Neonatal abstinence syndrome: strategies for care of the drug-exposed infant

Neonatal Abstinence Syndrome: An Insight Over Impact of Maternal Substance Use

Neonatal abstinence syndrome (NAS) highlights the intricate interplay between maternal substance use during pregnancy and the challenges neonates face from the distressing global opioid crisis. This comprehensive review captures the multilayered landscape of NAS, encircling its underlying mechanisms, epidemiology, diagnostic intricacies, clinical manifestations, continuing developmental impacts, treatment paradigms, and the crucial role of multidisciplinary care. The core pathophysiology of NAS involves the transplacental passage of addictive substances, activating chemical dependence in the maturing fetus, which is characterized by neurotransmitter dysregulation, neuroadaptations, and receptor sensitization. A diverse clinical presentation ranges from central nervous system hyperactivity and autonomic dysregulation to gastrointestinal manifestations, necessitating homogenous assessment tools such as the Finnegan Neonatal Abstinence Scoring System. The demand for a multilayered approach is essential for comprehensive management, involving pharmacological interventions like morphine or methadone and non-pharmacological strategies such as swaddling. The complications of NAS are not only limited to but are also well beyond infancy, leading to behavioral, longstanding cognitive, and socioemotional consequences. Addressing these developmental arcs demands decisive longitudinal monitoring and early interventions. NAS management is fundamentally multidisciplinary, requiring the teamwork of nurses, social workers, psychologists, pediatricians, and neonatologists. Apart from the clinical realm, managing the psychosocial needs of families traversing NAS requires resources and empathy. A crucial comprehensive approach is essential to confront the challenges and limitations of NAS. From early identification and prevention to longstanding support through pharmacological, non-pharmacological, and psychological channels, it creates a holistic structure that emerges as the basis for understanding the complicated relationship between maternal substance use and its impact on neonates. An amalgamation of community engagement, society, policy initiatives, and medical expertise is essential to mitigate the repercussions of NAS and adopt healthier outcomes for affected infants.

The Infant Cuddler Study: Evaluating the effectiveness of volunteer cuddling in infants with neonatal abstinence syndrome

Objectives

St. Michael's Hospital launched a volunteer cuddling program for all infants admitted into the neonatal intensive care unit in October 2015. The program utilizes trained volunteers to cuddle infants when caregivers are not available. This was a pilot study to assess the impact of a volunteer cuddle program on length of stay (LOS) and feasibility of implementation of the program.

Methods

A mixed methods approach was utilized to measure both quantitative and qualitative impact. A pilot cohort study with a retrospective control group assessed the feasibility of implementing a volunteer cuddling program for infants with neonatal abstinence syndrome (NAS). Length of stay was used as a surrogate marker to measure the impact of cuddling on infants being treated for Neonatal Abstinence Syndrome. Focus groups using semi-structured interviews were conducted with volunteers and nurses at the end of the pilot study.

Results

LOS was reduced by 6.36 days (U=34, P=0.072) for infants with NAS in the volunteer cuddling program. Focus groups with both bedside nurses and program volunteers described a positive impact of cuddling programs on infants, families, staff, and volunteers alike.

Conclusions

The study results suggest that the volunteer cuddling program may reduce LOS in infants with NAS and have potential economic savings on hospital resources. However, larger prospective cohort studies are needed to confirm these results.

Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome

BACKGROUND

Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio.

METHODS

To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 2² factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017.

RESULTS

Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC.

CONCLUSIONS

OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.

Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome

OBJECTIVES

In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS.

METHODS

We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified.

RESULTS

Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS.

CONCLUSIONS

We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.

Oral clonidine in the management of acquired opioid dependency

Clonidine is a nonnarcotic analgesic historically used as a nasal decongestant and more recently established as an antihypertensive agent in adults. Because of its sedative properties with few adverse effects, clonidine has also been reported to be an effective pharmacologic agent for the treatment of neonatal abstinence syndrome (NAS). The use of oral clonidine as a primary or secondary agent in the treatment of NAS has been found to reduce hospitalization and duration of treatment in this population.

Pregnancy under subutex (buprenorphine): opinions expressed on French internet forums

Internet forums record the opinions and advice exchanged about pregnancy under Subutex. Two hundred and fourteen messages under 92 nicknames from four forums, especially dedicated to this subject in France, from August 2005 to July 2008 were collected and analyzed with QSR NIVIVO8. Most of the Internet users were women, pregnant, or with children, using Subutex. Very few professionals took part in them. The analysis of the opinions and representations of this substance, of medical practices, of exchanged advice, particularly on posology, was realized by the construction of a thematic tree.

