Ver el código de «Neonatal abstinence syndrome»

==Background==
*Condition caused by neonatal withdrawal from substance exposure in utero
**Withdrawal within first 24-48 hrs → fetal [[alcohol]] syndrome
**Withdrawal within 48-72 hrs → [[heroin]]
**Withdrawal at 7-14 days → [[methadone]]
*Incidence has quadrupled since 1999 from 1.5 per 1000 hospital births to 6.0 per 1000 in 2013<ref>Ko JY et al. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. Weekly / August 12, 2016 / 65(31);799–802.</ref>
*Polysubstance withdrawal must also be considered

==Clinical Features==
*Agitated - high-pitched cry, restlessness, [[tremor]]s, hypertonia, [[seizure (peds)|convulsions]]
*Vasomotor - sweating, [[fever (Peds)|fever]]
*Respiratory - nasal congestion, persistent sneezing, [[shortness of breath (peds)|RR > 60/min]], nasal flaring
*Metabolic - [[failure to thrive (peds)|poor feeding]], [[vomiting]], [[diarrhea (peds)|loose stools]]

==Differential Diagnosis==
*[[Neonatal sepsis]]
*[[Hyperthyroidism]]/[[hypothyroidism]]
*[[Hypocalcemia]]
*[[Hypoglycemia]]
*Vertically transmitted diseases ([[viral hepatitis]] [[HIV]], etc.)
*Other withdrawal ([[caffeine withdrawal|caffeine]], [[cocaine withdrawal|cocaine]], nicotine, [[amphetamines]], [[SSRIs]])

==Evaluation==
*Pharmacologic treatment when 3 consecutive ≥ 8 on NAS([http://www.lkpz.nl/docs/lkpz_pdf_1310485469.pdf Finnegan scale]
*Enzyme immunoassay, urine toxicology, meconium analysis
*Consider cranial [[ultrasound]] for cocaine-exposed neonates with abnormal neurologic signs

==Management==
*Supportive - swaddling to decrease sensory stimulation, frequent small feedings of 24 cal/oz formula
*[[Opioids]] when supportive measures fail
**[[Morphine]] is 1st line for infants exposed to '''both''' opioids and benzos
***Neonatal morphine 0.4mg/ml PO sln
****Watch for side effect limiting dose ([[urinary retention]])
****Withdrawal symptoms need to be stabilized for 3-5 days before taper
***Mother's [[methadone]] < 50mg (or other opiate)
****Start morphine PO sln 0.1mg/kg q3hrs with feeds
****Increase by 0.1mg/kg hourly if NAS score ≥ 8, max 1mg/kg
***Mother's methadone > 50mg
****Start 0.2mg/kg q3hrs
****Increase by 0.2mg/kg hourly if NAS score ≥ 8, max 1mg/kg
**If NPO, use preservative free morphine at 50 mcg/ml
***Load 30 mcg/kg over 1hr, then infusion at 2 mcg/kg/hr
***Increase by 1 mcg/kg/hr hourly until NAS < 8, max 6 mcg/kg/hr
*Longer acting [[buprenorphine]] may significantly reduce hospital admission and treatment duration as compared to morphine<ref>Kraft WK et al. Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome. May 4, 2017DOI: 10.1056/NEJMoa1614835.</ref>
**Morphine q4 hours vs. buprenorphine q8 hours if NAS scale > 12
**[[Buprenorphine]] dosed initially at 5 mcg/kg q8 hrs to max dose of 20 mcg/kg q8 hrs
*[[Benzodiazepine withdrawal]] treatment
**[[Midazolam]] 0.1mg/kg IV q3hrs or 0.3mg/kg PO q3hrs
**OR [[phenobarbital]] 3mg/kg IV or PO q24hrs
*[[Phenobarbital]] for seizures OR side effect limiting morphine effects OR max morphine dose reached
**16mg/kg load divided into two consecutive feedings for day 1
**24 hrs later, use 2-8mg/kg/day maintenance dose

==Disposition==
*Admit

==See Also==
*[[Opioid withdrawal]]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Toxicology]]