How long should infants at risk of drug withdrawal be monitored after birth?

AIM: Neonatal abstinence syndrome (NAS) is an increasingly common disorder diagnosed in infants exposed to various drugs, causing immense financial and social burden. Recommendations from various bodies are for babies to be monitored for 4 to 7 days following birth so that prompt treatment can commence should symptoms develop. We aimed to determine the best post-natal observation period in babies at risk of NAS. METHODS: A retrospective review was undertaken of infants ≥35 weeks' gestation who received treatment for NAS in the period 2001-2010. During this time, the standard post-natal observation period was a minimum of 7 days. Data including drug exposure, day of admission and day of treatment were collected. RESULTS: Two hundred and ten babies were included. Drug exposure was predominantly to opiates (99%); however, most infants (58%) were exposed to additional substances (benzodiazepines, cannabis or amphetamines). Ninety-five per cent of infants were admitted by day 5 of life. Of the babies treated by day 7, 98.5% had been admitted to the nursery by day 5. Infants with polydrug exposure were admitted significantly earlier; however, time to treatment was not significantly different to those exposed to opiate replacement therapy alone. CONCLUSIONS: In our hospital, babies treated for NAS often required admission before day 5. This has implications for hospital resource allocation, suggesting that routine post-natal observation for NAS could be shortened to 5 days. Further research is needed to help identify neonates who require more careful post-natal observation.

Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without prolonging treatment.

AIM: Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome, secondary to in utero chemical exposure and characterised by tremor, irritability and feed intolerance. It often requires prolonged hospital treatment and separation of families. Outpatient therapy may reduce this burden, but current literature is sparse. This review aimed to evaluate the safety and efficacy of our home-based detoxification programme and compare it with standard inpatient care. METHODS: Infants requiring treatment for NAS between January 2004 and December 2010 were reviewed. Data on demographics, drug exposure, length of stay and type of therapy were compared between infants selected for home-based therapy and those treated conventionally. RESULTS: Of the 118 infants who were admitted for treatment of NAS, 38 (32%) were managed at home. Infants receiving home-based detoxification had shorter hospital stays (mean 19 days vs. 39 days), with no increase in total duration of treatment (mean 36 days vs. 41 days), and were more likely to be breastfeeding on discharge from hospital care (45% vs. 22%). CONCLUSION: In selected infants, home-based detoxification is associated with reduced hospital stays and increased rates of breastfeeding, without prolonging therapy. Safety of the infants remains paramount, which precludes many from entering such a programme.

Outcomes of preterm infants receiving positive pressure support at term corrected gestation.

AIM: To establish the mortality rate to hospital discharge of very preterm infants who remain on positive pressure support (PPS) at term corrected gestation and describe factors that are associated with increased mortality. METHODS: Infants born <30 weeks' gestation between 1 January 2001 and 31 December 2009 who were receiving PPS at 40 weeks' postmenstrual age (PMA) were identified from our database, and their medical records reviewed. The fraction of inspired oxygen (FiO2 ), mean airway pressure and partial pressure of carbon dioxide (PaCO2 ) at 40 weeks' PMA were recorded. Receiver operating characteristic curves for mortality before discharge were generated. RESULTS: One thousand three hundred fifty-nine of 1572 infants survived to term. Forty-nine infants were receiving PPS at 40 weeks' PMA. Of these, 15 (31%) infants died before hospital discharge. All three infants who were ventilated via an endotracheal tube died. Increased oxygen requirement at term was associated with increased risk of death before discharge (area under curve (AUC) 0.75). FiO2 > 0.5 was associated with an 80% risk of death. PaCO2 was not predictive of death (AUC 0.49). CONCLUSIONS: Two thirds of very preterm infants who remained on PPS at 40 weeks' PMA survived to hospital discharge. Risk of death rises with increasing oxygen requirements. All five infants with FiO2 > 0.70 died.

The anatomy and reconstruction of the medial patellofemoral ligament.

INTRODUCTION: Reconstruction of the MPFL for recurrent and acute lateral dislocation of the patella is becoming more accepted. This study aimed to further define the medial patellofemoral ligament (MPFL) anatomy and to describe the most suitable sites for graft attachment when reconstructing the MPFL. MATERIALS AND METHODS: Anatomical dissection was performed on 25 embalmed knee specimens. Four separate specimens were used to assess graft fixation points. Sites were tested for isometricity from 0 to 120 degrees of knee flexion. Length patterns were considered isometric if there was less than 5 mm of length change throughout range of motion. RESULTS: The MPFL attaches from the posterior part of the medial epicondyle, to the superomedial patella, the under-surface of vastus medialis, and the quadriceps tendon. Optimal attachment points for an MPFL graft were the superior patella and the femoral attachment points of the MPFL (just distal to the adductor tubercle) and points posterior and inferior to this. CONCLUSION: We have defined the anatomy and kinematics of the MPFL with reconstruction of this ligament in mind.