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Infant of the chemically dependent woman

• Summary 
• Prenatal And Perinatal Management
• Postnatal Management
• Supportive Care
• Morphine Therapy
• Phenobarbitone Therapy
• Breast Feeding
• Artificial Feeding
• Discharge Management
• Guidelines For Neonatal Abstinence Syndrome Scoring

Summary

• there is evidence of neonatal abstinence syndrome (NAS) in babies born to women dependent on (or intoxicated at time of birth with) opioids (including when use ceased within four weeks of birth), stimulants, some sedatives and alcohol  
• NAS is more common in babies born to opioid-dependent women than in babies born to women dependant on other drugs
• there is no dose-response relationship between maternal opioid intake and NAS
• clinical signs similar to those of NAS may be caused by concurrent illness, such as infection and hypoglycaemia.  This should be considered when assessing a baby at risk of NAS. 
• babies of women dependant on alcohol or drugs are at an increased risk of harm and poor developmental outcomes due to complex interplay of psychosocial and environmental adversity. Assessment of risk of harm or neglect to the baby should occur throughout the pregnancy and postnatally
  

Prenatal And Perinatal Management

• All pregnant women should receive comprehensive information about the risks of alcohol and tobacco use in pregnancy and should be screened for substance use at least twice in pregnancy.  More frequent assessments should be made if concerns exist such as women presenting
  •  after 20 weeks pregnancy
  •  with homelessness
  • with altered mental state
• Health outcomes for mothers and babies can be improved with provision of comprehensive models of care with assertive follow-up., Statewide secondary consultation services are available from the Women's Alcohol and Drug Service (WADS) on 03 9344 3631
• Problems encountered by drug-dependent pregnant women may include
  • obstetric - prematurity, growth restriction, fetal demise
  • medical - asthma, epilepsy, liver disease, valvular heart disease, blood-borne virus infection, nutritional deficiencies
  • neonatal - prematurity, growth restriction, neonatal withdrawal, sudden infant death
  • psychiatric, social, legal, domestic and financial problems
• The care of an infant born to such a woman needs to be holistic and multidisciplinary.

 

Summary of effects on baby of in-utero substance exposure and baby assessments recommended

	Antenatal effects*	Effects on baby in first week	Sub-acute withdrawal ***	Longer term effects on baby ****	Withdrawal assessments
Alcohol	Teratogen	CNS hyperexcitability, GI symptoms, poor settling, seizures Withdrawal/NAS		FAS, FASD, SIDS risk	NAS scoring for 7 days
Cannabis			Yes	SIDS risk	None
Opiates**	Fetal Loss, IUGR, prematurity (greater risk with regular heroin use than with methadone)	Respiratory depression, Withdrawal/NAS (seen in up to 66% of exposed babies)	Yes	SIDS risk, Increased risk of strabismus	NAS scoring for 7 days
Sedatives (including Benzodiazepines)	Unconfirmed as a  teratogen, case reports of malformations, fetal loss, increased perinatal death	Early onset symptoms associated with hypothermia, poor feeding, respiratory problems, lethargy, hypotonia. Chronic exposure associated with cardiorespiratory, neurological, settling and feeding difficulties	Yes	SIDS risk	Dependent on antenatal medical assessment: - NAS scoring for 7 days - weekly outpatient review until 4 weeks
Stimulants (including amphetamines, cocaine)	Unconfirmed as a  teratogen.  Case reports of malformations. Placental abruption, IUGR, prematurity, cerebral ischaemic lesions	Agitation, overactivity. Withdrawal/NAS (seen in up to 49%  of exposed babies)			NAS scoring for 7 days. Weekly outpatient review until 4 weeks.
Tobacco	Placental abruption, IUGR, prematurity	Increased motor activity, agitation	Yes	SIDS risk

  * Maternal lifestyle and health issues associated with all substance dependency may contribute to and compound with substance use, resulting in adverse fetal outcomes
  ** If Maternal use in last 4-6 weeks of pregnancy or intoxication at the time of birth
  *** Variable muscle tone, agitation, sleep and feeding difficulties reported lasting up to 4-6 months of age
  **** Causation of reported long term adverse neurodevelopmental difficulties is controversial due to potential confounding impact of adverse postnatal environmental factors including domestic violence and caregiver mental health issues and frequent polysubstance exposure

