Neonatal Opioid Withdrawal Syndrome Protocol

Neonatal Opioid Withdrawal Syndrome (NOWS) Protocol

• NOWS refers to a group of symptoms in newborns due to opioid exposure (natural, synthetic or semi-synthetic) in utero.
• Opioid exposure can happen during pregnancy or postnatally, from opioid or sedative withdrawal in seriously ill infants.
• Major public health concern due to over-prescription, diversion, and illegal opioid use.
• Non-medical use of analgesics during pregnancy has risen by 31% since 2012.
• Heroin use in the US has increased dramatically in the last decade.
• Opioid use during pregnancy can lead to withdrawal symptoms in the infant.
• NOWS symptoms include agitation, nasal congestion, yawning, sweating, muscle cramps, diarrhea, nausea, vomiting, and depression.
• Tolerance develops with chronic opioid use, leading to higher required doses, and eventually dependence, with withdrawal upon cessation.
• Mechanisms behind opioid dependence and withdrawal include increased opioid metabolic breakdown, decreased neurotransmitter release, and down-regulation of opioid receptors.
• Opioid-dependent pregnant patients are typically treated with medication-assisted treatment (MAT) with opioid agonists (methadone, buprenorphine) combined with counseling.
• Methadone, a synthetic opioid, eliminates withdrawal symptoms, reduces cravings, and prevents fluctuating opioid levels in the fetus, leading to a longer pregnancy and better fetal growth.
• Buprenorphine, a partial opioid agonist, is also used and may result in a lower incidence of neonatal withdrawal versus methadone.
• Prenatal care is critical for opioid-dependent pregnant patients to address their psychological and social needs, particularly those who may experience domestic violence, have limited education, financial constraints, or relationship problems. They often have co-morbid psychiatric conditions, such as depression and bipolar disorder, and low self-esteem.
• Maternal exposure to hepatitis C, HIV, and hepatitis B is more prevalent amongst opioid-dependent patients due to needle sharing and unsafe sexual practices.

NOWS Clinical Presentation

• NOWS in newborns presents with hyperactivity in the central nervous system, vasomotor issues, and gastrointestinal signs.
• Onset timing varies depending on the type of opioid exposure.
• Infants exposed to short-acting opiates (e.g., heroin) typically show symptoms within 48-72 hours after birth, while those exposed to methadone or buprenorphine may show symptoms later, usually within the first 5 days.
• A standardized scoring system (Finnegan scoring system) assesses the severity of withdrawal symptoms.
• Newborn urine and meconium drug screens can aid in diagnosis.

NOWS Treatment

• Infants with NOWS should be assessed with a 0-7 severity scale.
• If scores are high, it may be a candidate for pharmacologic treatment.
• Treatment options include short-acting opioids (morphine), clonidine, and phenobarbital.
• Supportive care is a vital part of the management, including keeping the mother and baby together, decreased stimulation, swaddling, and frequent feedings.
• Naloxone should be avoided during infant resuscitation of opioid-dependent mothers. Breastfeeding is encouraged unless the mother is HIV positive or experiences ongoing illicit drug use.
• Mothers undergo discharge planning that addresses maternal substance abuse treatment, a safe environment, parenting support, and community support.
• Infants on long-acting opioids (methadone or buprenorphine) may be observed for 5 days in the hospital and 3 days after discharge..
• Phenobarbital is frequently used in treatment failure and may be discontinued 24 hours after discharge.

NOWS Weaning

• Weaning protocols begin when NAS scores remain below 9 for 48 hours.
• Morphine dosage is reduced gradually (0.01-0.02 mg/kg every 24 hours) until the dose reaches 0.04 mg/kg, at which point clonidine weaning begins.
• Clonidine weaning involves a 50% reduction initially, followed by discontinuation the next day.
• Monitoring of blood pressure is critical for 48 hours after discontinuing clonidine.
• If only morphine is being used, its dose is reduced by 0.01-0.02 mg/kg every 24 hours until discontinued for infants meeting certain criteria.
• Infantiles can be discharged from the hospital 24 hours after their morphine dose is discontinued with a score of below 9.

This quiz covers the Neonatal Opioid Withdrawal Syndrome (NOWS), exploring its symptoms, causes, and public health implications. Learn about the impact of opioid use during pregnancy and its effects on newborns. Whether you're studying for health exams or seeking to understand this critical issue, this quiz provides valuable insights.