Substance Exposed Pregnant Women and their Babies

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Substance Exposed Pregnant Women and their Babies

• Dixie L. Morgese, BA, CAP, ICADC

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Premises

• Every woman wants a healthy baby.
• Every woman deserves a healthy baby.
• Pregnancy is a finite period that can be the
  determinant for a childs future.
• Pre-pregnancy is the BEST time to address alcohol
  and drug use!

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Learning Objectives

• Identify three screening techniques for use with
  pregnant women who may be using alcohol or other
  drugs.
• Gain an increased understanding of various
  classes of drugs and their effects on pregnant
  women, the developing fetus, and the newborn
  baby.
• Identify five systems of care and their roles and
  responsibilities related to substance exposed
  pregnant women and their babies.
• Learn a five point approach to effective
  multidisciplinary staffing and coordination.

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Terms

• SEN Substance Exposed Newborn
• CDN Chemically Dependent Newborn
• NAS Neonatal Abstinence Syndrome
• NAS - Neonatal Abstinence Scoring
• FASD Fetal Alcohol Spectrum Disorder
• FAS Fetal Alcohol Syndrome
• WIS Womens Intervention Specialist
• FIS Family Intervention Specialist
• ATOD Alcohol, Tobacco and Other Drugs
• CNS Central Nervous System

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Terms

• Hyperreflexia Overactive reflexes response to
  stimuli
• Overstimulated overwhelmed by stimulus
• Philtrum vertical groove on the median line of
  the upper lip.
• Feeding intolerance inability to suck, swallow
  or retain feedings.

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Terms

• Drug Endangered Infant/Child a wide range of
  risk associated with exposure to alcohol and
  other drugs.
• Marchman Act petition that supports legal
  remedy regarding evaluation and intervention.
• State Regulation ability to adapt to external
  stimulation.

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CNS Substances

• Children of mothers who used drugs
• Stimulants risk of preterm labor and abruption
• Depressants alcohol most damaging
• Opiates increasing numbers of cases
• Marijuana
• Hallucinogens
• Tobacco - 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.
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Screening is IMPORTANT!

• Find an approach that works for you.
• Be non judgmental
• Make it a routine part of care and conversation.
• Know how to respond
• Be positive
• Follow up with other systems of care

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The 5 As Framework
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5 As

• Ask about alcohol, tobacco or other drug use
• Advise to quit unless opiates/opioids are
  involved. If the woman is opiate/opioid
  dependent, gain consent and coordinate with
  health care providers.
• Assess willingness to quit
• Assist with support and referral
• Arrange follow-up

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Instruments Used for Screening

• 5 Ps and 4 Ps Plus
• CAGE AID
• T-ACE

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When Should You Screen?

• Screening should be a routine part of care.
• Look for physical and environmental indicators.
  (fingers, arms, eyes, paraphernalia, clothing,
  etc.)
• Review life management issues. (personal hygiene,
  behavioral incidences, avoidance, etc.)
• Use your senses and follow your instincts.
• Intervene and Support know what you will do
  next!

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5 Ps

• Parents - Did any of your parents have a problem
  with alcohol or other drug use?
• Peers - Do any of your friends have a problem
  with alcohol or other drug use?
• Partner - Does your partner have a problem with
  alcohol or other drug use?
• Past Have you used alcohol or drugs in the
  past?
• Present - In the past month, have you drunk any
  alcohol or used other drugs?

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CAGE-AID

• Have you ever felt you ought to cut down on your
  drinking or drug use?
• Have people annoyed you by criticizing your
  drinking or drug use?
• Have you felt bad or guilty about your drinking
  or drug use?
• Have you ever had a drink or used drugs first
  thing in the morning to steady your nerves or to
  get rid of a hangover (eye-opener)?

CAGE Source Ewing 1984. CAGE-AID Source.
Reprinted with permission from the Wisconsin
Medial Journal Brown, R.L. and Rounds, LA
Conjoint screening questionnaires for alcohol and
drug abuse. Wisconsin Medical Journal 94
135-140, 1995.
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The T-ACE Questionnaire

• T   Tolerance How many drinks does it take to
  make you feel high?
• A   Have people annoyed you by criticizing your
  drinking?
• C   Have you ever felt you ought to cut down on
  your drinking?
• E   Eye-opener Have you ever had a drink first
  thing in the morning to steady your nerves or get
  rid of a hangover?

