Neonatal Abstinence Syndrome Case Study



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Neonatal Abstinence Syndrome Case Study
Ms. S delivered Baby S, a female infant, early this morning at 0400. Ms. S is a 29 year old G4 P2 -> 3 Preterm 0, Ab 1, Living Children 1 -> 2, who delivered at 39 weeks by NSVD. The baby had grunting, flaring and retractions noted in Labor and Delivery, and came to the ICN3 for observation. Ms S began prenatal care at 18 weeks. At her first prenatal visit she disclosed using oxycontin 10 mg “four or five times” daily for chronic back pain after a fall from a horse in 2004. After starting prenatal care, she accepted a referral to the Milagro Program where she converted her pain medication to Methadone. She took 80 mg daily at the end of her pregnancy. She informed the nurses after delivery that she planned to breastfeed Baby S. What other information needed to plan management?


  1. What other information needed to plan management?

Toxicology screening of the mother and baby will assist with understanding recent drug exposure to Baby S at the time of delivery. Given Ms S’ history, the medical team anticipates a positive screen for her that shows methadone. At the time of delivery, technical issues around collecting urine from the baby may influence results. Those include the challenges of obtaining a urine from the standard urine collection bag, the type of screen done by the lab at UNM versus Tricore labs, and the degree of urine concentration by the baby. The technique of placing a urine collection bag presents challenges as the adhesive on the plastic surface applied to the perineum may not stick to skin well allowing leakage of the urine into the diaper. The contents of the bag may become contaminated by meconium. Delays in collection may reduce the likelihood of obtaining a positive screen, as the levels of drugs appearing in urine will fall as a function of length of time from delivery. The first urine produced by the infant would be predicted to have the highest level of drug or drug metabolite. The type of test done has an influence on interpretation of results. Currently the rapid lab at UNM may test the infant’s urine with a dipstick test that has not been validated in newborn practice. This testing method seems to create false negatives based on negative results that when retested with more sensitive tests show positives. Either type of testing assays for drugs or their metabolites above a specific quantitative threshold. Tests are reported positive if the concentration of the chemical exceeds the testing threshold. Conversely, the results are reported as negative if below the threshold. A metabolite for cocaine, benzoylecognine, for example, is not produced by human metabolic pathways from any other precursor except cocaine, so any level detected would imply prenatal use by the mother with passage into the body of the baby. Therefore, a negative drug screen has low specificity especially in context of a positive history of recent drug use by the mother. Finally, some parents may interfere with the collection by removing the bag before the nursing staff are notified.


  1. The results of Ms S’ urine drug screen returns collected from Labor and Delivery. How would you interpret the results? What do you do with the results?




Ur Amphetamine Screen Interpretation


Negative

Ur Barbiturate Screen Interpretation


Negative

Ur Benzodiazepine Screen Interpretation


Negative

Ur Cannabinoid Screen Interpretation


Negative

Ur Cocaine Screen Interpretation


Negative

Ur Darvon Screen Interpretation


Negative

Ur Methadone Screen Interpretation


Negative

Ur Opiate Screen Interpretation


Negative


The results do not seem to fit with the clinical picture. Currently, the rapid laboratory at UNM uses an approved dipstick testing kit. The clinical experience of the medical teams has found that the dipstick testing may provide negative results in the face of expected positives. The more appropriate test that the team should order is the “Urine Drug Quantitative Test.”


  1. The repeat test from Ms S with the following results. How would you interpret them?



Ur Amphetamine Screen Interpretation


Negative

Ur Barbiturate Screen Interpretation


Negative

Ur Benzodiazepine Screen Interpretation


Negative

Ur Cannabinoid Screen Interpretation


Positive

Ur Cocaine Screen Interpretation


Negative

Ur Darvon Screen Interpretation


Negative

Ur Methadone Screen Interpretation


Positive

Ur Opiate Screen Interpretation


Positive


The results from the more sensitive test suggest that Ms S received methadone as she described. In addition, the results suggest that she used marijuana and opiates close to the time of delivery. The pattern of results will require additional history taking to understand Baby S’ drug exposure.


  1. The results from Baby S Urine Drug Quantitative Test returns with the following results. How would you interpret them?




Ur Amphetamine Screen Interpretation


Negative

Ur Barbiturate Screen Interpretation


Negative

Ur Benzodiazepine Screen Interpretation


Negative

Ur Cannabinoid Screen Interpretation


Positive

Ur Cocaine Screen Interpretation


Negative

Ur Darvon Screen Interpretation


Negative

Ur Methadone Screen Interpretation


Positive

Ur Opiate Screen Interpretation


Negative


The results from the more sensitive test indicate that Baby S had exposure to methadone consistent with the mother’s history. She also had exposure to marijuana near the time of delivery. She also had exposure to opiates early and possibly later in pregnancy. The exposure to opiates places Baby S at risk for Neonatal Abstinence Syndrome.



