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NEONATAL ABSTINENCE SYNDROME

Mary Hope, RN, BSN Cardinal Glennon Children’s Medical Center

Perinatal Outreach Education

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• I have no conflict of interest to disclose• I will make no recommendation for an “off-

label” use of any drug or device in thislabel use of any drug or device in this presentation

• Images and photographs used in this presentation were obtained from publicly accessed sources

• Thank you for inviting me here to speak today

DISCLOSURES

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• Discuss the babies at risk for NAS and the drugs responsible

• Describe the physical findings of an infant withdrawing from drugs of abuse

• Discuss non-pharmacological and pharmacological treatment for these infants

• Describe the role of breastfeeding in caring for infants experiencing NAS

• Understand the support and education

OBJECTIVES

Understand the support and education needed for parenting babies with NAS

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• Use and abuse of drugs, alcohol and tobacco contribute significantly to the health burden of society

• Use of licit and illicit drugs has increased alarmingly in the past 25-30 years

• Patterns of use has changed

• Polydrug use is more prevalent

• Half of women who use

SUBSTANCE ABUSE

Half of women who use are of child-bearing age

• Physicians were trained to treat Pain

• Lack of positive relationship with their own parents• One or more parent with history of abuse• Trauma as a child • Chaotic life styles/ unstable living conditionsChaotic life styles/ unstable living conditions• Poor prenatal care• Lack social support• Limited knowledge of child development and child-care skills• Patterns of abuse by significant others• Biological father of infant or partner often a substance abuser• Poor ability to develop positive relationships

PROFILES OF A SUBSTANCE ABUSING MOTHER

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• Compulsive drug seeking• No regard for safety of self or others• Very impulsive with failure to plan ahead• Emotional instability• Trouble asking for help• Low self-esteem

PSYCHOLOGICAL PROFILES

• Lack coping mechanisms

• Agencies potentially faced with infants experiencing neonatal abstinence syndrome need the following:– Scripted conversation for nurses to use to interview

moms of suspected infants– Referral protocols in place for suspected infants in

withdrawal

THE PLAN

withdrawal• Referral for any and all support needed for mom and

baby

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• Use of multiple means to screen gives the most accurate assessment – Self-reporting during obstetrical history– Use of standardized tools for screening moms

• Reported rates most likely underestimate true rates

• Fear of prosecution prevent women from getting prenatal care and treatment

IDENTIFICATION

• Hospital/Agency to set standards for screening– Triggers for Drug Screening-reportable to

provider to determine if drug screen is fneeded for neonate

• Maternal history– Absent, late or inadequate prenatal care– Prior documented/admitted history of drug

abuse or positive drug screen– Previous unexplained late fetal demise– Repeated spontaneous abortions– Preterm labor, preterm delivery, or PROM

IDENTIFICATION

Preterm labor, preterm delivery, or PROM– Abruptio placentae– Precipitous labor– Hypertension episodes

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– Unexplained maternal behavior-unexplained mood swings, anxiety, psychosis, hallucinations, panic

– Cerebrovascular accident/MI– Gum or periodontal disease-broken teeth, severe

decay, infectionsSi ifi t i ht l l i h d l BMI

IDENTIFICATION

– Significant weight loss, malnourished, low BMI– STD’s or hepatitis– Teen Pregnancy

• Neonatal History– SGA neonate (<10%) or IUGR – unknown etiology– Perinatal depression

• Neonatal clinical signs and symptoms– Neurological symptoms: irritability increased– Neurological symptoms: irritability, increased

wakefulness, high pitched cry, tremors, increased muscle tone, hyperactive deep tendon reflexes, frequent yawning and sneezing, seizures

– Gastrointestinal: vomiting/diarrhea, dehydration, poor wt. gain, uncoordinated and constant sucking, poor feeding

– Autonomic symptoms: diaphoresis, nasal stuffiness, fever mottling temperature instability mild elevations

IDENTIFICATION

fever, mottling, temperature instability, mild elevations in RR or BP

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• Onset of symptoms based on type of drug– Narcotics-birth to 14 days; duration 4-6 months– Methadone-12-96 hours; duration 2-4 months– Heroine and Methodine-48-96 hours

