Neonatal Drug Withdrawal

and
Associated Concerns
Lisa McGee, MSN, RN, CCNS
Neonatal Clinical Nurse Specialist
UK Childrens Hospital
December 17, 2013


1. Discuss the incidence of neonatal drug withdrawal.
2. Describe toxicology screening in newborns
3. Identify the signs and symptoms of neonatal abstinence
syndrome.
4. Delineate care and treatment of an infant experiencing
neonatal abstinence.
5. Explore Social Services concerns associated with infants
experiencing neonatal drug withdrawal.
6. Verbalize outcomes associated with infants who have
experienced neonatal drug withdrawal.
OBJECTIVES
INCIDENCE
4

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%



JAMA 2012
In 2009, the estimated number of
newborns with NAS was 13,539.
JAMA 2012



Hospital Charges for NAS
2000 - $190 million
2009 - $720 million


JAMA 2012
NEWBORN TOXICOLOGY
SCREENING
Kentucky Revised Statute
Annotated 214.160
14
Any physician or person legally permitted to engage in
attendance upon a pregnant woman may administer to
each newborn infant born under that persons care a
toxicology test to determine whether there is evidence
of prenatal exposure to alcohol, a controlled substance,
or a substance identified on the list provided the the
Cabinet for Health and Family Services, if the attending
person has reason to believe, based on a medical
assessment of the mother or the infant, that the mother
used any such substance for a nonmedical purpose
during the pregnancy.
Toxicology Screens
15
URINE


MECONIUM

HAIR
Urine Analysis
16
traditionally the specimen of choice for
neonatal drug testing
relatively easy to obtain
has a short detection window provides
maternal drug use data only for a few days
prior to delivery
detects recent use of cocaine and its
metabolites, amphetamines, marijuana,
barbiturates and opiates
Meconium Analysis
17
currently considered the best method for
detecting drug exposure in pregnancy
provides a wider window of detection of
gestational exposure, presumably as remote as
the second trimester when drugs begin to
accumulate in meconium
is reliable for detecting opioid and cocaine
exposure after the first trimester and can be
used to detect other illicit and prescribed drugs
Hair Analysis
18
technique is expensive and not widely available
a positive result indicates use during the last
trimester reveals 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 point
during the first 3 months of life
19
UK utilizes urine and
meconium drug
screens.
Drug screens are done for
all infants admitted to the
NICU.

SIGNS & SYMPTOMS
of NAS
20
A Multi-System Disorder

2/3 of neonates will show signs
onset varies
majority of signs appear within
72 hours of birth
duration 8 to 16 weeks
presentation is variable
chronic users more severe withdrawal


hypertonia
tremors
hyperreflexia
irritability and
restlessness
high-pitched cry
sleep disturbances
seizures
Neurologic
23
http://newborns.stanford.edu/PhotoGallery/Jitt
ery3.html



Autonomic
yawning
nasal stuffiness
sweating
sneezing
low-grade fever
skin mottling
Gastrointestinal
diarrhea
vomiting
poor feeding
regurgitation
dysmature
swallowing
excessive
sucking
Respiratory &
Miscellaneous
tachypnea
retractions
skin excoriation
CARE AND TREATMENT
of NAS
Non-Pharmacologic Interventions
28
SWADDLING
Wrapping babies SNUGLY
helps them to control
their bodies.
29
C-POSITION
Holding or laying the
baby in a C position
increases the babys
sense of control and
ability to relax.
30
SWAY
This head-to-toe
movement is
soothing to the
drug-affected
babys jangled
nerves.
31





http://www.youtube.com/watch?v=IdR3D3_sY
Dk
Mamaroo
Swing
32
CLAPPING
Soothes the baby
by relaxing the
nerves at the base
of the spine.

VERTICAL
ROCK
Lifting baby up and
down helps to calm
and quiet the baby.

