Hello everyone.
Today we will be discussing withdrawal babies also known as
neonatal abstinence disorder and these are the concepts that
we will be covering in this video, enjoy!
Meet Jane an expecting mom thrilled to be having her
first child. A few weeks before she found out
She was pregnant
She had gotten a leg injury and had to undergo
surgery,
the pain was unbearable and the doctor prescribed opioids to
help Jane relieve her pain.
Her body was quick to get dependant on it and
ever since she's been taking opioids to prevent
any withdrawal symptoms,
she was unaware of the risks posed to her baby
through her use of opioids and so she continued to
do so throughout her pregnancy.
Unfortunately for Jane her baby
Bella was born and diagnosed with neonatal abstinence syndrome or NAS for short.
This is a term
that describes a collection of withdrawal symptoms
that arise when a newborn is exposed to certain substances
such as opioids in the womb before birth.
To clarify, opioids are drugs that travel through your blood
and to your brain and cause signals that muffle your perception of pain
and increase feelings of pleasure.
the most common,
cause of NAS is opioid usage such as heroin,
the use and misuse of prescription painkillers
but it could also include antidepressants, nicotine, caffeine, and even alcohol.
So what should Jane expect when her baby is born?
Well the reality is that NAS is a very complex disorder where the signs
and severity vary greatly amongst different infants and even in the same infant over time.
In fact, one can think of it as the symptoms
existing
on a continuum where the timing of exposure
during gestation AKA pregnancy
maternal stress associated with opioid use
poor maternal nutrition
or lack of medical or obstetric care can affect the fetus and the
intrauterine environment and consequently
the symptoms of NAS that end up manifesting. So let's take a step back.
We know that NAS is bad and we know that it leads to
signs and symptoms that are diverse, but why?
And what even are these different signs and symptoms?
Well,
to understand that we need to understand what normal development looks like.
In normal development, one forms a more integrated and diverse form of self-regulation as they grow
A skill that is vital for both the baby and the mother to monitor both their own
and the other's behavior and responses. There are 4 behavioral subsystems that help the infant interact with their environment.
The first is autonomic control this
encapsulates things that you cannot control such your heart rate and breathing
The second is motor and tone control.
this encapsulates muscle movement and the proportion
your body that is made up of muscle.
For example,
this system would help with the development of the muscles
in your leg that help you walk.
The third is state control and attention
this encapsulates the development in the amount of attention and ability that you use to focus
The fourth is sensory processing
This encapsulates the way that you take in information using
your senses and are able to interpret the world.
Hence, development of your vision as an example.
However, in NAS, development of one or more of these behavioral Systems are disrupted.
This causes dysregulation or an imbalance between these four systems that
translates to the various symptoms that can arise in each
individual case of a baby with NAS. For example,
an opioid-exposed infant could have extreme development in the Motor & Control System
which can lead to the development of too much muscle
and hence difficulty for the baby to move due to the resulting stiffness.
However,
as a result,
this baby will also not be able to spend as much
time developing in another system such as
perhaps attention and hence be unable to focus and be hypersensitive to stimuli.
To provide context, this could manifest so that they have difficulty achieving a quiet alert state that is necessary for feeding, and hence this would
result in weight loss.
As you and Jane have started to realize, there are
a whole variety of combinations of possible
symptoms and signs
that can arise, due to the several combinations of systems
that can be under or overdeveloped.
This table by Janson at al. depicts
this complicated interplay between the four subsystems and some of
the symptoms that can result. Feel free to pause the video at
this time to take a more comprehensive look.
So, why should we care about NAS, aside from the horrible
symptoms
these newborns have to experience that often last for
the entirety of their development?
Unfortunately,
the reality is cases, like
Jane and Bella aren't all that uncommon. As this graph depicts,
across Canada,
between 2010 and 2020 there were a whopping 16,920 total NAS
hospitalizations.
That's a 73% increase from 2010 and a 5% increase from 2019
When looking at 2020,
Now that we have learned about what NAS is, let's talk more about how Jane's
pregnancy is progressing.