B bit t fi t d k– Barbiturates-first or second week– Narcotics and Barbiturates-birth to weeks with sub-acute

symptoms lasting 3 months– Alcohol-within 24 hours – Cocaine-and Amphetamines-48 hours to 14 days– PCP-a few hours to 2 weeks– Marijuana- 3-4 days after birth; duration 6 days after birth

IDENTIFICATION

j y ; y– Inhalant abuse (solvents, lacquers, glue, spray paint,

butane)-birth; duration 5-8 days

• Various approaches exist to screen for substance exposure– Consent is not required for neonatal drug testing

Urine detects exposure in utero within 1 10 days– Urine - detects exposure in utero within 1-10 days prior to testing

• Must be collected asap after birth– Meconium – Longitudinal assessment, detects

substances used since beginning of 2nd trimester• Must be collected before contamination by transitional,

human milk, or formula stools• Must be stored in secure location

A more significant amount of meconium yields more

IDENTIFICATION

• A more significant amount of meconium yields more accurate evidence of drug exposure

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• Indications for DCFS referral– Positive UDS at delivery– Positive meconium drug screen– Substance abuse during pregnancy– Risk factors posing risk to Patient’s well being– Concerns for caretaker’s ability to provide care and/or

necessary resources for baby– Medical non-compliance– Caretaker incapacity/impairment– Lack of involvement/refusal to complete discharge

teaching

DCFS

• Alcohol• Hallucinogens

– PCP• Sedatives or Opiates• Sedatives or Opiates

– Heroine– Methadone

• Stimulants– Cocaine– Methamphetamine

• Psychoactive

EXPOSURE

– Marijuana• Tobacco and Nicotine

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• Acute Toxicity – Signs and Symptoms decrease with drug elimination (time)− SSRI’sSSRI s

• Withdrawal – Signs and Symptoms worsen with drug elimination (time)− Opioids

• Permanent Drug Effect – Signs and Symptoms are the result of a permanent drug effect− Fetal Alcohol Syndrome

DRUG EFFECT

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• SSRI’S (Selective Serotonin Reuptake Inhibitors)– Fluoxetine (Prozac)– Citalopram (Celexa)– Escitalopram (Lexapro)– Paroxetine (Paxil)– Sertraline (Zoloft)– Fluvoxamine (Luvox)– 3rd trimester use =

• Withdrawal vs serotonin syndrome

EXPOSURE

• Withdrawal vs serotonin syndrome• Onset hours to days after birth• Resolve within 1-2 weeks

– Treatment should continue thru pregnancy

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• Intrauterine exposure to certain drugs– Congenital anomalies– Fetal growth restriction (symmetrical)– Preterm birth – Withdrawal or toxicity– Impaired neurodevelopment

DRUG USE AND ABUSE IN PREGNANCY

• CocaineM th h t i• Methamphetamines– Ecstasy– Crystal meth

STIMULANTS

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• Cocaine– Powerful addicting

substance of abuseCauses peripheral– Causes peripheral vasoconstriction, tachycardia, hypertension and hyperthermia

• Leads to: MI, CVA, pulmonary edema, and renal or bowel

COCAINE

and renal or bowel infarction

– Crack Cocaine• Mixture of cocaine

powder, ammonia, water, and baking soda

• Mixture cracks when heated and releases cocaine vapor that is inhaled

• High is reached in 60 to 90 seconds lasting 5-10 minutes

CRACK

• Associated with polydrug use

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• Neonatal effects– Neurobehavioral abnormalities – on

second or third postnatal days• Irritability• hyperactivity • tremors • high-pitched cry• excessive sucking

COCAINE

• Cocaine or its metabolites detected in• Cocaine or its metabolites detected in neonatal urine up to 7 days after delivery– May be effect of drug rather than withdrawal

