FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Diagnosis: Neonatal opioid withdrawal syndrome (NOWS) / Neonatal abstinence syndrome (NAS).
• Typical clinical features (CNS, GI, autonomic):
- CNS: High-pitched cry, irritability, tremors (jitteriness), hyperactive Moro reflex, increased muscle tone, seizures (rare).
- GI: Poor feeding, uncoordinated suck, regurgitation, loose stools, diarrhea, vomiting.
- Autonomic: Sneezing, yawning, sweating, nasal stuffiness, tachypnea, fever, mottling.
- Behavioral: Excessive crying, difficulty sleeping, inability to be consoled, frantic sucking of fists.

✅ Candidate's answer:
• Opioids (most common): Heroin, morphine, methadone, buprenorphine, oxycodone, hydrocodone, fentanyl.
• Other CNS depressants: Barbiturates, benzodiazepines.
• Other agents: Alcohol (fetal alcohol spectrum disorder – different symptoms), nicotine (milder withdrawal), SSRIs (rare).
• Onset of withdrawal by substance:
- Heroin (short-acting): 24-48 hours of life.
- Methadone (long-acting): 48-72 hours (up to 5-7 days).
- Buprenorphine: 24-48 hours, but may be later.
- Morphine: 24-48 hours.
- Barbiturates: Up to 7-10 days.
- Benzodiazepines: 1-2 weeks (may be delayed).
• Observation duration: For methadone/buprenorphine, observe for at least 5-7 days; for short-acting opioids, 3-4 days.

✅ Candidate's answer:
• Opioids cross the placenta freely and affect the fetal central nervous system.
• Chronic in utero exposure leads to upregulation of opioid receptors and adaptive changes in multiple neurotransmitter systems (dopamine, norepinephrine, serotonin, GABA).
• At birth, the infant is suddenly deprived of the maternal opioid supply (because the placenta is removed).
• The sudden discontinuation of opioid effect results in a state of central nervous system hyperexcitability and autonomic imbalance → clinical withdrawal symptoms.
• The half-life of the maternal opioid determines onset: short-acting opioids (heroin) → earlier withdrawal (24-48h); long-acting (methadone) → later onset (48-72h) and more prolonged course.

✅ Candidate's answer:
• Finnegan Neonatal Abstinence Scoring System (modified):
- 21-item scoring tool assessing CNS, GI, autonomic, and respiratory symptoms.
- Scores recorded every 3-4 hours (especially before feeds).
- Score ≥8 (or ≥12 in some centers) on two consecutive assessments → initiate pharmacotherapy.
- Limitations: Time-consuming, inter-rater variability.
• Eat-Sleep-Console (ESC) model (newer, function-based):
- More family-centered, less burdensome.
- Assesses three domains:
  • Eat: Takes >10 minutes to coordinate feeding, takes <10 mL of feed, or breastfeeding is uncoordinated.
  • Sleep: Sleeps <1 hour after a feed.
  • Console: Takes >10 minutes to be consoled, or cannot stay consoled for 10 minutes.
- Failure in ≥2 domains indicates need for pharmacotherapy.
- Associated with shorter length of stay, less medication use, better maternal-infant bonding.

✅ Candidate's answer:
• Rooming-in (mother and baby together): Most important intervention – reduces severity and need for medication.
• Breastfeeding (if mother is stable, no other contraindications): Associated with less severe withdrawal, shorter length of stay, and reduced need for pharmacotherapy. Breast milk contains small amounts of methadone/buprenorphine but benefits outweigh risks.
• Environmental modifications: Quiet, low-stimulation environment; dim lights; reduce loud noises.
• Swaddling and gentle holding.
• Skin-to-skin contact (Kangaroo care).
• Demand feeding (small, frequent feeds).
• Non-nutritive sucking (pacifier).
• Minimize disruption during sleep cycles (cluster care).
• Parent education and support.

