Neonatal Drug Withdrawal and Concerns

8/10/2019 Neonatal Drug Withdrawal and Concerns

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Neonatal Drug Withdrawaland

Associated Concerns

Lisa McGee, MSN, RN, CCNS

Neonatal Clinical Nurse SpecialistUK Childrens HospitalDecember 17, 2013


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1. Discuss the incidence of neonatal drug withdrawal.2. Describe toxicology screening in newborns

3. Identify the signs and symptoms of neonatal abstinencesyndrome.

4. Delineate care and treatment of an infant experiencingneonatal abstinence.

5. Explore Social Services concerns associated with infants

experiencing neonatal drug withdrawal.

6. Verbalize outcomes associated with infants who haveexperienced neonatal drug withdrawal.

OBJECTIVES


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INCIDENCE


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2011 National Survey of Drug Use and Health

Average rate of current illicit drug use among pregnant

women is 5% (4.5% 2008-2009)

9% Kentucky

Non-medical use of pain relievers, tranquilizers,

stimulants and sedatives is 1% nationally

Pain relievers account for 0.9%

No significant difference between 2008-2009

Kentucky: Prescription pain meds 7%

Tranquilizers 4.6%

Prescription stimulants 2%


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JAMA 2012


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In 2009, the estimated number ofnewborns with NAS was 13,539.


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JAMA 2012


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Hospital Charges for NAS

2000 - $190 million

2009 - $720 million

JAMA 2012


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NEWBORN TOXICOLOGY

SCREENING


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Kentucky Revised StatuteAnnotated 214.160

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Any physician or person legally permitted to engage in

attendance upon a pregnant woman may administer toeach newborn infant born under that persons care a

toxicology test to determine whether there is evidenceof prenatal exposure to alcohol, a controlled substance,

or a substance identified on the list provided the theCabinet for Health and Family Services, if the attending

person has reason to believe, based on a medicalassessment of the mother or the infant, that the mother

used any such substance for a nonmedical purposeduring the pregnancy.


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Toxicology Screens

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URINE

MECONIUM

HAIR


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Urine Analysis

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traditionally the specimen of choice forneonatal drug testing

relatively easy to obtain

has a short detection windowprovidesmaternal drug use data only for a few daysprior to delivery

detects recent use of cocaine and itsmetabolites, amphetamines, marijuana,barbiturates and opiates


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Meconium Analysis

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currently considered the best method fordetecting drug exposure in pregnancy

provides a wider window of detection of

gestational exposure, presumably as remote asthe second trimester when drugs begin toaccumulate in meconium

is reliable for detecting opioid and cocaineexposure after the first trimester and can beused to detect other illicit and prescribed drugs


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Hair Analysis

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technique is expensive and not widely available

a positive result indicates use during the lasttrimesterreveals maternal drug use pattern

during the previous 3 months

useful in detecting narcotics, marijuana,cocaine, and cocaine-alcohol metabolites

the specimen can be collected at any pointduring the first 3 months of life


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UK utilizes urine andmeconium drugscreens.

Drug screens are done forall infants admitted to the

NICU.


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SIGNS & SYMPTOMS

of NAS

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A Multi-System Disorder

2/3 of neonates will show signsonset varies

majority of signs appear within

72 hours of birth

duration 8 to 16 weeks

presentation is variable

chronic usersmore severe withdrawal


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hypertonia tremors

hyperreflexia

irritability andrestlessness

high-pitched cry

sleep disturbances seizures

Neurologic


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http://newborns.stanford.edu/PhotoGallery/Jittery3.html
http://newborns.stanford.edu/PhotoGallery/Jittery3.htmlhttp://newborns.stanford.edu/PhotoGallery/Jittery3.htmlhttp://newborns.stanford.edu/PhotoGallery/Jittery3.htmlhttp://newborns.stanford.edu/PhotoGallery/Jittery3.html


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Autonomic

yawning

nasal stuffiness

sweating

sneezing

low-grade fever

skin mottling


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Gastrointestinal

diarrhea

vomiting

poor feeding

regurgitation dysmature

swallowing

excessivesucking


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Respiratory &

Miscellaneous

tachypnea

retractions

skin excoriation


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CARE AND TREATMENT

of NAS


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Non-Pharmacologic Interventions

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SWADDLING

Wrapping babies SNUGLYhelps them to control

their bodies.


