonic jerks or even seizures.
2. Metabolic derangements in NAS present in the vital signs changes such
as fever and tachypnea. On exam you can see sweating, mottling and nasal flaring.
Always be cautious of infants that have frequent yawning, sneezing or nasal stuffiness as those can all be signs of opioid withdrawal in the infant.
3. From a GI standpoint, infants appear excessively hungry with rooting and sucking but have poorly coordinated feeding, excessive disorganized sucking and are unable to self sooth or satisfy. They also can have vomiting and loose, watery stools.The majority of symptoms will present within the first 48-72hrs of life. The initial acute symptoms can persist up to 10-30 days but the milder, subacute symptoms such as feeding difficulties, irritability and sleep dysregulation can persist for up to 6 months.
Assessment:
To quantify the severity of withdrawal symptoms, we use the Modified Finnigan Scoring Tool*. This Withdrawal Assessment Tool, (WAT), gives you a score based on behaviours associated with withdrawal.
*Modified Finnegan Neonatal Abstinence Score (NAS) from MD Calc
What follows is from the MD Calc link above:
Stratifies severity of opioid withdrawal in newborns.
INSTRUCTIONS
The NAS should be monitored over time; protocols for management based on scoring may differ by institution but some studies suggest monitoring every 3-4 hours.
FORMULA
Addition of the selected points:
Variable
Points
Central nervous system disturbances
Cry
Normal
0
Excessive high-pitched cry <5 minutes
2
Continuous high-pitched cry >5 minutes
3
Sleep
Normal
0
Sleeps <3 hours after feeding
1
Sleeps <2 hours after feeding
2
Sleeps <1 hour after feeding
3
Moro reflex
Normal
0
Hyperactive
2
Markedly hyperactive
3
Tremors
None
0
Mild tremors when disturbed
1
Moderate-severe tremors when disturbed
2
Mild tremors when undisturbed
3
Moderate-severe tremors when undisturbed
4
Increased muscle tone
No
0
Yes
1
Excoriation (e.g. chin, knees, elbow, toes, nose)
No
0
Yes
1
Myoclonic jerks (twitching/jerking of limbs)
No
0
Yes
3
Generalized convulsions
No
0
Yes
5
Metabolism, vasomotor, and respiratory disturbances
Sweating
No
0
Yes
1
Hyperthermia
None
0
37.2-38.3ºC (99.0-100.9ºF)
1
>38.3ºC (>100.9ºF)
2
Frequent yawning (>3-4 times per scoring interval)
No
0
Yes
1
Mottling
No
0
Yes
1
Nasal stuffiness
No
0
Yes
1
Sneezing (>3-4 times per scoring interval)
No
0
Yes
1
Nasal flaring
No
0
Yes
2
Respiratory rate
Normal
0
>60 breaths/minute, no retractions
1
>60 breaths/minute with retractions
2
Gastrointestinal disturbances
Excessive sucking
No
0
Yes
1
Poor feeding (infrequent/uncoordinated suck)
No
0
Yes
2
Regurgitation
No
0
≥2 times during/post feeding
2
Projectile vomiting
No
0
Yes
3
Stools
Normal
0
Loose (curds/seedy)
2
Watery (water ring on diaper around stool)
3
MANAGEMENT
Protocols for management based on scoring may differ by institution, but one study (Kocherlakota 2014) suggests the following:
Start scoring within 24 hours of birth and monitor every 3-4 hours.
For two consecutive scores ≥12 or three consecutive scores ≥8, initiate pharmacologic treatment.
If neither of the above, continue to monitor scores at every 3-4 hour intervals.
Now we’re returning to excerpts from the Peds Cases Transcript:
Management
This brings us to management of these infants.
There are two phases of interventions, non pharmacological and pharmacological.
Initial treatment should always begin with non-pharmacological as medications can prolong hospital stay and disrupt maternal-infant bonding.
Second line therapy is medications. Indications to progress to this second line are:
1. Infants whose withdrawal signs are increasingly severe with WAT scores of 8 and over for three consecutive evaluations or 12 and over for two consecutive evaluations or
2. Infants whose concurrent NAS scores climb despite supportive measures to reduce and manage symptoms. Usually these infants need to be admitted to the NICU for cardiorespiratory monitoring if initial medication management becomes escalated.
Take home messages:
So let us recap the 4 clinical pearls discussed in this podcast:
1. Use the Finnigan scoring system (or equivalent scoring system)
to quantify the NAS symptoms and guide your treatment plan.
2. Always include non-pharmacological treatment in your treatment
plan of infants presenting with NAS. Remember that it will decrease their need for medication and their length of stay!
3. If medications are required, monitor carefully and frequently to
ensure that you are using the minimum amount of medication required and that you are tapering slowly to not worsen the withdrawal effects.
4. Start planning discharge and follow up in the community early on!