✅ Candidate's answer:
• Indication for pharmacotherapy:
- Failure of non-pharmacologic measures.
- High Finnegan scores (e.g., ≥8 on two consecutive assessments) OR failure of ≥2 ESC domains (Eat, Sleep, Console).
- Signs of severe withdrawal (seizures, poor feeding with significant weight loss, dehydration).
- Inability to sleep or feed adequately despite optimal non-pharmacologic support.
• First-line medications:
- Morphine (oral solution): Starting dose 0.03-0.05 mg/kg/dose every 3-4 hours (or 0.2-0.5 mg/kg/day divided q3-4h). Increase by 0.01-0.02 mg/kg/dose as needed based on scores. Wean slowly over weeks.
- Methadone (oral): Starting dose 0.05-0.1 mg/kg/dose every 6-12 hours. Longer half-life, less frequent dosing, but risk of accumulation.
- Buprenorphine (sublingual): Emerging evidence; starting dose 4-6 mcg/kg/dose every 8 hours. May be superior to morphine (shorter treatment duration, less need for adjunctive medication).
• Second-line / adjunctive: Phenobarbital (for sedative-hypnotic withdrawal or severe CNS symptoms) or clonidine (for autonomic symptoms).

✅ Candidate's answer:
• Breastfeeding is encouraged and recommended for mothers on methadone or buprenorphine maintenance who are not using illicit drugs, are HIV-negative, and have no other contraindications.
• Benefits:
- Reduces severity of NAS.
- Decreases need for pharmacologic treatment.
- Shorter hospital stay.
- Promotes maternal-infant bonding.
- Small amounts of methadone/buprenorphine in breast milk (about 1-3% of maternal dose) help alleviate withdrawal without causing sedation.
• Contraindications to breastfeeding:
- Active illicit drug use (cocaine, amphetamines, PCP, heroin).
- HIV infection (in resource-rich settings – risk of transmission outweighs benefits; in resource-limited settings, WHO advises breastfeeding with ART).
- Maternal hepatitis C with cracked/bleeding nipples (theoretical risk).
- Mother is not adherent to treatment or has uncontrolled polysubstance use.
• Always check local guidelines and discuss with mother.

✅ Candidate's answer:
• Stable Finnegan scores (or ESC criteria) without medication for at least 24-48 hours (or on a stable weaning dose ready for outpatient wean – some centers discharge on medication).
• Adequate feeding and weight gain (no signs of dehydration or poor intake).
• Stable temperature regulation.
• No significant apnea or bradycardia events.
• A safe home environment and responsible caregivers who are not under the influence of drugs/alcohol.
• Mother is engaged in substance use treatment program (methadone/buprenorphine maintenance) and has a recovery plan.
• Appropriate follow-up arranged: Primary care within 48-72 hours, early intervention services referral, social work involvement if needed.
• Parents educated on signs of withdrawal and when to seek care.

✅ Candidate's answer:
• Studies show variable outcomes, and confounding factors (poverty, maternal polydrug use, environment) make interpretation difficult.
• Potential long-term effects:
- Increased risk of attention-deficit/hyperactivity disorder (ADHD).
- Higher rates of behavioral problems and conduct disorders.
- Lower cognitive scores (small effect size) in some studies, but not all.
- Visual-motor integration and processing speed deficits.
- Increased risk of language and speech delays.
- Higher rates of autism spectrum disorder (ASD) in some studies.
- Continued need for early intervention services.
• Protective factors: Stable home environment, maternal recovery, breastfeeding, early intervention.
• All infants with NOWS should be referred to early intervention (EI) or developmental follow-up programs.

✅ Candidate's answer:
• Tobacco (nicotine): Associated with lower birth weight, but effect on NAS severity is inconsistent. Some studies show increased risk of more severe withdrawal.
• Benzodiazepines (e.g., diazepam, clonazepam): Increase severity of NAS, prolong duration of treatment, and may require adjunctive phenobarbital (since benzodiazepine withdrawal is not well treated by opioids alone).
• SSRIs (e.g., fluoxetine, sertraline): Minimal effect on NAS severity; however, SSRIs alone can cause a milder neonatal adaptation syndrome (irritability, poor feeding) that may be confused with opioid withdrawal.
• Gabapentin: May increase severity of NAS.
• Marijuana (cannabis): Minimal effect on NAS severity; however, co-exposure may affect neurodevelopment.
• Alcohol: Not associated with NAS (alcohol causes fetal alcohol spectrum disorder) – different management.