Using population data to examine the prevalence and correlates of neonatal abstinence syndrome

The objective of this study was to determine the population prevalence and correlates of neonatal abstinence syndrome among neonates born to women on methadone, using a cross-sectional analysis of linked population health data. A total of 2941 live births to women actively on methadone at delivery were analysed over an 11-year period (1992 - 2002). Of these births, 796 neonates (27%) were diagnosed with an International Classification of Diseases - 9CM (ICD-9CM) or International Classification of Diseases ICD - 10AM (ICD-10AM) diagnosis related to neonatal withdrawal from exposure to opiates in utero (NAS). There were significant differences found between mothers whose neonates did and did not receive an International Classification of Diseases NAS-related diagnosis. Mothers of neonates with a NAS-related diagnosis had a higher number of previous pregnancies, were more likely to be indigenous, to smoke more heavily and were more likely to present for delivery unbooked. Neonates diagnosed with NAS were admitted to Special Care Nursery more often. NAS is diagnosed less frequently using International Classification of Diseases (ICD) codes than when using clinical scales measuring opiate-related neonatal withdrawal. This suggests that NAS may be under-represented in hospital morbidity databases that use ICD codes to quantify patient throughput and in some circumstances this may result from under-detection of the condition. Future research should therefore seek to determine the validity of NAS recording in hospital morbidity databases reliant on the use ICD codes.

Factors associated with substance use during pregnancy: results from a national sample

OBJECTIVE

To examine the prevalence and correlates of substance use during pregnancy among women in the United States.

METHODS

We analyzed data from pregnant (n=1800) and non-pregnant women (n=37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design.

RESULTS

The overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9% and 10%, respectively. Compared to the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income.

CONCLUSIONS

Although the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

Neonatal abstinence syndrome: reconstructing the evidence

Neonatal abstinence syndrome (NAS) is the term used to describe the presence of withdrawal symptoms in neonates exposed prenatally to opiates. Much of what is known about NAS is based on the biomedical model of illness. There is less consideration of the social, historical, and political influences on knowledge development about the NAS phenomenon. Social construction presents an alternate framework within which to consider the diagnosis of NAS and on which to strengthen theoretical foundations, expand research programs, and improve practice.

Identification and Management of Neonatal Abstinence Syndrome

The nursing care of infants experiencing withdrawal from drug abuse through passive exposure is often challenging. These infants are at higher risk for many medical complications in addition to withdrawal itself. Often, infusion nurses play an important role in caring for an infant with drug withdrawal by providing infusion therapy for the infant's compromised medical condition, poor oral intake, and withdrawal symptoms. This article focuses on drug abuse during pregnancy, the withdrawal symptoms it may cause in the infant, ways to recognize an infant experiencing neonatal abstinence syndrome, and available scoring tools and treatment options.

Mu-opioid receptors modulate the stability of dendritic spines

Opioids classically regulate the excitability of neurons by suppressing synaptic GABA release from inhibitory neurons. Here, we report a role for opioids in modulating excitatory synaptic transmission. By activating ubiquitously clustered mu-opioid receptor (MOR) in excitatory synapses, morphine caused collapse of preexisting dendritic spines and decreased synaptic alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors. Meanwhile, the opioid antagonist naloxone increased the density of spines. Chronic treatment with morphine decreased the density of dendritic spines even in the presence of Tetrodotoxin, a sodium channel blocker, indicating that the morphine's effect was not caused by altered activity in neural network through suppression of GABA release. The effect of morphine on dendritic spines was absent in transgenic mice lacking MORs and was blocked by CTOP (D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-ThrNH2), a mu-receptor antagonist. These data together with others suggest that endogenous opioids and/or constitutive activity of MORs participate in maintaining normal morphology and function of spines, challenging the classical model of opioids. Abnormal alteration of spines may occur in drug addiction when opioid receptors are overactivated by exogenous opiates.

Traitement par le diazépam du syndrome de sevrage néonatal aux opiacés (23 cas)

INTRODUCTION

The fetal opiate exposure presents many risks for the newborn. One of the most important is the neonatal abstinence syndrome that associates neurological and digestive signs. In some cases the vital prognosis can be involved. The evaluation of the syndrome's severity is based on certificated scales. The mortality has been reduced by the improved management of these neonates. Diamorphine, phenobarbital, chlorpromazine and diazepam are the most currently used. However, there is no consensus on the treatment. The data concerning the treatment are controversial, especially for the use of diazepam. The aim of our study was to describe the effects of diazepam obtained in three different centers and to compare our results to those of the literature.

POPULATION AND METHODS

Twenty-three neonates were included. They were all hospitalized for abstinence syndrome and treated by diazepam. The Finnegan scale was used to evaluate the symptom's severity and the effects of the diazepam. The principal evaluation criteria were the duration of treatment and hospitalization, the timing in recovery of birth weight and the percentage of birth weight loss.

RESULTS

The average treatment duration was 7 days, the average hospitalization duration was 18 days, the birth weight was recovered at 10 days of life and the percentage of loss of birth weight was 6.5%. Diazepam treatment failed in only one case. No case of intense dehydration occurred.

CONCLUSION

Due to the retrospective design of the study, the diazepam could not be compared to other drugs. Nevertheless, it argues against the "anti-diazepam" attitude. A controlled randomised prospective study is needed to evaluated the optimal therapeutic strategy.