St. Xavier's College (Autonomous),
Mumbai, Maharashtra, India
“ Drugs take you to hell, disguised as heaven.”- This statement by Donald Lyn Frost defines the meaning of drugs explicitly in eight simple words. #Drugs, #opioids, #weedporn, #smoke, etc. are setting up new trends in the world. Various reasons can be linked to substance abuse, the most common being ‘Gate away from reality.’
The use of these substances can be licit or illicit. Over the previous two decades, the use of Opioid Pain Relievers (OPRs) has elevated across the world. Many complications have been equated among the populations with a pulled focus on pregnant women and infants, with the escalating use of substances. Both prescribed and illicit use of opioids during pregnancy has resulted in a new hidden rife of Neonatal Abstinence Syndrome (NAS).
A chaotic lifestyle, drug supporting and drug-seeking behaviors often end up complicating the illicit use of opioids. The use or misuse of prescription painkillers, maternal treatment drugs, and Opioids like Methadone, buprenorphine, oxycodone, fentanyl, codeine, morphine, heroin, etc leads to intrauterine drug exposure syndrome called Neonatal Abstinence Syndrome. Dr. Lorette Finnegan was the first to describe Neonatal Abstinence Syndrome in the literature. Infants born to women with opioid exposure undergo a postnatal drug withdrawal syndrome, that evinces shortly after the birth. This is known as NAS. Autonomic nervous system dysfunction and the Central Nervous system hyper tetchiness typifies Neonatal Abstinence Syndrome, which is a serious yet highly wavering condition. Every opioid-exposed infant is unique and types of signs and severity diversify in each infant. The expression of NAS depends on many factors like the time of exposure of the drugs during gestation, poor maternal nutrition, shortfall of obstetric care, genetic polymorphism, and certain environmental factors.
The pathophysiology underlying Neonatal Abstinence Syndrome is obscure. Many mechanisms have been proposed stating the pathways of manifestation, but this disease has come out to be an intricate interlinkage between various neurotransmitters like Dopamine, serotonin, and glutamate. Overall making it a disorder of neurobehavioral dysregulation. We have four types of behavioral sub-systems namely autonomic control, motor and tone control, state control and attention, and sensory processing. Each of the 4 subsystems supports each other and communes with the infant’s environment. An infant exposed to opioids shows an imbalance in functions of the sub-systems. Such infants tend to spend an extortionate amount of energy in one sub-system while a midget amount of energy in the other. This turns out to be a hallmark of infants affected by NAS. Apart from OPRs and maternal treatment drugs, exposure to other multiple substances like benzodiazepines, antidepressants, cigarette smoking, etc may alter the onset of symptoms and also increase the severity of the syndrome. Exposure to substances during the third trimester primarily affects the duration of the hospital stay. The infants affected show a varying range of symptoms like irritability and crying, poor state control, tremors, jitteriness, skin breakdown, hypo/hypersensitivity to ordinary stimuli, diarrhea, hiccups, gagging, fever, weight loss, and a lot of others. These symptoms develop within the first few days after the birth of the infant whilst the timing of their onset and the severity fluctuate. The manifestation of the symptoms depends on the half-life of the drug, the infant is exposed intrauterine. An infant exposed to a drug with a longer half-life will develop the symptoms later as compared to the ones exposed to drugs with a shorter half-life. Generally, NAS from heroin occurs at 24-48 hours of life, buprenorphine at 36-60 hours while methadone occurs at 48-72 hours of life due to its long half-life.
Evidence has shown that the countries which prescribe higher rates of OPRs, also have higher rates of NAS. Infants with NAS are at an increased risk of contracting infections and other comorbidities. It is therefore important to identify the infant at the risk of NAS for instigating the treatment. There are three known ways to manage NAS which include non-pharmacologic management, pharmacologic treatment, and comprehensive care of the mother. The main aim of the management strategies used is to promote the normal growth and development of the infant with NAS. Many mothers feel guilty and pour scorn on themselves but due to the social and legal fears, they are reluctant to admit substance abuse, and hence it is essential to create a compassionate and safe environment for the mothers as well. Overall the care given should have a multidisciplinary approach, collaborative and non-judgemental, depending on the needs of the mother-infant dyad. The initial care given should be non-pharmacologic and much more supportive creating a gentle and calming environment with minimal or no stimulation to soothe the infant born with NAS. A lot of other non-pharmacologic treatments include music therapy, water bed, cuddling, etc.
Alongside the non-pharmacological treatment, 60 to 80% of the infants require medications to mitigate the signs and symptoms of NAS. Usually, opioid-induced abstinence should include the use of opioids like morphine or methadone in negligible amounts to be effective. Apart from all the treatment options, available breastfeeding is consistently associated to reduce the severity of the syndrome. It is very crucial to seek regular medical follow-up as a lot of long-term effects have been recorded as compared to the short-term effects to ensure a hundred percent growth and development of the child.
It is important to understand the factors that affect the severity of the syndrome and the ideal prenatal and postnatal care of mothers and infants exposed to substances, as even today the burden of NAS continues to elevate. We have been knowing and learning the complications of drug abuse and dependence. The use of such substances may be licit or illicit by mothers, not only affects the mother but also the child born. Being a responsible human and a mother alongside, our acts should not affect the new budding life. It is so disheartening to see how these little angels suffer!
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