• Long term effects– Heavily exposed infants more excitability and poor

state regulation around 2-3 weeks after birth

COCAINE: WITHDRAWAL VS DRUG EFFECT

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• Nursing care– Usually does not require pharmacological

treatmenttreatment– Swaddling and frequent small feeds and minimal

environmental stimuli– Address needs of prematurity more than

substance exposure• Increased risk for NEC

– Arrange for supportive care for mother prior to discharge

COCAINE

discharge

• Includes: methamphetamine, dextroamphetamine, MDMA, ecstasy (Adam, bean, E, M, roll, X, XTC, lovers’ speed) crystal methamphetamine (Batu, crystal, glass, hiropon, ice, shabu, shards, Tina, ventano, vidrio), and Methylphenidate (Ritalin)Methylphenidate (Ritalin)

• Neurotoxic• Vasoconstriction and hypertension• Intense physical and psychological exhilaration • 2-14 hour duration dependent on dose• Crystal meth compared to crack cocaine in its effects

AMPHETAMINES

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• Neonatal withdrawal– Abnormal sleep patterns, state disorganization– Poor feeding abnormal weight gains– Tremors, fevers, yawning– Loose stools, excoriation knees, elbows and buttocks– Diaphoresis, hyperrflexia– Frantic fist sucking, high pitched cry– Agitation alternating with lassitude

AMPHETAMINES

NAS

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• Substance abuse – missed diagnosis• Passive Dependence - neonates exposed in utero to addictive,

illicit drugsA well recognized constellation of symptoms in the newborn• A well-recognized constellation of symptoms in the newborn experiencing withdrawal from drugs of addiction such as opiates, barbiturates, and methadone is known as Neonatal Abstinence Syndrome

• Also called neonatal drug withdrawal-a condition that develops as a result of an abrupt removal of exposure to addictive substances

NEONATAL ABSTINENCE SYNDROME

OPIOIDS ANDOPIOIDS AND NARCOTICS

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• Natural opioids – morphine and opium• Semisynthetic opioids – heroin, methadone• Synthetic opioids – propoxyphene(Darvon),

hydormorphone hydrochloride(Dilaudid)hydormorphone hydrochloride(Dilaudid), oxycodone(OxyContin)– Produce supraspinal analgesia– Other effects: sedation, euphoria, miosis, respiratory

depression and decreased gastric motility– Cross placental and blood brain barrier– Active or passive maternal detoxification is associated

with fetal distress or loss

OPIOIDS AND NARCOTICS

• Opioids inhibit release of noradrenalin at synaptic terminals

• Chronic exposure – tolerance develops, that rate of noradrenalin release increases over time toward normal

• Abrupt discontinuation of exogenous opioids –supranormal release of noradrenalinsupranormal release of noradrenalin – Autonomic signs of withdrawal – Behavioral symptoms of withdrawal

OPIOIDS AND NARCOTICS

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Neurologic Excitability

• Tremors• Irritability• Increased

wakefulness

Gastrointestinal Dysfunction

• Poor feeding• Uncoordinated and

constant suckingV iti d Di hwakefulness

• High-pitched cry• Increased muscle tone• Hyperactive deep

tendon reflexes• Exaggerated Moro

reflex• Seizures

• Vomiting and Diarrhea• Dehydration/poor wt.

gainAutonomic Signs• Increased sweating• Nasal Stuffiness• Fever

• Frequent yawning and sneezing

Fever• Mottling• Temperature instability

NAS – CLINICAL PRESENTATION

• Lower gestational age = lower risk of withdrawal

• Decrease in signs/symptoms of NAS in preterm– Related to developmental immaturity of CNS– Differences in total drug exposureg p– Lower fat deposits of drug

PRETERM INFANTS - NAS

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• When infants present in hospitals with symptoms, they are scored according to a scoring tooly g g– Modified Finnegan (or other tool) – Used for neonates with proven or suspected intrauterine

opiate/polydrug exposure– Not for use for withdrawal from other drugs– Inter-Observer Reliability is very important in

administering any assessment/scoring tool

SCORING

THE EXAM

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• In order to best meet the needs of the community nurses, this exam will focus on the assessment of the infant withdrawing from drugs of abuse and not how to score an infant according to any scoring tool

THE EXAM

• It is important to note that these symptoms assessed just for one moment in time may not be indicative of substance withdrawal but should be observed over a period ofbut should be observed over a period of time

• They may be the beginning to some scripted conversation with mom.

