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N E O N A T A L A B S T I N E N C E S Y N D R O M E Handling drug misuse in the
neonatal unit
Neonatal abstinence syndrome (NAS), a syndrome of newborn drug withdrawal, is increasing inincidence across the developed world. To optimally manage the infant with NAS an integratedmultidisciplinary approach is necessary, spanning the intrauterine and postnatal period. Such anapproach should incorporate screening for drugs of misuse, early involvement of communityservices, standardised scoring of NAS symptoms in the drug exposed infant, and the appropriatecommencement and monitoring of evidence-based pharmaceutical therapy.
Lesley Jackson
MD, MBChB, FRCPCH
Neonatal Abstinence Syndrome (NAS) City of Glasgow has a well-established,
integrated, multidisciplinary service for the uterine exposure to a variety of different consequences for the offspring. Short term chemical substances. These include the well caffeine and antidepressants1 (particularly The clinical presentation of NAS is varied selective serotonin reuptake inhibitors) can and affected infants exhibit non-specific features include irritability, jitters, poor persistent high-pitched crying. Seizures can Keywords
infants has been reported to vary between Key points
urban and socially deprived areas reporting Jackson, L. (2006) Handling drug misuse in
the neonatal unit. Infant 2(2): 64-67.
Scottish statistics on drug misuse reported 2. Scoring charts can be used to identify explore the methods used to identify cases the evidence underlying appropriate treat- 3. Since opiates are excreted in breast milk risen 10-fold over the last decade, such that Care Baby Unit (SCBU) are transferred for term consequences for these infants.
Screening for drugs of misuse in
clinical burden has clear implications for pregnancy
NAS, awareness of the local pattern of drug V O L U M E 2 I S S U E 2 2 0 0 6 infant
N E O N A T A L A B S T I N E N C E S Y N D R O M E meconium and thereafter can be detected.
This includes illicit drugs excreted by the scoring should occur relative to feeds (i.e. a extent of misuse during pregnancy and the liver into the biliary system and substances specific substances misused. These include recently fed baby). Scoring charts are not clinical use were developed for use within opiate withdrawal. Increasingly such charts clinical scenarios i.e. premature infants, infants exposed to other illicit substances 16 weeks’ gestation until term, giving a substances can be analysed in detail. The sensitivity and positive predictive value of Treatment of NAS
In-patient management
Despite the increasing clinical burden of antenatal clinics reported that 11-16% had NAS, clinical trial evidence is insufficient used at least one illicit substance by the also been examined for drug metabolites.
time of booking: cannabis misuse being the In the adult, hair grows at a rate of 10mm condition. In Glasgow, infants treated for deposited in the growing hair shaft, giving a wide time potential analytical window for additional morbidity, such as prematurity, history relative to biochemical screening the detection of substance misuse15. In the methodologies, identified that the actual incidence of drug misuse during pregnancy third trimester, but can often be sparse, which may limit analytical potential. Hair analysis in the newborn remains relatively infant, and often the mother, remains the an infant exposed to cocaine in utero. mother-infant bonding18,19. Breastfeeding extensively utilised, and relies on the ability metabolites of illicit substances in the urine to concentrations many times greater than Scoring charts
that detected through analysis of plasma.
assessing the infant with NAS, clinicians potential disadvantages10. Urinary screening management decisions. Scoring the clinical is necessary (FIGURE 1).
substance exposure pre-delivery, resulting have been used as treatments for NAS.
subdivided into two major classes: disease borns may pass little urine in the first 48 hours of life and urine collection bags, to treatment initiated. All scoring charts are facilitate sample collection, can produce observer variability and a recent national central nervous system suppressants which survey in the United States reported that first stool passed by a newborn infant, is clonidine, chloral hydrate, chlorpromazine, presently the ‘gold standard’ methodology used such a scoring chart16. A variety of opioids, opiates and phenobarbitone20.
scoring charts exist, from the simple to the treat NAS can be criticised for their lack of tool is a relatively simple validated method usefulness of meconium analysis11-13.
Theoretically, all substances that reach the to utilise validated scoring systems to allow infant VO L U M E 2 I S S U E 2 2 0 0 6
N E O N A T A L A B S T I N E N C E S Y N D R O M E Service, or can be replicated in the UnitedKingdom, remains to be determined.
Long term consequences of NAS
Few studies have followed drug-exposedchildren beyond the first few years of life,and confounding variables, such asenvironment and dysfunctional caregiversmake it extremely difficult to attribute anydifferences observed in ability to NAS perse. Detailed long term evaluation ofchildren exposed to drugs in utero isnecessary to determine whether cognitiveability, social interactions and schoolachievement are detrimentally affected,and to also determine whether specifictreatments for NAS have beneficial effects.
In addition, long term follow-up ofsubsequent growth and development,extending into health in adult life isdesperately needed. Of the few published FIGURE 1 A six week old baby with neonatal abstinence syndrome treated with Oramorph.
reports available Ornoy et al haveattempted to dissect whether differences in pharmaceutical therapy20-24. In addition, little published evidence exists on the long is important from an early stage to address ‘nature’ or ‘nurture’29. Children living term effects of any of these pharmaceutical child protection issues. Child protection NAS have been covered in detail in a recent edition of Infant and will not be further arithmetic skills and an increased incidence explored in this article30. All infants that could be discharged to a potentially ‘high against hepatitis B prior to discharge, with may have a role as a second-line treatment arrangements and referral pathways should Conclusion
single small study infers that combination PCR + for hepatitis C virus as well as other therapy to treat symptomatic cases of NAS.
considered domiciliary treatment of NAS.
and application of its observations to the therapy remains the first-line treatment, management of NAS would be premature.
criteria and a multidisciplinary approach.
decisions. A multidisciplinary approach is ceutical treatments for NAS at a high initial dose, thereafter titrating downwards once thought needs to be given to the possibility general practioners and health visitors is follow-up studies are required to further domiciliary NAS service observed a reduced guide the management of this increasingly duration of hospital stay with a conversely Preparation for hospital discharge
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