NEONATAL ABSTINENCE SYNDROME - Springfield · PDF fileexperiencing neonatal abstinence syndrome ... vomiting/diarrhea, dehydration, poor wt. gain, ... • Nursing care
Post on 10-Mar-2018
238 Views
Preview:
Transcript
12/10/2014
1
NEONATAL ABSTINENCE SYNDROME
Mary Hope, RN, BSN Cardinal Glennon Children’s Medical Center
Perinatal Outreach Education
0
1
12/10/2014
2
• 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
y
• 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
12/10/2014
3
• 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
12/10/2014
4
• 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
12/10/2014
5
• 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
12/10/2014
6
– 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
12/10/2014
7
• 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
12/10/2014
8
• 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
12/10/2014
9
• 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
16
• 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
12/10/2014
10
• 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
12/10/2014
11
• 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
12/10/2014
12
• 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
12/10/2014
13
• 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
12/10/2014
14
• 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
12/10/2014
15
• 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
12/10/2014
16
• 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
12/10/2014
17
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
12/10/2014
18
• 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
12/10/2014
19
• 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
12/10/2014
20
• 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
12/10/2014
21
• 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
12/10/2014
22
• 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
12/10/2014
23
• 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
12/10/2014
24
• 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
12/10/2014
25
• 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
12/10/2014
26
• 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
12/10/2014
27
• 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
12/10/2014
28
− 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
54
• 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
55
12/10/2014
29
• 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
56
• 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
12/10/2014
30
• 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
12/10/2014
31
• 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
12/10/2014
32
• 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
62
– 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
12/10/2014
33
• 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
12/10/2014
34
• 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
12/10/2014
35
• 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
12/10/2014
36
• 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
12/10/2014
37
• 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
72
• 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
73
12/10/2014
38
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.
top related