Why I’m giving your baby morphine
Neonatal abstinence syndrome, or NAS, refers to the postnatal syndrome experienced by newborns whose mothers were using opioids while pregnant. But before we even get into these details, let’s set the stage. The first question we ask this week is: How did opiate use among pregnant women become so common?
Our story begins in ancient Mesopotamia, over 5,000 years ago, when recreational and medicinal opium use was initially documented. But opium abuse never surfaced as a serious problem until it achieved international infamy in the late 19th century when morphine entered the medical market. Fifty years later, the first case of NAS was reported in 1875, just one year after heroin was first synthesized. The condition was referred to as “congenital morphinism” at the time. But it would be nearly another full century before we figured out how to manage it.
Why am I featuring this topic on BrainWaves? Believe me when I say that NAS is now a global problem. And it’s not getting any better. In 2012, over 20,000 infants were diagnosed with this disorder, about 3 for every 1000 newborns. This number is 500% greater than it was a decade prior, despite an increase in the world’s population of only 20%.
But why have these numbers grown so rapidly?
What are the manifestations of NAS? They are complicated, and they span across a range of severity and complexity. The child often starts with irritability, which can be difficult to pin down in a newborn. But excess irritability and inconsolability will lead to excess high-pitched crying, difficulty sleeping, tremors, diarrhea, and sometimes even seizures in 2-11% of cases. Some symptoms may often mimic seizures, like the myoclonic jerks and hypertonia that’s more frequently observed in methadone withdrawal. Autonomic involvement is common. And while symptoms are typically short-lived, the poor feeding, poor sleep quality, and diarrhea can create entirely new problems for the newborn, leading to dehydration and poor weight gain. To make matters confusing, many newborns will develop hyperphagia, likely as a result of the irritability, lack of appropriate sleep, and because of the excess energy expenditure during withdrawal. Risk factors associated with more severe neonatal withdrawal include birth at term, good birth weight, polysubstance abuse by the mother, and several gene mutations have also been implicated.
An ounce of prevention is worth a pound of cure. But if opiates cannot be avoided, how should these children be managed? [Without providing ANY sort of recommendation here, let me just say] experts have recommended that these patients be managed swiftly and aggressively. Many providers stick to the Finnegan scoring system when categorizing disease severity and deciding on a management strategy. Pharmacologic management is escalated from supportive measures to opiates when simple measures fail, when the patient’s symptoms become severe (as in the case of seizures) or withdrawal leads to serious vomiting or diarrhea that can cause dehydration. When it comes to opiate selection, morphine is the drug of choice, and it has known efficacy in managing symptoms of withdrawal, improves feeding, and can even reduce the risk of seizures. But dosing should be minimized whenever possible because larger doses have been associated with longer hospital stays for the newborn. Worth noting is that opioid antagonists, like naloxone, are contraindicated in cases of NAS because they are known to precipitate seizures.
What will happen to my baby? NAS is rarely fatal, but that does not mean it is a benign condition. Newborns with this disorder often develop multi-organ dysfunction and have prolonged hospital stays. Not to mention these children frequently may ultimately be brought home to an unsafe environment. Granted, a large number of newborns with NAS are born to mothers who may not have intentionally abused opiate products, or they may even be on methadone maintenance for a prior addiction. But even so, it does raise a concern, and it may not be a bad idea to involve a multi-disciplinary care team to discuss the safest and healthiest way to manage these children in the long-term, or even to determine what the most suitable discharge disposition may be for the patient. Over the long-term, these children will require neurobehavioral follow up and other medical appointments. They are at greater risk of developing ADHD, cognitive impairment, poor school behaviors, poor weight gain and failure to thrive. It goes without saying that these children and their families often require extensive psychosocial support in order to prevent maternal relapse or at least to continue encourage safe practices and abstinence from substance abuse. Even in fully rehabilitated families, care remains complex and challenging. Multi-disciplinary intervention is often required in order to achieve the best possible outcome for newborns with NAS.
Bottom line: If it cannot be prevented, it should be recognized early, and managed swiftly. And as we see this inexorable epidemic of opiate use continue to snowball, you should expect more and more children born with this disorder.
The BrainWaves podcast and online content are intended for medical education purposes only. This should not be used as a reference for anyone to give their child opiates.
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