Medical ProgressCurrent Management of Neonatal Abstinence Syndrome Secondary to Intrauterine Opioid Exposure
Section snippets
Epidemiology of NAS
In a recent national survey, 18.3% of pregnant teens, 9% of pregnant women ages 18-25 years, and 5.9% of all pregnant women reported some illicit drug use.3 Opioids specifically are ubiquitous and the upsurge in use is contemporaneous with pain management standards set by the Joint Commission on Accreditation of Healthcare Organizations in 2001. Correspondingly, there has been a 5-fold increase in opioid use during pregnancy during the last decade, with a prevalence of 5.6 per 1000 hospital
Clinical Presentation of NAS
NAS manifestations are modulated by a combination of maternal and neonatal factors, including the opioid dose, frequency and timing before delivery, maternal pharmacokinetics (PK), placental metabolism, concurrent medications, and neonatal PK and pharmacogenomics. The clinical presentation of NAS reflects a greater abundance of opioid receptors in the nervous system and the gastrointestinal tract. These may exhibit as neurologic excitability (eg, tremors, irritability, increased muscle tone,
Assessment Tools for NAS
The Neonatal Intensive Care Unit Network Neurobehavioral Scale was developed for use in the neonatal intensive care unit to better understand the long-term implications of intrauterine exposure to opioids.17 Although the complexity of this comprehensive and sensitive research tool makes its routine use for clinical purposes impractical, it shows that opioid-exposed infants demonstrate high levels of dysregulated behavior and stress, it is predictive of worse neurodevelopmental outcome, and it
Management of Infants at Risk for NAS
The risk of withdrawal is variable and is related to the type of opioid, dose, and timing of exposure. The AAP recommends that infants exposed to shorter half-life drugs and who manifest no signs of withdrawal could be safely discharged after 3 days of observation, whereas it is reasonable to monitor infants exposed to drugs with a longer half-life, such as methadone, for a longer period of time (4-7 days).25 The authors' institutional policy calls for universal maternal drug screening during
Nonpharmacologic Treatment of NAS
Mothers participating in opioid-treatment programs should be encouraged to breastfeed their infants; active or recent illicit drug use is considered a contraindication to breastfeeding.26, 27 Breastfeeding has been associated with less severe symptoms of NAS and a reduced requirement for pharmacologic intervention.28, 29 In a recent study by Welle-Strand et al,30 this effect was found to be particularly prominent in a cohort of mother-infant dyads in which the mothers received methadone
Pharmacologic Treatment of NAS
Several medications, including paregoric, tincture of opium, phenobarbital, morphine, methadone, buprenorphine, and clonidine have been used to treat NAS. The AAP and Cochrane Reviews have concluded that opioids are ideal treatment for neonates exposed to opioids in utero.25, 35, 36 The treatment of choice is less clear for NAS secondary to exposure to substances other than opioids because of paucity of data as it relates to medications used to treat NAS and their PK, pharmacodynamics (PD), and
Adjunctive Pharmacologic Therapies
Despite best efforts to maintain monotherapy regimens, adjunctive pharmacologic agents often are required for infants who do not respond to first-line medications. Common indications for adjunctive therapy include poorly controlled signs of withdrawal despite optimizing the dose of a first-line treatment agent, a persistent inability to wean first-line treatment doses, or relapse of signs of NAS after withdrawal has been treated adequately.
Future Directions
Treatment of the maternal-infant dyad should be the goal. However, most facilities are not equipped to support the mother during the entire period of observation, and infants often are admitted to an intensive care unit after pharmacologic treatment is initiated. Regardless of the hospital set-up, few programs have the capability to adopt a more comprehensive model of care that includes sex-specific approaches to medical and mental health care; individual and group addiction treatment; advanced
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Cited by (0)
J.W. was supported by the National Institutes of Health (5T32HD069054). The authors declare no conflicts of interest.