Neonatal abstinence syndrome (NAS) is a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. It is estimated that 3 to 50 percent of newborn babies have been exposed to maternal drug use, depending on the population and area of the country.
In this segment, Dr Steve Liao, MD, Washington University Neonatal-Perinatal medicine physician at St. Louis Children's Hospital, discusses NAS and when a pediatrician should refer to a specialist.
Neonatal Abstinence Syndrome
Featured Speaker:
Learn more about Steve Liao, MD
Steve Liao, MD
Steve Liao, MD, is a Washington University Neonatal-Perinatal medicine physician at St. Louis Children’s Hospital.Learn more about Steve Liao, MD
Transcription:
Neonatal Abstinence Syndrome
Melanie Cole (Host): Neonatal abstinence syndrome is a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. It’s estimated that 3 to 50% of newborn babies have been exposed to maternal drug use depending on the population and area of the country. My guest today, is Dr. Steve Liao. He’s a Washington University neonatologist at Saint Louis Children’s Hospital. Welcome to the show, Dr. Liao. What is neonatal abstinence syndrome?
Dr. Steve Liao (Guest): Thank you, so much, for inviting me to talk about this very important issue that’s been gaining a lot of attention both in the professional world and also in public press. Neonatal abstinence syndrome is the occurrence of neonatal withdrawal symptoms as a result of intrauterine exposure to drugs. It can happen with many drugs or medications used by mothers during pregnancy, such as caffeine, heroin, painkillers, tobacco, and antidepressant medications. However, most of the time when people are talking about using the term neonatal abstinence syndrome, or NAS for short, we’re usually talking about withdrawal symptoms associated with opioid exposure. Neonatal opioid withdrawal can cause really significant symptoms in the newborn period, such as autonomic instability when they have a temperature or breathing control issues, tremors, irritability, poor feeding, loose stool, poor weight gain, and there are even reports of seizures that have happened. That’s obviously more rare.
Melanie: Have you been seeing a rising incidence in NAS as there is an epidemic of maternal opioid use during pregnancy?
Dr. Liao: Oh, absolutely. Nationally, the rate of NAS more than doubled from 3.6 per thousand live births in 2009 to 7.3 per thousand births in 2013. At the same time, we’re also seeing a five-fold increase in the maternal use of narcotics or opioids during pregnancy. In certain areas of the country, NAS is even more of a problem. For example, there are some reports in Kentucky – this is research studies – incidences up to 23 per thousand births in 2014. Remember, the national average, the most recent data we have is 7.3 per thousand.
Speaking locally, our most recent data from our delivering hospital in an urban setting, our rate can be up to 15 to 20 per thousand births, so this is a real issue for us. Speaking of prescription opioid epidemics, 28% of pregnant mothers fill at least one opioid prescription during pregnancy. Prescriptions for opioid pain medication increased from 76 million in 1991 to 207 million in 2013. This is enough for every adult in the US to have one prescription for opioids, so this is a lot. We can do better.
Melanie: Wow. Is there a lack of prescription monitoring program in Missouri?
Dr. Liao: Unfortunately, we live in a state that’s the only state without a statewide prescription monitoring program. Not for lack of trying, though. I think the most recent bill that’s been put forth for the fourth time in a row recently just failed again. I have to say I’m proud of our own local government, Saint Louis County, Saint Louis City, have actually already passed our own version of prescription drug monitoring programs. Certainly, physicians, and pharmacists, and clinicians within our local area do have access to a database. It started actually fairly recently this year, but then we can definitely benefit from having a state-wide program to try and – studies certainly show from many other states that once they implemented a prescription drug monitoring program, the pattern of use decreases, the total number of opioid prescription, total volume, and total exposure all decrease. It’s definitely beneficial, and we certainly need to put a lot more effort into passing a similar program here in Missouri.
Melanie: Dr. Liao, what would you tell the obstetrician-gynecologist that’s delivering -- if they have no idea of maternal drug use in the past, what would you like them to know about diagnosing and screening – the identification of infants at risk?
Dr. Liao: That’s definitely a very important first step. I think the traditional neonatal abstinence syndrome – I mean we talked about neonatal issues, but this is – the problem really starts from even before pregnancy begins. I think our obstetrician colleague definitely has a very important role in terms of educating the family. It’s very unfortunate sometimes that the family when they first heard about the potential of having their baby going through withdrawal is at the time when they’re actually in the hospital delivering the baby.