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C-POSITION

Holding or laying the

baby in a C positionincreases the babys

sense of control andability to relax.


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SWAYThis head-to-toe

movement is

soothing to thedrug-affectedbabys jangled

nerves.


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http://www.youtube.com/watch?v=IdR3D3_sYDk

Mamaroo

Swing
http://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDkhttp://www.youtube.com/watch?v=IdR3D3_sYDk


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CLAPPING

Soothes the babyby relaxing the

nerves at the base

of the spine.

VERTICAL

ROCKLifting baby up anddown helps to calm

and quiet the baby.


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FEEDING

The key to feeding is to

get the baby into atherapeutic hold and

relaxed enough to suck.


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RESPOND

PROMPTLY to

CRYING

The longer a baby inearly withdrawal cries,the harder it will be to

calm him/her.


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CONTROLLING THE

ENVIRONMENT

Lower the amount of stimulus in the environment

low, soft lights

decreased noise/loud talking

slow, deliberate, purposeful movements

limit number of caregivers


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Evaluating WithdrawalScoring the Infant

Lipsit Tool(Lipsit, 1975)

Neonatal Narcotic Withdrawal Index(Green & Suffet, 1981)

Neonatal Withdrawal Inventory

(Zahorodny, et. al., 1998)

Finnegan Neonatal Abstinence Score(Finnegan, 1975)


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developed by Loretta Finnegan, MD

contains a list of 21 withdrawal s/s

each item has a weighted score

total score determined by adding thescore assigned to each symptom observed

throughout the entire scoring interval

Finnegan Scoring Tool


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Pharmcologic Intervention

Medication primarily used at UK is MORPHINE.

Morphine is begun at 0.4 mg/kg/day total dose

0.07 mg/kg q 4 hours with feeds if eating q 4 hours0.05 mg/kg q 3 hours with feeds if eating q 3 hours

Scoring is continued and dosages advanced by 25% of

initial dose every 12-24 hours until scores areconsistently < 8 and subjective nursing indicators show

easy consolability, adequate feeding and sleep.


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Medication is administered

orally.

If unable to stabilize on

< 1mg/kg/day total dose ofmorphine, a second drug is

added(phenobarbital or clonidine)


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Once stable on acceptable dose,

(


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http://vimeo.com/10038566
http://vimeo.com/10038566http://vimeo.com/10038566


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SOCIAL SERVICES

CONCERNS & ACTIVITY


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Activities of DCBS

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investigates anyone living in the householdwill talk to day care providers and childrenat school

may complete the investigation and closethe case or open a case with the family in thehome


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Parents have to be

able to provide asafe homeenvironment and

basic physical andemotional needs ofthe child before the

DCBS will close thecase.


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Prevention Services

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Implementation of a Family Preservation Planparenting skills, time management, basic life skills

Parents sent for drug and alcohol assessment

by licensed providerrandom drug screening accomplished

Parents sent to parenting classes


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HANDS Program

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Health Access Nurturing Development Services

Goals

Healthy child growth and development

Healthy, safe homes

Self-sufficient homes


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Infant Disposition

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Home with Mother

Home with Family Member

Home with Foster Care


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OUTCOMES


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Infants neurobehavioral dysfunction

influences the ability to self-organize andself-regulate.

Mothers physical and

psychological well being may bedebilitated in the perinatal periodand her ability to recognize and

respond to the newborns cuesmay be limited.

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P t I f t


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Preterm Infants

Up to 24% methadone-

maintained infants areborn preterm

25% are considered SGA(


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Other long-term effects ongrowth havenot beendocumented inthe opiate-exposed child.

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Increased motor rigidity

Dysregulated motor patterns

Decreased activity byobservation and maternal report.


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Mental Development Index

(Bayley Scales of Infant Development)

Significantly lower in opiate-exposedchildren at 12 and 18 months.


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Hyperactivity and short attention span

have been noted in toddlers prenatallyexposed to opiates.

Older children have demonstrated

memory and perceptual problems.


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Opiate exposure is associated withattention problemsmore evident as

children become older.

Behavior problems may not be evident at

3-5 years but noted at preadolescence andadolescence.


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No significant abnormalities in MRI inNBN period but long-term studies in

older children and adolescents reflecta decrease in brain volume.


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Neonatal Drug Withdrawal and Concerns

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