Methadone substitution for heroin use in pregnancy results in

• •   improved fetal growth
  •   improved survival
  •   less risk of prematurity
• Methadone stabilisation is recommended rather than dose reduction in pregnancy. Withdrawal from narcotics should be avoided due to the risks of
  • miscarriage in the first trimester
  • premature labour in the third trimester
  • fetal distress
  • death in-utero
• A majority of women still use some heroin in pregnancy despite methadone treatment.
• Induction of labour frequently occurs at or less than due date due to the high-risk nature of these pregnancies. There is no indication for an induction of labour solely because of maternal substance use.
• Avoid naloxone administration to the newborn baby with respiratory depression - naloxone can precipitate instantaneous and dramatic narcotic withdrawal including convulsions. If this occurs, the infant should commence morphine therapy as below.
• Due to heroin's short half life, withdrawal often manifests in the first one or two days of life, whereas significant withdrawal from methadone may take up to 7 days to become apparent. Mothers and their babies should be routinely observed as in-patients for at least seven days before being discharged.

 

Postnatal Management

Normal rooming-in is appropriate unless other medical problems exist. However, the practice of mother and baby sleeping in the same bed should be discouraged as a woman taking sedative medication sometimes sleeps more deeply and is more difficult to rouse. This may result in her not being alert to her baby's needs at that time, and has been associated with babies being accidentally asphyxiated.  SIDS prevention safe sleeping practices should be practiced in hospital.

The Paediatric medical team should be involved in the day to day care of these infants.

• Infants of mothers with a drug and/or alcohol problem are at increased risks of preterm birth and low birth weight conditions frequently associated with chorioamnionitis. Clinical signs of illness such as infection and hypoglycaemia may overlap with those of NAS.
• Due to the frequency of maternal mental health co-morbities the possible impact on theinfant of medications prescribed for those conditions requires consideration.Neonatal discontinuation syndrome due to SSRI antidepressants can occur at the usual dose ranges. Reported symptoms include  tremor, restlessness, rigidity and myoclonus. The onset and severity is associated with both the half life, placental passage and breast milk excretion for particular medications. A shorter half life seems to be associated with a more significant risk of withdrawal syndrome, however, medications that have a longer half life but higher placental passage and breast milk excretion are also associated with withdrawal syndromes.

Infants at risk of NAS are evaluated for signs of withdrawal by NAS scoring  (using the  modified Finnegan Scoring System) starting two hours after birth or sooner if signs of withdrawal are evident, and subsequently at 4 hourly intervals. The scoring should be performed ½ to 1 hour after baby the baby has been fed. The NAS score chart lists 21 signs most commonly seen in the passively narcotic addicted neonate. Each sign and its associated degree of severity are assigned a score. Higher scores accompany those signs found in babies with more severe abstinence that are at an increased risk of morbidity. The total abstinence score is determined by summation of scores assigned to each sign observed throughout the entire scoring interval.

The baby's mother should assist with the scoring and discuss each sign as it is assessed - it is usually the mother who has been with the baby during the scoring interval. Further, it appears to be important in the mother's acceptance of her baby's condition that she be actively involved in the scoring process.

Neonates with an abstinence score averaging 8 or more for three consecutive scores should be transferred to the Special Care Nursery for evaluation for pharmacotherapy. If there are inconsistencies in the scores, the baby may be observed for a period of time to ensure pharmacotherapy is truly indicated.

Babies of women dependant solely on cannabis may have delayed onset of withdrawal  (after 10 days) and should be referred for weekly assessment until one month of age with a suitably qualified clinician, GP or paediatrician but do not require assessment with the modified Finnegan NASS.

Supportive Care

Non-pharmacological supportive care is the first line of treatment for all babies exposed to maternal use of substances of dependency in pregnancy.  Supportive therapy is an important adjunct to medical therapy. This includes supportive care interventions such as

• a quiet setting
• breastfeeding
• use of a pacifier (if parents give consent)
• small frequent feeds
• cuddling
• swaddling
• close skin contact
• carrying in a sling

Pain relief for procedures should be provided based on need as for any baby.

