Management of Neonatal Abstinence Syndrome

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Management of Neonatal Abstinence Syndrome

• Karena Fellowes
• Neonatal Sister
• David Morgan Neonatal Unit

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Neonatal Abstinence Syndrome
A generalized disorder characterized by central
nervous system hyper-irritability,
gastro-intestinal dysfunction, respiratory
distress and vague autonomic symptoms Finnegan
Weiner (1993)
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UK Incidence of NAS

• UK (1996)
• 580 cases of opiate withdrawal nationally
• 80 (14) Merseyside
• (Morrison Siney 1996)
• Northern and Yorkshire Region (2002)
• 9.3 drug users per 1000 deliveries
• 365 babies born to a drug using mother
• 7.5 babies per 1000 born to drug using mothers
• 37 babies required pharmacological treatment
• ( Northern and Yorkshire Public health
  Observatory 2002)

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Prevalence of NAS
David Morgan Neonatal Unit
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Situation in 1998

• Increasing numbers of pregnant drug users
• Maternal and Neonatal Care delivered in isolation
  
• Communication difficulties common
• Inconsistencies noted in care delivery
• Inconsistencies in professionals response
• Conflicting advice

• Neonatal Unit
• Complex social histories
• Lack of Information
• Delayed discharge of Infants
• Increased the length of stay
• Pressured existing service

• Parents
• Increased anxiety
• Confusion
• Communication problems
• Challenging behaviours

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NAS Management Review

• Nursing Times Scholarship
• Comparative Review / Dissertation
• Environmental modification
• Pharmacological review
• Implemented new protocol
• Establishment of multidisciplinary pregnant drug
  user groups/ Drug liaison midwife
• Monthly Antenatal case reviews
• Production of in-patient / discharge NAS leaflet

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Principles of NAS Management

• Accurate Observation Assessment
• Supportive Care a. Environment of
  Care b. Therapeutic Handling c. Symptomatic
  Care
• Pharmacological Intervention

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David Morgan Neonatal Unit
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Detoxification

• Detoxification should be undertaken with the
  maximum speed that can be tolerated by the
  infant, causing minimal distress to avoid
  prolonged hospitalisation and prolonged
  separation from family

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Pharmacological Intervention
Part 1 Stabilization

• Start on Moderate Dose 4 Hourly
• Increase Dose until Symptoms subside
• Be aware of biphasic withdrawal patterns
• Assess and Evaluate effect 4 hourly
• Review medication dosage on a daily basis
• with a view to reduction

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Oral Morphine Regime

• Level 6 60mcg / kg / dose 4 hourly
• Level 5 5omcg / kg / dose 4 hourly
• Level 4 40mcg / kg / dose 4 hourly
• Level 3 30mcg / kg / dose 4 hourly
• Level 2 20mcg / kg / dose 4 hourly
• Level 1 10mcg / kg / dose 4 hourly
• Starting Level

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PART ONE NAS STABILIZATION
Implement Supportive Measures Finnegan Scoring
Assessment 4 Hourly
Scores gt 12 then Score 2 hourly Scores remain gt
12 for next 2 consecutive scores Start Oral
Morphine 4 hourly Starting Level Level 4 Scores
Remain gt 12 for next 2 consecutive
scores Increase Morphine to next level ( i.e.
Level 5 ) Scores Stabilise lt 12 REDUCTION
Scores lt 12 Continue Observationand Scoring
until discharge
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Part 2 Reduction

• Stabilisation has been achieved when the infant
  is consolable, has rhythmic sleep and feed
  cycles, a steady weight gain and is clinically
  stable
• Aim for Daily Reductions
• Maintain 4 Hourly Dosing Intervals
• Once stopped observe for further 24 hours then
  
• HOME

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PART TWO NAS REDUCTION
NAS Infant on Morphine Replacement Calculate
Daily the Average Score for the last 24 hours
(DAS)
DAS gt 9 Remain on samelevel of Morphine
DAS lt 9 Reduce to next level of Morphine Stop
Medication after 24 hours of Level 1 Morphine if
DAS lt 9 Observe for further 24 Hours Scores
Remain lt 9 DISCHARGE
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Substance Users Case Review Meetings

• Held 1st Monday of the month
• Attended by
• Drug Liaison Midwife
• Neonatal Drug Liaison
• Development Nurse Substance Misuse
• Drug and Alcohol worker
• Lead Paediatrician
• Named Community midwife

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Aims of Case Review meeting

• To monitor progress throughout pregnancy
• To ensure prompt referral
• For information exchange
• Educational benefits from other agency input
• To instigate pre-birth planning meetings
• To co-ordinate postnatal care
• To ensure discharge is not delayed

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Evaluation and Audit
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Benefits noted

• Reduced average length of stay for infants of
  drug users admitted to DMNU from average of 22.3
  13.8 days
• Reduced time on morphine therapy for NAS from
  average of 24.9days to 8.3 days
• Reduced average length of stay for infants
  requiring treatment for NAS from 39.6 days to
  13.8 days
• Reduction in delays in discharge
• Improved communication
• Increased awareness / knowledge

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Incidence of all Infants of Maternal Drug users
admitted to DMNU 1995 -2002

• New protocol
• introduced

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NAS 1995-2002
Duration of stay for babies requiring
Pharmacotherapy (Days)
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Average Length of Stay for infants requiring
pharmacotherapy 1995-2001
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Duration of Morphine Therapy in days
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Average duration of Morphine Therapy 1995 2001
for Neonatal Abstinence Syndrome
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(No Transcript)
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Total Days Care Neonatal Abstinence Syndrome
David Morgan Neonatal Unit