SUBSTANCE ABUSE SUBSTANCE ABUSE The Drug-Exposed InfantThe Drug-Exposed Infant
Authored by: Kathy McKee MS, RNCAuthored by: Kathy McKee MS, RNC
OBJECTIVESOBJECTIVES
List three physiological or List three physiological or behavioral signs of an infant behavioral signs of an infant exposed to drugs in uteroexposed to drugs in utero
Describe use of Neonatal Describe use of Neonatal Abstinence ScoringAbstinence Scoring
Discuss nursing interventions Discuss nursing interventions appropriate for infants exposed to appropriate for infants exposed to drugs in uterodrugs in utero
The StatisticsThe Statistics
National Institute on Drug AbuseNational Institute on Drug Abuse– 500,000 – 700,000 affected babies 500,000 – 700,000 affected babies
annually in the United Statesannually in the United States Washington StateWashington State
– 12,000 drug affected babies each year12,000 drug affected babies each year
Guidelines for Testing and Guidelines for Testing and ReportingReporting
ScreeningScreening– It is the responsibility of every practice to make It is the responsibility of every practice to make
sure that all pregnant and postpartum women are sure that all pregnant and postpartum women are screened for substance use (WA State Dept of screened for substance use (WA State Dept of Health)Health)
TestingTesting– Drug testing is based on specific criteria and Drug testing is based on specific criteria and
medical indicatorsmedical indicators ReportingReporting
– Reports of prenatal substance exposure shall not Reports of prenatal substance exposure shall not be construed to be child abuse or neglect and be construed to be child abuse or neglect and shall not require prosecution of the mothershall not require prosecution of the mother
TestingTesting MomMom
– Risk IndicatorsRisk Indicators No prenatal careNo prenatal care Previous Previous
unexplained fetal unexplained fetal demisedemise
Precipitous laborPrecipitous labor Abruptio placentaeAbruptio placentae Hypertensive Hypertensive
episodesepisodes Severe mood swings Severe mood swings Repeated Repeated
spontaneous spontaneous abortionsabortions
– ConsentConsent
BabyBaby– Risk IndicatorsRisk Indicators
Jittery with normal Jittery with normal glucose levelglucose level
Marked irritabilityMarked irritability Preterm birthPreterm birth Unexplained Unexplained
seizures or apneic seizures or apneic spellsspells
Unexplained IUGRUnexplained IUGR Neurobehavioral Neurobehavioral
abnormalitiesabnormalities Congenital Congenital
abnormalitiesabnormalities Signs of NASSigns of NAS
– ConsentConsent
The Drug-exposed InfantThe Drug-exposed Infant Transient effectsTransient effects Teratogenic effectsTeratogenic effects
– DysmorphicDysmorphic– BehavioralBehavioral
Confounding variablesConfounding variables– Maternal health, socioeconomic status, Maternal health, socioeconomic status,
lifestylelifestyle– Drug used/Poly-drug useDrug used/Poly-drug use– Use in relation to gestational ageUse in relation to gestational age– Time used prior to deliveryTime used prior to delivery
Common Findings in Drug Common Findings in Drug Exposed InfantsExposed Infants
Hypersensitivity to stimuliHypersensitivity to stimuli Abnormal muscle toneAbnormal muscle tone Sleep ProblemsSleep Problems Feeding ProblemsFeeding Problems GI ProblemsGI Problems
AlcoholAlcohol Fetal Alcohol Spectrum Fetal Alcohol Spectrum
Disorders/Alcohol Related Birth Disorders/Alcohol Related Birth DefectsDefects– Growth RestrictionGrowth Restriction– Facial DysmorphismFacial Dysmorphism
MicrocephalyMicrocephaly Short palpebral fissures Short palpebral fissures Hypoplastic philtrumHypoplastic philtrum Thin upper lipThin upper lip
– CNS DysfunctionCNS Dysfunction Neurological symptomsNeurological symptoms Cognitive & behavioral signsCognitive & behavioral signs
NicotineNicotine
17% of pregnant women between 17% of pregnant women between the ages of 15 and 44 smokethe ages of 15 and 44 smoke
Adverse EffectsAdverse Effects– Decreased blood flow through the Decreased blood flow through the
placentaplacenta– Low birth weightLow birth weight– Neurobehavioral impactNeurobehavioral impact– Increased respiratory tract illnessesIncreased respiratory tract illnesses– Sudden infant death syndromeSudden infant death syndrome
CocaineCocaine
StimulantStimulant– TachycardiaTachycardia– HypertensionHypertension– Decreased blood flow and oxygen delivery Decreased blood flow and oxygen delivery
to fetusto fetus– Increased uterine contractionsIncreased uterine contractions
Effect of Cocaine on the Effect of Cocaine on the InfantInfant
IrritabilityIrritability Poor feedingPoor feeding Decreased Decreased
interaction interaction DisorganizationDisorganization Sleep disturbancesSleep disturbances TremorsTremors SneezingSneezing Tone abnormalitiesTone abnormalities High-pitched cry High-pitched cry
Possible Possible association association with:with:
