Specialty focus: Pediatrics
The opioid epidemic and the newborn patient
by Jean K. Rex, MD
While the current opioid epidemic has had a devastating effect on the adult population, an increasing number of children have also become victims, especially infants. Recent studies have found that 14-28 percent of pregnant women filled a prescription for an opioid medication during their pregnancy[1,2]. The effect of ongoing opioid use can be hazardous to the pregnant mother and fetus, with complications including increased incidence of preterm birth, low birth weight and neonatal abstinence syndrome.
Neonatal abstinence syndrome (NAS) is a constellation of symptoms found in the newborn who was exposed to opioids in utero. It was first described by Hippocrates in the 5th century B.C., but became more clearly defined in the medical literature in the 1970s. Since the advent of the current opioid epidemic the rates of NAS have soared, increasing five-fold from 2000 to 2012[4,5]. By 2012 the rate of NAS was 5.8/1000 live births, and accounted for over $1.5 billion in hospital charges annually. While more recent data is not yet reported, the rates in the past five years have likely continued to grow.
Providers who care for newborns should pay close attention to the mother’s obstetrical chart for documentation of antenatal opioid use so that at-risk infants can be closely monitored for signs of NAS (see table). Symptoms of opioid withdrawal may not be apparent at birth, but usually emerge in the first four to five days of life, often necessitating a prolonged period of monitoring in the hospital after birth.
Mothers who combined opioids with sedative medications or those on high-dose methadone during pregnancy may have infants with delayed onset of symptoms taking up to two weeks before the withdrawal symptoms become apparent. There is a higher risk of NAS symptoms if the mother also had a concomitant history of tobacco or selective serotonin reuptake inhibitor use during pregnancy. Short-acting opioid preparations and longer cumulative opioid exposure are also related to increased incidence of NAS2.
Infants noted to be at risk for NAS should be monitored closely using a scoring system such as the modified Finnegan system, which includes recommendations for supportive care of the infant and possible medical intervention for infants with more severe symptoms of withdrawal. In-hospital management of these infants includes maternal urine toxicology screen, infant urine and meconium, or cord blood toxicology screens to help confirm the diagnosis.
Case Management consultants are vital in their roles of counseling families about the risks of opioid use to the whole family, providing resources to families affected by opioid use, and involving child protective services if needed, if there is a positive drug screen or the infant has symptoms of NAS.
For infants who show signs of NAS, there are several non-pharmacologic strategies to help relieve symptoms. Infants should be swaddled, kept in a dimly-lit and quiet room with minimal stimulation. In recent years many newborn nursery units have begun the practice of infants rooming-in with their mothers as much as possible. One study showed that parental presence at the bedside of infants with NAS symptoms led to significantly decreased NAS scores and shorter opioid treatment duration for those with more severe NAS scores.
Breastfeeding should be promoted for all infants with NAS, unless otherwise contraindicated in the mother, such as in the case of maternal HIV infection. In fact breastfeeding can help decrease NAS symptoms in infants and decrease the need for pharmacologic treatment of NAS. Even mothers who are undergoing treatment for opioid addiction, such as those on long-term methadone, can breastfeed their babies, as the low levels of methadone transmitted across the breastmilk may help alleviate withdrawal symptoms.
Infants with moderate to severe NAS scores may benefit from pharmacologic treatment to decrease the symptoms of withdrawal by providing a slow wean from the medication. Infants are typically treated with oral morphine or methadone, but some studies are emerging that suggest buprenorphine, often used in addicted pregnant women, may be efficacious for infants as well8. For infants with refractory symptoms, phenobarbitol or clonidine can be added to improve the effects of medication and shorten treatment duration. Infants on pharmacologic treatment should continue to be followed for symptoms of NAS once stable on treatment and while medications are weaned.
An infant can usually be discharged home once he or she is off medications without evidence of moderate to severe NAS symptoms for 48 hours, has achieved good oral intake of breastmilk or formula, has shown good weight gain, has been cleared by social services, and close follow up has been arranged. Occasionally infants are sent home to continue a medication wean with close supervision by the pediatric provider. The mean length of stay in the hospital for an infant on pharmacologic treatment is 23 days, a significant increase in hospitalization length and costs compared to the typical infant discharged between one and four days after birth.
The long-term prognosis for infants treated for NAS has not been studied extensively. Even with successful treatment mild symptoms may continue for up to four months3. Long-term effects include possible vision, motor, behavioral or attention problems, cognitive deficits and sleep disturbances9. The risk of hospital readmission is higher in infants treated for NAS, as are the chances of child abuse and neglect1. It is hoped that through a concerted public health effort to reduce the prevalence of opioids in our population, as well as the efforts of individual health care providers, we will soon see the numbers affected by opioid addiction decrease in the tiniest members of our communities.
1. Pryor JR, Maalouf FI, Krans EE, et al. The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care. Arch Dis Child Fetal Neonatal Ed 2017; 102: F183-F187.
2. Patrick SW, Dudley J, Martin PR, et al. Prescription opioid epidemic and infant outcomes. Pediatrics 2015; 135 (5): 842-850.
3. McNett W. Chapter 56: Neonatal abstinence syndrome. In: Zaoutis LB, Chiang VW, eds. Comprehensive Pediatric Hospital Medicine. Philadelphia: Mosby; 2007: 286-290.
4. Corr TE, Hollenbeak CS. The economic burden of neonatal abstinence syndrome in the United States. Addiction 2017; 112 (9):1590-1599.
5. Patrick SW, Davis MM, Lehman CU, et al. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009-2012. J Perinatol 2015; 35 (8): 650-655.
6. Howard MB, Schiff DM, Penwill N, et al. Impact of parental presence at infants’ bedside on neonatal abstinence syndrome. Hosp Pediatr 2017; 7 (2): 63-69.
7. Welle-Strand GK, Skurtveit S, Jansson LM, et al. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr 2013; 102 (11):1060-1066.
8. Kraft WK, Adeniyi-Jones SC, Chervoneva I, et al. Buprenorphine for the treatment of the neonatal abstinence syndrome. N Engl J Med 2017; 376: 2341-2348.
9. Maguire DJ, Taylor S, Armstrong K, et al. Long-term outcomes of infants with neonatal abstinence syndrome. Neonatal Netw 2016: 35 (5): 277-286.
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