NEONATAL ABSTINENCE SYNDROME CASE STUDY DONE AT KILIFI COUNTY HOSPITAL

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JANE NURU,FLOICE OMBISO,JAMES GATIMU& MWANAMVUA BOGA

OUTLINE

• DEFINITION
• INTRODUCTION
• CLINICAL CASE PRESENTATION
• CLINICAL CASE MANAGEMENT
• PATIENT OUTCOME
• DISCUSSION
• CONCLUSION

DEFINITION

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• Neonatal Abstinence Syndrome (NAS) is a condition that affects newborns exposed to addictive substances, particularly opioids like methadone during pregnancy.
• NAS is characterized by a range of withdrawal symptoms that can occur shortly after birth including tremors, irritability, difficult feeding and in severe cases seizures.

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INTRODUCTION

• Globally the burden of NAS varies significantly due to differences in opioid use, health systems and reporting practices.
• According to the 2024 World Drug Report by the United Nations Office on Drug and Crime (UNODC) opioid use including heroin, remains a major concern.
• In Africa approximately 680,000-2.9 million people use opiates
• In Kenya heroin addiction burden in the last 3decades stands at 0.7% of the total population. Highest number of users being between the age of 15-64 years

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Beckerleg S, Telfer M, Hundt GL. The rise of injecting drug use in East Africa: A case study from Kenya. Harm Reduction Journal. 2005;2:1-9

NIDA. The Neurobiology of Drug Addiction Table of contents. 2007;(January):1-34 Available from: https://dl4rmgtrwzf5a. cloudfront.net /sites/default/files/1922-the- neurobiology-of-drug-addiction_2.pdf

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CASE PRESENTATION

• This is a case of a 5days old baby admitted in HDU at Kilifi county referral hospital, as a referral from Mtwapa subcounty hospital.
• Baby born at term via SVD with birth weight of 3.5kgs to a para 3+0 mother with heroin addiction for 18yrs.
• Mother has been on methadone and anti-retroviral therapy for the past four years
• The baby presented to the hospital with respiratory distress, hypoxia, fever, agitation, tachypnea and inability to feed.
• A diagnosis of Neonatal Abstinence Syndrome (NAS) in sero-exposed baby was made

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EXAMINATION AND FINDINGS ON ADMISSION

A – Airway was clear and patent.

B – SPO2 before oxygen 65% and 95% on high flow oxygen RR- 106 cycles/min with distress and chest indrawing

C – HR 175 b/min CRT 2sec, peripheral cyanosis

AVPU- A

E – Temp 38.2 degrees baby exposed

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BLOOD RESULTS

HB -17.9 g/dl WBC 13.6 platelets 138

Na+ 153 ( Ranges 133-143)

K+ 5.3 ( Ranges 3.7-5.4)

Creatinine 162 (26-43)

Bilirubin 90

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INITIAL MANAGEMENT DAY 1

• Oxygen therapy
• 1^st line antibiotics – Ampicillin ( 50mg/kg/dose BD) and Gentamicin( 5mg/kg OD)
• Anti-retroviral exposure prophylaxis AZT( 15mg/kg)1.5mls BD and Nevirapine (15mg/kg)1.5mls OD
• Intravenous fluids 10% dextrose/Ringers' lactate at 140mls/kg per day
• Vitamin K 1mg STAT
• Vital signs monitoring

NB: Antibiotics changed to ceftriaxone due to high creatinine level

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SUBSEQUENT MANAGEMENT: DAY 2 & 3

DAY 2

• Nursing management continued.
• Patient was still in distress, but peripheral cyanosis had resolved
• Routine blood works done

HB 18.1 WBC 14 platelets 114 Na+ 149 K+ 4.2 Creatinine 134 Bilirubin 68

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DAY 3

• Distress was gradually resolving with RR-52,SPO2-98%
• Weaned to low flow oxygen at 2ltrs via nasal prongs
• Nasogastric tube inserted
• Started feeding via NG tube while attempting to breast feed

