Podcast
Questions and Answers
What score is given for an infant demonstrating excessive sucking prior to feeding but sucking infrequently during feeding?
What score is given for an infant demonstrating excessive sucking prior to feeding but sucking infrequently during feeding?
If an infant has a respiratory rate of 65 breaths per minute after being quieted, what score will be assigned for tachypnea?
If an infant has a respiratory rate of 65 breaths per minute after being quieted, what score will be assigned for tachypnea?
What is indicated by nasal flaring during an infant's breathing?
What is indicated by nasal flaring during an infant's breathing?
Which assessment scoring corresponds to an infant demonstrating red broken skin due to excessive rubbing?
Which assessment scoring corresponds to an infant demonstrating red broken skin due to excessive rubbing?
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What scoring is assigned for an infant who has experienced tremors lasting more than 3 seconds?
What scoring is assigned for an infant who has experienced tremors lasting more than 3 seconds?
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An infant shows signs of difficulty in straightening arms, but head lag is present. What score should be assigned for increased muscle tone?
An infant shows signs of difficulty in straightening arms, but head lag is present. What score should be assigned for increased muscle tone?
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How is regurgitation scored for an infant that frequently vomits the entire feeding not associated with burping?
How is regurgitation scored for an infant that frequently vomits the entire feeding not associated with burping?
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What score is assigned if an infant has liquid stools that are at least half liquid?
What score is assigned if an infant has liquid stools that are at least half liquid?
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What is the recommendation for adjusting the Phenobarbital dosage after discharge?
What is the recommendation for adjusting the Phenobarbital dosage after discharge?
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Which of the following signs contributes to the Neonatal Abstinence Syndrome scoring system?
Which of the following signs contributes to the Neonatal Abstinence Syndrome scoring system?
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In the Moro reflex assessment, what indicates a markedly hyperactive response?
In the Moro reflex assessment, what indicates a markedly hyperactive response?
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What is considered a score of '0' for sleeping according to the NAS scoring?
What is considered a score of '0' for sleeping according to the NAS scoring?
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How should caregivers score sweating on the infant according to the NAS scoring?
How should caregivers score sweating on the infant according to the NAS scoring?
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Which aspect should NOT be scored for infants older than 1 month in the NAS scoring system?
Which aspect should NOT be scored for infants older than 1 month in the NAS scoring system?
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Which of the following is NOT a typical strategy for supportive care in managing neonatal abstinence syndrome?
Which of the following is NOT a typical strategy for supportive care in managing neonatal abstinence syndrome?
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What is essential to alert the primary care physician during discharge planning for infants on Phenobarbital?
What is essential to alert the primary care physician during discharge planning for infants on Phenobarbital?
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What is the primary purpose of swaddling an opioid-exposed newborn?
What is the primary purpose of swaddling an opioid-exposed newborn?
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When should NAS scoring begin for an infant?
When should NAS scoring begin for an infant?
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Which of the following criteria would prompt the initiation of pharmacologic treatment for an opioid-exposed infant?
Which of the following criteria would prompt the initiation of pharmacologic treatment for an opioid-exposed infant?
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If an infant's NAS score is 10, what is the appropriate morphine loading dose?
If an infant's NAS score is 10, what is the appropriate morphine loading dose?
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What should be done if an infant has three NAS scores of 9 or greater within a 24 hour period?
What should be done if an infant has three NAS scores of 9 or greater within a 24 hour period?
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Which of the following strategies can help prevent excessive crying in opioid-exposed newborns?
Which of the following strategies can help prevent excessive crying in opioid-exposed newborns?
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Where should NAS scoring ideally take place?
Where should NAS scoring ideally take place?
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How should the morphine dose be adjusted if the NAS score remains 9 or higher after the maintenance dose?
How should the morphine dose be adjusted if the NAS score remains 9 or higher after the maintenance dose?
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Study Notes
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.
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Description
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.
