SUBSTANCE ABUSE SUBSTANCE ABUSE The Drug-Exposed InfantThe Drug-Exposed Infant

Authored by: Kathy McKee MS, RNCAuthored by: Kathy McKee MS, RNC

OBJECTIVESOBJECTIVES

List three physiological or List three physiological or behavioral signs of an infant behavioral signs of an infant exposed to drugs in uteroexposed to drugs in utero

Describe use of Neonatal Describe use of Neonatal Abstinence ScoringAbstinence Scoring

Discuss nursing interventions Discuss nursing interventions appropriate for infants exposed to appropriate for infants exposed to drugs in uterodrugs in utero

The StatisticsThe Statistics

National Institute on Drug AbuseNational Institute on Drug Abuse– 500,000 – 700,000 affected babies 500,000 – 700,000 affected babies

annually in the United Statesannually in the United States Washington StateWashington State

– 12,000 drug affected babies each year12,000 drug affected babies each year

Guidelines for Testing and Guidelines for Testing and ReportingReporting

ScreeningScreening– It is the responsibility of every practice to make It is the responsibility of every practice to make

sure that all pregnant and postpartum women are sure that all pregnant and postpartum women are screened for substance use (WA State Dept of screened for substance use (WA State Dept of Health)Health)

TestingTesting– Drug testing is based on specific criteria and Drug testing is based on specific criteria and

medical indicatorsmedical indicators ReportingReporting

– Reports of prenatal substance exposure shall not Reports of prenatal substance exposure shall not be construed to be child abuse or neglect and be construed to be child abuse or neglect and shall not require prosecution of the mothershall not require prosecution of the mother

TestingTesting MomMom

– Risk IndicatorsRisk Indicators No prenatal careNo prenatal care Previous Previous

unexplained fetal unexplained fetal demisedemise

Precipitous laborPrecipitous labor Abruptio placentaeAbruptio placentae Hypertensive Hypertensive

episodesepisodes Severe mood swings Severe mood swings Repeated Repeated

spontaneous spontaneous abortionsabortions

– ConsentConsent

BabyBaby– Risk IndicatorsRisk Indicators

Jittery with normal Jittery with normal glucose levelglucose level

Marked irritabilityMarked irritability Preterm birthPreterm birth Unexplained Unexplained

seizures or apneic seizures or apneic spellsspells

Unexplained IUGRUnexplained IUGR Neurobehavioral Neurobehavioral

abnormalitiesabnormalities Congenital Congenital

abnormalitiesabnormalities Signs of NASSigns of NAS

– ConsentConsent

The Drug-exposed InfantThe Drug-exposed Infant Transient effectsTransient effects Teratogenic effectsTeratogenic effects

– DysmorphicDysmorphic– BehavioralBehavioral

Confounding variablesConfounding variables– Maternal health, socioeconomic status, Maternal health, socioeconomic status,

lifestylelifestyle– Drug used/Poly-drug useDrug used/Poly-drug use– Use in relation to gestational ageUse in relation to gestational age– Time used prior to deliveryTime used prior to delivery

Common Findings in Drug Common Findings in Drug Exposed InfantsExposed Infants

Hypersensitivity to stimuliHypersensitivity to stimuli Abnormal muscle toneAbnormal muscle tone Sleep ProblemsSleep Problems Feeding ProblemsFeeding Problems GI ProblemsGI Problems

AlcoholAlcohol Fetal Alcohol Spectrum Fetal Alcohol Spectrum

Disorders/Alcohol Related Birth Disorders/Alcohol Related Birth DefectsDefects– Growth RestrictionGrowth Restriction– Facial DysmorphismFacial Dysmorphism

MicrocephalyMicrocephaly Short palpebral fissures Short palpebral fissures Hypoplastic philtrumHypoplastic philtrum Thin upper lipThin upper lip

– CNS DysfunctionCNS Dysfunction Neurological symptomsNeurological symptoms Cognitive & behavioral signsCognitive & behavioral signs

NicotineNicotine

17% of pregnant women between 17% of pregnant women between the ages of 15 and 44 smokethe ages of 15 and 44 smoke

Adverse EffectsAdverse Effects– Decreased blood flow through the Decreased blood flow through the

placentaplacenta– Low birth weightLow birth weight– Neurobehavioral impactNeurobehavioral impact– Increased respiratory tract illnessesIncreased respiratory tract illnesses– Sudden infant death syndromeSudden infant death syndrome