 

Morphine Therapy

All doses for entire period of withdrawal management are calculated on birth weight and not current weight.

Score	Dosage (oral)
3 consecutive scores average  8 or more	0.5mg/kg (birthweight)/day 4-6 hourly*
2 consecutive scores average 12 or more	0.5 - 0.7mg/kg (birthweight)/day 4-6 hourly* (consider higher dosage)
*If NAS symptoms are not assessed as controlled with 6 hourly medication, change dose frequency to 4 hourly in the first instance before increasing the dosing amount (local consensus). Currently the Royal Women's Hospital routinely uses 6 hourly dosing. Mercy Hospital for Women and Monash Medical Centre use 4 hourly dosing during initial phases of stabilisation.

Babies receiving morphine should be closely monitored including use of an apnoea monitor whilst commencing and stabilising on treatment, as morphine is a respiratory depressant (local consensus). Overdosing may result in

Once abstinence has been controlled (three consecutive scores less than 8) the following should be implemented

• maintain control for 72 hours
• initiate the detoxification process by decreasing the total daily dose by 10% of maximum dose every 48-72 hours
• when dosage levels reach 0.10 -12mg/kg/day - maintain this dose for 72 hours prior to ceasing all medication
• when oral morphine treatment is discontinued, NAS scoring should continue for a further 72 hours

Supportive therapy (using a pacifier, swaddling, close wrapping, small frequent feeds, providing close skin contact) is an important adjunct to medical therapy.

If an infant is vomiting in association with morphine dosing, ensure that the infant is not being overfed and that the infant is being appropriately postured during and after feeding. Give the morphine before the feed. If baby has a large vomit after being given morphine

• if vomits within 10 minutes of dose, re-dose
• if vomits between10 - 30 minutes after dose, give ½ dose
• if baby vomits more than 30 minutes after feed, do not give further morphine (always err on side of caution)

Phenobarbitone Therapy

Assays of phenobarbitone levels should be performed if

Once NAS symptoms have been assessed as controlled (three consecutive scores less than 8) for 48 hours, the phenobarbitone dose should be reduced by 2mg per dose every 4th day or longer until less than 2mg/kg/day, depending on paediatric assessment of clinical condition.

Breastfeeding

Breast-feeding is generally not discouraged. The risk of transmission of Hepatitis C via breast milk is very low. Small amounts of methadone are transmitted to the baby in breast milk, but not usually in sufficient quantities to affect the baby clinically or to prevent a woman from breast-feeding.

Contraindications to breastfeeding include

• Intoxication with alcohol or other drugs
• HIV positive mother
• Hepatitis C positive mother who has cracked and/or bleeding nipples
• Breastfeeding may be contraindicated for intermittent periods, including after drug or alcohol use. 

 

 All women who breastfeed should be advised how and when to express and store or discard breast milk and to develop a safety plan for feeding the baby.

Breastfeeding women who use stimulants (amphetamines, ecstasy, or cocaine) should be

Breastfeeding women who smoke cannabis or tobacco should be advised to

• breastfeed prior to smoking
• smoke outside and away from the baby, to minimise secondary exposure to the baby.

  Heavy use of cannabis may pose a risk of transmission in breast milk, but this is uncertain.

Breastfeeding women should be informed that l

• alcohol passes into breast milk
• there is no known safe level of alcohol consumption.
• advised to breastfeed before drinking alcohol (or express and store breast milk), then wait a minimum of 3-4 hours after the last drink before breastfeeding again
• if the woman exceeds the recommended levels of alcohol consumption for non-pregnant women, she should be advised to wait approximately 3 hours per standard drink consumed before breastfeeding again.

If women or babies are experiencing breastfeeding problems or have complex needs, consider a referral to a lactation consultant .

