NURSING CARE FOR THE INFANT WITH NEONATAL ABSTINENCE SYNDROME

Learning Objectives

• Discuss the increased incidences of maternal opioid use• Learner will describe the mechanism and clinical presentation of

NAS• Learner will describe scoring tools for NAS• Learner will recognize recommended pharmacologic treatment

for NAS• Learner will describe nursing interventions for patients with NAS• Learner will describe teaching points for parents

Maternal Drug Use & NAS – Growing Epidemic

• Over 238 million prescriptions were written for opioid analgesics in 2011. 1.1% of pregnant women abused opioids with 0.9% being opioid pain relievers and 0.2% heroin. (Substance Abuse and Mental Health Services Administration, 2011)

• In a national study, maternal opioid use was shown to have increased:• 1.2% mothers per 1000 births in 2000 to 5.6% mothers per 1000 births in 2009

• Between 2014 – 2015 NAS exposed infants increased from 7.6 to 7.9 per 1000 births.

• Total economic burden totaled over 1 billion nationally in 2015

Maternal Drug Use & NAS – Growing Epidemic

• Increased incidence of NAS has been uniformly reported across community hospitals, teaching hospitals and children’s hospitals.

• NAS affects all communities and ethnicities

• APP recommends:• All nurseries caring for infants with NAS, develop guidelines for screening for

maternal substance abuse• Formulate standard plans of care to identify newborns at risk and manage their

care

What is Neonatal Abstinence Syndrome (NAS)

• Generalized multi-system disorder that predominately involves the central and autonomic nervous system as well the gastrointestinal tract. Infants exposed to opioids/narcotics during gestation will begin experiencing withdrawal with the abrupt cessation of these substances after birth

• What makes them susceptible

• First case documented in 1875

• Effects of NAS• Economic• Long-term

Diagnosis

• Comprehensive prenatal medical and drug history, especially in respect to polydrugabuse

• R/O other conditions• Laboratory data

• Serum glucose• Serum calcium/magnesium• Urine test for toxicology • Meconium drug analysis

Diagnosis cont’d

• Observation for common signs/symptoms associated with NAS

• Presentation of symptoms:

• Shortly after birth and up to 2 weeks of age

• Majority are exhibited with 36-72 hours

• Severity of symptoms depends on multiple factors

Signs & Symptoms of NAS

COMMON SIGN & SYMPTOMS OF NAS

Neurologic Excitability GI Dysfunction Autonomic Signs

TremorsIrritabilityIncreased wakefulnessHigh pitched cryHyperactive tendon reflexesSeizuresFrequent yawning and sneezing

Poor feedingUncoordinated and constant suckingVomitingDiarrheaDehydrationPoor weight gain

Increased sweatingNasal stuffinessFeverMottlingTemperature instability

Abstinence Scoring Tools

• Observer reported questionnaires used for assessing severity of withdrawal, determining need and duration and titration of pharmacologic therapy.

• Finnegan Neonatal Abstinence Scoring Tool (FNAST)

• Eat, Sleep, Console

Finnegan Neonatal Abstinence Scoring Tool

(FNAST)

• Most widely used and accepted tool

• Recommended by APP

Finnegan Neonatal Abstinence Scoring Tool

(FNAST)

• Limitations of the tool

• Reliability & Validity

• Complexity

Eat, Sleep, Console (ESC)

• Developed in 2017, program to manage NAS based upon the neonate’s ability to function

• Less complex

• Evaluates 3 criteria:

• Empowers parents

• Administration of Morphine

Eat, Sleep, Console (ESC)

• Average length of stay ↓ from 22.4 to 5.9 d

• Pharmacologic treatment with Morphine ↓ from 98% to 14%

• Costs ↓ from $44,824 to $10,289 per patient

• Research on ESC has shown:

Pharmacologic Management

• Oral Morphine • First line choice in majority of NICUs• Short half-life – administered Q 3-4 hours• Improves feeding, eliminates diarrhea, ↓agitation• Prolongs hospital stay

• Oral Methadone• 15% of NICUs use as first line• Alternative to Morphine• Long half life – can only be administered twice per day

• Phenobarbital• Drug of choice for non-opiate NAS/polydrug use• Often used as adjunct to Morphine or Methadone• Effective in controlling irritability and insomnia

• Oral Clonadine• Decreases symptoms such as tachycardia, hypertension, diaphoresis, restlessness and diarrhea• Cessation of treatment can result in a rebound of these symptoms.