CocaineCocaine

StimulantStimulant– TachycardiaTachycardia– HypertensionHypertension– Decreased blood flow and oxygen delivery Decreased blood flow and oxygen delivery

to fetusto fetus– Increased uterine contractionsIncreased uterine contractions

Effect of Cocaine on the Effect of Cocaine on the InfantInfant

IrritabilityIrritability Poor feedingPoor feeding Decreased Decreased

interaction interaction DisorganizationDisorganization Sleep disturbancesSleep disturbances TremorsTremors SneezingSneezing Tone abnormalitiesTone abnormalities High-pitched cry High-pitched cry

Possible Possible association association with:with:

–Congenital Congenital heart defectsheart defects–Urinary Urinary obstruction obstruction defectsdefects–GastrointestinGastrointestinal obstructional obstruction

MethamphetamineMethamphetamine

Potent stimulantPotent stimulant– VasoconstrictionVasoconstriction– Increased heart rateIncreased heart rate– HyperthermiaHyperthermia– Decreased appetite in userDecreased appetite in user– Decreased oxygen and Decreased oxygen and

nutrient delivery through nutrient delivery through placentaplacenta

– Prolonged circulation of drug Prolonged circulation of drug in fetal circulationin fetal circulation

Effects of Effects of Methamphetamine on the Methamphetamine on the

Infant Infant

Poor state controlPoor state control LethargicLethargic Poor feedingPoor feeding

– Disorganized suckDisorganized suck– No suckNo suck

IrritableIrritable Abnormal toneAbnormal tone Excoriated Excoriated

buttocksbuttocks

Associated with:Associated with:

–Congenital brain Congenital brain lesionslesions

–Cleft lipCleft lip

–Cardiac defects Cardiac defects

–Low birth weight Low birth weight and reduced OFCand reduced OFC

–HyperbilirubinemiHyperbilirubinemiaa

Narcotics/OpiatesNarcotics/Opiates

Morphine, Heroin, MethadoneMorphine, Heroin, Methadone Continued use will lead to profound Continued use will lead to profound

physiologic and psychological addictionphysiologic and psychological addiction Neonatal Abstinence SyndromeNeonatal Abstinence Syndrome

– Passive exposure in utero as a Passive exposure in utero as a consequence of maternal addiction.consequence of maternal addiction.

– Iatrogenic exposure by the administration Iatrogenic exposure by the administration of narcotic analgesics to the neonateof narcotic analgesics to the neonate

Neonatal Abstinence Neonatal Abstinence SyndromeSyndrome

Generalized disorder characterized Generalized disorder characterized by 21 symptoms most commonly by 21 symptoms most commonly seen in withdrawing infants.seen in withdrawing infants.

2/3 of infants born to opiate-2/3 of infants born to opiate-dependent women will exhibit signs dependent women will exhibit signs of NASof NAS

Time of onset variesTime of onset varies Symptoms varySymptoms vary

Neonatal Abstinence Neonatal Abstinence ScoringScoring

Assists in the detection ofAssists in the detection of– Onset of withdrawal symptomsOnset of withdrawal symptoms– Severity of symptomsSeverity of symptoms– Response to interventionResponse to intervention– Resolution of symptomsResolution of symptoms

Assess high risk infant Assess high risk infant – 2 hours after birth2 hours after birth– Every 3-4 hoursEvery 3-4 hours

NAS ScoringNAS Scoring The Finnegan scaleThe Finnegan scale

– If score is 8 or greaterIf score is 8 or greater Score every 2 hours for Score every 2 hours for

24 hours24 hours

– Scores > 8 on three Scores > 8 on three consecutive scoresconsecutive scores

Evaluate need for Evaluate need for medicationmedication

– If intervention not If intervention not needed by 72 hoursneeded by 72 hours

Scoring may be Scoring may be discontinueddiscontinued

System DisturbancesSystem Disturbances

Central Nervous SystemCentral Nervous System

Metabolic/Vasomotor/Metabolic/Vasomotor/RespiratoryRespiratory

GastrointestinalGastrointestinal

Central Nervous SystemCentral Nervous System

CryCry Sleep patternSleep pattern Exaggerated Moro Reflex Exaggerated Moro Reflex TremorsTremors Muscle toneMuscle tone ExcoriationExcoriation Myoclonic jerksMyoclonic jerks ConvulsionsConvulsions

