Both in our region and nationally, the occurrence of Neonatal Abstinence Syndrome (NAS) has grown steadily over the past few years.
Combining the expertise of neonatologists, pediatric clinical pharmacologists and a multidisciplinary team of caregivers into a single NAS program has put Children’s Mercy Kansas City in a unique position to explore new methods for treating this growing problem.
Children's Mercy has developed a family-integrated process for infants at risk for Neonatal Abstinence Syndrome.
The goal moving forward is to work with area community hospitals to prenatally identify infants at risk for NAS and provide education to the family before birth.
Dr. Tamorah R. Lewis, a Neonatologist at Children’s Mercy Kansas City, is here to help families better understand NAS.
Neonatal Abstinence Syndrome: Exploring New Treatment Methods for a Growing Problem
Featured Speaker:
Learn more about Dr. Lewis
Tamorah R. Lewis, MD, PhD
Dr. Lewis is a Neonatologist at Children’s Mercy Kansas City and an Assistant Professor at the University of Missouri-Kansas City School of Medicine. She completed a combined fellowship in Neonatal/Perinatal Medicine and Clinical Pharmacology at the Johns Hopkins University School of Medicine. She is a clinical neonatologist with a research interest in clinical pharmacology, drug development and optimizing clinical trial designs. Her research interests include population pharmacokinetic and pharmacodynamic investigations in neonates, pertaining to both drugs in common use and drugs under development. The intersection between ontogeny and pharmacogenetic effects on the PK and PD of drugs in infants and neonates is also a future direction of her research. In fellowship, her research focused on optimization of pharmacologic management of Neonatal Abstinence Syndrome via elucidating the mechanisms behind current and future therapies.Learn more about Dr. Lewis
Transcription:
Neonatal Abstinence Syndrome: Exploring New Treatment Methods for a Growing Problem
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is Neonatal Abstinence Syndrome, Exploring New Treatment Methods for a Growing Problem. My guest is Dr. Tamara Lewis. Dr. Lewis is a Neonatologist at Children’s Mercy Kansas City and an Assistant Professor at the University of Missouri Kansas City School of Medicine. Dr. Lewis, welcome to the show.
Dr. Tamara Lewis (Guest): Thank you for having me.
Dr. Smith: How big of a problem is Neonatal Abstinence Syndrome?
Dr. Lewis: Well, I think that many pediatricians and neonatologists around the county subjectively feel that we are seeing an increase in the number of newborns are affected by in utero drug exposure. In the past few years, there have been some nice epidemiologic studies that give us actual proof of the increase in Neonatal Abstinence Syndrome. One study published in JAMA by Dr. Patrick in 2012 showed a tripling of the discharge diagnosis of Neonatal Abstinence Syndrome in newborns between 2000 and 2009. Specifically, the rate increased from 1.2 infants per 1000 live births to 2.4 infants per 1000 live births. This increase in Neonatal Abstinence Syndrome was confirmed in another study published by Dr. Tollia and colleagues in the New England Journal of Medicine in 2015. This group showed that in a large nationally representative database, the number of infants admitted to the Neonatal ICU for abstinence increased from 7 per 1000 to 27 per 1000 over a decade. Shockingly, there were eight centers that reported that more than 20% of their NICU/ICU days were due to inpatient Neonatal Abstinence Syndrome treatment. So, there is objective evidence that there is indeed a national increase in Neonatal Abstinence Syndrome in the United States.
Dr. Smith: You know when you hear some of those numbers tripling in one study, that’s pretty alarming. Why do you think we are seeing that increase? Are we just prescribing more narcotics and opioids? What’s your opinion there?
Dr. Lewis: I think 15 years ago, the majority of Neonatal Abstinence Syndrome was from either illicit drug use by pregnant women, namely heroin, or prescription opiate use during pregnancy but in the setting of illicit drug treatment. So, what I mean by that is a mother that was addicted to heroin pre-conception and then enrolled in a methadone or buprenorphine treatment program during the pregnancy. But 15 or 20 years ago, this phenomena of short-acting prescription opiate abuse was not really widespread. I’d say in the past decade with the extreme boom of prescription opiates like oxycodone, hydrocodone, OxyContin, you know, there are many different populations that are becoming increasingly addicted to these medications. Unfortunately, women of child-bearing age are one such population. If a mom is addicted to prescription opiate medications before she gets pregnant, it’s uncommon for her to be able to stop due to the pregnancy and so part of the problem is, indeed, the large increase in prescription opiate abuse in this country.
