NEONATAL ABSTINENCE SYNDROME - Springfield neonatal abstinence syndrome ... vomiting/diarrhea, dehydration, poor wt. gain, ... • Nursing care

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  • 12/10/2014

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    NEONATAL ABSTINENCE SYNDROME

    Mary Hope, RN, BSN Cardinal Glennon Childrens 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 STDs or hepatitis Teen Pregnancy

    Neonatal History SGA neonate (

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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 Patients well being Concerns for caretakers 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) SSRIsSSRI 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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    SSRIS (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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