Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs Dixie L. Morgese, BA, CAP, ICADC.

Handle With CareHandle With CareTherapeutic Approaches for Therapeutic Approaches for Managing Babies Exposed to Managing Babies Exposed to

Alcohol and Other DrugsAlcohol and Other DrugsDixie L. Morgese, BA, CAP, ICADCDixie L. Morgese, BA, CAP, ICADC

Learning ObjectivesLearning Objectives Identify terms associated with SENSIdentify terms associated with SENS Learn common symptoms of drug exposed Learn common symptoms of drug exposed

babiesbabies Learn appropriate therapeutic handling of Learn appropriate therapeutic handling of

drug exposed newborns and babiesdrug exposed newborns and babies Understand scoring guide for babies with Understand scoring guide for babies with

Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome Understand fundamentals of conducting an Understand fundamentals of conducting an

Infant AssessmentInfant Assessment Identify techniques for managing Identify techniques for managing

withdrawalwithdrawal

TermsTerms SEN – Substance Exposed NewbornSEN – Substance Exposed Newborn CDN – Chemically Dependent NewbornCDN – Chemically Dependent Newborn NAS – Neonatal Abstinence SyndromeNAS – Neonatal Abstinence Syndrome NAS* - Neonatal Abstinence ScoringNAS* - Neonatal Abstinence Scoring FASD – Fetal Alcohol Spectrum DisorderFASD – Fetal Alcohol Spectrum Disorder FAS – Fetal Alcohol SyndromeFAS – Fetal Alcohol Syndrome WIS – Women’s Intervention SpecialistWIS – Women’s Intervention Specialist FIS – Family Intervention Specialist FIS – Family Intervention Specialist ATOD – Alcohol, Tobacco and Other DrugsATOD – Alcohol, Tobacco and Other Drugs CNS – Central Nervous SystemCNS – Central Nervous System

TermsTerms

Hyperreflexia – Overactive reflexes – Hyperreflexia – Overactive reflexes – response to stimuli “Moro” response to stimuli “Moro”

Overstimulated – “overwhelmed” by Overstimulated – “overwhelmed” by stimulusstimulus

Philtrum – vertical groove on the Philtrum – vertical groove on the median line of the upper lip.median line of the upper lip.

Feeding intolerance – inability to Feeding intolerance – inability to suck, swallow or retain feedings.suck, swallow or retain feedings.

TermsTerms

Drug Endangered Infant/Child – a Drug Endangered Infant/Child – a wide range of risk associated with wide range of risk associated with exposure to alcohol and other drugs.exposure to alcohol and other drugs.

Marchman Act – petition that Marchman Act – petition that supports legal remedy regarding supports legal remedy regarding evaluation and intervention.evaluation and intervention.

State Regulation – ability to adapt to State Regulation – ability to adapt to external stimulation.external stimulation.

CNS SubstancesCNS Substances Children of mothers who used drugs:Children of mothers who used drugs:

– Stimulants – risk of preterm labor and Stimulants – risk of preterm labor and abruption abruption

– Depressants – alcohol most damaging*Depressants – alcohol most damaging*– Opiates – increasing numbers of casesOpiates – increasing numbers of cases– MarijuanaMarijuana– HallucinogensHallucinogens– Tobacco* - low birth weight, SIDSTobacco* - low birth weight, SIDS

Varying responses, particularly during infancy. Prognosis for other drugs is better than with FAS depending on term of pregnancy and environment.

Common SymptomsCommon SymptomsThere are characteristics and symptoms that drug exposed babies will have in common. The nature of these – their frequency and timing will depend on factors such as:

• The drug that the baby was exposed to

• How each individual baby metabolizes the drug

• The baby’s own tolerance

No two babies will react exactly alike. It is the responsibility of the caregiver to carefully monitor and “read” the infant and the signs.

Hypersensitivity to StimuliHypersensitivity to Stimuli

One of the most common traitsOne of the most common traits Little tolerance to stimuliLittle tolerance to stimuli Swallowing, closeness, sound, can Swallowing, closeness, sound, can

escalate baby into “frantic” stateescalate baby into “frantic” state Babies need protection from Babies need protection from

overstimulation but should not be overstimulation but should not be stimulus-deprived.stimulus-deprived.