Dr. Smith: In most cases, as you are saying, it’s narcotics and opioids. Are there other drugs that you are seeing causing Neonatal Abstinence Syndrome?
Dr. Lewis: Neonatal Abstinence Syndrome is typically thought to define the clinical symptoms of in utero opiate exposure but it’s actually fairly common, one would almost say the norm, for there to be polysubstance exposure in utero. Oftentimes, a baby is exposed to an opiate plus an anti-depressant medication or an opiate plus a benzodiazepine plus alcohol. So, Neonatal Abstinence Syndrome is very well-defined for opiate exposure but we know that you can see symptoms of exposure from other medications. Interestingly, there’s been reports of a neonatal symptomatology after in utero exposure to SSRI’s – a class of anti-depressants that are serotonin reuptake inhibitors. Although it’s not as severe as the withdrawal you get after in utero opiate exposure, that’s a type of medication withdraw that’s increasingly been seen and described.
Dr. Smith: What is Children’s Mercy doing to address the growing problem?
Dr. Lewis: Well, I think Children’s Mercy Hospital is taking a few different approaches. There’s kind of a clinical approach and a research approach. The clinical approach includes the very hard work that Dr. Jody Jackson and colleagues in the peripheral Children’s Mercy NICU such as Shawnee Mission Medical Center have done to improve the care of these pregnant women and their newborns. So, there’s a program that is comprehensive and includes prenatal consults to the women that are opiate dependent during pregnancy. The same doctors take care of the moms through the perinatal period and the mothers are well educated and well informed before the baby is even born about what to expect in the neonatal period, what Neonatal Abstinence Syndrome looks like, how it will be monitored and how it will be treated. I think that takes a lot of the stigma and a lot of the fear and worry off of these families because the education and the treatment is actually started before the baby is even born. That’s been a very successful program at Children’s Mercy. The second approach….
Dr. Smith: It sounds like there’s a lot of…Oh, go ahead. I’m sorry.
Dr. Lewis: The second approach is research. I joined the faculty as a combined Neonatologist and Clinical Pharmacologist and my personal research will focus on not only how to best take care of the babies after their born but actually how to address the problem even earlier during the pregnancy. Because the problem with Neonatal Abstinence Syndrome is that once the baby is born, essentially the damage is done. So, I’m launching a large multi-site clinical trial in the Kansas City area to understand the genetic determinants of placental opiate transfer and how that affects the severity of NAS or Neonatal Abstinence Syndrome once the baby is born.
Dr. Smith: Very nice. Dr. Lewis, thank you for all that you’re doing. It’s obviously very important work and I appreciate everything that you’ve done for Children’s Mercy. I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Mike Smith. Have a great day.
Neonatal Abstinence Syndrome: Exploring New Treatment Methods for a Growing Problem
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is Neonatal Abstinence Syndrome, Exploring New Treatment Methods for a Growing Problem. My guest is Dr. Tamara Lewis. Dr. Lewis is a Neonatologist at Children’s Mercy Kansas City and an Assistant Professor at the University of Missouri Kansas City School of Medicine. Dr. Lewis, welcome to the show.
Dr. Tamara Lewis (Guest): Thank you for having me.
Dr. Smith: How big of a problem is Neonatal Abstinence Syndrome?
Dr. Lewis: Well, I think that many pediatricians and neonatologists around the county subjectively feel that we are seeing an increase in the number of newborns are affected by in utero drug exposure. In the past few years, there have been some nice epidemiologic studies that give us actual proof of the increase in Neonatal Abstinence Syndrome. One study published in JAMA by Dr. Patrick in 2012 showed a tripling of the discharge diagnosis of Neonatal Abstinence Syndrome in newborns between 2000 and 2009. Specifically, the rate increased from 1.2 infants per 1000 live births to 2.4 infants per 1000 live births. This increase in Neonatal Abstinence Syndrome was confirmed in another study published by Dr. Tollia and colleagues in the New England Journal of Medicine in 2015. This group showed that in a large nationally representative database, the number of infants admitted to the Neonatal ICU for abstinence increased from 7 per 1000 to 27 per 1000 over a decade. Shockingly, there were eight centers that reported that more than 20% of their NICU/ICU days were due to inpatient Neonatal Abstinence Syndrome treatment. So, there is objective evidence that there is indeed a national increase in Neonatal Abstinence Syndrome in the United States.