I think that we definitely need to do a better job during their prenatal visits or even before the family is thinking about doing family planning. We need to start talking about their prescription drug use, their illicit drug use, and we need to approach it in a very caring, non-judgmental way, so we can retain this trusting relationship between the families and physicians. I would much rather have the moms come to the obstetricians for prenatal care versus having them be afraid to seek help during their pregnancy because we know for sure that the family and the babies would benefit from having good prenatal care and a good relationship with obstetricians.
Melanie: What about observation for symptoms in the hospital after birth? What assessment tools do you use?
Dr. Liao: This is also very important. The pediatricians and also our nurses and clinical staff are trained to be very vigilant based on the available history, the pregnancy history, maternal medication history, and drug use. If we are able to identify some risk factors during their hospital stay, a lot of these babies will have to be observed in the hospital for potential withdrawal. A lot of times it depends on what type of medication you’re using. If you’re using a short-acting drug or medication – for example, if a mother is taking heroin, often times the babies will go through withdrawal within the first 24-hours. You’ll definitely know it right away, usually within the first day. If a mother comes in on a methadone rehab program or is taking chronic pain medications for back pain, for example, then potentially these symptoms may not come until the third, or fourth, or fifth day of life.
We always try our best to educate the family, letting them know – hopefully even well before they come into the labor and delivery floor – that there’s a high possibility because of their drug history that the baby will have to be observed in the hospital for a certain amount of days. Our protocol here is anywhere between 48-hours to 7-days to make sure that the baby is not going through withdrawal and that we’re not running the risk of sending a baby home going through withdrawal at home. That will definitely cause a lot of safety concerns. It could definitely cause a lot of burden for the family to take care of a baby like that at home. We do actually try our best to be able to have the baby room in with the mother if we can. We also try to encourage active bonding and positive interaction between the parents and the baby during their hospital stay because we know for sure that also makes their symptoms better.
Melanie: Is there optimal treatment for NAS? Has that been established yet? And speak a little bit about pharmacological treatment, what are you doing for the infant?
Dr. Liao: That is a very good question. I’ve done recently a lot of reading and searching through literature and working with lots of experts within our hospital recently. There’s certainly – this is an area of active research. People have shown that rooming in, as I mentioned before, potentially could shorten the length of stay for these babies and help lessen the symptoms for these babies. There are other non-pharmacological treatments available for these babies during their hospital stay, such as having them in a non-stimulating, quiet, dimly-lit room, and encouraging breastfeeding when appropriate. And also, gentle massages, a cluster of care from their nursing staff and also from their family, and appropriate swaddling for the babies, making them feel comfortable, frequent, small amounts of feeding, providing breast milk versus – high caloric intake, high-calorie formula if breast milk is not available.
There are many, many things that we can do to try to make a baby more comfortable during their hospitalization before we think about using a pharmacological treatment. However, unfortunately, sometimes the baby’s symptoms are so severe that we, based on a set of objective scoring system, we may have to start pharmacological treatment. Across the country, the most commonly used, first-line of treatment is morphine. There is a set dose that we give to the baby over regular intervals, and then once we start the morphine treatment we will have to continue to monitor their symptoms, continue to use the Finnegan Scoring System to objectively evaluate the effectiveness of the treatments. Based on these scores and based on the clinical decision algorithm that’s standardized in our hospital we can adjust the dose to help the baby, and over time, slowly wean them off of the medication as they get better.
Now, I mentioned a lot of these things that potentially could help, it’s also very important to know that I truly don’t think that there is – if people are looking for a cookie-cutter way of managing these babies, unfortunately, I think many studies show that there is no such thing as a cookie-cutter standardized management that you can just go step-by-step and just line-by-line. The goal is to observe the baby, observe for symptoms, and the goal is to do everything we can to make them comfortable and then safely withdraw from the drug in their system, and then to make sure that these babies will have a safe environment and is in good health condition to go home where the family can continue their care at home.
There are potential – I think rather than having a right answer or right approach, I’d rather refer to them as guidelines – as potential better practices where the care should be tailored, but in a very consistent way.
