Recently, I was working with a group of paramedic students, and they were given the following discussion question:
You are called to the home of a 24-year-old female who is 36 weeks pregnant and in labor. You are met at the door and advised that she has had no prenatal care. You are also told that the patient has been previously admitted to the ER for an opioid overdose and that she is currently taking methadone. As you enter the bedroom you see that the baby has delivered. You find that the umbilical cord is still pulsating and begin to provide care to the newborn while the other crew assesses the mom. The newborn has an APGAR of 6 and is lethargic. The other crew finds what appear to be recent track marks and the boyfriend admits that he helped the patient shoot up with heroin to dull the pain of delivery.
The students were then asked to answer the following questions:
- Would you consider administering naloxone to this infant as part of your resuscitation? Why or why not?
- What are your primary concerns regarding oxygenation of the newborn? How will you address each of them?
- When both crews decide to transport, do you transport the two patients together or separately? Why?
I am going to break up the above questions and discuss each of individually in 3 separate articles.
Question #1, Would you consider administering naloxone to this infant as part of your resuscitation? Why or why not?
I found it quite surprising the number of paramedic students that jumped to administering Narcan to the infant. And when I questioned them, they would double down and refer to their protocol and/or paramedic partner who stated that he or she would absolutely give Narcan to the newborn that has been exposed to opioids throughout the duration of pregnancy. We cannot blindly administer medication without thinking about the big picture. The mindset of opioid overdose equals give the patient Narcan has got to go away! Narcan has the potential to be a very dangerous medication.
In this scenario, the baby is an addict because the mother has been using methadone and heroin during the pregnancy. What is going to happen if you administer Narcan to this baby? You are going to put the baby into acute withdrawals, this will cause a seizure that could kill him/her. “The AAP Committee on Drugs has advised that naloxone should not be administered to infants of opioid‐dependent mothers as naloxone may precipitate acute withdrawal and seizures in opioid‐habituated infants.” Also, 0.2 up to 3.6% of patients that receive Narcan will also develop Narcan-induced non-cardiogenic pulmonary edema.
How sensitive are babies to medication doses? Are you going to be able to accurately determine the baby’s weight? How often is a child born to addiction underweight and premature? We know the Broselow tape has issues and is considered unreliable. In fact, the Broselow tape can no longer be used as a stand-alone resuscitation tool.
With that in mind, what’s the likelihood that you are administering the correct dose of Narcan? This baby will experience withdrawals and there is a high probability of seizure. How long will that seizure last? The half-life of Narcan in a premature newborn is 70 minutes IV and it is longer with IM administration. While the baby is seizing will it be breathing? If it is breathing, will it be breathing effectively? How sensitive is a newborn, especially a premature newborn to hypoxia? Are there also potential complications secondary to over-oxygenation?
The focus of patient care should be appropriate levels of oxygen and BVM ventilation. If after these measures and the heart rate remains below 80 bpm chest compressions and ventilations in a 3:1 every 2 seconds for 60-second increments with a reevaluation of the heart rate between sets. If you still are not at the hospital because of an extended transport time you can discuss Narcan with online medical direction making sure you clearly inform the doctor of mom’s history of addiction.
References:
Elli Brown, J. V., & McGuire, W. (2017). Naloxone for opioid‐exposed newborn infants. The Cochrane Database of Systematic Reviews, 2018(10). https://doi.org/10.1002/14651858.CD003483.pub3
Nasheena, J., Himesh, S. and Silverman, R. (2018, May 10). Naloxone-Induced Non-Cardiogenic Pulmonary Edema: A Case Report. Retrieved from the National Library of Medicine, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5945567/.
The American Academy of Pediatrics. (1990). Naloxone Dosage and Route of Administration for Infants and Children: Addendum to Emergency Drug Doses for Children. Retrieved from Pediatrics. 86 (3): 484–485.
