#17: Neonatal Abstinence Syndrome – Treat it Right NOWS

January 20, 2021 | By Justin Berk

Summary

 Did you know that NOWS is the new NAS? Learn more about the new AAP Clinical Report on Neonatal Opioid Withdrawal Syndrome with lead author Dr. Stephen Patrick. Dr. Patrick is the Director of the Vanderbilt Center for Child Health Policy, an Associate Professor of Pediatrics and Health Policy, and an attending neonatologist at Monroe Carol Jr. Children’s Hospital at Vanderbilt. In this episode, he teaches us about the approach to treating withdrawal in infants, the importance of keeping moms and babies together, and the need for destigmatizing addiction in healthcare. 

Credits

• Producer, Writer, and Infographic: Jessica Hane, MD
• Cover Art: Chris Chiu, MD
• Hosts: Justin Berk MD; Chris Chiu, MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest: Stephen Patrick, MD

Neonatal Opioid Withdrawal Pearls

1. Neonatal opioid withdrawal syndrome (NOWS) describes the condition of infants who are withdrawing from opioids and is more specific than the older term neonatal abstinence syndrome.
2. Among infants exposed to opioids, risk factors for withdrawal include being a term infant, male, and exposure to opioids with a longer half life.  
3. Hospitals should use a standardized scoring system for NOWS. 
4. The type of medication used to treat NOWS is probably less important than the non-pharmacologic management strategies, especially keeping mom and baby together.
5. Infants can and should be cared for outside of the NICU and often do better in a quiet environment with mom.
6. The new AAP Clinical Report on NOWS is focused on a more holistic approach to the mother-baby dyad.

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Diagnosis

Dr. Patrick discusses the term Neonatal Opioid Withdrawal Syndrome and provides an approach to caring for infants with NOWS.

Definitions

The AAP recently released a new Clinical Report on Neonatal Opioid Withdrawal Syndrome. The term neonatal opioid withdrawal syndrome (NOWS) is currently being used by the AAP and federal agencies including the FDA as it more specifically describes the condition of withdrawal from opioids. Neonatal Abstinence Syndrome is a more general term that includes non-opioid exposures such as nicotine and benzodiazepines.

Epidemiology

• The rates of opioid use disorder in pregnancy grew significantly from 1999-2014 and rural communities were disproportionately affected. 
• Between 2011-2017, the child welfare system reported an increase of greater than 10,000 infants in foster care mostly due to concerns about parental substance use. 

Social Determinants of Health

• Families of infants with opioid exposure are more likely to  experience social and economic challenges. Additionally, they are often involved with the child welfare system. (AAP Clinical Report on Neonatal Opioid Withdrawal Syndrome) 
• Among pregnant women with opioid use disorder, there are racial disparities in who has access to medications for treatment of opioid use disorder. (Schiff et al., 2020)
• The stigma associated with addiction is a barrier for people getting into treatment. 
• Language matters. Infants are not born addicted! 
• One study showed that despite similar rates of substance abuse among Black and White women, Black women were reported to the child welfare system at approximately 10 times the rate of White women. (Chasnoff, Landress, & Barrett, 1990)

Clinical Presentation

If mom has a history of opioid use, you should consider Neonatal Opioid Withdrawal Syndrome. Infants typically have gastrointestinal and/or CNS symptoms including poor weight gain, dehydration, loose stools, tremors, and increased muscle tone. The clinical presentation will vary based on opioid type and what other substances are involved. The onset of symptoms can begin at birth or up to several days of age depending on the half life of the opioid involved.

Among infants exposed to opioids, risk factors for withdrawal include being a term infant, male, and exposure to opioids with a longer half life. Interestingly, premature infants are less likely to experience withdrawal.

Work-up and Diagnosis 

Infant toxicology testing should be completed only if it will inform clinical management. If we know a mother is on buprenorphine for her OUD and doing well, a urine drug screen is probably not needed. If infant toxicology testing is indicated, a urine, meconium or umbilical cord tissue sample can be collected. 

Withdrawal is a diagnosis of exclusion. It is important to consider sepsis and hypoglycemia. The diagnosis is made based on a combination of history and clinical presentation. 