Changes to Muscle ToneChanges to Muscle Tone

Muscle tone is the degree of stiffnessMuscle tone is the degree of stiffness Unusually limp or unusually stiffUnusually limp or unusually stiff Particularly in limbs and neckParticularly in limbs and neck Stiffness may “come and go”Stiffness may “come and go” Tremors, jerking, other signs of Tremors, jerking, other signs of

distress – sign of baby trying to distress – sign of baby trying to control uncomfortable sensations.control uncomfortable sensations.

Gastrointestinal ProblemsGastrointestinal Problems

Drugs attack gastric system – 12 mosDrugs attack gastric system – 12 mos Watery stool, explosive diarrhea, Watery stool, explosive diarrhea,

excoriated buttocks, gas, constipationexcoriated buttocks, gas, constipation Need proper handling to prevent Need proper handling to prevent

serious health concernsserious health concerns Distress and high stimulation can Distress and high stimulation can

increaseincrease Diarrhea can irritate fragile lining of the Diarrhea can irritate fragile lining of the

intestines and also lead to dehydration.intestines and also lead to dehydration.

Other Related Other Related ComplicationsComplications

Chronic Ear InfectionChronic Ear Infection Unexplained fever (opiates and Unexplained fever (opiates and

opioids)opioids) Sleep/wake irregularitySleep/wake irregularity Extreme appetite (barbiturates)Extreme appetite (barbiturates) Hyperreflexia/MoroHyperreflexia/Moro

Therapeutic HandlingTherapeutic Handling

Caregivers need appropriate trainingCaregivers need appropriate training Comforting techniques are critical to Comforting techniques are critical to

management of withdrawing infantsmanagement of withdrawing infants Each type of drug exposure presents Each type of drug exposure presents

unique challengesunique challenges Basic principles of handling apply to Basic principles of handling apply to

allall

Eight PrinciplesEight Principles

SwaddlingSwaddling C-PositionC-Position Head to Toe MovementHead to Toe Movement Vertical RockVertical Rock ClappingClapping FeedingFeeding Controlling the EnvironmentControlling the Environment Introducing StimuliIntroducing Stimuli

Principle #1 SwaddlingPrinciple #1 Swaddling

Drug exposed infants cannot do three Drug exposed infants cannot do three things simultaneously – body, breathe, things simultaneously – body, breathe, sucksuck

Swaddling provides comfort in helping Swaddling provides comfort in helping them to control their bodiesthem to control their bodies

Allows them to focus on breathing – Allows them to focus on breathing – then feeding with greater comfort.then feeding with greater comfort.

Principle #2 – C-PositionPrinciple #2 – C-Position

Increases sense of control and ability Increases sense of control and ability to relaxto relax

Hold baby firmly and curl head and Hold baby firmly and curl head and legs into a Clegs into a C

When laying down – place on side, When laying down – place on side, wrap blanket into a role around body.wrap blanket into a role around body.

Then introduce back position for Then introduce back position for sleeping as recommended by sleeping as recommended by Academy of Pediatrics.Academy of Pediatrics.

Principle #3 “Head to Toe”Principle #3 “Head to Toe”

Back and forth motions not Back and forth motions not recommendedrecommended

Slow, rhythmic swaying following line Slow, rhythmic swaying following line from head to toe while swaddled and from head to toe while swaddled and held in C position is comforting.held in C position is comforting.

Keeping movement slow and Keeping movement slow and rhythmic will help relax and settle rhythmic will help relax and settle the infant.the infant.

Principle #4 Vertical RockPrinciple #4 Vertical Rock

Best when baby is frantic and hard to Best when baby is frantic and hard to calmcalm

Maintain C position and hold directly in Maintain C position and hold directly in front of you and turned away.front of you and turned away.

Slowly and rhythmically rock baby up Slowly and rhythmically rock baby up and down – soothes neurological system.and down – soothes neurological system.

Be aware of personal energy level – keep Be aware of personal energy level – keep baby at a distance while rocking if baby at a distance while rocking if necessary.necessary.

Principle #5 – “Clapping”Principle #5 – “Clapping”

Cup hand Cup hand Clap/pat baby’s blanketed bottomClap/pat baby’s blanketed bottom Clap slow and rhythmicallyClap slow and rhythmically Baby’s muscles may start to relaxBaby’s muscles may start to relax This technique does not work with all This technique does not work with all

babies – if baby does not respond, babies – if baby does not respond, discontinue.discontinue.

