Neonatal Abstinence Syndrome: Taking Care of Mom and Baby Heather Rodman, PharmD PGY-2 Pediatric Pharmacy Resident Peyton Manning Children’s Hospital St. Vincent Hospital and Health Services September 2014 This speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.
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Neonatal Abstinence Syndrome: Taking Care of Mom and Baby Heather Rodman, PharmD PGY-2 Pediatric Pharmacy Resident Peyton Manning Children’s Hospital St.
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Neonatal Abstinence Syndrome: Taking Care of Mom and Baby
Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.
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TAKING CARE OF MOM
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Prenatal Care
• Enrollment in an opioid maintenance program• Minimizes cravings and optimizes maternal health• Prevents fetal stress and suppresses withdrawal• Anticipatory neonatal withdrawal
• Methadone is most commonly chosen• Buprenorphine may shorten treatment duration and hospital stay of the neonate• Increased dropout rate with buprenorphine
• Increased doses may be required during 3rd trimester
Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.Jones HE, et al. NEJM. Dec 2010; 363(24): 2320-2331.
• United States Recovery• List of support groups and treatment centers by state• http://www.usrecovery.info/index.htm
• National Institute on Drug Abuse (NIH)• Resources for professionals, patients, and families• http://www.drugabuse.gov/
• National Council on Alcoholism and Drug Dependence• http://ncadd.org/index.php
• American Congress of Obstetricians and Gynecologists (ACOG)• http://www.acog.org/Patients/FAQs/Tobacco-Alcohol-Drugs-and-Pregnancy
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TAKING CARE OF THE NEONATE
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Non-Pharmacologic Measures
• Dark, quiet environment• Swaddling and comforting techniques• Swaying, rocking• Skin-to-skin contact (parents only)• Music therapy
• Small but frequent feedings• Breast feeding approved by AAP• Contraindications: HIV (+) • Relative contraindications: Hepatitis C (+), heroin, cocaine, alcohol abuse
• Family education
Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.
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Pharmacologic Treatment Options
Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36.Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856.Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165.Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.
Dosing not established Requires additional studies
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Langenfeld S, et al. Drug Alcohol Depend. 2005; 77(1): 31-36.Agthe AG, et al. Pediatrics. May 2009; 123(5): e849-e856.Kraft WK, et al. Pediatr Clin N Am. 2012; 59: 1147-1165.Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.
Adjuvant Therapy
Drug Neonatal Dosing (oral) Comments
Phenobarbital Load: 16 mg/kg day 1Maintenance: 1-4 mg/kg/dose
Q12HWean by: 20% every other day
Fallen out of favor due to cognitive
behavioral effects
Clonidine ≥ 35 week gestation: 0.5-1 mcg/kg Q4-6H
Weaning not established
Not as well studied as
phenobarbital
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Long-Term Outcomes
• Difficult to evaluate• Confounding variables
• Withdrawal seizures respond to opiates and do not necessarily carry an increased risk of poor outcomes
• Neurocognitive delays possible during infancy• Working memory updating - Resolved at ~ 7 months• Regulation and quality of movement• Excitability• Delay in milestones: Independent sitting, crawling
Hudak, ML, et al. Pediatrics. 2012; 129: e540-e560.Sutter MB, et al. Obstet Gynecol Clin N Am. 2014; 41: 317-334.Logan BA, et al. Clin Obstet Gynecol. March 2013; 56(1): 186-192.
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Take Home Points
• Pregnant women on methadone may require higher doses during pregnancy
• Buprenorphine is now considered a safe, alternative option for pregnant women enrolled in an opioid maintenance program
• Breastfeeding is beneficial for NAS even while the mom is still enrolled in the maintenance program
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Assessment Question
• During which trimester is a pregnant woman most likely to require her highest dose of methadone?A. 1st TrimesterB. 2nd TrimesterC. 3rd Trimester