Scoring Systems for NOWS

It is important to have a standardized scoring system. There are many different scoring systems for NOWS but two of the most common are the Modified Finnegan Score and Eat, Sleep, Console. These tools have not been validated on preterm infants. The AAP does not endorse one tool over another.

Management

Non-Pharmacologic Management

The best intervention is keeping mom and baby together. Additionally, pediatricians should encourage breastfeeding and provide mom with lactation support. Infants with NOWS should not go to the NICU unless there is another concern as they do better in a quiet environment with mom. 

Breastfeeding

Women in recovery should be encouraged to breastfeed given the health benefits and bonding. Additionally, infants often experience less severe withdrawal when breastfeeding.  There is no clear recommendation regarding contraindications to breastfeeding in the setting of a mother with opioid use disorder.. Many institutions recommend formula feeding over breastfeeding if the mother has had a relapse in the last 30 days.

Supporting Mothers

It is important that women are provided adequate treatment for opioid use disorder.  Treating pregnant women for OUD with buprenorphine or methadone makes it much more likely that the infant will make it to term. Additionally, treatment for OUD reduces the risk of relapse, overdose, Hepatitis C and HIV.

Pharmacologic Management

There is a role for pharmacologic treatment for severe withdrawal in infants. Each scoring system has an objective threshold for starting treatment. On the Modified Finnegan Score, pharmacologic treatment should be considered after 2 scores of 8 or one score of 12. The most commonly used treatment is morphine, though recent studies show that buprenorphine and methadone may result in a shorter duration of treatment and length of hospital stay. If non-pharmacologic measures are optimized and the infant is on a primary agent such as morphine, it is rare to need a secondary medication such as clonidine and phenobarbital. There are many different methods of tapering medications, but if the baby is doing well, it is reasonable to reduce the medication by 20% per day. There is not a standardized weaning protocol. 

Discharge 

The AAP recommends an observation period of 3-7 days for any infant born to a mother using opioids or on medications to treat opioid use disorder. If neonates require pharmacologic therapy, they should be monitored for an additional 24-48 hours after finishing the wean. Parents should receive counseling on when to seek care if an infant shows signs of ongoing withdrawal and safe sleep practices. 

Follow-up

Families should have a home nurse visit and follow up with a pediatrician within 48 hours of discharge from the hospital. Outpatient pediatricians should monitor weight gain and look for any signs of ongoing withdrawal in addition to typical newborn care. Infants with opioid exposure should be referred to early intervention services and be evaluated for hepatitis C exposure. Pediatricians should also make sure that the infant’s mother is monitored for postpartum depression and is receiving adequate support for her opioid use disorder.

There may be some speech and attention difficulties as a long term consequence of neonatal opioid use disorder, however, more research is needed in this area. Additionally, the current data is confounded by other developmental risk factors including concomitant alcohol use, food insecurity and poverty.

Other Stuff

Advocacy Opportunities at the AAP

Interested in learning more about policy related to the opioid crisis and  neonatal opioid withdrawal syndrome? Click here.

Citations

1.     Data and Statistics About Opioid Use During Pregnancy. https://www.cdc.gov/pregnancy/opioids/data.html. Accessed December 26, 2020.
2.     Patrick SW, Frank RG, McNeer E, Stein BD. Improving the Child Welfare System to Respond to the Needs of Substance-Exposed Infants. Hosp Pediatr.
3.     Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA – J Am Med Assoc. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951
4.     Patrick SW, Barfield WD, Poindexter BB. CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Neonatal Opioid Withdrawal Syndrome. doi:10.1542/peds.2020-029074

Links

1. When Breath Becomes Air by Paul Kalanithi
2. Juniper by Kelley French
3. Yellowstone (TV Show)
4. Infographics from The Center for Child Health Policy at Vanderbilt University

Disclosures

Dr. Patrick reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Hane J, Patrick S, Chui C, Berk J. “Neonatal Opioid Withdrawal Syndrome: Eat, Sleep, Console, Repeat”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ Final publishing date, January 2020.