Websites to Recommend

All information is at the fingertips of everyone with an internet connection. This allows the population to learn about different syndromes that are not talked about in normal conversation. An example of this is Neonatal Abstinence Syndrome (NAS). While more information needs to be done to look at long term effects of a child diagnosed with NAS, people can learn about what NAS is and what goes on in the infant. 

To learn about what NAS is and to learn the basics about the syndrome, visit the website below. Stanford Children's Health goes over the basics of what the syndrome is, how the infant is diagnosed and how the infant will be treated. To start learning about what NAS is, this is a great resource to learn the basics (Neonatal Abstinence Syndrome, 2016).
http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387

To learn about specific symptoms and treatment visit the website below. This website lists common signs and symptoms of NAS. Then it explains what tests can be done to diagnose NAS and what is done to treat those infants (Lee, 2014).
https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm

To learn about how the infants are scored based on their symptoms, visit the website below. This resource allows people who don't regularly take care of infants with NAS to learn and understand how infants are scored on severity of NAS and how pharmacological intervention is reviewed. (Withdrawal Scoring Sheet, 2016). 
http://newborns.stanford.edu/ScoringSheet.html

To learn about possible short and long term effects of a fetus exposed to drugs while in the womb visit the website below. This website goes more in depth on what effects specific drugs can have on infants. The long term effects need to be studied more, but with the prevalence of NAS increasing, the medical world will start to learn what happens to those children born with NAS (Behnke, & Smith, 2013).
http://pediatrics.aappublications.org/content/131/3/e1009

References

Behnke, M., & Smith, V. (2013). Prenatal substance abuse: Short-and long-term effects on the exposed fetus. Retrieved from http://pediatrics.aappublications.org/content/131/3/e1009 

Lee, K. (2014). Neonatal abstinence syndrome: MedlinePlus Medical Encyclopedia. Retrieved February 29, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm 

Neonatal Abstinence Syndrome. (2016). Retrieved February 29, 2016, from http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387 

Withdrawal Scoring Sheet. (2016). Retrieved February 29, 2016, from http://newborns.stanford.edu/ScoringSheet.html 

Medical Treatment Options

The treatment for Neonatal Abstinence Syndrome (NAS) is to assist the infant through detox as painless as possible. First, knowing what type of drug the mother is on is very important. On average, if the mother is on a narcotic with a short half life, like Hydrocodone, the infant could be discharged at age 3 days if no withdrawal symptoms occur. If the mother is on a narcotic with a long half life, such as Methadone, the infant needs to be observed until age 5 to 7 days and then can be discharged if no withdrawal symptoms occur (Hamdan, 2016). Then appropriate follow up care is needed. 
After an infant is diagnosed with NAS the infant is sent to the NICU, which is better equipped to treat such a diagnosis. Nonpharmacologic interventions include assessing the infant closely with sleeping habits, feeding patterns, weight gain and any signs of withdrawal. Minimizing stimuli in the room is very important along with swaddling, non-nutritive sucking with a pacifier and frequent small feedings of hypercaloric formula (Hamdan, 2016).

(Kocherlakota, 2014)

Pharmacologic therapy should only be used for supportive therapy because it can prolong hospitalization and expose infants to more agents that are not necessary. Approximately 30-91% of infants who are diagnosed with NAS receive pharmacological treatment. This treatment allows the infants to feed, sleep, gain weight and interact with caregivers. The most common treatment is  oral morphine solution, followed by methadone and even clonidine (Hamdan, 2016).

 (Kocherlakota, 2014)

The chart above explains the types of medication used to assist the infant through detox. As the infant grows older and symptoms decrease, weaning of the pharmacological intervention is started. The goal is to get the infant off all medications. Side effects that are the most concerning are sedation and longer treatment. Types of medications were stopped if the infant was not responding well to them, mainly not getting comfortable with the type of medication. Luckily medication is given on a schedule of on average every four hour. This allows medical staff to step in if any worsening side effects occur, but the main objective is to keep the infant comfortable (Kocherlakota, 2014).

References

Hamdan, A. (2016). Neonatal Abstinence Syndrome Treatment & Management. Retrieved February 23, 2016, from http://emedicine.medscape.com/article/978763-treatment 

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

 

Signs and Symptoms

Signs and symptoms of Neonatal Abstinence Syndrome (NAS), are very similar to the signs and symptoms of drug detox in adults. The most common symptoms include tremors, irritability, excessive crying and diarrhea. Seizures can occur in about 2% to 11% of newborns born with NAS. Those listed are considered the initial phase.  The chart below illustrates the onset, frequency and duration of this syndrome depending on the type of drug the mother is using (Kocherlakota, 2014)

(Kocherlakota, 2014)

The duration of time the drug is in the infant depends on the last time of dose, how long the fetus was exposed and what type of drug being used. Different drugs have a different half-life and that also attributes to how long or short detox can be. When the infant goes through detox, the initial symptoms decline in frequency and intensity. However, after the initial phase, that can last weeks to months, the infant can go through long chronic and relapsing hyperirritability sleep disturbances, hyperphagia and other neurologic and autonomic signs (Kocherlakota, 2014). The symptoms that contribute most to the discomfort of the infants are the irritability, tremors and excessive crying. The infant is going through severe detox and will feel bad, the only thing that can help is proper medical care and time. (Doctors, 2011)

(Doctors, 2011)

The video above goes over common symptoms of NAS, what they look and sound like. The medical staff does what they can to decrease intensity of symptoms, but the infants need to clear there system before the effects of detox stop.