• This will be an area for development in your local program moving forward

THE EXAM

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• Throughout your interaction with mom and g yher infant, if you should note any of the following on exam, these would be red flags to note for possible substance withdrawal

THE EXAM

• How does mom hold her infant?I h k i th b b ti htl b dl d?• Is she keeping the baby tightly bundled?

• Does she seem fearful of her infant’s excessive crying?

INITIAL EXAM

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• Excessive crying– Self-consoling measures usually work in 15 g y

second period– If not… interventions from caregiver such as

holding, rocking offering pacifier should assist infant to calm

– If crying extends up to or exceeds 5 minutes during your interaction

CRYING

• Ask mom how long her baby usually sleeps after a feeding

I f t ith NAS ll h l– Infants with NAS generally have poor sleep patterns with frequent wake periods

SLEEP

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• Normal reflex evaluates integrity of the infants central nervous system.

• 2 ways to elicit a Moro reflex– Lift slightly off mattress by arms and allow infant to

fall gently back onto the mattressfall gently back onto the mattress– Hold infant supine with both hands one beneath

occiput and the other supporting the upper back, suddenly allowing the head to fall backward (about 30 degrees)

MORO

• Hyperactive Moro Reflex– Pronounced jitteriness of the hands during or at the end of a

Moro reflex• Rhythmic tremors that are symmetrical and involuntary• Infant should be quiet before Moro is done• Also indicative if non-elicited Moro reflexes occurAlso indicative if non elicited Moro reflexes occur

MORO

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• Babies may tremor with handling or they may tremor at rest with no handling

f• Tremors may involve the hands or feet or the entire extremity

• The more involvement-the more severe• Undisturbed tremors worse than disturbed tremors• Presence of undisturbed tremors indicates excessive

irritation of the central nervous systemT d Jitt i t

TREMORS

• Tremors and Jitteriness are synonymous terms

• Ability of muscle to resist movement y• Recoil phenomenon: when passively stretched

muscle is released it should spring back to its original position– Examine infant when quietly awake and alert or awake and

moving

INCREASED MUSCLE TONE

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• Constant rubbing of an extremity against a fabric such as bed linenExcoriation to chin, nose, knees, cheeks, elbows, or toesor toes

EXCORIATION

• Involuntary spasms or twitching of a muscle

Rarely seen in newborn period– Rarely seen in newborn period

• Twitching movements of the face or extremities or jerking movements of the arms or legs

MYOCLONIC JERKS

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• Generalized motor seizures or rhythmic myoclonic jerks (tonic seizures)– Often accompanied by apnea and a few clonic

movements– If movement does not stop with touching

• Any seizure activity present– Subtle seizure activity not a common sign of

opioid withdrawal

CONVULSIONS

• Sweating-wetness to the forehead, upper lip, or back of the neck

• Yawning• Mottling if present to trunk chest or extremities• Mottling-if present to trunk, chest or extremities• Nasal Stuffiness – noisy breathing/runny nose• Sneezing• Nasal Flaring-outward spread of the nostrils• RR > 60/min with or without retractions

METABOLIC, VASOMOTOR, AND RESPIRATORY DISTURBANCES

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• Excessive sucking –• Poor feeding – demonstrated multiple ways

– Sucks infrequently during feed taking small amounts of formulaU di t d ki fl– Uncoordinated sucking reflex

– Continuously gulping formula and stops frequently to breath

• Poor Feeding– How is the baby’s weight gain-Poor?– Report from mom on eating pattern– How much is infants taking at a feeding

H t di

EXCESSIVE SUCKING AND POOR FEEDING

– How many wet diapers

• Regurgitation-effortless return of stomach contents to infants mouth– How often does it occur– Babies spit

• Projectile Vomiting-forceful ejection of stomach contents from the infants mouth– How often does it occur– Other causes