✅ Candidate's answer:
• Universal verbal screening using a validated tool (e.g., 4 Ps: Parents, Partner, Past, Present) is recommended for all pregnant women.
• Biologic testing (meconium, umbilical cord, maternal urine, infant urine) is NOT recommended universally. Testing should be based on:
- Maternal disclosure of substance use.
- Clinical signs of withdrawal in the infant.
- History of prior child with NAS.
- Known maternal substance use disorder.
- Maternal participation in medication-assisted treatment (MAT).
• Meconium testing: Detects exposure from mid-second trimester to birth (most sensitive for chronic use).
• Umbilical cord tissue: Alternative to meconium, easier to collect.
• Infant urine: Only detects very recent exposure (1-2 days).
• Informed consent is required for testing in most jurisdictions.

✅ Candidate's answer:
• Methadone (full opioid agonist):
- More extensive safety data.
- Requires daily clinic attendance (highly regulated).
- Associated with more severe NAS (higher incidence, longer treatment duration) compared to buprenorphine.
- May require higher doses in third trimester due to increased metabolism.
• Buprenorphine (partial agonist):
- Lower risk of overdose.
- May be prescribed in office-based settings (less restrictive).
- Associated with less severe NAS: shorter duration of treatment, shorter hospital stay, lower need for adjunctive medication.
- Lower rates of preterm birth and higher birth weight compared to methadone in some studies.
- Risk of precipitated withdrawal if started too soon after last opioid use.
• Neonatal outcomes: Buprenorphine is associated with milder NAS, shorter length of hospital stay, and less need for morphine treatment compared to methadone.
• Both are preferred over no treatment (detoxification or continued illicit use).

✅ Candidate's answer:
• Epidural anesthesia is the preferred method for labor analgesia in women on methadone/buprenorphine – it does not worsen NAS.
• Systemic opioids (fentanyl, morphine) can be used but may transiently increase neonatal respiratory depression and potentially affect NAS scoring in the first 24-48 hours.
• Methadone/buprenorphine should be continued during labor (no need to hold the dose).
• Postpartum pain management: Non-opioid analgesics (NSAIDs, acetaminophen) first-line. If opioids are needed (e.g., after C-section), short-acting opioids (morphine, oxycodone) can be used but may affect NAS; breastfeeding is generally safe with standard doses.
• Communication with neonatology team is essential to coordinate care and interpret NAS scores appropriately.

✅ Candidate's structured answer:
• “Thank you for sharing your concerns. Your baby is showing signs of withdrawal because he was exposed to the medication methadone that you need for your own health. This is not your fault – you did the right thing by staying in treatment, which is much safer for both you and your baby than using illicit drugs during pregnancy.”
• “The good news is that we have effective ways to help your baby. First, we will try simple comfort measures: keeping the room quiet, swaddling him, letting you hold him skin-to-skin, and feeding him on demand. Many babies respond to these without needing medicine.”
• “If he still struggles, we have medicines like morphine that can calm his symptoms. These are temporary and will be slowly weaned off.”
• “Breastfeeding is encouraged – it will help reduce his withdrawal and is safe with your methadone dose. We also encourage you to stay in the same room with him (rooming-in).”
• “Most babies with this condition do very well in the long run, especially when they have a loving, stable home and a mother who is engaged in recovery.”
• “We are here to support you and your baby. You are not alone. We will work together as a team.”

✅ Candidate's answer:
• Yes, selected infants can be discharged on opioid weaning if home environment is safe and parents are capable of administering medication correctly.
• Criteria for discharge on medication:
- Stable vital signs and feeding.
- Safe, sober caregivers.
- Parental understanding of medication dosing, weaning schedule, and signs of overdose/withdrawal.
- Reliable follow-up within 24-48 hours.
- Engagement with early intervention and primary care.
• Weaning schedule (example for morphine): Reduce dose by 10-20% every 2-3 days as tolerated. Monitor for signs of withdrawal. Total duration can be weeks to months.
• Methadone weaning: Longer half-life allows once-daily dosing. Reduce by 5-10% every 3-7 days.
• Outpatient monitoring: Weekly visits to pediatrician or specialized NAS clinic, weight checks, and dose adjustments.
• Do not stop medications abruptly – risk of rebound withdrawal and seizures.
• Social work and home nursing support may be beneficial.