SUBSEQUENT MANAGEMENT:DAY 4

DAY 4

• Baby breast feeding well on demand
• Weaned off oxygen with stable vitals with some irritability on and off
• Transferred to Newborn unit for continuity of care until discharge
• Mother – continued with methadone while in the ward ( 70mgs OD) with support from the methadone center at Mtwapa

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OUTCOME

• The baby progressed well and was discharged home after 10 days of hospital stay
• Follow up at the nearest clinic for routine baby clinic.
• Follow up through a phone call was made on 17^th August 2024 and both mother and baby are doing fine

METHADONE & DISPENSING LOG

WHO STANDARD APPROACH TO NEONATAL ABSTINENCE SYNDROME��Identification and diagnosis�

• History taking: Obtain a detailed maternal history, including use of substance like opioids, alcohol and other drugs
• Screening : Babies at risk of NAS should be observed for signs of withdrawal. The use of Finnegan Neonatal Abstinence scoring system to monitor symptoms is highly recommended
• Laboratory testing: where appropriate, testing of maternal and neonatal urine or meconium for substance may be conducted

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FINNEGAN SCORING SYSTEM

• Is used as a daily score to assess the effectiveness of treatment and recovery of the infant
• The areas of score include;
• Central nervous system
• Metabolic/vasomotor/Respiratory Disturbances
• Gastrointestinal disturbances
• Finnegan proposed use of 3 consecutive scores of 8 /> OR 2 of consecutive scores of 12/> to initiate pharmacological treatment

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NON-PHARMACOLOGICAL MANAGEMENT

• Supportive care: This includes a quiet environment, gentle handling, swaddling and skin to skin contact to help sooth the baby
• Breastfeeding: Encourage unless contraindicated example in continued maternal substance use. Breastfeeding has been shown to reduce the severity of NAS.
• Rooming-in: keeping the baby in the same room as the mother can help reduce NAS severity and the need for pharmacological treatment

PHARMACOLOGICAL TREATMENT

• If symptoms are severe and non-pharmacological measures are insufficient, medication may be required
• First-Line Treatment: oral morphine or methadone is typically used. Dosing is carefully titrated to control symptoms and then gradually tapered
• In some cases, phenobarbital may be used as adjuvant to primary therapy.

Monitoring and follow-up

• close monitoring of the infant’s weight, feeding patterns and withdrawal symptoms is essential
• Regular follow-up appointments are important to monitor the infant development and to provide support to the family
• Parents and caregivers should be educated about NAS, its management and the importance of follow-up care.

Complications of NAS

• Growth delays – due to poor feeding
• Neurodevelopmental issues- children with history of NAS may have developmental delays, behavioral problems or learning disabilities as they grow
• Increased in risk of sudden infant death

Challenges in managing NAS

• Limited access to health resources –many region lack access to neonatal intensive care units (NICUs) and health care professionals trained in managing NAS
• Inconsistent guidelines and practices- there is often luck of standardized protocols for the management of NAS, leading in inconsistence in care and outcomes.
• Public health infrastructure challenges- inadequate systems for monitoring and reporting NAS cases can hinder the ability to understand the scope of problem and allocate resources effectively
• Stigma and discrimination- mothers who use substance during pregnancy often face significant stigma which can limit them from seeking prenatal care and support

CONCLUSION

• Opioid use including heroin, remains a major public health concern.
• Screening and early identification- during prenatal care should be enhanced
• Development of national guidelines-WHO encourages countries to develop and implement national guidelines for management of NAS based on local resources and needs
• Multidisciplinary care- WHO recommends integrated care team in management of NAS including social workers and mental health professionals.
• Support for mothers and families- provide comprehensive support services as addiction treatment, mental health services, social support and providing a non-judgmental environment for mothers to encourage them seek for care.

QUESTIONS?

THANK YOU