Pediatrics group issues guideline on neonatal opioid withdrawal syndrome

Abstract

The opioid crisis in the United States affects everyone—including pregnant women. As opioid use disorder (OUD) increased in the general population, it also increased for pregnant women. In November, the American Academy of Pediatrics (AAP) published a clinical report with recommendations for neonatal opioid withdrawal syndrome (NOWS). For mothers with OUD, optimal care includes either methadone or buprenorphine replacement therapy, according to the report. Despite clear data on the safety and efficacy of these drugs, however, barriers limit access to OUD therapies. The guideline authors, led by Stephen Patrick, MD, from Vanderbilt University Medical Center, cite social, economic, and environmental factors as primary barriers, as well as systemic racism and mental health issues in patients. NOWS requires chronic exposure to opioids throughout the pregnancy, not exposure around the time of delivery. Factors such as opioid type and maternal and fetal pharmacokinetics affect the presentation of NOWS. Concurrent use of benzodiazepine, gabapentin, or nicotine can impact the onset, severity, and/or duration. Methadone and buprenorphine used to treat OUD do not have this same relationship, the guideline authors said. Symptoms of NOWS include irritability, loose/watery stools, vomiting, sweating, fever, increased respiratory rate, frequent yawning and sneezing, nasal stuffiness, nasal flaring, and even seizures. These withdrawal symptoms may begin within 24 hours of birth for opioids excreted/metabolized quickly (heroin) or up to 3 days for longer acting opioids (methadone). To further complicate presentation, sometimes these symptoms do not show up until day 7, when many infants have been discharged from the hospital, the authors noted. This is why screening for OUD is important for the duration of a patient's pregnancy. Diagnosing NOWS is challenging because there is no single agreed-upon scoring system for diagnosis. Multiple scoring tools are available. A newer tool, called the Eat, Sleep, Console (ESC), is easy to use and can help guide treatment decisions. Infants are evaluated on their ability to eat 1 ounce or more (or breastfeed well), sleep undisturbed for 1 hour or longer, and be consoled. If any of these three items are not met, the medical team should discuss environment changes, as well as nonpharmacologic and pharmacologic approaches to NOWS management. The guideline authors recommend that health systems decide which scoring tool to use and focus heavily on standardizing the scoring process at their institution. This standardization is valuable because evaluation in some scoring tools is subjective. AAP does not endorse any specific scoring tool, as studies do not show any to be clearly superior to another. Managing an infant after chronic opioid exposure should occur for at least 72 hours, according to the guideline. In addition, nonpharmacologic management—such as a dimly lit environment for an overactive infant or swaddling for an infant with hypertonia—are helpful, stated the authors. For infants with severe NOWS, pharmacotherapy is warranted. Opioids are first-line agents for opioid withdrawal, and the most common first-line agent is morphine. Methadone or buprenorphine are also appropriate to consider. Common secondary agents for NOWS include phenobarbital and clonidine. However, phenobarbital has been shown to be associated with neurotoxicity and adverse developmental outcomes and should be avoided. Secondary agents may be useful if the primary agent does not adequately treat the infant's withdrawal symptoms. Agents with a high alcohol content (some formulations of buprenorphine), tincture of opium, or tincture of opioid should not be used for NOWS, the authors stated. Following discharge from the hospital, mothers are at risk for losing access to medications to treat OUD, and this risk could translate to overdose death. The authors stressed that it is important to make sure mothers have additional support and that OUD treatment is not interrupted. According to the guideline, an infant with NOWS should be seen by a pediatrician within 48 hours of discharge and followed up 1 week later. Multiple studies have evaluated duration of outpatient drug therapy for infants with NOWS, but the lack of follow-up data makes evaluating outcomes difficult. For this reason, the guideline authors do not recommend outpatient opioid tapers for infants with NOWS unless a structured and comprehensive follow-up schedule has been established.