We discuss the prevalence of substance use in pregnancy, evaluation and management of the newborn, and discharge planning. We are joined by Kelly Mazzarella, DO, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern newborn nursery. Welcome back to the podcast. In today's episode, we will be discussing neonatal abstinence syndrome. We're recording remotely due to the ongoing COVID pandemic. We are joined today by Dr. Kelly Mazzarella, Assistant Professor of Neonatal-Perinatal Medicine at UT Southwestern, and a colleague of mine in the newborn nursery.
Dr. Kelly Mazzarella:
Hi, there.
Dr. Neeta Goli:
Hi, Dr. Mazzarella. Thanks for joining us today.
Dr. Kelly Mazzarella:
Hi, everyone. Thank you so much for having me back.
Dr. Neeta Goli:
Neonatal abstinence syndrome, or NAS, is a term used to describe the constellation of signs and symptoms in an infant who is withdrawing from substances used by the mother during pregnancy. We typically use the term NAS to refer to neonatal withdrawal for maternal opiate use. With increased opiate use in the US over the past few decades, the CDC reports that the incidence of NAS has increased by over 300% from 2000 to 2012. Dr. Mazzarella, please can you start by giving us some background on substance use in pregnancy?
Dr. Kelly Mazzarella:
Of course, and Dr. Goli is right. The incidence of NAS has gone up exponentially, specifically over the past decade, I would say. And so it's pretty important for us to be aware of this, to know what to monitor for, and to know how to step in and manage it. We evaluate for NAS because it can cause some serious complications for an infant, like dysfunction in their neurologic, gastrointestinal, and musculoskeletal systems. Fortunately, we have ways around this, and we've learned to manage these complications, and the sooner we get that management on board, the better the outcomes for the infant and for the mom.
Dr. Kelly Mazzarella:
Statistics: you were mentioning some statistics before. From a 2012 national survey on drug use and health conducted in the United States. This survey showed that approximately 6% of pregnant women reported illicit drug use during their pregnancy. And as you can imagine, that number is more than likely an underestimated value, just given all the negative connotation that comes with reporting any type of drug use during pregnancy. This survey also showed that women are more at risk for developing a substance use disorder during their reproductive years.
Dr. Kelly Mazzarella:
When we suspect something like this is going on, like there's a history of substance use in mom's history or there are concerns on the infant's exam, we screen infants by evaluating their urine, meconium, and monitoring for symptoms of NAS. The most common substances used in pregnancy vary from over-the-counter medications to prescribed medications, and then we have illicit drug use, of course. And every area is different, every county, every city. But here in Dallas, we see a lot of marijuana use and opiate use. There's caffeine, nicotine, alcohol, methamphetamines. We can also see things like benzodiazepines, cocaine, PCP, even inhalants.
Dr. Neeta Goli:
And then what are the most common opiates that we see used in pregnancy?
Dr. Kelly Mazzarella:
Yeah, this is a good question. We can see prescription opiates that are used for some sort of history of pain or pain management, whether it had been in pregnancy or even prior to pregnancy, so things like codeine or oxycodone, hydrocodone, morphine, they're pretty common. We also see illicit drug use like heroin. Fentanyl's another one. And then some more medications would include methadone or buprenorphine.
Dr. Kelly Mazzarella:
Nowadays, many hospitals are running these programs called MAT programs. These are medication-assisted treatment programs. Pretty cool. And it's where pregnant women who are interested in getting support for their substance use or their substance use disorders, they can come in and work on tapering off an opiate. We mentioned the medications methadone and buprenorphine. The success rate with these for mothers is high and with the added benefit of helping the fetus and the newborn.
Dr. Neeta Goli:
If we have these babies born, what are some symptoms of NAS that we might see?
Dr. Kelly Mazzarella:
We see a range of symptoms indicating withdrawal. And once you see the constellation of signs and symptoms impact a baby, you won't forget it. We classify symptoms in categories like gastrointestinal neurologic, respiratory, metabolic, vasomotor disturbances, and they can be a little bit broad, but bear with me as I discuss this because like I said, once you see the constellation, you won't forget it.
Dr. Kelly Mazzarella:
In regards to our gastrointestinal signs and symptoms, you can get vomiting, loose stools, a big appetite, or you can get poor feeding. In regards to the neurologic signs and symptoms, we can see infants with irritability or lethargy. They can have convulsions, tremors, or seizures, or it can be as simple as an over-exaggerated Moro. Infants can have hypertonia or jitters, restlessness. They can have excessive crying or excessive sucking that we need to look out for. For respiratory signs and symptoms, babies can have respiratory distress, things like tachypnea, nasal flaring, retractions. We have to watch out for those things. It might just even be as simple as looking out for congestion or sneezing. In regards to our metabolic or vasomotor issues that we watch out for, fevers, sweating, modeling, all these things.