REGURGITATION AND PROJECTILE VOMITING

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• May or may not be explosive– Slightly curdy, mushy or seedy– More liquid than normal

Red buttocks may or may not be present– Red buttocks may or may not be present

• Any stool accompanied by a water ring on the diaper– Red buttocks may or may not be present

• Other causes

LOOSE/WATERY STOOLS

• You have a baby with suspicious symptoms for NAS

Al b l t f th f i f t– Always be alert for other causes for infants symptoms

– Scripted conversation with mom– Be supportive– Mom may be very scared– Offers of support and help may need to be

repetitive and often

WHAT TO DO

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− Know your agencies referral protocolsI f t d f l t di t i i f− Infant needs referral to pediatrician for exam and treatment as indicated

− Mom needs appropriate treatment, counseling and support

WHAT TO DO

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• Understanding drug addictiong g− Chronic disease – physiologic changes in the brain that

drives behavior− Normal brain chemicals - no longer effective due to the

opioid use− Behaviors are driven by addiction rather than moral decision− Risk factors for opioid addiction

− Biological psychosocial/developmental and environmental

MOMBiological, psychosocial/developmental, and environmental

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• Mom’s treatment depends on many factors− Willingness for treatment− Supportive care− Want for infant− Want for better lifestyle− Availability of treatment− Transportation to treatment− Influence of family/friends

MOM

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• Nursing Care – non-pharmacological– For all drug exposed infants– Decrease environmental stimuli

• Light reduction- consider placing infant in dark environment• Sound reduction – consider placing infant in a quiet

environment, use of white noise or humming to soothe infant• Limit stimulation/visitors

TREATMENT

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• Positioning techniques– Position with hands to mouth– Use containment holding– Gentle swaying or rocking– Skin to skin

TREATMENT

• Minimize Interruptions– Cluster Care– Allowing infant to demand feed

• Flex schedule slightly to fit babies needs

TREATMENT

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• Feeding Techniques– Encourage breastfeeding unless contraindicated

• Not recommended if mom using illicit drugs - until mom is sober

• Methadone/Buprenorphine treatment is okayp p y– Smaller volume with increased calorie feeds

TREATMENT

• Is it safe for a mother on methadone to breastfeed? YES!– Addictive drugs are excreted in variable

amounts in breast milkMethadone treatment and breastfeeding is– Methadone treatment and breastfeeding is deemed compatible by the AAP

– Breastfeeding is associated with • Reduced NAS severity• Delayed onset of NAS• Decreased need for pharmacological treatment• Shortened hospital stays

BREASTFEEDING AND NAS

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• Drug use and the effects to the breastfed infant− Alcohol – Use discouraged-Changes sleep-wake

patterns and gross motor development− Cocaine – Contraindicated-Cocaine intoxication, poor

sleep patterns, irritability, vomiting, diarrhea, seizures, tremors

− Amphetamines – Contraindicated-poor sleep patterns, irritability, vomiting, diarrhea, tremors, seizures

DRUG USE AND BREASTFEEDING

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– Marijuana – Discourage continued use of marijuana– Heroine – Contraindicated-Tremors, restlessness, vomiting,

and poor feeding/sleep patterns– Methadone – Compatible-minimal transfer in breast milk;

avoid abrupt discontinuation of breastfeeding– Sedatives/Hypnotics – Use is individualized-discontinue if

signs of weight loss and lethargy occur in infant

DRUG USE AND BREASTFEEDING

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• Soothing behaviors– Pacifier– Soft music– Massage Therapy

TREATMENT

• With confirmed drug exposure if infant…– Is unaffected– Demonstrates minimal signs of withdrawal

• Then…– Do not treat with pharmacological therapy

• Could lengthen infants hospital stay• Interfere with maternal-infant bonding

TREATMENT

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• If exam/scores indicate pharmacological treatment is necessary then– Infant must be admitted to a hospital with a

nursery that is prepared to care for infants with NASNAS

– Infant must be monitored on Cardio/Respiratory Monitor during the medication administration