Melanie: So, in summary, Doctor, let other pediatricians – what you’d like them to know about recognizing neonatal abstinence syndrome and when they should refer to a neonatologist?
Dr. Liao: I think not just to the local pediatricians, but I’d also like to speak to all healthcare professionals – our O-B colleagues, our nursing colleagues, and also social workers, and therapists, and all of the clinicians that are involved – I think all of this is a team approach. This is a problem that’s increasing. This is a problem that’s causing a lot of money – it’s causing a lot of stress for the family, and it is a problem that we definitely need to get better at.
For me, the most important thing is education -- the education of the family about the potential danger of babies going through withdrawal. This is a potential side-effect of -- any drug that we give to anybody potentially has side-effects, right? This could be a potential side-effect when the mothers are on their painkillers – pain medication during pregnancy. We need to let them know – be aware of the potential side-effects. When we identify pregnant mothers with drug addiction issues, it doesn’t have to be heroin; it can be pain killers that, unfortunately, they get addicted to. Simply, they don’t know, and then they just keep taking it, and then they start going to their doctors to ask for more. We need to pay special attention to these cases and then provide a caring approach -- a non-judgmental, non-biased approach to help them realize the potential issue and to help them seek help and direct them to community resources to make sure that the baby is safe and the mother is safe, as well.
So that’s number one, definitely, is the education of the family. And also, increased awareness of our healthcare colleagues in the hospital to be vigilant about identifying potential risky babies who may be exposed in-utero, and do a good job at screening them to make sure that we don’t let them fall through the cracks. And once we identify them in the hospital, to do a very good job of communicating with the families, communicating with O-B, communicating with the nursing staff, that everybody’s on the same page, and then we observe them to make sure that they have a very good, safe environment to withdrawal, and a safe environment to go home and for the family to continue their care.
As for local pediatricians, I can’t stress enough the importance of their role in the community. Once these babies go home, they will definitely need to be followed. Studies show that these babies potentially down the road will have cognitive problems. Studies show that these babies don’t do as well in school systems. They definitely need to have a close follow-up, and we can provide intervention for them to the best of our ability. The local pediatricians definitely need to be very aware once these babies are going home. Like I said, I think this is a team approach. It’s a compassionate approach, and I think together we can definitely take care of this problem much better.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678- 4357. You’re listening to Radio Rounds with Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.
Neonatal Abstinence Syndrome
Melanie Cole (Host): Neonatal abstinence syndrome is a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. It’s estimated that 3 to 50% of newborn babies have been exposed to maternal drug use depending on the population and area of the country. My guest today, is Dr. Steve Liao. He’s a Washington University neonatologist at Saint Louis Children’s Hospital. Welcome to the show, Dr. Liao. What is neonatal abstinence syndrome?
Dr. Steve Liao (Guest): Thank you, so much, for inviting me to talk about this very important issue that’s been gaining a lot of attention both in the professional world and also in public press. Neonatal abstinence syndrome is the occurrence of neonatal withdrawal symptoms as a result of intrauterine exposure to drugs. It can happen with many drugs or medications used by mothers during pregnancy, such as caffeine, heroin, painkillers, tobacco, and antidepressant medications. However, most of the time when people are talking about using the term neonatal abstinence syndrome, or NAS for short, we’re usually talking about withdrawal symptoms associated with opioid exposure. Neonatal opioid withdrawal can cause really significant symptoms in the newborn period, such as autonomic instability when they have a temperature or breathing control issues, tremors, irritability, poor feeding, loose stool, poor weight gain, and there are even reports of seizures that have happened. That’s obviously more rare.
Melanie: Have you been seeing a rising incidence in NAS as there is an epidemic of maternal opioid use during pregnancy?
Dr. Liao: Oh, absolutely. Nationally, the rate of NAS more than doubled from 3.6 per thousand live births in 2009 to 7.3 per thousand births in 2013. At the same time, we’re also seeing a five-fold increase in the maternal use of narcotics or opioids during pregnancy. In certain areas of the country, NAS is even more of a problem. For example, there are some reports in Kentucky – this is research studies – incidences up to 23 per thousand births in 2014. Remember, the national average, the most recent data we have is 7.3 per thousand.