References

Doctors. (2011). Struggles of Drug Addicted Babies. Retrieved February 18, 2016, from

            https://www.youtube.com/watch?v=c07RnhNYsPk

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

Diagnosis

When diagnosing Neonatal Abstinence Syndrome (NAS) it is always important to consult with the infant's doctor because signs and symptoms of NAS can look like other medical problems. It is important to know what drugs the mother is on, and when the last use was for each substance. A maternal drug test would be beneficial to see exactly what is in the mother's system and at what strength. To make a true diagnosis in the infant, toxicological confirmation is necessary, as this confirms what narcotics are in the infants system (Trevino, 2016).


A scoring system is used to measure how severe the infants symptoms are, which allows a systematic, objective, periodic and thorough evaluation of the newborn of the progression of NAS (Jansson,  Velez, & Harrow, 2009). There are a few different scoring sheets that can be used, a common model is the  Modified Finnegan Neonatal Abstinence Score Sheet. This model allows the medical staff to assess 31 items to quantify the severity of NAS, this is repeated every four hours. Other scoring systems that are used in the medical setting include  The Lipsitz Neonatal Drug-Withdrawal Scoring System, The Neonatal Withdrawal Inventory, and The Neonatal Narcotic Withdrawal Index, the later two being simplified versions of the Finnegan scoring tool (Jansson, Velez, & Harrow, 2009).


The scoring sheets work well with treating the infants because with the score, it lets the medical staff know when medications need to be used to cut down the severity of symptoms. But keep in mind, no scoring system is perfect, these measuring tools are subject to observer variability and simplified versions of longer measuring tools have had little success. 

This syndrome progresses in the infant, and expresses itself through detox symptoms, which include tremors, high pitch crying, and not being able to get comfortable. The nursing staff keeps the infant comfortable through the symptoms by weaning the infant off the narcotic and healthy enough to go home (Kocherlakota, 2014).

References

Jansson, L. M., Velez, M., & Harrow, C. (2009). The Opioid Exposed Newborn: Assessment and Pharmacologic Management. Journal of Opioid Management, 5(1), 47–55.

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

Trevino, H. (2016). University of Rochester Medical Center. Retrieved February 11, 2016, from https://www.urmc.rochester.edu/Encyclopedia/Content.aspx?ContentTypeID=90

Etiology and Pathophysiology

The etiology of Neonatal Abstinence Syndrome (NAS) is when the mother uses and is addicted to opiate drugs while pregnant. The type of narcotics include heroin, codeine, oxycodone, Oxycontin, methadone and buprenorphine. The narcotic goes into the mother and into the fetus through the placenta (Lee, 2014). Huestis and Choo (2002) explain the mechanisms of transfer from mother to fetus, these include, active transport which requires energy, passive diffusion requiring no energy, and pinocytosis which moves fluids by creating a cavity of cell membranes. Along with the mechanisms of transport, it is also important on the size of the drug molecule, because equilibrium will always be reached across the placenta membrane, meaning mother and fetus will be on the same substances (Huestis & Choo, 2002). The cause of NAS is substance abuse and dependence, which is a growing problem especially in women. The treatment of addiction takes time and is different for every individual. Plus with the availability of opiate narcotics increasing, this contributes to the morbidity of NAS (Huestis & Choo, 2002).

(ABC News, 2012)

The mother in this video was seeking drug abuse treatment when she found out she was pregnant. Since she was still dependent on methadone, the baby became addicted and had to go through withdrawal after being born. The progression of NAS is illustrated above, the mother of this infant, while under methadone treatment, passed the drug onto her fetus and once the infant was born, detox started. Then all the mother could do is watch, while her infant was treated for withdrawal off a narcotic that the infant had no choice in. Resulting in harsh symptoms and more medications to wean the infant off the narcotic and try and ease the symptoms of detox.

 References

ABC News (2012). Drug-Dependent Infants Detox at Tenn. NICU. Retrieved February 05, 2016, from https://www.youtube.com/watch?v=2eP5EnFSG0c

Huestis, M.A., & Choo, R.E. (2002). Drug abuse’s smallest victims: In utero drug exposure. Forensic Science International, 128, 20-30.

 Lee, K. (2014). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Retrieved February 05, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm