Special Topics in Pain: Opioids

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Neonatal Abstinence Syndrome

Author(s): McQueen K, et al.
Journal: N Engl J Med. 2016; 375:2468-2479. 95 references.
Reprint: Karen McQueen, RN, PhD, Lakehead University School of Nursing, 955 Oliver Rd., Thunder Bay, ON P7B 5E1, Canada. Email: kmcqueen@lakeheadu.ca
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: Neonatal abstinence syndrome is an increasing problem being dealt with by standard protocols. A few unexpected factors which help are breast feeding and in-room location of the baby.

Class: Pharmacology: opioids

Special group: Neonatal Abstinence Syndrome

Neonatal abstinence syndrome refers to a postnatal opioid withdrawal syndrome that can occur in 55% to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant. The clinical manifestations of the syndrome vary, ranging from mild tremors and irritability to fever, excessive weight loss, and seizures. These infants with neonatal abstinence syndrome are at risk for admission to the neonatal intensive care unit, birth complications, the need for pharmacologic treatment, and prolonged hospital stay with separation of mother and infant during a critical time for infant development and bonding.

Primary-prevention strategies are needed, such as targeted initiatives to address prescribing practices to help reduce opioid use in women of childbearing age and prevent the subsequent development of the neonatal abstinence syndrome as well as treatment programs specifically designed for pregnant women. Punitive legislation for women using substances during pregnancy should be discouraged, since negative consequences of disclosing substance use may prevent women from seeking prenatal care.

Identification of infants at risk is important to ensure accurate clinical assessment, promote early intervention, and mitigate signs of withdrawal in the newborn. In addition to self-report of the mothers, biologic testing of the woman or newborn can ensure accurate assessment of substance exposure and can guide treatment. There are several tools available to aid assessment of newborns for the syndrome. These include The Finnegan Neonatal Abstinence Scoring Tool (either in original or modified form) and the MMOTHER NAS Scale. The specific psychometric properties of these two tools have been published. There are other tools available but additional tools are needed.

The primary concerns regarding management of the neonatal abstinence syndrome are to promote normal growth and development and to avert or minimize negative outcomes, including discomfort and seizures in the infant and impaired maternal bonding. Ideally, care should be multidisciplinary, collaborative, nonjudgmental, and based on the identified needs of the infant-mother dyad so that care of the infant does not occur in isolation from the mother.

Adequate nutrition to minimize weight loss should be part of the initial therapy as well as creating a gentle, soothing environment with minimal stimulation in an effort to calm and soothe the infant. Studies have consistently shown that infants with the neonatal abstinence syndrome who are breast-fed tend to have less severe symptoms, require less pharmacologic treatment, and have shorter length of stay than formula-fed infants. Infants who stay in the room with their mothers have a shorter hospital stay and duration of therapy and are more likely to be discharged home with their mothers. Rooming-in has also been associated with improved breast-feeding outcomes, enhanced maternal satisfaction, and greater maternal involvement. Barriers to these actions include difficulties with infant feeding, separation of the newborn from the mother for special care, and lack of encouragement from health care providers.

The main objective of pharmacologic treatment is to relieve moderate-to-severe signs such as seizures, fever and weight loss or dehydration. Despite the importance of pharmacologic treatment, there is no universally accepted standard of care and variations exist regarding the use of doses based on weight or symptoms, as well as the threshold for initiating treatment, starting doses, weaning protocols and adjunctive medication.

Current consensus is that first-line pharmacotherapy consists of opioid replacement with either oral morphine solution or methadone. Recent evidence suggests that the use of a standardized protocol for pharmacologic treatment of the neonatal abstinence syndrome may be more important than the choice of drugs. Emerging evidence exists regarding the effects of sublingual buprenorphine to treat infants who have the neonatal abstinence syndrome. Buprenorphine, a partial agonist, has been associated with significant reductions in the duration of treatment (23 days vs. 38 days) and hospitalization (32 days vs. 42 days).

The majority of infants receive inpatient treatment, but in some cases, a combination of inpatient and outpatient treatment may be used. Although outpatient weaning shortens the hospital stay and reduces the financial burden on the health care system, infants often have a longer duration of treatment because weaning is typically less aggressive in the outpatient setting.

Important Points:
Recent innovations in management of the neonatal abstinence syndrome include standardized protocols for treatment, which have positive effects on important outcomes such as the duration of opioid treatment, length of the hospital stay, and the use of adjunctive drugs. In addition, evidence from pharmacokinetic models supports the development of empirically based dosing protocols. Breast-feeding and rooming-in are promising non-pharmacologic strategies that may also improve outcomes for infants and mothers, including maternal satisfaction with and involvement in the care of the newborn. However, there are barriers to the implementation of these practices Rigorous research is needed for evidence supporting the development of protocols, including validated standardized assessment tools and evidence based guidelines for non-pharmacologic and pharmacologic treatment.

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