Principle #6 - FeedingPrinciple #6 - Feeding

Withdrawal may adversely affect sucking – Withdrawal may adversely affect sucking – babies may suck frantically or have babies may suck frantically or have disorganized suckdisorganized suck

Makes it difficult for them to take in Makes it difficult for them to take in enough formula or to breastfeedenough formula or to breastfeed

The key is to get baby relaxed enough to The key is to get baby relaxed enough to suck steadily in a low-stimulus suck steadily in a low-stimulus environment.environment.

Baby should be swaddled and in C-positionBaby should be swaddled and in C-position

Principle #7 – Controlling the Principle #7 – Controlling the EnvironmentEnvironment

Limit number of caregiversLimit number of caregivers Offer calm surroundingsOffer calm surroundings Minimize any loud noise – music and Minimize any loud noise – music and

voices should be low volumevoices should be low volume Keep lights lowKeep lights low Caregiver should have calm presenceCaregiver should have calm presence Routine is beneficialRoutine is beneficial

Neonatal Abstinence Neonatal Abstinence

Neonatal Abstinence – term given to Neonatal Abstinence – term given to the condition of an infant born to a the condition of an infant born to a drug affected mother – withdrawaldrug affected mother – withdrawal

Withdrawal – set of symptoms as the Withdrawal – set of symptoms as the body attempts to remove an addictive body attempts to remove an addictive substancesubstance

Must be accurately assessedMust be accurately assessed May be controlled by using May be controlled by using

therapeutic measures and often therapeutic measures and often medicationmedication

Neonatal Abstinence Neonatal Abstinence SymptomsSymptoms

(not exhaustive)(not exhaustive) Hyper-irritabilityHyper-irritability Respiratory distressRespiratory distress Gastrointestinal distressGastrointestinal distress Sleep disturbancesSleep disturbances

Neonatal Abstinence Neonatal Abstinence ScoringScoring

Determines the level of therapeutic Determines the level of therapeutic intervention necessaryintervention necessary

Helps to determine the effectiveness Helps to determine the effectiveness of interventions being usedof interventions being used

Assesses symptomsAssesses symptoms Originally developed by Loretta Originally developed by Loretta

Finnegan Finnegan

NAS Scoring ToolNAS Scoring Tool

Set of observed signs and symptoms Set of observed signs and symptoms in the infantin the infant

Observed at regular intervals – every Observed at regular intervals – every 3 hours3 hours

Should reflect all symptoms observed Should reflect all symptoms observed since the last scoringsince the last scoring

High scores that are not lowered by High scores that are not lowered by therapeutic handling should be therapeutic handling should be assessed for medical interventionassessed for medical intervention

Medication Medication

Medication is likely to be initiated in Medication is likely to be initiated in the following instances:the following instances:– NAS scores greater than 10 on 3 NAS scores greater than 10 on 3

consecutive scoring intervalsconsecutive scoring intervals– The average of 3 consecutive scores is The average of 3 consecutive scores is

greater than 10greater than 10– The score is greater than 12 on 2 The score is greater than 12 on 2

consecutive scoresconsecutive scores– The average of 2 consecutive scores is The average of 2 consecutive scores is

greater than 12greater than 12

Medication and NAS ScoresMedication and NAS Scores

Tapered down based on NAS scoresTapered down based on NAS scores– Remains below 10 and infant tolerates Remains below 10 and infant tolerates

medication decreases wellmedication decreases well– Medication can be decreased as quickly Medication can be decreased as quickly

as 10% per dayas 10% per day– After medication discontinued, NAS After medication discontinued, NAS

scoring should be continued for at least scoring should be continued for at least five days,five days,

Tools NeededTools Needed

NAS Score SheetNAS Score Sheet Watch or clock with a second handWatch or clock with a second hand ThermometerThermometer StethoscopeStethoscope

System Signs & Symptoms Score

Excessive High Pitched ( or other) cry 2

Continuous high pitched (or other) cry3

Sleeps < 1 hr after feeding3

Sleeps < 2hr after feeding2

Sleeps <3 hr after feeding1

Hyperactive Moro Reflex2

Hypersensitivity3

Markedly hyperactive Moro Reflex3

Mild tremors disturbed 1

Moderate-Severe tremors disturbed 2

Mild Tremors Undisturbed 3

Moderate-Severe tremors Undisturbed 4

Increased muscle tone 2

Excoriation (specific area)1

Myoclonic jerks 3

Convulsions/Seizures 5

Cen

tral N

erv

ou

s S

yst

em

D

istu

rban

ces

Assessment of the InfantAssessment of the Infant

CryingCrying SleepSleep Moro ReflexMoro Reflex TremorsTremors Increased Increased