  1. On further questioning, Ms S provides further information that she continued to have back pain especially the last week before she delivered. She found some 10 mg oxycontin tablets and took one every morning and at bedtime to help reduce her pain. She also explained that she smoked marijuana “two or three times a week for nausea.” She did not communicate her use of oxycontin or marijuana to her counselors at Milagro. She does not know why her drug screens remained negative except for methadone at the end of her pregnancy. How does this information affect your plans for observing and caring for Baby S?

The recent use of daily oxycontin may place Baby S at risk of early symptoms of Neonatal Abstinence Syndrome. The presence of shorter acting opiates may result in more rapid declines in brain and serum levels in Baby S. The fall in levels correlates with the appearance of symptoms. At this time, you should refer to the Neonatal Abstinence Score sheet to understand the possible symptoms in the syndrome and to understand the scoring system to evaluate the severity of symptoms.


  1. The mother communicates with the nurses that she may have to go home tomorrow to take care of her other child. She wants to know if the baby will be ready to leave. How long should the baby stay in the hospital?

Based on the work of Finnegan at Jefferson Memorial Hospital in Philadelphia, 90% of infants that will have Neonatal Abstinence Syndrome and require pharmacologic treatment manifest symptoms in 96 hours. The experienced nursing staff has begun observing Baby S for symptoms and recording their findings on the bedside chart. At this time the baby has had scores of 3, 4 and 6.


  1. Ms S receives the information about Baby S having Neonatal Abstinence Syndrome and after thinking on it agrees to stay for another day. She asks you to explain the syndrome. What do you tell her?

Neonatal Abstinence Syndrome occurs in babies who have prenatal exposure to opiates and methadone. The syndrome involves many body systems and presents with effects on the central nervous system, effects to the gastrointestinal system, and disturbances of the metabolic, respiratory, and vasomotor functions of the baby. The signs of the syndrome increase over time as the levels of opiates or methadone fall in the babies’ brain and serum. To manage the syndrome, the nursery and medical staff observe the baby carefully and assign scores for the severity of signs. They use the scores to determine how well the baby handles the syndrome’s effects and to determine what interventions to use.

The scores for babies who do not have the syndrome did not exceed 5 in the studies of Finnegan. Babies who had the syndrome scored above 5. With scores between 5 and 7, babies receive supportive care. With scores of 8 or higher three times consecutively or when three consecutive scores average 8 or higher, babies begin receiving pharmacologic treatment. Generally that means the babies receive methadone to treat the syndrome. Please see handout with methadone dosing schedule.
Symptoms found more in term infants

Severity of NAS possibly correlated with

Maternal methadone dosage

More rapid drop in umbilical cord methadone levels

Term infants had more NAS–related seizures

Symptoms present in 3 categories seen most in Neonatal Abstinence Syndrome

CNS disturbances

Excessive high pitched cry

Sleeps less than 2 hours after eating
Vasomotor, Respiratory, Metabolic disturbances

Moderate tremors, increased muscle tone

Sweating, skin mottling

Nasal Stuffiness

Fast breathing, more than 60 per minute
Gastrointestinal disturbances
Excessive sucking, problems eating

Loose stools
Premature infants have less NAS symptoms at first

Reduced symptoms in preterms may be from:

Immature development of brain dendritic ramifications,

Immature neurotransmitter function in brain,

Immaturity of specific opiate receptors

Reduced total drug exposure in pregnancy



Less muscle mass affecting neuromotor symptoms

Long term effects from exposure apparent with age


  1. She continues to express an interest in breastfeeding. What information do you need and what will you counsel?

Ms S states that she had a prenatal breastfeeding consult with the doctors in the

FOCUS Program. When you review the notes in her prenatal electronic medical record, you find a note from the eighth month of her pregnancy. The note confirms that Ms S has had a past addiction to oxycontin, that she has established prenatal care with Milagro, and that her toxicology screens to the date of the consult have shown positive only for methadone. The consult note goes on to state that the FOCUS Program medical team would support Ms S initiating breastfeeding if she and her baby have toxicology screens negative for all other substances besides methadone. The note recommends contact with the FOCUS team if the results show otherwise.