Breastfeeding and NAS

• Infants with Methadone- or Buprenorphine- dependent mothers has been identified as safe and beneficial regardless of dose

• Lactation Support

• Contraindication

Parental Presence

“The goals of care should be patient- and family- centered. It is the patient we treat, but it is the family of whatever construct, with whom the baby will go home. Indeed, it is the family who must live with the long-term consequences of our daily decisions in caring for their baby.” (Brian Carter – Merenstein & Gardner’s Handbook of Neonatal Intensive Care)

• Positive impact

• Importance of positive nurse-parent relationship

Non-Pharmacologic Interventions

• Rooming-In• ↓ Stimulation • Safe swaddling• Developmental Positioning• Vertical rockers• Music, massage and aromatherapy

Parent Teaching

• Symptoms may persist for 2-6 months• Importance of second caregiver• Safe Sleep education • Importance of follow-up with primary physician• Provide information on community based support systems

QUESTIONS?

ReferencesKumar, R., & Garg, S. (2019). Neonatal abstinence syndrome: a current update. Infant, 15(4), 132–136.

Grisham, L. M., Stephen, M. M., Coykendall, M. R., Kane, M. F., Maurer, J. A., & Bader, M. Y. (2019). Eat, Sleep, Console Approach: A Family-Centered Model for the Treatment of Neonatal Abstinence Syndrome. Advances in Neonatal Care, 19(2), 138–144. doi: 10.1097/ANC.0000000000000581

McCarty, D. B., Peat, J. R., O'Donnell, S., Graham, E., & Malcolm, W. F. (2019). "Choose Physical Therapy" for Neonatal Abstinence Syndrome: Clinical Management for Infants Affected by the Opioid Crisis. Physical Therapy, 99(6), 771–785. doi: 10.1093/ptj/pzz039

Oji-Mmuo, C. N., Schaefer, E. W., Liao, L., Kaiser, J. R., & Sekhar, D. L. (2019). The Possibility of Early Discharge for Newborns Being Monitored for Neonatal Abstinence Syndrome Based on Modified Finnegan Score Distributions. Clinical Pediatrics, 58(6), 641–646. doi: 10.II77/00099228I9832022

Whalen, B. L., Holmes, A. V., & Blythe, S. (2019). Models of care for neonatal abstinence syndrome: What works? Seminars in Fetal and Neonatal Medicine, 24, 121–132. Retrieved from https://doi.org/10-1016/j.siny.2019.01.004

Kondili, E., & Duryea, D. G. (2019). The role of mother-infant bond in neonatal abstinence syndrome (NAS) management. Archives of Psychiatric Nursing, 33, 267–274. Retrieved from https://doi.org/10-1016/j.apnu.2019.02.003

Verklan, M. T. (2019). Time for the Finnegan Neonatal Abstinence Syndrome Scoring Tool to Be Retired? The Journal of Perinatal & Neonatal Nursing, 276–277. doi: 10.1097/JPN.0000000000000427

Brandt, L., & Finnegan, L. P. (2017). Neonatal abstinence syndrome: where are we, and where do we go from here? Current Opinion-Psychiatry, 30, 268–274. doi: 10.1097/YCO.0000000000000334

References continuedClark, L., & Rohan, A. (2015). Identifying and Assessing the Substance-Exposed Infant. MCN, The American Journal of Maternal /Child Nursing, 40(2), 87–95. doi: 10.1097/NMC.0000000000000117

Artigas, V. (2014). Management of Neonatal Abstinence Syndrome in the Newborn Nursery. Nursing for Women's Health, 18(6), 509–514. doi: 10.111/j.1751-486X.12163

Kocheriakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2), e547–e561. doi: 10.1542/peds.2013-3524

Jansson, L. M., Velez, M., & Harrow, C. (2009). The Opioid Exposed Newborn: Assessment and Pharmacologic Management. Baltimore. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729086

Freeman-Ladd, M., Owens, L., & Placencia, J. (2017). Neurology. Guidelines for Acute Care of the Neonate (25th ed., pp. 129–132). Houston, TX: Section of Neonatology, Department of Pediatrics Baylor College of Medicine.

Weiner, S. M., & Finnegan, L. P. (2016). Drug Withdrawal in the Neonate. In Merenstein & Gardner's Handbook of Neonatal Intensive Care (8th ed., pp. 199–217). St. Louis, MO: Elsevier.

Shub, T., Ashley, T., & Pravikoff D. (2018). Neonatal Abstinence Syndrome: an Overview CINAHL Nursing Guide, EBSCO Publishing (Quick Lesson – CEU)