In this lecture, we’re going to discuss
the neonatal abstinence syndrome.
So basically, in utero drug exposure
in U.S. pregnant women is very high.
4% percent of pregnant
women use illicit drugs,
11% percent use alcohol, 4%
percent admit to binge drinking,
and 16% percent
We have a problem in the United
States with pregnant women
ingesting substances that are
inherently bad for infants.
Especially on the rise is
illicit use of opiates.
And that epidemic in the United
States is causing a wide outbreak
of infants with neonatal
Let’s look through the illicit drugs
in pregnancy and what they do.
Marijuana is generally fairly
safe compared to the others.
There are no fetal growth effects
of smoking marijuana in utero.
Cocaine and methamphetamine
can cause prematurity.
They can make infants
small for gestational age
and they can give infants IVH
or bleeds inside their head.
Heroine can cause stillbirth.
It can make infants small
for gestational age.
It can result in SIDS or
sudden infant death syndrome
and it can create neonatal
which we’re going to spend the
bulk of this conversation on.
So let’s talk about neonatal
This is a nonspecific CNS and
autonomic nervous dysfunction.
It’s a result of in utero
exposure to opiates.
And then abrupt cessation at delivery.
It’s like making a newborn
go through withdrawal.
The symptoms typically begin
one to two days after birth.
So here is the list of some of the symptoms
we have to contend with in these infants.
They have vomiting, the have diarrhea, they
have uncoordinated and inconstant suck.
Or they suck very frequently,
but it’s uncoordinated so they aren’t
getting the breast mild they need.
Thus, they may have poor wait gain.
They get irritability,
jitteriness, a shrill cry.
They may have hypertonia or have myoclonic
jerks or they may frankly seize.
Additionally, they can develop fever,
which is perhaps the
most annoying part of it
because the fever can be
misinterpreted as an infection
and then create an
entire rule out sepsis.
They may have sweating, they may have
tachycardia, they may have tachypnea
and one classic thing
is nasal stuffiness.
So if we see an infant where we suspect
withdrawal, we will do a score.
There are several
scores out there
and the score that’s used in your center is
probably the best one for you to be using.
The Finnegan score, the Lipsitz
score, the neonatal withdrawal index.
I suspect the Finnegan is
probably the most popular.
So if you look at Finnegan,
there are literally eighteen different
symptoms that usually a nurse will score.
For example, they’ll score how
much nasal stuffiness they have
and that will give
them a point or two.
Or they might say something
about how bad is the diarrhea
or how bad is the vomiting and
it’s basically 18 points.
They take the points and then they add
them all up and that gives them a score.
You will not on an exam be asked to
recapitulate one of these scoring systems
or to calculate a score in an infant,
but you will definitely need to know
that these scores are what we are using
to track improvement or to make
a diagnosis in the first place.
We’re going to use these scores
to have us decide exactly how
much we should dose the infant
in terms of the morphine we’re going
to be giving this infant back
and then we’ll use them also to track
our gradual withdrawal of the morphine
to see when they’re safe
to be weaned further.
So we also do
There are a lot of things we can do
to these infants who are very fussy
to make them feel better and
feeling better is important.
This infant didn’t ask to
go through withdrawal.
So swaddling is critical.
These kids loved to swaddled
and we should do it.
Rock them, not in a swing-like this.
I mean one of those little baby
swings that goes back and forth.
We should avoid excessive sensory
or environmental stimulation.
So for example, we shouldn’t have
them too irritated or bothered.
Don’t let all the friends and the
family come in and examine the child.
We should minimize their
and just keep them in a
warm, comfortable place.
stability is important
because these infants can
get cold very quickly.
Also, remember, feeds are comforting.
So we want to breastfeed if possible,
keeping in mind that excessive
sucking is often non-nutritive.
It doesn’t mean the child’s hungry, it’s
just part of their symptoms of withdrawal.
So what do we do with the medications?
Well, the key is morphine.
And what we’ll do is we’ll put
them on morphine to the point
where they’re at an
appropriate Finnegan’s score.
Then we will engage in a gradual
wean by about 10% per day.
Slowly bringing them down to a
point where now they can come off
and everything will be fine.
If the infant has a higher score,
we will give a breakthrough dose
and if that happens a lot, we
may bump up the daily dose
so we can keep them
on a controlled wean.
Many people use phenobarbital.
This is an additional therapy
for polysubstance exposure
or in combination with morphine,
for an infant that’s having a hard
time coming off the morphine.
Another key thing is treating
the mother for addiction.
Remember that opiates in mom get into the
breastmilk and they complicate the picture.
Also, an addicted mother may have
problems in terms of raising that child
and she may need more help to help her
get off this very addictive substance.
So that’s a critical part of
caring for these infants.
So that’s my review of neonatal
abstinence syndrome in children.
Thanks for your time.