Download - Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs
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 withdrawalIdentify techniques for managing withdrawal
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 toleranceNo 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 serious Need proper handling to prevent serious
health concernshealth 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 – Be aware of personal energy level –
keep baby at a distance while rocking if keep 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 therapeutic May be controlled by using therapeutic
measures and often medicationmeasures and often medication
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) cry
3 Sleeps < 1 hr after feeding
3 Sleeps < 2hr after feeding
2Sleeps <3 hr after feeding
1Hyperactive Moro Reflex
2 Hypersensitivity
3Markedly hyperactive Moro Reflex
3 Mild tremors disturbed
1 Moderate-Severe tremors disturbed
2 Mild Tremors Undisturbed
3 Moderate-Severe tremors Undisturbed
4Increased muscle tone 2Excoriation (specific area)
1Myoclonic jerks 3Convulsions/Seizures 5
Cent
ral N
ervo
us S
yste
m
Dist
urba
nces
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
Met
abol
ic, V
asom
otor
, Res
pira
tory
M
etab
olic,
Vas
omot
or, R
espi
rato
ry
Dist
urba
nces
Dist
urba
nces
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
Dist
urba
nces
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, physicians, – CHD’s, CMS, hospitals, physicians,
midwives 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 Based (DCF and Community Based
Care) – legal, investigative, case 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 dates, Identify additional staffing activities – establish dates,
times.times. Key coordinator – typically case management or care Key coordinator – typically case management or care
coordination.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 care Establish family planning and interconceptional care
plan.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!