–Congenital Congenital heart defectsheart defects–Urinary Urinary obstruction obstruction defectsdefects–GastrointestinGastrointestinal obstructional obstruction
MethamphetamineMethamphetamine
Potent stimulantPotent stimulant– VasoconstrictionVasoconstriction– Increased heart rateIncreased heart rate– HyperthermiaHyperthermia– Decreased appetite in userDecreased appetite in user– Decreased oxygen and Decreased oxygen and
nutrient delivery through nutrient delivery through placentaplacenta
– Prolonged circulation of drug Prolonged circulation of drug in fetal circulationin fetal circulation
Effects of Effects of Methamphetamine on the Methamphetamine on the
Infant Infant
Poor state controlPoor state control LethargicLethargic Poor feedingPoor feeding
– Disorganized suckDisorganized suck– No suckNo suck
IrritableIrritable Abnormal toneAbnormal tone Excoriated Excoriated
buttocksbuttocks
Associated with:Associated with:
–Congenital brain Congenital brain lesionslesions
–Cleft lipCleft lip
–Cardiac defects Cardiac defects
–Low birth weight Low birth weight and reduced OFCand reduced OFC
–HyperbilirubinemiHyperbilirubinemiaa
Narcotics/OpiatesNarcotics/Opiates
Morphine, Heroin, MethadoneMorphine, Heroin, Methadone Continued use will lead to profound Continued use will lead to profound
physiologic and psychological addictionphysiologic and psychological addiction Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome
– Passive exposure in utero as a Passive exposure in utero as a consequence of maternal addiction.consequence of maternal addiction.
– Iatrogenic exposure by the administration Iatrogenic exposure by the administration of narcotic analgesics to the neonateof narcotic analgesics to the neonate
Neonatal Abstinence Neonatal Abstinence SyndromeSyndrome
Generalized disorder characterized Generalized disorder characterized by 21 symptoms most commonly by 21 symptoms most commonly seen in withdrawing infants.seen in withdrawing infants.
2/3 of infants born to opiate-2/3 of infants born to opiate-dependent women will exhibit signs dependent women will exhibit signs of NASof NAS
Time of onset variesTime of onset varies Symptoms varySymptoms vary
Neonatal Abstinence Neonatal Abstinence ScoringScoring
Assists in the detection ofAssists in the detection of– Onset of withdrawal symptomsOnset of withdrawal symptoms– Severity of symptomsSeverity of symptoms– Response to interventionResponse to intervention– Resolution of symptomsResolution of symptoms
Assess high risk infant Assess high risk infant – 2 hours after birth2 hours after birth– Every 3-4 hoursEvery 3-4 hours
NAS ScoringNAS Scoring The Finnegan scaleThe Finnegan scale
– If score is 8 or greaterIf score is 8 or greater Score every 2 hours for Score every 2 hours for
24 hours24 hours
– Scores > 8 on three Scores > 8 on three consecutive scoresconsecutive scores
Evaluate need for Evaluate need for medicationmedication
– If intervention not If intervention not needed by 72 hoursneeded by 72 hours
Scoring may be Scoring may be discontinueddiscontinued
System DisturbancesSystem Disturbances
Central Nervous SystemCentral Nervous System
Metabolic/Vasomotor/Metabolic/Vasomotor/RespiratoryRespiratory
GastrointestinalGastrointestinal
Central Nervous SystemCentral Nervous System
CryCry Sleep patternSleep pattern Exaggerated Moro Reflex Exaggerated Moro Reflex TremorsTremors Muscle toneMuscle tone ExcoriationExcoriation Myoclonic jerksMyoclonic jerks ConvulsionsConvulsions
Metabolic,Vasomotor, Metabolic,Vasomotor, RespiratoryRespiratory
SweatingSweating FeverFever YawningYawning MottlingMottling Nasal stuffinessNasal stuffiness SneezingSneezing Nasal flaringNasal flaring Increased respiratory rate, Increased respiratory rate,
retractionsretractions
GastrointestinalGastrointestinal
Excessive suckingExcessive sucking Poor feedingPoor feeding Regurgitation, projectile vomitingRegurgitation, projectile vomiting Loose stools, watery stoolsLoose stools, watery stools
MedicationsMedications for NASfor NAS
Morphine SulfateMorphine Sulfate PhenobarbitalPhenobarbital AtivanAtivan OtherOther
Nursing Care of the Drug Nursing Care of the Drug Exposed InfantExposed Infant
Careful AssessmentCareful Assessment NAS Scoring (if NAS Scoring (if opiateopiate exposure) exposure) Control of the environmentControl of the environment Feeding techniquesFeeding techniques Therapeutic HandlingTherapeutic Handling
– Swaddle Swaddle – ClappingClapping– Vertical rocking Vertical rocking – C-positionC-position
Nursing Care of the Drug Nursing Care of the Drug Exposed InfantExposed Infant
Dealing with the familyDealing with the family– Personal feelingsPersonal feelings– Public health issue vs. CrimePublic health issue vs. Crime– Involve in care—teach Involve in care—teach
Opportunities for changing the addicted woman’s behavior and her view of health care providers can be influenced by the care she and her infant receive while hospitalized
Questions ?Questions ?