Dr. Smith: You know when you hear some of those numbers tripling in one study, that’s pretty alarming. Why do you think we are seeing that increase? Are we just prescribing more narcotics and opioids? What’s your opinion there?
Dr. Lewis: I think 15 years ago, the majority of Neonatal Abstinence Syndrome was from either illicit drug use by pregnant women, namely heroin, or prescription opiate use during pregnancy but in the setting of illicit drug treatment. So, what I mean by that is a mother that was addicted to heroin pre-conception and then enrolled in a methadone or buprenorphine treatment program during the pregnancy. But 15 or 20 years ago, this phenomena of short-acting prescription opiate abuse was not really widespread. I’d say in the past decade with the extreme boom of prescription opiates like oxycodone, hydrocodone, OxyContin, you know, there are many different populations that are becoming increasingly addicted to these medications. Unfortunately, women of child-bearing age are one such population. If a mom is addicted to prescription opiate medications before she gets pregnant, it’s uncommon for her to be able to stop due to the pregnancy and so part of the problem is, indeed, the large increase in prescription opiate abuse in this country.
Dr. Smith: In most cases, as you are saying, it’s narcotics and opioids. Are there other drugs that you are seeing causing Neonatal Abstinence Syndrome?
Dr. Lewis: Neonatal Abstinence Syndrome is typically thought to define the clinical symptoms of in utero opiate exposure but it’s actually fairly common, one would almost say the norm, for there to be polysubstance exposure in utero. Oftentimes, a baby is exposed to an opiate plus an anti-depressant medication or an opiate plus a benzodiazepine plus alcohol. So, Neonatal Abstinence Syndrome is very well-defined for opiate exposure but we know that you can see symptoms of exposure from other medications. Interestingly, there’s been reports of a neonatal symptomatology after in utero exposure to SSRI’s – a class of anti-depressants that are serotonin reuptake inhibitors. Although it’s not as severe as the withdrawal you get after in utero opiate exposure, that’s a type of medication withdraw that’s increasingly been seen and described.
Dr. Smith: What is Children’s Mercy doing to address the growing problem?
Dr. Lewis: Well, I think Children’s Mercy Hospital is taking a few different approaches. There’s kind of a clinical approach and a research approach. The clinical approach includes the very hard work that Dr. Jody Jackson and colleagues in the peripheral Children’s Mercy NICU such as Shawnee Mission Medical Center have done to improve the care of these pregnant women and their newborns. So, there’s a program that is comprehensive and includes prenatal consults to the women that are opiate dependent during pregnancy. The same doctors take care of the moms through the perinatal period and the mothers are well educated and well informed before the baby is even born about what to expect in the neonatal period, what Neonatal Abstinence Syndrome looks like, how it will be monitored and how it will be treated. I think that takes a lot of the stigma and a lot of the fear and worry off of these families because the education and the treatment is actually started before the baby is even born. That’s been a very successful program at Children’s Mercy. The second approach….
Dr. Smith: It sounds like there’s a lot of…Oh, go ahead. I’m sorry.
Dr. Lewis: The second approach is research. I joined the faculty as a combined Neonatologist and Clinical Pharmacologist and my personal research will focus on not only how to best take care of the babies after their born but actually how to address the problem even earlier during the pregnancy. Because the problem with Neonatal Abstinence Syndrome is that once the baby is born, essentially the damage is done. So, I’m launching a large multi-site clinical trial in the Kansas City area to understand the genetic determinants of placental opiate transfer and how that affects the severity of NAS or Neonatal Abstinence Syndrome once the baby is born.
Dr. Smith: Very nice. Dr. Lewis, thank you for all that you’re doing. It’s obviously very important work and I appreciate everything that you’ve done for Children’s Mercy. I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Mike Smith. Have a great day.