Purpose and Goal: CNEP # 2050

  • Understand the effects of maternal opioid use on the neonate.
  • Learn about the long-term outcomes for infants exposed to opioids.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for Successful Completion

  • Successfully complete the post-test
  • Complete the evaluation form

Date

  • December 2016 – December 2018

Learning Objectives

  • Describe the characteristics of neonatal abstinence syndrome (NAS).
  • Describe the long-term effects of in utero opioid exposure on the neonate.

Introduction

  • The incidence of opioid use has increased
    • Maternal opioid use has increased
      • Illicit drug use
      • Prescription drug use
       
    • Fetal drug exposure has increased
     
  • The incidence of NAS has also increased
  • Every hour in the US, an infant is born with NAS
    • >10,000 babies are born with NAS every year
     
  • Infants with NAS may require long-term support

Neonatal Abstinence Syndrome

  • NAS is a variable and complex disorder
  • It is seen in infants exposed to opioids in utero
    • Heroin
    • Fentanyl
    • Morphine
    • Codeine
    • Methadone
    • Buprenorphine
    • Hydromorphone
     
  • It can also be seen with other substances
    • SSRIs
    • Nicotine
    • Benzodiazepines
     
  • NAS describes a spectrum of signs and symptoms
    • Symptoms of behavioral disorganization
      • State control and attention
      • Motor and tone control
      • Sensory integration
      • Autonomic functioning
       
     
  • 75-90% of exposed babies develop NAS
  • The number of babies requiring treatment
    • Varies between 42-94%
    • ~27/1000 NICU admissions
    • Median length of stay 13-19 days
     

Clinical Manifestations of NAS

  • The onset of NAS is widely variable
  • The presentation can also be widely variable
    • The variability is poorly understood
     
  • This is likely due to several factors
    • Maternal exposures
      • Substances used
      • Polysubstance use
      • Psychotropic drug use
      • Timing of exposures
      • Frequency and dose of drugs
       
    • Maternal factors
      •  Stress
      • Nutrition
      • Infections
       
    • Placental opioid metabolism
    • Genetics and Epigenetics
    • Infant factors
      • Infections
      • Preterm birth
      • Metabolic rate
       
    • Environmental factors
      • Physical environment
       
     

Clinical Presentation of NAS

  • The characteristic signs of NAS include:
    • Tremors
    • Irritability
    • Tachypnea
    • High-pitched cry
    • Sleep disturbances
    • Hyperactive reflexes
    • Hypertonic muscle tone
    • Skin excoriation
    • Feeding difficulties
    • Gastrointestinal disturbances
      • Vomiting
      • Loose stools
       
    • Autonomic dysfunction
      • Sweating
      • Sneezing
      • Mottling
      • Fever
      • Nasal stuffiness
      • Yawning
       
    • Failure to thrive
    • Other findings in NAS include:
      • Small for gestational age
      • Respiratory complications
      • Abnormal EEG changes
        • Reported in >30%
         
       
    • Seizure activity
      • Reported in 2-11%
       
     

Long-Term Outcomes in NAS

  • Long-term studies are challenging
    • Chronic stress
    • Family instability
    • Mistrust of healthcare
    • Inconsistent caregiving
    • Out-of-home placements
     
  • There is evidence NAS has a long-term impact
  • Several studies report long-term outcomes
    • Behavioral problems are common
    • Developmental problems are common
     
  • Specific long-term problems include:
    • Otitis media
    • Vision problems
    • Motor development problems
    • Behavioral and cognitive problems
    • Child abuse and neglect
    • Risk of future drug use
    • Risk of SIDS or SUID
     
  • Infants raised by drug using caregivers
    • Have poor outcomes
     
  • Infants raised by non-drug using caregivers
    • Have improved outcomes
     
  • Environmental risks magnify weaknesses caused by exposure
  • Referral for early intervention and support is important

Specific Long-Term Problems

  • Otitis media problems
    • Otitis media is common with methadone
    • Severe or chronic otitis media:
      • Hearing disabilities
      • Developmental disabilities
      • Learning disabilities
       
    • Recurrent otitis media:
      • Hearing loss
      • Language delays
       
     
  • Vision problems
    • There is growing evidence about impairment
    • Vision problem include:
      • Strabismus
      • Nystagmus
      • Reduced acuity
      • Refractive errors
      • Cerebral impairment
       
    • Overall visual development is delayed
     
  • Motor problems
    • There is inconsistent evidence about development
    • Methadone exposed infants tend to develop normally
    • Buprenorphine exposed infants tend to be delayed
      • Significant motor skills delay
        • Impulsivity
        • Hyperactivity
         
      • Significant memory skills delay
        • Short attention spans
         
       
     
  • Behavioral and cognitive problems
    • Heroin exposed infants have poor development
      • Poor cognitive skills
      • Poor perceptual skills
      • Poor memory skills
       
    • Methadone exposed infants have ongoing problems
      • Hyperactivity
      • Poor verbal skills
      • Poor memory skills
      • Poor perceptual skills
       
    • Buprenorphine exposed infants have similar problems
      • Hyperactivity
      • Poor memory skills
       
     
  • Child abuse and neglect
    • Adverse childhood experiences can cause:
      • Obesity
      • Cardiovascular disease
      • Psychiatric illnesses
       
    • Genetic, social and environmental factors
      • Complex interplay of outcomes
       
    • Complex interpersonal trauma is common
      • Lack of responsiveness to infant
      • Unrealistic expectations of infant
      • Increased maternal aggression
      • Increased physical punishment
      • Intergenerational transmission
       
    • Intergenerational trauma is commonly seen
      • Distorted thought patterns
      • Poor parenting interactions
      • Poor self-esteem and sense of worth
      • Heightened sensitivity to drug triggers
       
    • The incidence of child abuse is tripled
      • With psychiatric illnesses
      • With drug using caregivers
      • With environmental stressors
       
    • Child Protective Services considers drug use
      • A primary factor in child abuse
      • A primary factor in child neglect
       
     
  • Risk of future drug use
    • Studies show higher rate of drug use
      • With tobacco exposure
      • With marijuana exposure
       
    • Studies have not shown these effects with opioids
    • Large longitudinal research studies are needed
     
  • Risk of SIDS or SUID
    • A few studies have shown an increase in SIDS
      • All SIDS deaths reported tobacco using mothers
       
    • More studies are needed before inferring an association
     

Summary

  • Maternal opioid use is an increasing problem
  • More infants are being born exposed to opioids
  • More infants are requiring hospitalization and treatment
  • The short-term effects of NAS are well documented
  • The long-term effects are becoming more well known
  • Early intervention and environmental stability are important
  • Parent education and support is crucial
  • Ongoing intervention can optimize outcomes

References

  1. Maguire, D.J., Taylor, S., Armstrong, K., Shaffer-Hudkins, E., Germain, A.M., Brookes, S.S., Cline, G.J. and Clark, L. 2016. Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome. Neonatal Network, 35 (2), p. 277-286.
  2. Vassoler, F.M., Byrnes, E.M. and Pierce, R.C. 2014. The Impact of Exposure to Addictive Drugs on Future Generations: Physiological and Behavioral Effects. Neuropharmacology, 76 (B), p. 269-275.
  3. Jansson, L.M. 2016. Neonatal Abstinence Syndrome. Up-To-Date

Evaluation

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