Neonatal Abstinence Syndrome (NAS)

Neonatal Abstinence Syndrome (NAS)

• A spectrum of clinical manifestations seen in neonates due to withdrawal, secondary to intrauterine drug/substance exposure

• Multisystem disorder resulting from infant’s abrupt cessation of exposure to a substance used or abused by mother during pregnancy

• Clinical presentation: CNS, GI, Respiratory, and autonomic manifestations

NOWS

Neonatal Opioid Withdrawal Syndrome

• A subset of NAS, specifically referring to withdrawal symptoms caused by opioid exposure during utero

• Surge in opioid use disorder (OUD) specifically in pregnancy

• Untreated OUD in pregnant women can cause overdosing, fetal loss, and preterm birth

NAS Pathophysiology & Etiology

• Neonatal & maternal factors

• Maternal-fetal-placental pharmacokinetics

• Gestational age, gender, genetics, maternal substance abuse

• Several drugs for etiology in research – *Opioids = most common illicit drug

• Synthetic opioids: hydrocodone, oxycodone, fentanyl, methadone, buprenorphine, morphine, codeine, heroine

• Psychiatric medication: SSRIs/SNRIs, antipsychotics

• Polysubstance: cannabis – most commonly abused substance in pregnancy

• Other substances: benzodiazepines, nicotine, alcohol, methamphetamine

NAS Evaluation and Testing

Urine

• May be identified in infant’s urine between 2-4 days (may not be recognized in time for discharge)

• Longer delay, more chance of false-negatives

Meconium

• Can identify exposure back to 20 weeks gestation

• Most sensitive *

• Cord blood

• Less sensitive, more practical difficulties in collection

NAS Clinical Signs & Symptoms

• Withdrawal symptoms typically start 48-72 hours after birth lasting 1 week - 6 months

• Extent of symptoms, time of onset, & duration depend on type of substance(s), duration of use, frequency of use, route of administration, and gestational age at time of exposure

Central Nervous System (CNS) NAS Symptoms

hyperirritability, high-pitched cry, jitteriness, tremors (disturbed & undisturbed), increased muscle tone, exaggerated Moro reflex, myoclonic jerks, seizures, disturbed sleep pattern

Gastrointestinal NAS Symptoms

poor feeding, diarrhea or loose stool, emesis, weight loss, failure to thrive

Respiratory NAS Symptoms

Metabolic & Vasomotor:

nasal congestion, nasal flaring, frequent yawning, sneezing, mottling, sweating, retractions, apnea, tachypnea, increased WOB, sweating, temp > 37.5C

Nursing Assessment for NAS

• Maternal history

• Symptoms of withdrawal begin within 72 hours after birth

• Toxicology screening of birth parent (if able) and newborn’s blood, urine, and meconium

• Newborn behaviors - WITHDRAWAL assessment

Withdrawal Assessment

• W—Wakefulness

• I – Irritability

• T – Tremors

• H – hyperactivity, high-pitched cry, hypertonus

• D – diarrhea, diaphoresis, disorganized suck

• R – respiratory distress, rub marks, rhinorrhea

• A – apneic attacks, autonomic dysfunction

• W - weight loss

• A – alkalosis (respiratory)

• L - lacrimation

Finnegan Neonatal Abstinence Scoring System (FNASS)

assess the severity of drug withdrawal symptoms, primarily opioids, in newborns

Eat, Sleep, Console (ESC)

assess an infant’s ability to eat, sleep, and be consoled to determine when neonatal abstinence syndrome requires pharmalogical management

Nursing Management of NAS

• Assessment and management of complications includes assessment, risk factors, and collaborative care

• Immediately identify symptoms and implement appropriate interventions

• Eat, Sleep, Console scoring system that assesses for symptoms and helps to determine treatment

• Daily weight, I & Os; fluid and electrolyte balance, hydration

Non-Pharmacologic Treatments

Maximize non-pharmacologic interventions 1st line of treatment

• Decrease environmental stimuli (lights, noise, movement)

• Swaddle tight, hold infant firmly to contain

• Cluster care *

• Adequate hydration and nutrition; encourage breastfeeding (feed on demand)

• Consider high calorie formula / fortifiers

• Pacifier for non-nutritive sucking

• Avoid over-feeding in response to frequent crying

• Decrease stimuli during feeds

• Assess suck/swallow/breathe (SSB) coordination

• Risk for skin breakdown: Barrier cream or Duoderm/Mepilex if needed

• Encouragement for family involvement in care (skin to skin contact!)

Pharmacologic Treatment

Confirmed drug exposure accompanied by:

• Poor feeding, disturbed sleep patterns, fever unrelated to infection, seizures, diarrhea and vomiting

• Meeting or exceeding the scoring parameters of scale used (Finnegan Scoring or Eat, Sleep, Console)

most commonly used—morphine (short-acting)

Parental/caregiver teaching

• Parent- newborn interaction may be difficult due to NOWS s/s, can lead to detachment, avoidance

• Parent support – may be a victim of abuse; had poor parenting themselves; lack knowledge infant development; unrealistic expectations

• TEACH – newborn care; promote secure relationships and effective parenting skills

• REFER – parent to social services; parent to treatment programs; infant to early interventions

Long-term Outcomes

Association between infants with prenatal opioid exposure and poor long-term outcomes

Evidence of changes in:

• Neurodevelopment

• Cognition

• School performance

• Behavior

• Vision

• Increased morbidity/mortality in infants

ADHD treatment isn’t effective

Fetal Alcohol Spectrum Disorders (FASDs)

Range of preventable conditions, birth defects, and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure (AAP, 2020)

Umbrella term that includes:

• Fetal Alcohol Syndrome (FAS)

• Alcohol-related Neurodevelopment Disorder (ARND)

• Alcohol-Related Birth Defects (ARBD)

• Leading cause of non-genetic intellectual disability in the United States

• Affects 1 in 100 infants

• Growth restriction (prenatal and postnatal), craniofacial structural abnormalities, and CNS dysfunction – these three findings were called Fetal Alcohol Syndrome (FAS)

(FASDs) Cause

• Fetus is exposed to same blood level as mother

• Alcohol is a teratogen – no amount is safe!!

Fetal Alcohol Syndrome (FAS) Clinical Manifestations

Growth restriction (pre/postnatal)

• height and/or weight below 10th percentile

Craniofacial structural anomalies

• microcephaly

• abnormally small eyes

• thin upper lip

• receding jaw

• short nose

CNS abnormalities

• structural

• neurologic

• functional