Neonatal abstinence syndrome: The nurse's role.
Neonatal Abstinence Syndrome (NAS) is an increasing health problem among newborn infants (U. S. Department of Health and Human Services, 2010). Drug-exposed infants are withdrawing from the addictive substances received in utero that were taken by their mothers. As the use and abuse of addictive substances increases in pregnant mothers, so will the incidence of NAS. Most infants born to drug-dependent mothers will undergo Neonatal Abstinence Syndrome and will require pharmacotherapy for withdrawal symptoms. According to findings of the 2009 National Survey on Drug Use and Health, "The rate of current illicit drug use in the combined 2009-2010 data was 16.2 percent among pregnant women aged 15 to 17, 7.4 percent among pregnant women aged 18 to 25, and 1.9 percent among pregnant women aged 26 to 44" (U. S. Department of Health and Human Services, 2010).
Though many pregnant women who are substance abusers do not seek prenatal care, many seek addiction help by replacing their current narcotics with methadone. Also, women who have already sought help for addiction have replaced narcotics with methadone and then have become pregnant. These women are encouraged to remain on methadone so that they do not miscarry the infant. Many practitioners teach prenatal classes to the high-risk mother, and drug addiction is just one of the many issues facing the high-risk pregnancy. Lastly, many women are polydrug users (combined users of narcotics and methadone) and healthcare personnel are unaware of this until the delivery of the infant. Care of these drug-addicted mothers and their drug-dependent newborns brings many challenges to healthcare personnel. Nurses are in a unique position to assess pregnant drug-addicted mothers and to observe for signs and symptoms of withdrawal in their newborns.
Loretta Finnegan, a pediatrician from Philadelphia General Hospital, first began to report withdrawal symptoms of newborns from drug-dependent mothers in 1969. Finnegan (1975) developed the first scoring system for NAS called the Neonatal Abstinence Scoring System (NASS). This primary work describing this scoring system is cited in most articles on NAS. In 1990, Loretta Finnegan published the modified Finnegan scoring system, which is in use in most NICUs today and is informally called the "Finnegan score." Beginning with Finnegan (1974) to the current American Academy of Pediatrics statements on NAS (2012), there is a general agreement on the cluster of symptoms that encompass the newborn with NAS. The withdrawal symptoms are exhibited through the central nervous system (tremors, irritability, high-pitched cry, abnormal suck, excessive sucking or poor feeding, seizures), autonomic nervous system (sneezing, yawning, mottling), gastrointestinal (diarrhea/loose or watery stools, vomiting), and pulmonary (increased apnea and respiratory distress) and can be evidenced at varying degrees between infants (Finnegan, 1974; Hudak, 2012). The Finnegan score is comprised of 21 withdrawal symptoms that are scored every three hours before feedings. The withdrawal symptoms are divided into central nervous system symptoms, metabolic/respiratory symptoms, and gastrointestinal symptoms. Infants receiving a score > 8 on two consecutive scores will usually receive morphine to help ease withdrawal symptoms. Phenobarbital and clonidine are medications that are also used for the drug withdrawal in these infants.