In Jane's case,
her reliance on opioids to manage the pain from her
injury and continued use
In order to discourage withdrawal,
may have led to opioid use disorder. Opioids pass
through the mother's bloodstream and cross through the placenta, which is an organ
that develops in the uterus.
during pregnancy as a structure to provide oxygen and nutrients
to a growing baby effectively reaching the developing baby.
Even before Bella was born Jane's use of opioids could
have had a plethora of implications on Bella's development.
A study done with over 112 000
pregnant woman found that opioid-exposed infants
were more likely than unexposed infants to be born at
a low birth weight.
Other Studies have found a link between maternal opioid use
and congenital defects with oral clefts,
Ventricular and atrial septal defects otherwise known as holes in
the walls of the heart and clubfoot, which is a
condition describing foot abnormalities that cause it to be twisted
out of position as the most common ones.
Moreover opioid use during pregnancy can also lead to a
higher risk of miscarriage and maternal death and has been
linked to poor fetal growth, preterm births,
which means birth before 37 weeks of pregnancy,stillbirth and
other birth defects. Dealing with opioid use disorder while pregnant
can be an extremely difficult situation to navigate.
Even if Jane had been informed of the risks posed
to her baby and the possibility of neonatal abstinence syndrome
when she was already dependent on opioids during her pregnancy,
she would likely not have been recommended to quit the
drugs
Cold turkey. Quitting suddenly can cause severe consequences such as fetal distress,
preterm labor and miscarriage.
In fact,
current clinical recommendations include treatment using medication for opioid use disorder.
However,
the first-line therapy agents encompassing medicine for opioid use disorder
are methadone,
and buprenorphine,
which themselves also lend to expected
Neonatal abstinence syndrome within the baby upon birth.
Now that
Jane has given birth to her baby Bella
What is next?
Now to find out if Bella indeed has NAS,
a drug test,
would have to be performed on both Jane and Bella.
The drug test will also help determine the type and
Drug dose that is active within Bella's system.
Normally drug tests are done using blood saliva or urine
but for newborns
The preferred method is to use umbilical cord tissue or
meconium,
which is essentially the baby's first poop.
After the drug test comes back positive
and Bella has officially been diagnosed with NAS
her symptoms will be recorded using a scoring system to determine
whether she will need any type of medicinal therapy.
Amongst many scoring systems, the most common and comprehensive is the Finnegan
neonatal abstinence scoring system.
The Finnegan scoring system is a 31 item scale
that is used to measure the severity of NAS and
is a guide to possible treatments.
Each NAS symptom is given a numerical score between 1 to 5
depending on the severity.
And Bella will be scored every 4 hours until she
is stable.
Normally infant scoring above an 8 are recommended to receive
medication to help their symptoms.
In the meantime,
Bella will have to stay in the neonatal Intensive Care unit
otherwise known as a NICU until all her symptoms
have subsided,
the drug has left her system and the physician has
decided she is stable enough to leave. As Bella grows up
she is likely to experience a multitude of challenges including
sudden infant death syndrome.
Growth problems,
including difficulty
gaining weight, deformities of the head and face, heart defects
as well as hearing, and vision problems
She could also experience other ailments such as seizures and
significant,
cognitive, social,
and motor and development delays.
Some studies have even shown that children with NAS
are more likely to later get diagnosed with mental
health concerns
such as anxiety,
depression,
and ADHD,
Ultimately how can Jane help her daughter Bella?
Since Bella is having trouble feeding and is dehydrated
she may need to be fed extra calories through high-calorie,
baby formula,
and may need IV fluids.
However,
Bella may also require medicine to treat her severe symptoms,
such as seizures.
She will most likely be given the same family of
drugs that she was exposed to before birth.
Once the signs of withdrawal are controlled, then the
amount of medicine will be slowly
decreased
ultimately
helping Bella wean off the drug.
As you may have learned today
Neonatal abstinence syndrome is complicated and impacts the baby in
adverse ways.
If you're thinking about getting pregnant or are pregnant,
the best way to prevent NAS is to not use
NAS associated drugs throughout your pregnancy.
However,
if you are taking those drugs and are currently pregnant
talk to your health care provider.
Quitting drugs
at once can also cause serious problems for you and
your growing baby,
and therefore alternatives,
may be recommended by your doctor.
It is always good to be
informed as prevention is definitely better than a cure.