Speaking locally, our most recent data from our delivering hospital in an urban setting, our rate can be up to 15 to 20 per thousand births, so this is a real issue for us. Speaking of prescription opioid epidemics, 28% of pregnant mothers fill at least one opioid prescription during pregnancy. Prescriptions for opioid pain medication increased from 76 million in 1991 to 207 million in 2013. This is enough for every adult in the US to have one prescription for opioids, so this is a lot. We can do better.
Melanie: Wow. Is there a lack of prescription monitoring program in Missouri?
Dr. Liao: Unfortunately, we live in a state that’s the only state without a statewide prescription monitoring program. Not for lack of trying, though. I think the most recent bill that’s been put forth for the fourth time in a row recently just failed again. I have to say I’m proud of our own local government, Saint Louis County, Saint Louis City, have actually already passed our own version of prescription drug monitoring programs. Certainly, physicians, and pharmacists, and clinicians within our local area do have access to a database. It started actually fairly recently this year, but then we can definitely benefit from having a state-wide program to try and – studies certainly show from many other states that once they implemented a prescription drug monitoring program, the pattern of use decreases, the total number of opioid prescription, total volume, and total exposure all decrease. It’s definitely beneficial, and we certainly need to put a lot more effort into passing a similar program here in Missouri.
Melanie: Dr. Liao, what would you tell the obstetrician-gynecologist that’s delivering -- if they have no idea of maternal drug use in the past, what would you like them to know about diagnosing and screening – the identification of infants at risk?
Dr. Liao: That’s definitely a very important first step. I think the traditional neonatal abstinence syndrome – I mean we talked about neonatal issues, but this is – the problem really starts from even before pregnancy begins. I think our obstetrician colleague definitely has a very important role in terms of educating the family. It’s very unfortunate sometimes that the family when they first heard about the potential of having their baby going through withdrawal is at the time when they’re actually in the hospital delivering the baby.
I think that we definitely need to do a better job during their prenatal visits or even before the family is thinking about doing family planning. We need to start talking about their prescription drug use, their illicit drug use, and we need to approach it in a very caring, non-judgmental way, so we can retain this trusting relationship between the families and physicians. I would much rather have the moms come to the obstetricians for prenatal care versus having them be afraid to seek help during their pregnancy because we know for sure that the family and the babies would benefit from having good prenatal care and a good relationship with obstetricians.
Melanie: What about observation for symptoms in the hospital after birth? What assessment tools do you use?
Dr. Liao: This is also very important. The pediatricians and also our nurses and clinical staff are trained to be very vigilant based on the available history, the pregnancy history, maternal medication history, and drug use. If we are able to identify some risk factors during their hospital stay, a lot of these babies will have to be observed in the hospital for potential withdrawal. A lot of times it depends on what type of medication you’re using. If you’re using a short-acting drug or medication – for example, if a mother is taking heroin, often times the babies will go through withdrawal within the first 24-hours. You’ll definitely know it right away, usually within the first day. If a mother comes in on a methadone rehab program or is taking chronic pain medications for back pain, for example, then potentially these symptoms may not come until the third, or fourth, or fifth day of life.
We always try our best to educate the family, letting them know – hopefully even well before they come into the labor and delivery floor – that there’s a high possibility because of their drug history that the baby will have to be observed in the hospital for a certain amount of days. Our protocol here is anywhere between 48-hours to 7-days to make sure that the baby is not going through withdrawal and that we’re not running the risk of sending a baby home going through withdrawal at home. That will definitely cause a lot of safety concerns. It could definitely cause a lot of burden for the family to take care of a baby like that at home. We do actually try our best to be able to have the baby room in with the mother if we can. We also try to encourage active bonding and positive interaction between the parents and the baby during their hospital stay because we know for sure that also makes their symptoms better.
Melanie: Is there optimal treatment for NAS? Has that been established yet? And speak a little bit about pharmacological treatment, what are you doing for the infant?
Dr. Liao: That is a very good question. I’ve done recently a lot of reading and searching through literature and working with lots of experts within our hospital recently. There’s certainly – this is an area of active research. People have shown that rooming in, as I mentioned before, potentially could shorten the length of stay for these babies and help lessen the symptoms for these babies. There are other non-pharmacological treatments available for these babies during their hospital stay, such as having them in a non-stimulating, quiet, dimly-lit room, and encouraging breastfeeding when appropriate. And also, gentle massages, a cluster of care from their nursing staff and also from their family, and appropriate swaddling for the babies, making them feel comfortable, frequent, small amounts of feeding, providing breast milk versus – high caloric intake, high-calorie formula if breast milk is not available.