Artificial feeding

Some women may choose to artificially feed their infants. This may be the primary source of nutrition for the infant or provided in conjunction with breastfeeding. Women who choose to artificially feed their infants will require the same information as all women who choose this feeding method (regularly or occasionally), including

• preparation and storage of formula
• heating of milk in an appropriate manner
• cleaning and sterilisation of feeding equipment

Women with ongoing or intermittent substance use need to have a safety or backup plan for the times when they are under the influence of substances. This safety plan should be discussed with women prior to their discharge from the acute setting.
Safety plans should include

• mother's ability/plans to have baby cared for and fed by another appropriate person if she is substance affected
• making formula up prior to substance use
  

Discharge Management

An infant can be considered for discharge when either

• a 7 day postnatal observation period is completed and there are no signs of continuing significant withdrawal. There is a significant risk of unsupervised withdrawal occurring at home if infants are discharged earlier than 7 days, particularly if mother is on methadone

• the infant requiring medical therapy for withdrawal has been off all medication for at least 72 hours (this may not apply to phenobarbitone)

• any child protection issues and significant parental issues (eg suitable accommodation) have been appropriately addressed

• the infant should have early medical followup (within 2 weeks of discharge) and have early and regular review by domiciliary/maternal and child health nurses

AGE	WHO	FOLLOW-UP REQUIRED
Birth	Babies of mothers with positive Hepatitis B test	Hepatitis B immunoglobulin within one hour or as soon as practicable after birth
Day 1	All babies	Hepatitis B vaccine on day of birth according to normal immunization schedule
Discharge	All babies	Referral from hospital, assertive follow-up and engagement with comprehensive community services to provide ongoing support and promote optimal neurodevelopment.  Discharge preparation should include assessment of home environment SIDS prevention information education about infant/child cues offer parents of infant CPR training
Discharge	Babies at risk of Fetal Alcohol Syndrome (FAS) or FASD	Additional social support as necessary, and referral for monitoring and follow-up. Paediatric review at 6 months
Discharge to school entry	Babies with FAS	Referral to specialist or comprehensive community neurodevelopment support services
Discharge to 4 weeks of age	Babies exposed in utero to cannabis, stimulants or sedatives	Referral for weekly monitoring and assessment for signs of withdrawal and education about supportive techniques via enhanced home visiting, MCH nurse, GP or paediatrician
Birth-6 weeks	Babies of mothers with positive HIV test	Paediatric monitoring and provision of antiviral prophylaxis as required
4-6 months and/or 12-18 months	Babies of mother who is Hepatitis C positive and viraemic in pregnancy	Paediatric follow-up to offer PCR or antibody test for Hepatitis C
6 months	Babies of mothers who are Hepatitis B positive	Paediatric follow-up to offer test for Hepatitis B antibody status

Guidelines For Neonatal Abstinence Syndrome Scoring

Neonatal abstinence syndrome scoring was designed for term babies fed four hourly. Scoring should be performed ½ to 1 hour after a feed, before the baby falls to sleep. See below for modifications necessary for premature babies *

SIGNS

High pitched cry	Score 2 if high-pitched at its peak, 3 if high-pitched throughout
Tremors	This is a scale of increasing severity and a baby should only receive one score from the four levels of severity. Undisturbed refers to the baby being asleep or at rest in the cot.
Increased muscle tone	Score if the baby has generalised muscle tone greater than the upper limit of normal.
Excoriation	Score only when excoriations first appear, increase or appear in a new area.
Yawning and sneezing	Score if occurs more than 3 to 4 times in 30 minutes.
Nasal flaring/respiratory rate	Score only if present without other evidence of lung or airways disease.
Excessive sucking	Score if more than that of an average hungry baby.
Poor feeding	Score if baby is very slow to feed or takes inadequate amounts.
Regurgitation	Score only if occurring more frequently than would be expected in a newborn baby.

* Modification for prematurity - mainly necessary in the sections on sleeping and feeding. A baby on 3 hourly feeds can sleep at most 2 ½ hours. Scoring should thus be 1 if a baby sleeps less than 2 hours, 2 if sleeps less than 1 hour, and 3 if it does not sleep between feeds. Many premature babies require tube feeding. Babies should not be scored for poor feeding if tube feeding is expected at their gestation.

• Neonatal Abstinence Scoring System   (PDF 120KB)

 

 

First Published 04/05/02. Last updated 08/06/10.

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