Substance Abusing Mothers
The scoring of infants can be subjective to many nurses. Therefore, adequate training and education is needed to prevent inaccurate scores, inappropriate treatment and increased length of stay (Lucas & Knobel, 2012). Currently, the Finnegan score is the most widely used tool in the United States and Canada (Marcellus, 2001). Hudak (2012) states, "The clinical presentation of NAS varies with the opioid, the maternal drug history (including timing of the most recent use of drug before delivery), maternal metabolism, net transfer of drug across the placenta, placental metabolism, infant metabolism and excretion, and other factors" (p. e544). According to the literature, the known drugs taken by pregnant mothers are: methadone, buprenorphine, opioids, benzodiazepines, barbiturates, alcohol, heroin, and marijuana (Finnegan, 1974; Hudak & Tan, 2012; Lall, 2008). After the mother delivers the infant, the infant then begins to withdraw from the narcotics previously received from the mother in utero. Methadone specifically, is the most used drug by pregnant mothers as they attempt to withdraw from other, more harmful drugs (Bakstad, Sarfi, Welle-Strand, & Ravndal, 2009). Methadone has a long duration of action (approximately 26 hours half-life) compared to the short half-life of heroin. In pregnancy, methadone creates a stable intrauterine environment and helps to prevent fluctuations in maternal drug levels (Hulatt, 2000, p. 160). The continued use of methadone during pregnancy is standard pharmacotherapy for opioid-dependent women. When methadone is combined with prenatal care, there are improved obstetric and neonatal outcomes. (Gray, et al., 2010). This is why methadone is not discouraged from use in these mothers while they are pregnant. The dose-response connection between maternal methadone levels and infant withdrawal has been studied, but remains unclear and inconsistent (Lim, 2009; Pritham et al., 2007). Therefore, there are many factors that can affect the symptoms and the severity of withdrawal in these fragile infants.
Infant Withdrawal Symptoms
The literature suggests that symptoms begin anywhere from 48 hours to 72 hours after birth (Marcellus, 2001). One article stated specifically that infants show symptoms between 8 and 48 hours after the mother's last dose of methadone (Lim, Prasad, Samuels, Gardner, & Cordero, 2009, p. 70.ei). Finnegan and Macnew (1974) state of observed symptoms, "Withdrawal symptoms become most pronounced between 48 and 72 hours of life. Cord clamping is the initiating event, which begins withdrawal for the infant. As the circulating levels of the mother's addictive substances decreases in the infant, the infant begins to show signs and symptoms of NAS. According to the severity of the withdrawal, the duration of symptoms is anywhere from six days to eight weeks" (p. 687). Therefore, the newborn nursery nurse may be the first to observe for withdrawal symptoms in these infants. A mother's lack of prenatal care, very late prenatal care (after 24 weeks), abruptio placentae, preterm labor with no obvious cause, or intrauterine growth retardation with no obvious cause will alert healthcare personnel of possible drug addiction in the mother and subsequent addiction and withdrawal in the newborn.
After the infant is assessed for NAS symptoms and is diagnosed, these infants are then transferred to a Neonatal Intensive Care Unit (NICU) for specialized withdrawal care. Many times, the mothers of these infants are not present to provide care to their infants. The nurse will be responsible to assess, feed, and comfort the infant while in withdrawal. These infants need to be rocked, have a quiet and calm atmosphere (darkened room, alarms turned down, quieter voices), have a pacifier provided and have human contact. Although step nine of the United Nations Children's Fund/ World Health Organization Baby Friendly Hospital Initiative: Ten Steps to Successful Breastfeeding states, "give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants," most of these infants are not breastfed (1989). Methadone is present in very low concentrations in human milk and there are no reasons to discourage mothers who want to breastfeed or pump their milk for their infants. The current American Academy of Pediatrics (AAP) statement on the care of NAS infants includes include "minimizing environmental stimuli, promoting adequate rest and sleep, and providing sufficient caloric intake to establish weight gain." Also, according to the AAP, each NICU is encouraged to develop protocols for the medical and nursing care of these infants. Nurses feel as if they are the "mothers" for these infants. Over-stimulation of NAS infants has been shown to increase fussiness, crying and sleep disturbances (Marcellus, 2001). A decrease in environmental stimuli of noise, light and equipment alarms, and the specific training of the nurses who care for these infants provide the best possible outcomes for these infants.
Implications for Nursing
Though normal nursery care is provided to these infants for comfort from withdrawal symptoms, there has been little empirical research of nursing interventions to decrease withdrawal symptoms in these infants (D'Apolito, 1999). A holistic plan is needed to assess all aspects of comfort and to design specific nursing interventions that can be measured as patient outcomes. Newborn nursery nurses, NICU nurses, post-partum nurses and obstetrical nurses are in positions to conduct research on nursing interventions that decrease symptoms for these fragile infants.