Dr. Kelly Mazzarella:
Like I said, this description is so broad and variable, but you put it together and the constellation can scream NAS. That being said, big stipulation here, but you also have to think about, or maybe even evaluate for other problems that might mimic some of these signs and symptoms, issues like sepsis or hypoglycemia, HIE - things that we can see in the newborn period. A lot to think about, but like I said before, when you put the pieces together with maternal history and the evaluation of the newborn, the pieces of the puzzle come together and usually fit nicely. And just some interesting follow-up facts here, in preterm infants, withdrawal is less prominent or severe than in a term baby. And another one, if a mother has a history of concurrent cigarette smoking, like she smokes a lot, like more than 20 cigarettes a day, there's an association with increased withdrawal symptoms.
Dr. Neeta Goli:
And then when would we expect these symptoms to present in a baby who is withdrawing?
Dr. Kelly Mazzarella:
We can better understand that question when we know what drug we're working with, so knowing a mother's history is very important in regards to this. The longer the half-life of the drug that's used, the later the onset of withdrawal. Let me give you an example. With heroin, for instance, symptoms usually appear in the first 24 to 48 hours of life because it has a shorter half-life. But when we're using things, when moms are in the MAT program, when we're using things like methadone or buprenorphine, they have a longer half-life, and so symptoms usually present later on, like five to seven days out. When we have a mom who is in the MAT program, we usually monitor their babies for at least five days because of this reason.
Dr. Neeta Goli:
And then, Dr. Mazzarella, one thing that we haven't addressed yet but I think that's an interesting point is what is the likelihood of a baby withdrawing depending on what substance mom was using during pregnancy?
Dr. Kelly Mazzarella:
Specifically, with methadone, I can say that usually when a mom has been on that methadone therapy, they've been in that medication-assisted treatment program, that I will get infants having the NAS symptoms within that five-day period that we watch out for them. It's more common for infants to have NAS symptoms with moms who are on methadone or who are in the MAT programs that we were talking about.
Dr. Neeta Goli:
Okay. As compared to maternal heroin use?
Dr. Kelly Mazzarella:
Yeah, as compared to maternal heroin use.
Dr. Neeta Goli:
Okay. If we do start noticing these symptoms, what are some different approaches to management of these babies?
Dr. Kelly Mazzarella:
Yeah, so first, I'll stipulate that this information that I'm about to mention is, as of now, this is October 2020 info, so things will likely be updated over time. But right now there's the Eat Sleep Console model of care for NAS. It's a newer process that's been known to help in cost-savings and decreasing length of stay for newborns. It decreases transfers to the NICU and decreases use of medication, so that's pretty awesome. It's based primarily on non-pharmacological interventions, so keeping mom and the baby together so they're rooming in, and then we also try and respond to signs and symptoms that infants are having as quickly as possible, so like working on decreasing their environmental stimuli. We keep the baby in a darker room, a more quiet setting, softer noises always help babies. We allow them to suck on a pacifier, and we encourage moms to go skin to skin with their babies.
Dr. Kelly Mazzarella:
We also really try and encourage breastfeeding if there are no contraindications. At Parkland, we do try and keep the mom and baby together with this model, but we also continue using Finnegan scores, or Fin scores, to assess the infant. The Finnegan Neonatal Abstinence Scoring Tool, or the FNAST, it's performed whenever opiate withdrawal is suspected based on history, signs or symptoms that the infant's having, or tox screen results from mother or baby. And we recommend assessing early if there's any indication or suspicion that an infant has been exposed to substances in utero. This scoring helps us monitor not only for withdrawal, but also for the severity of withdrawal. When you get an opportunity, you can do a quick online search for this, so look up Finnegan scoring, or you can look it up on our UT Southwestern NeoSource webpage.
Dr. Kelly Mazzarella:
But to summarize, the infant is assessed for one full minute by two different nurses, where they evaluate for common signs and symptoms as we mentioned before, and then we can generate a score. We get a baseline score about two hours after delivery, and then we can get scoring that's assessed about once per shift, unless scores become elevated. Now, an elevated score would be anything greater than or equal to eight. If we get that kind of score, we increase the frequency of evaluation to every two hours.
Dr. Kelly Mazzarella:
When do you start pharmacological interventions with methadone or transferring a baby over to the NICU? It's warranted to do this if our scores are getting on the higher side, so if our scores are greater than or equal to eight for three evaluations, so three consecutive evaluations, we'll go ahead and transfer the baby over to the NICU and consider starting medications or if we're getting an average of greater than or equal to eight for three consecutive scores.