– Integration of other therapies is of the upmost importance for successful recovery

• OT• PT

TREATMENT

• Social Services

• Morphine – primary pharmacologic treatment when supportive measures fail to control symptoms

• Titrating the dose– Dose is adjusted according to scores until infant

has symptoms controlled as evidenced by the exam

– Once stable by exam for 48 hours, weaning can begin

– Length of stay depends on severity of NAS• Weeks to months

TREATMENT

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• Nurses impact on mother– Rooming-in encouraged with judgment– Work through personnel attitudes and feelings– Moms need to be taught how to hold, feed,

comfort and the general care of their infant– Create a nurturing environment to positively

influence the bonding of mother and infant– Support the new skills mom is learning

NURSING’S ROLE

• Prenatal care for women with substance abuse improves perinatal outcomes

– Babies show increased growth, lower hospitalization days

– Mothers in long term treatment with support more likely to recover

PARENTING

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• Parenting– Caregivers need to learn:

• Care of infant• Any signs or symptoms of withdrawal

in infant• How to handle stressful situations

with infant• Follow-up appointments/programs• Appropriate babysitting arrangements

PARENTING

• Appropriate babysitting arrangements• Back-up plan if help is needed

• Social Services– Very important part of the health care team– Goal is always keeping the family intact

C di t ll l l i– Coordinate all legal issues– Will be able to arrange back-up plan for

mom if needed• Crisis nursery• Nurses for Newborns

PARENTING

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• Preserving the maternal –infant dyad− Encourage mom to enter rehab− Encourage support group participation− Know your local resources− Antenatal consults and ongoing education of parents for what to

expect− Allow rooming in

− Decreased use of morphine− Improved weight gain− More babies home with mothers

SUMMARY

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• Culture Change− Nursing education to help change attitudesNursing education to help change attitudes− Addiction is a disease− Drugs change addicts brains interfering with normal mother-

baby bonding− Must support mom before, during and after hospitalization

SUMMARY

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THANK YOU!

• Verklan, M. T. and Walden, M.: Core Curriculum for Neonatal Intensive Care Nursing 4th

edition• Murphy-Oikonen,J., Montelpare, W., Southon, S., Bertoldo, L. and Persichino, N.: Identifying

Infants at Risk for Neonatal Abstinence Syndrome. Journal of Perinatal Neonatal NursingVol. 24, No. 4: 366-372

• Chasnoff, IJ., Neuman, K., Callsghan, A.: Screening for Substance Use in Pregnancy: A Practical Approach for the Primary Care Physician. American Journal Obstetrics Gynecology. 2001;184(4): 169-194

• Hudak, M., Tan, R. Neonatal Drug Withdrawal The Committee of Drugs and The Committee on Fetus and Newborn. Pediatrics DOI:10.1542/peds.2011-3212

• Abdel-Latif, M; Pinner, J; Clews, S.; Cooke, KL; Oei, J. Effects on Breast Milk on the Severity and Outcome of Neonatal Abstinence Syndrome Among Infants of Drug-Dependent Mothers, Pediatrics, 2006;117;e1163

• Washington State Dept. of Health office of Health Committee Substance Abuse During Pregnancy: Guidelines for Screening. Revised Edition 2012

• D’Apolito, K, and Finnegan, L. (2010). Assessing Signs and Symptoms of Neonatal Abstinence Using the Finnegan Scoring Tool. An inter-observer reliability program NeoAdvances

• Bio, L.L., Siu, A., and Poon, C.Y. (2011). Update of the Pharmacologic Management of Neonatal Abstinence Syndrome Journal of Perinatology

REFERENCES

Neonatal Abstinence Syndrome. Journal of Perinatology• Jansson, L.M., Velez, M., and Harrow, C. (2009). The Opioid Exposed Newborn:

Assessment and Pharmacologic Management. Journal of Opioid Management, 5(1), 47-55• Maguire, PhD, RN, CNL. Mothers on Methadone: Care in the NICU. Neonatal Network 2013,

Vol. 32, No. 6 Nov./Dec.