Muscle ToneMuscle Tone

ExcoriationExcoriation Myoclonic Myoclonic

JerksJerks Generalized Generalized

Convulsions/ Convulsions/ SeizuresSeizures

SystemSystem Signs & SymptomsSigns & Symptoms ScorScoree

SweatingSweating 22

Fever > 101 (99-11.8F/37.2-38.2C)Fever > 101 (99-11.8F/37.2-38.2C) 11

Fever > 101 (38.4C or higher)Fever > 101 (38.4C or higher) 22

Frequent Yawning (3-4 times/intervalFrequent Yawning (3-4 times/interval 11

MottlingMottling 11

Nasal StuffinessNasal Stuffiness 11

Sneezing (>3-4 times/interval)Sneezing (>3-4 times/interval) 11

Nasal FlaringNasal Flaring 22

Respiratory Rate>60/minRespiratory Rate>60/min 11

Meta

bolic

, V

aso

moto

r, R

esp

irato

ry

Meta

bolic

, V

aso

moto

r, R

esp

irato

ry

Dis

turb

an

ces

Dis

turb

an

ces

AssessmentAssessment

Sweating – forehead, Sweating – forehead, upper lip, back of the upper lip, back of the head* head*

Fever – auxiliary Fever – auxiliary temptemp

Frequent Yawning – Frequent Yawning – more than 3 per more than 3 per intervalinterval

Mottling – “marbling” Mottling – “marbling” discoloration*discoloration*

Nasal Stuffiness – Nasal Stuffiness – noisy respirations noisy respirations due to mucousdue to mucous

Sneezing – more Sneezing – more than 3 times per than 3 times per intervalinterval

Nasal FlaringNasal Flaring Respiratory Rate – Respiratory Rate –

normal: 30-60- normal: 30-60- breaths per minutebreaths per minute

SystemSystem Signs & SymptomsSigns & Symptoms ScoreScoreDisorganized SuckDisorganized Suck 33

Excessive SuckingExcessive Sucking 11

FlatusFlatus 11

Poor FeedingPoor Feeding 22

RegurgitationRegurgitation 22

Projectile VomitingProjectile Vomiting 33

Loose StoolsLoose Stools 22

Water Ring StoolsWater Ring Stools 22

Watery StoolsWatery Stools 33

Initials Initials TOTAL SCORETOTAL SCORE

Gast

roin

test

inal D

istu

rban

ces

Gastrointestinal Gastrointestinal DisturbancesDisturbances

Disorganized SuckDisorganized Suck Excessive SuckingExcessive Sucking Flatus – more than 3 hrs at Flatus – more than 3 hrs at

a timea time Poor Feeding – minimum Poor Feeding – minimum

intake amount takes intake amount takes longer than 30-45 minslonger than 30-45 mins

Regurgitation – 2 or more Regurgitation – 2 or more episodes during feeding episodes during feeding (not associated with (not associated with burping) or more than 5 burping) or more than 5 cc’s or more between cc’s or more between feedingsfeedings

Projectile Vomiting – forceful Projectile Vomiting – forceful ejectionejection

Loose Stools – liquid or Loose Stools – liquid or explosiveexplosive

Water Ring Stools – Water Ring Stools – substance and water ring substance and water ring surrounding substancesurrounding substance

Watery Stools – liquidWatery Stools – liquid Blood traces in the stoolBlood traces in the stool Hypersensitivity – oral feeds, Hypersensitivity – oral feeds,

touch, sound, smell, energy touch, sound, smell, energy levels, surroundings, light, levels, surroundings, light, eye, contact, movement eye, contact, movement above and beyond normal above and beyond normal scope of withdrawals.scope of withdrawals.

Managing Initial Stages of Managing Initial Stages of WithdrawalWithdrawal

Swaddle with cotton thermal receiving Swaddle with cotton thermal receiving blanket.blanket.