There are many, many things that we can do to try to make a baby more comfortable during their hospitalization before we think about using a pharmacological treatment. However, unfortunately, sometimes the baby’s symptoms are so severe that we, based on a set of objective scoring system, we may have to start pharmacological treatment. Across the country, the most commonly used, first-line of treatment is morphine. There is a set dose that we give to the baby over regular intervals, and then once we start the morphine treatment we will have to continue to monitor their symptoms, continue to use the Finnegan Scoring System to objectively evaluate the effectiveness of the treatments. Based on these scores and based on the clinical decision algorithm that’s standardized in our hospital we can adjust the dose to help the baby, and over time, slowly wean them off of the medication as they get better.
Now, I mentioned a lot of these things that potentially could help, it’s also very important to know that I truly don’t think that there is – if people are looking for a cookie-cutter way of managing these babies, unfortunately, I think many studies show that there is no such thing as a cookie-cutter standardized management that you can just go step-by-step and just line-by-line. The goal is to observe the baby, observe for symptoms, and the goal is to do everything we can to make them comfortable and then safely withdraw from the drug in their system, and then to make sure that these babies will have a safe environment and is in good health condition to go home where the family can continue their care at home.
There are potential – I think rather than having a right answer or right approach, I’d rather refer to them as guidelines – as potential better practices where the care should be tailored, but in a very consistent way.
Melanie: So, in summary, Doctor, let other pediatricians – what you’d like them to know about recognizing neonatal abstinence syndrome and when they should refer to a neonatologist?
Dr. Liao: I think not just to the local pediatricians, but I’d also like to speak to all healthcare professionals – our O-B colleagues, our nursing colleagues, and also social workers, and therapists, and all of the clinicians that are involved – I think all of this is a team approach. This is a problem that’s increasing. This is a problem that’s causing a lot of money – it’s causing a lot of stress for the family, and it is a problem that we definitely need to get better at.
For me, the most important thing is education -- the education of the family about the potential danger of babies going through withdrawal. This is a potential side-effect of -- any drug that we give to anybody potentially has side-effects, right? This could be a potential side-effect when the mothers are on their painkillers – pain medication during pregnancy. We need to let them know – be aware of the potential side-effects. When we identify pregnant mothers with drug addiction issues, it doesn’t have to be heroin; it can be pain killers that, unfortunately, they get addicted to. Simply, they don’t know, and then they just keep taking it, and then they start going to their doctors to ask for more. We need to pay special attention to these cases and then provide a caring approach -- a non-judgmental, non-biased approach to help them realize the potential issue and to help them seek help and direct them to community resources to make sure that the baby is safe and the mother is safe, as well.
So that’s number one, definitely, is the education of the family. And also, increased awareness of our healthcare colleagues in the hospital to be vigilant about identifying potential risky babies who may be exposed in-utero, and do a good job at screening them to make sure that we don’t let them fall through the cracks. And once we identify them in the hospital, to do a very good job of communicating with the families, communicating with O-B, communicating with the nursing staff, that everybody’s on the same page, and then we observe them to make sure that they have a very good, safe environment to withdrawal, and a safe environment to go home and for the family to continue their care.
As for local pediatricians, I can’t stress enough the importance of their role in the community. Once these babies go home, they will definitely need to be followed. Studies show that these babies potentially down the road will have cognitive problems. Studies show that these babies don’t do as well in school systems. They definitely need to have a close follow-up, and we can provide intervention for them to the best of our ability. The local pediatricians definitely need to be very aware once these babies are going home. Like I said, I think this is a team approach. It’s a compassionate approach, and I think together we can definitely take care of this problem much better.
Melanie: Thank you, so much, for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678- 4357. You’re listening to Radio Rounds with Saint Louis Children’s Hospital. For more information on resources available at Saint Louis Children’s Hospital, you can go to SaintLouisChildrens.org, that’s SaintLouisChildrens.org. This is Melanie Cole. Thanks, so much for listening.