33
FEEDING
The key to feeding is to
get the baby into a
therapeutic hold and
relaxed enough to suck.

34
RESPOND
PROMPTLY to
CRYING
The longer a baby in
early withdrawal cries,
the harder it will be to
calm him/her.
35
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
36
Evaluating Withdrawal
Scoring 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)

37
developed by Loretta Finnegan, MD
contains a list of 21 withdrawal s/s
each item has a weighted score
total score determined by adding the
score assigned to each symptom observed
throughout the entire scoring interval
Finnegan Scoring Tool
38
39
Scoring is done every 6 hours.

Medications are given for:
Three consecutive scores > 8
or
Two consecutive scores > 12
40
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 hours
0.05 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 are
consistently < 8 and subjective nursing indicators show
easy consolability, adequate feeding and sleep.
41
Medication is administered
orally.

If unable to stabilize on
< 1mg/kg/day total dose of
morphine, a second drug is
added
(phenobarbital or clonidine)
42
Once stable on acceptable dose,
(<1 mg/kg/day total dose) for 48 hours,
consideration is given to moving to the
weaning algorithm.
Morphine is typically weaned
every 48 hours by 10% of the
maximal dose.
http://vimeo.com/10038566
SOCIAL SERVICES
CONCERNS & ACTIVITY
Referrals to DCBS
45
Social Services follows drug screens
if screen positive for anything mom has not
been prescribed, contact is made with DCBS
and a referral is made
if no drug screen has been done or a drug
screen is negative but the infant is treated with
medication, a referral to DCBS is automatically
made
Activities of DCBS
46
investigates anyone living in the household
will talk to day care providers and children
at school
may complete the investigation and close
the case or open a case with the family in the
home
47
Parents have to be
able to provide a
safe home
environment and
basic physical and
emotional needs of
the child before the
DCBS will close the
case.
Prevention Services
48
Implementation of a Family Preservation Plan
parenting skills, time management, basic life skills
Parents sent for drug and alcohol assessment
by licensed provider
random drug screening accomplished
Parents sent to parenting classes


HANDS Program
49
Health Access Nurturing Development Services
Goals
Healthy child growth and development
Healthy, safe homes
Self-sufficient homes
Infant Disposition
50
Home with Mother
Home with Family Member
Home with Foster Care
OUTCOMES
52
Infants neurobehavioral dysfunction
influences the ability to self-organize and
self-regulate.
Mothers physical and
psychological well being may be
debilitated in the perinatal period
and her ability to recognize and
respond to the newborns cues
may be limited.
53
Infants at risk for neglect and abuse.
54
Preterm Infants
Up to 24% methadone-
maintained infants are
born preterm
25% are considered SGA
(<10
th
percentile for
weight).
55
Birth weights, birth length, and head circumference or infants
born to opiate-dependent women are significantly lower than
those for non-opiate-dependent women.
56
Over the first 18 months of life there was
catch-up of growth in all areas expect
height.
Opiate-exposed infants remained shorter
than controls.
Difference in height persisted and
increased by three years of age.

Other long-
term effects on
growth have
not been
documented in
the opiate-
exposed child.
57
58
Increased motor rigidity

Dysregulated motor patterns
Decreased activity by
observation and maternal report.
59
Mental Development Index
(Bayley Scales of Infant Development)
Significantly lower in opiate-exposed
children at 12 and 18 months.
60
Hyperactivity and short attention span
have been noted in toddlers prenatally
exposed to opiates.
Older children have demonstrated
memory and perceptual problems.
61
Opiate exposure is associated with
attention problems more evident as
children become older.
Behavior problems may not be evident at
3-5 years but noted at preadolescence and
adolescence.
62
No significant abnormalities in MRI in
NBN period but long-term studies in
older children and adolescents reflect
a decrease in brain volume.
Internalizing Behaviors
Eating too much or too
little
Depression
Abusing substances
Cutting

Externalizing Behaviors
Physical aggression
Verbal bullying
Relational aggression
Defiance
Theft
63
64
65
66
The End!