Metabolic,Vasomotor, Metabolic,Vasomotor, RespiratoryRespiratory

SweatingSweating FeverFever YawningYawning MottlingMottling Nasal stuffinessNasal stuffiness SneezingSneezing Nasal flaringNasal flaring Increased respiratory rate, Increased respiratory rate,

retractionsretractions

GastrointestinalGastrointestinal

Excessive suckingExcessive sucking Poor feedingPoor feeding Regurgitation, projectile vomitingRegurgitation, projectile vomiting Loose stools, watery stoolsLoose stools, watery stools

MedicationsMedications for NASfor NAS

Morphine SulfateMorphine Sulfate PhenobarbitalPhenobarbital AtivanAtivan OtherOther

Nursing Care of the Drug Nursing Care of the Drug Exposed InfantExposed Infant

Careful AssessmentCareful Assessment NAS Scoring (if NAS Scoring (if opiateopiate exposure) exposure) Control of the environmentControl of the environment Feeding techniquesFeeding techniques Therapeutic HandlingTherapeutic Handling

– Swaddle Swaddle – ClappingClapping– Vertical rocking Vertical rocking – C-positionC-position

Nursing Care of the Drug Nursing Care of the Drug Exposed InfantExposed Infant

Dealing with the familyDealing with the family– Personal feelingsPersonal feelings– Public health issue vs. CrimePublic health issue vs. Crime– Involve in care—teach Involve in care—teach

Opportunities for changing the addicted woman’s behavior and her view of health care providers can be influenced by the care she and her infant receive while hospitalized

Questions ?Questions ?

ReferencesReferences

Askin, Debbie Frasier (2001). Cocaine: Effects of in utero Askin, Debbie Frasier (2001). Cocaine: Effects of in utero exposure on the fetus and neonate. exposure on the fetus and neonate. The Journal of The Journal of Perinatal and Neonatal Nursing, Perinatal and Neonatal Nursing, 14 (4), 83-10214 (4), 83-102

D’Apolito, Karen (2001). Prominence of withdrawal D’Apolito, Karen (2001). Prominence of withdrawal symptoms in polydrug-exposed infants. symptoms in polydrug-exposed infants. The Journal of The Journal of Perinatal and Neonatal Nursing, Perinatal and Neonatal Nursing, 14 (4), 46-60.14 (4), 46-60.

Jorgensen, Katherine M. (1999). The drug-exposed infant: Jorgensen, Katherine M. (1999). The drug-exposed infant: Physiology, signs, and symptoms. Physiology, signs, and symptoms. Central Lines, Central Lines, 15 (2), 1-15 (2), 1-11.11.

Ostrea, Enrique M. (2001). Understanding drug testing in Ostrea, Enrique M. (2001). Understanding drug testing in the neonate and the role of meconium analysis. the neonate and the role of meconium analysis. The The Journal of Perinatal and Neonatal Nursing, Journal of Perinatal and Neonatal Nursing, 14 (4), 61-82.14 (4), 61-82.

Tillett, Jackie & Osborne, Kathryn (2001). Substance Tillett, Jackie & Osborne, Kathryn (2001). Substance abuse by pregnant women: Legal and ethical concerns. abuse by pregnant women: Legal and ethical concerns. The Journal of Perinatal and Neonatal Nursing, The Journal of Perinatal and Neonatal Nursing, 14 (4), 1-14 (4), 1-11.11.

Weiner, Susan M. & Finnegan, Loretta P. (2002). Drug Weiner, Susan M. & Finnegan, Loretta P. (2002). Drug withdrawal in the neonate. In withdrawal in the neonate. In Handbook of Neonatal Handbook of Neonatal Intensive Care Intensive Care 5 5thth Ed. St. Louis, Missouri, Mosby, Inc. Ed. St. Louis, Missouri, Mosby, Inc.

Wilbourne, Paula, Wallerstedt, Cheryl, Dorato, Veronica, Wilbourne, Paula, Wallerstedt, Cheryl, Dorato, Veronica, & Curet, Luis B. (2001). Clinical management of & Curet, Luis B. (2001). Clinical management of methadone dependence during pregnancy. methadone dependence during pregnancy. The Journal The Journal of Perinatal and Neonatal Nursing, of Perinatal and Neonatal Nursing, 14 (4), 26-45.14 (4), 26-45.

Guidelines for Testing and Reporting Drug Exposed Guidelines for Testing and Reporting Drug Exposed Newborns in Washington State. Washington State Newborns in Washington State. Washington State Department of Health, 2006.Department of Health, 2006.

Williams, Jill Schlabig (2006). The neurobehavioral Williams, Jill Schlabig (2006). The neurobehavioral legacy of prenatal tobacco exposure. NIDA.legacy of prenatal tobacco exposure. NIDA.