Dr. Kelly Mazzarella:
We'll actually transfer a baby a little bit sooner if their scores are greater than or equal to twelve for two consecutive evaluations. We'll continue to use these Finnegan scores even after we start medications on babies because it tells us how well the medications are working. It tells us: Do we need to increase the methadone? Do we need to decrease the methadone? That's pretty important to keep that going. If a baby is not on any medications at all, not transferred to the NICU, stays with us, scoring can be stopped on an infant if their scores are less than or equal to three for more than 48 hours.
Dr. Neeta Goli:
And for our listeners, sometimes you might hear this referred to as the Rule of 24s in terms of when to transfer baby because like, as Dr. Mazzarella mentioned, if you have a score greater than eight for three scores or a score of 12 or greater for two scores, so eight times three and 12 times two is 24. And just one other note for our listeners, there's a lot more detail in terms of the dosing of medication and the tapering of all those medications. We won't be getting into the details of all that in this talk, so that will be kind of outside the scope of this.
Dr. Neeta Goli:
How should we counsel these moms whether to breastfeed or offer formula?
Dr. Kelly Mazzarella:
Breastfeeding should be encouraged if possible. We'll talk about when it's not recommended first. It's kind of not recommended ... Well, it is not recommended in any type of usual contraindicated setting, so if a mom has a viral infection like HIV, we recommend that formula be used for the baby. If a mom has active HSV lesions on the breast, or if they have untreated TB, they shouldn't directly breastfeed. They can, and we recommend breast milk, but they need to express their breast milk until that has been resolved.
Dr. Kelly Mazzarella:
Specifically in regards to drug use, if a mom has active maternal illicit drug use in that month prior to delivery, we say we don't recommend breastfeeding in that regard, so formula feeding. The exception to this is marijuana. If they have that history in the past month, we'll say, okay, you can breastfeed. But I do still tell moms in this regard, I don't recommend them using marijuana and breastfeeding. We do encourage breastfeeding if possible, and we recommend it when a mom is on that MAT program that I was talking about. So if they're receiving methadone or buprenorphine, I say, "Hey, let's do this." If she wants to.
Dr. Kelly Mazzarella:
If they're enrolled in an opioid maintenance therapy for longer than a month, I'll kind of encourage that as well. If a mom has completed inpatient detoxification, I'll say, "Let's breastfeed." That being said, any circumstances where mom is in that MAT program and still receiving methadone, it's transferred via breast milk and can actually help an infant wean from the substance that mom's been using. So in other words, it actually protects them from severe withdrawal symptoms. Pretty cool.
Dr. Neeta Goli:
Yeah. And then what else should we do to ensure safe discharge planning for these babies?
Dr. Kelly Mazzarella:
I think some other big resources that we have in our hospitals are social work and child life, so putting in consults for these are a must, especially here at Parkland. Our teams are so attuned to caring for moms with this history. They can and they will, they will really make a big impact for these families. And I've seen it time and time again, where they're such big helpers. And then they update me about how the family is feeling, too, so it's a good form of communication. I also like to make sure that I'm updating the family frequently about the newborn's status and discussing the Finnegan scores, their vital signs, their exam findings, examining the baby in the room. This, all in all, it's open communication, and it helps in making the moms, the families more comfortable, so it really just helps in developing a good therapeutic and good rapport, a good trusting relationship between the families and the physician.
Dr. Neeta Goli:
And then can you speak to specifically what child life's role is in caring for these mom-baby dyads?
Dr. Kelly Mazzarella:
Yeah, so child life will come in, and they will actually go over why we're doing what we're doing. They'll go over the Finnegan scores with the parents. They'll go over the whole physiology of this. Sometimes as physicians, we don't necessarily have that time to do that, although we love going over that thoroughly with our families. But child life will make sure that they go into specific details, asking if the families have questions or concerns and understand why we're doing what we're doing with these babies.
Dr. Neeta Goli:
And then to end the episode today, what is your favorite part of your work day?
Dr. Kelly Mazzarella:
I love so many things about being a pediatrician. I'm so thankful that I get to do my job. I'm so blessed. But today, and recently, I've been thinking a lot about how awesome it is to be able to soothe an infant. I get them all riled up when I examine them, but I always tell parents I'll never leave them with a crying baby. I always promise that as I'm doing it. I love being able to settle them down, to soothe them, and to reassure their parents that it's okay for an infant to cry and that they can learn that magic touch, too.
Dr. Neeta Goli:
I love it. Thanks so much for joining us today, Dr. Mazzarella.
Dr. Kelly Mazzarella:
Yeah, thank you guys so much for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@UTSouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.