Curl infant body into C-positionCurl infant body into C-position Do not speak loudly into faceDo not speak loudly into face Sway rhythmically (do not jiggle)Sway rhythmically (do not jiggle) Feed more frequently (due to calorie burning)Feed more frequently (due to calorie burning) Cotton products are a ‘must’ throughout Cotton products are a ‘must’ throughout

withdrawal periodwithdrawal period– Do not remove clothes for increased temperature Do not remove clothes for increased temperature

due to withdrawaldue to withdrawal

Managing Infants During Managing Infants During Withdrawal – 7 StepsWithdrawal – 7 Steps

#1 – Control #1 – Control EnvironmentEnvironment

#2 – Learn baby’s #2 – Learn baby’s cuescues

#3 – Attempt to #3 – Attempt to calm crying EARLYcalm crying EARLY

#4 – If difficulty #4 – If difficulty regaining control –regaining control –swaddle & vertical swaddle & vertical rock,rock,

#5 – Gradually #5 – Gradually introduce stimuliintroduce stimuli

#6 – Gradually #6 – Gradually introduce AMOUNT introduce AMOUNT of stimuliof stimuli

#7 As infant’s #7 As infant’s ability to remain ability to remain calm increases, calm increases, unwrap for short unwrap for short periods of timeperiods of time

BarriersBarriers

DependenceDependence Language/Culture – paradigm to a strengthLanguage/Culture – paradigm to a strength Fear of system/outcomesFear of system/outcomes Partner – control or violence issuesPartner – control or violence issues Treatment access/residential availabilityTreatment access/residential availability Family system/relationships and other Family system/relationships and other

childrenchildren StressorsStressors DepressionDepression Economic LimitationsEconomic Limitations

Systems of CareSystems of Care

MedicalMedical – CHD’s, CMS, hospitals, – CHD’s, CMS, hospitals, physicians, midwives physicians, midwives

Treatment CentersTreatment Centers – SMA, Haven House, – SMA, Haven House, DMTC – WIS, TOPWA otherDMTC – WIS, TOPWA other

Early StepsEarly Steps – screening of children – screening of children Child WelfareChild Welfare (DCF and Community (DCF and Community

Based Care) – legal, investigative, case Based Care) – legal, investigative, case management, wrap around services – use management, wrap around services – use PNAPNA

Healthy StartHealthy Start – care coordination and – care coordination and linkage to additional resources.linkage to additional resources.

Other Possible SystemsOther Possible Systems

LegalLegal – drug court, probation, child – drug court, probation, child support enforcement.support enforcement.

Workforce DevelopmentWorkforce Development – economic – economic self sufficiency for mother and partner.self sufficiency for mother and partner.

Child Care/ELCChild Care/ELC – respite, structure, – respite, structure, stability.stability.

OthersOthers – Homeless Services, Domestic – Homeless Services, Domestic Violence support, HIV/TOPWA, Mental Violence support, HIV/TOPWA, Mental Health, Healthy Families, Insurance.Health, Healthy Families, Insurance.

Five Point ApproachFive Point Approach Identify Identify key playerskey players – including and – including and

centeringcentering on the patient. on the patient. Unify Unify referralreferral processes - identify the processes - identify the

point person/entity.point person/entity. Coordinate Coordinate consentconsent – Healthy Start – Healthy Start

screening form can support collaboration screening form can support collaboration until further consent is obtained.until further consent is obtained.

Align Align policies and procedurespolicies and procedures – – ensure ensure systems have interagency agreements systems have interagency agreements which delineate which delineate rolesroles and and responsibilitiesresponsibilities....

Utilize Utilize unified staffingunified staffing forms. forms.

Follow UpFollow Up Identify additional staffing activities – establish Identify additional staffing activities – establish

dates, times.dates, times. Key coordinator – typically case management or Key coordinator – typically case management or

care coordination.care coordination. Ensure client completed referrals and verify Ensure client completed referrals and verify

subsequent appointments.subsequent appointments. Prior to delivery, coordinate with hospital/birthing Prior to delivery, coordinate with hospital/birthing

center.center. Provide documentation for pediatric follow up.Provide documentation for pediatric follow up. Identify who will provide ongoing education to the Identify who will provide ongoing education to the

family.family. Establish family planning and interconceptional Establish family planning and interconceptional

care plan.care plan.

Points to RememberPoints to Remember

SEN babies are at elevated risk for SEN babies are at elevated risk for SUIDS – ensure family has safe SUIDS – ensure family has safe sleeping environment.sleeping environment.

Mothers at elevated risk for PPD or Mothers at elevated risk for PPD or relapse – identify support system.relapse – identify support system.

Caregivers need to know how to Caregivers need to know how to handle SEN babies – ensure special handle SEN babies – ensure special instruction is provided and ongoing.instruction is provided and ongoing.

Questions?Questions?

Let’s work together to keep them ALL safe, healthy, and happy!

Thank You!Thank You!