ReferencesReferences
Askin, Debbie Frasier (2001). Cocaine: Effects of in utero Askin, Debbie Frasier (2001). Cocaine: Effects of in utero exposure on the fetus and neonate. exposure on the fetus and neonate. The Journal of The Journal of Perinatal and Neonatal Nursing, Perinatal and Neonatal Nursing, 14 (4), 83-10214 (4), 83-102
D’Apolito, Karen (2001). Prominence of withdrawal D’Apolito, Karen (2001). Prominence of withdrawal symptoms in polydrug-exposed infants. symptoms in polydrug-exposed infants. The Journal of The Journal of Perinatal and Neonatal Nursing, Perinatal and Neonatal Nursing, 14 (4), 46-60.14 (4), 46-60.
Jorgensen, Katherine M. (1999). The drug-exposed infant: Jorgensen, Katherine M. (1999). The drug-exposed infant: Physiology, signs, and symptoms. Physiology, signs, and symptoms. Central Lines, Central Lines, 15 (2), 1-15 (2), 1-11.11.
Ostrea, Enrique M. (2001). Understanding drug testing in Ostrea, Enrique M. (2001). Understanding drug testing in the neonate and the role of meconium analysis. the neonate and the role of meconium analysis. The The Journal of Perinatal and Neonatal Nursing, Journal of Perinatal and Neonatal Nursing, 14 (4), 61-82.14 (4), 61-82.
Tillett, Jackie & Osborne, Kathryn (2001). Substance Tillett, Jackie & Osborne, Kathryn (2001). Substance abuse by pregnant women: Legal and ethical concerns. abuse by pregnant women: Legal and ethical concerns. The Journal of Perinatal and Neonatal Nursing, The Journal of Perinatal and Neonatal Nursing, 14 (4), 1-14 (4), 1-11.11.
Weiner, Susan M. & Finnegan, Loretta P. (2002). Drug Weiner, Susan M. & Finnegan, Loretta P. (2002). Drug withdrawal in the neonate. In withdrawal in the neonate. In Handbook of Neonatal Handbook of Neonatal Intensive Care Intensive Care 5 5thth Ed. St. Louis, Missouri, Mosby, Inc. Ed. St. Louis, Missouri, Mosby, Inc.
Wilbourne, Paula, Wallerstedt, Cheryl, Dorato, Veronica, Wilbourne, Paula, Wallerstedt, Cheryl, Dorato, Veronica, & Curet, Luis B. (2001). Clinical management of & Curet, Luis B. (2001). Clinical management of methadone dependence during pregnancy. methadone dependence during pregnancy. The Journal The Journal of Perinatal and Neonatal Nursing, of Perinatal and Neonatal Nursing, 14 (4), 26-45.14 (4), 26-45.
Guidelines for Testing and Reporting Drug Exposed Guidelines for Testing and Reporting Drug Exposed Newborns in Washington State. Washington State Newborns in Washington State. Washington State Department of Health, 2006.Department of Health, 2006.
Williams, Jill Schlabig (2006). The neurobehavioral Williams, Jill Schlabig (2006). The neurobehavioral legacy of prenatal tobacco exposure. NIDA.legacy of prenatal tobacco exposure. NIDA.