You contact the FOCUS team through the hospital social workers. The doctor remembers Ms S, listens to the report of the toxicology screens, and agrees to meet with Ms S to further discuss her interest. The plan might include clarification with Ms S that she cannot use additional oxycontin or use any marijuana and have support for breastfeeding. If she agrees that the passage of additional drugs to Baby S presents additional and unacceptable risk to the baby, the FOCUS team may recommend that Ms S pump and dump her colostrum and breastmilk until her urine quantitative drug toxicology screen becomes negative. At that time she might be able to initiate breastfeeding with support including frequent urine quantitative drug screens.


  1. Ms. S agrees to pump and dump her breastmilk and to provide daily urine quantitative drug screens until they become negative. Then she would plan to breastfeed. She wants to know if breastfeeding while taking methadone will delay Baby S’ treatment.

Initial transfer of methadone in colostrum and breastmilk is very hard to quantify but thought to transfer at a low level. Early literature suggested babies might successfully wean without treatment except breastfeeding by mothers receiving methadone treatment. However, the consistency of care and observation required seem too great a barrier to support newborn treatment with only methadone transferred by breastfeeding in the current standard of care. The clinical experience has not shown that breastfeeding has made the hospital stay longer in a very small series of babies.
Summary points for ideal management.

  • Develop plan in prenatal care at FOCUS clinic

  • Possible benefit to mother and baby in bonding

  • Presumed small quantity passes in breastmilk

  • Amounts may influence weaning protocol

  • Risk of delayed NAS with stopping of breastfeeding

  • Discourage breastfeeding if

  • Relapse to opiate use

  • Use of cocaine, methamphetamine

  • Long-term effects unknown




  1. Baby S observed to have signs associated with Neonatal Abstinence Syndrome. "How would you plan management of baby S if she has moderate NAS and what would be the goals of treatment? How would you plan management if she has more severe NAS and what would be the goals in this case?"


Treatment of Moderate Neonatal Abstinence Syndrome

Scores >5 but < 8, supportive care for moderate NAS.

Reduce stimuli

Swaddling

Pacifier


Treatment of More Severe Neonatal Abstinence Syndrome

Scores above threshold means more severe NAS, use medication

Long acting preferred; methadone

Short acting medications effective; however increased dosing and greater risk of medication error

Goals of treatment

Reduction in symptoms

Prevent dehydration from GI symptoms

Prevent increased CNS instability

Withdrawal has uncoordinated and ineffectual sucking reflex

Improve nutrition and maintain hydration

Stabilize sleep and wake cycles

Increase quiet-alert state

Not to sedate!

Methadone is best treatment for Neonatal Abstinence Syndrome

Starting methadone dose is 0.7 mg / kg

Divided in 6 doses for first 24 hours, loading model

Next 24 hours, given 1/2 dose every 4 hours

Weaning by lengthening interval between doses

Scores of < 8 = acceptable control

Poor control indicated when

Scores >= 8 three consecutive periods or

Mean >= 8 over three consecutive periods
Treatment stops progression of syndrome signs

Score sheet used to monitor treatment

Methadone adjusted based on scores

Scores more than 8 requires more methadone

Scores less than 8 means less methadone

Goal is to help babies become more alert

Reduce risk of higher scores

Intervene before severe symptoms like seizures occur

Goal is to help babies become more alert

Reduce risk of higher scores



Intervene before severe symptoms like seizures occur


  1. Now on Day 9 of life, Baby S has received treatment with methadone and Ms S successfully establishes breastfeeding. On day eight Baby S received a dose of methadone at 1700. The baby has had scores since then of 2, 3, 2, 4, 3, and 5. How do you decide when to stop treatment and what do you need to do to plan discharge?

As babies wean to every 24 hour treatment and scores remain low, usual protocol calls for observation for approximately 48 hours in the ICN3 off methadone with scores below 8 to clear Baby S for discharge.

Given that Ms S continues to breastfeed on a daily dose of 80 mg of methadone, the medical care of the baby calls for an outpatient appointment with the FOCUS Program in the next seven days for follow up. Also, the social worker in the ICN3 has made a referral to FOCUS for case management services. The FOCUS team has assigned a staff member to work with Ms S, and a meeting will occur in the ICN3 prior to discharge of Baby S.

The medical team following Baby S will see the mother and baby weekly to determine that the baby has adjusted well to being home. Ms S will provide a urine quantitative drug test at her weekly visits. The goal will be to maintain breastfeeding through the first six months of life so that with good growth the dose of methadone passed to the baby drops relative to the baby’s weight and that the amount of breastmilk received by the baby decreases with introduction of solid foods. Ms S agrees to the discharge plan.

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