Although maternal drug screens are not mandated in most states, childbirth educators, nurses, doulas, post-partum nurses and newborn nursery nurses are in a rare position to build relationships with the drug-addicted mother. Many times, the substance abusing pregnant mother will return for prenatal care if there is no threat of criminal action. This therapeutic relationship between the mother and health care provider cannot be understated. Addiction is a disease that is not easily understood; therefore, quality care in a nonjudgmental atmosphere may be the first step in helping these women and their infants. Prenatal care has been proven to help women have healthier babies (U.S. Department of Health and Human Services, 2010). The fear of drug testing and possible court-ordered drug rehabilitation will deter the drug-abusing mother from prenatal care appointments. Regular prenatal care can improve birth outcomes whether or not the mother is able to stop using drugs (Racine, 1993).
Prenatally, the childbirth educator, nurse practitioner and other healthcare personnel need to observe the mother for signs of addiction. Table 2 provides a list of suspicious prenatal behaviors to alert the nurse to possible drug or alcohol use. The American College of Obstetricians and Gynecologists (ACOG) 2012 committee report suggests the use of a screening tool to begin the questions of possible drug use in the pregnant mother. Of course, these conversations need to be conducted in a nonjudgmental environment where the mother feels free to share this information without fear of disclosure. ACOG (2012) states, "In addition to the use of screening tools, certain signs and symptoms may suggest a substance use disorder in a pregnant woman. Pregnant women with opioid addiction often seek prenatal care late in pregnancy; exhibit poor adherence to their appointments; experience poor weight gain; or exhibit sedation, intoxication, withdrawal, or erratic behavior" (p. 3). Maintaining a caring and unprejudiced approach is vital to this ongoing relationship and will yield the most admission of drug or alcohol use.
There is a general lack of quality literature on NAS in the discipline of nursing. Karen D' Apolito is the one nurse researcher who has done extensive research on withdrawal symptoms in poly-drug-exposed infants (2001) and the effects of rocking beds to comfort NAS infants (1999). Marcellus has written about current nursing care of substance-exposed infants (2001) and a challenging article for nurses to look beyond the accepted biomedical model to reflect on the social and political influences on these mothers and their infants.
Lucas and Knobel (2012) have developed an intervention program for practice guidelines and education for the NICU nurse. Medicine has dominated the past and current literature in research and review of literature studies. This important work in medicine has been the foundation for nursing care and nursing interventions. However, it is nurses who care for these infants and they require a very specific and unique set of skills to help these infants withdraw. Marcellus (2007) states, "The level of knowledge, skill, patience, and commitment required to provide excellent nursing care to this group of infants should not be underestimated"(p. 38).
Neonatal Abstinence Syndrome is a growing nursing, medical, social and psychological issue. Though this problem is 100% preventable, it is an issue that needs to be addressed from all disciplines. Collaboration is needed for the prevention of the drug-abusing mother, the care of the addicted mother, and the care of the drug-dependent infant. Further research is needed for best practices of care for these infants. The practicing nurse is strategically located to research the effective care of these infants. Nursing has the opportunity to lead the research, nursing interventions and best practices that are needed to care for the infant with NAS.
Monica Marie Nelson is a doctoral student at East Tennessee State University. She is part of ongoing research in the NICU at East Tennessee Children's Hospital in Knoxville, Tennessee.
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Table 1. NAS Withdrawal Symptoms Central Nervous System * Tremors * Irritability * High-pitched cry * Abnormal suck * Excessive sucking or poor feeding * Seizures Autonomic System * Sneezing * Yawning * Mottling Gastrointestinal Symptoms * Diarrhea/loose or watery stools * Vomiting Pulmonary Symptoms * Increased apnea * Respiratory distress Table 2. Suspicion of Maternal Drug Abuse * Lack of prenatal care * Very late prenatal care (after 24 weeks) * Abruptio placenta * Preterm labor with no obvious cause * Intrauterine growth retardation with no obvious cause
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|Author:||Nelson, Monica Marie|
|Publication:||International Journal of Childbirth Education|
|Date:||Jan 1, 2013|
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