The T-ACE is considered to be positive with a
score of 2 or more. Affirmative answers to the A,
C, and E questions are each scored 1 point. A
reply of more than two drinks to the T question
is scored 2 points (Sokol et al. 1989).
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How Do You Start the Conversation?

• Be non-judgmental and build rapport.
• Keep it Simple.
• Use observable strengths.
• When the door opens be straight-forward.
• Know your limitations.
• Know your resources.

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What Next?

• Know your limitations and disclose them
• Negotiate Consent for Release.
• Develop a short term contract.
• Be aware of timing and environment (conflict at
  home, day of the week, other children, etc.)
• Seek supervision and coordination.
• Consider resources and barriers.

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Barriers

• Dependence
• Language/Culture paradigm to a strength
• Fear of system/outcomes
• Partner control or violence issues
• Treatment access/residential availability
• Family system/relationships and other children
• Stressors
• Depression
• Economic Limitations

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Systems of Care

• Medical CHDs, CMS, hospitals, physicians,
  midwives
• Treatment Centers FADAA WIS, TOPWA other
  check directory.
• Early Steps screening of children
• Child Welfare (DCF and Community Based Care)
  legal, investigative, case management, wrap
  around services use PNA
• Healthy Start care coordination and linkage to
  additional resources.

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Other Possible Systems

• Legal drug court, probation, child support
  enforcement.
• Workforce Development economic self sufficiency
  for mother and partner.
• Child Care/ELC respite, structure, stability.
• Others Homeless Services, Domestic Violence
  support, HIV/TOPWA, Mental Health, Healthy
  Families, Insurance.

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Five Point Approach

• Identify key players including and centering on
  the patient.
• Unify referral processes - identify the point
  person/entity.
• Coordinate consent Healthy Start screening form
  can support collaboration until further consent
  is obtained.
• Align policies and procedures ensure systems
  have interagency agreements which delineate roles
  and responsibilities..
• Utilize unified staffing forms.

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Follow Up

• Identify additional staffing activities
  establish dates, times.
• Key coordinator typically case management or
  care coordination.
• Ensure client completed referrals and verify
  subsequent appointments.
• Prior to delivery, coordinate with
  hospital/birthing center.
• Provide documentation for pediatric follow up.
• Identify who will provide ongoing education to
  the family.
• Establish family planning and interconceptional
  care plan.

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Points to Remember

• SEN babies are at elevated risk for SUIDS
  ensure family has safe sleeping environment.
• Mothers at elevated risk for PPD or relapse
  identify support system.
• Caregivers need to know how to handle SEN babies
  ensure special instruction is provided and
  ongoing.

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Common Symptoms

• There 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 babys 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.

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Hypersensitivity to Stimuli

• One of the most common traits
• Little tolerance to stimuli
• Swallowing, closeness, sound, can escalate baby
  into frantic state
• Babies need protection from overstimulation but
  should not be stimulus-deprived.

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Changes to Muscle Tone

• Muscle tone is the degree of stiffness
• Unusually limp or unusually stiff
• Particularly in limbs and neck
• Stiffness may come and go
• Tremors, jerking, other signs of distress sign
  of baby trying to control uncomfortable
  sensations.

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Gastrointestinal Problems

• Drugs attack gastric system 12 mos
• Watery stool, explosive diarrhea, excoriated
  buttocks, gas, constipation
• Need proper handling to prevent serious health
  concerns
• Distress and high stimulation can increase
• Diarrhea can irritate fragile lining of the
  intestines and also lead to dehydration.

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Other Related Complications

• Chronic Ear Infection
• Unexplained fever (opiates and opioids)
• Sleep/wake irregularity
• Extreme appetite (barbiturates)
• Hyperreflexia/Moro

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Therapeutic Handling

• Caregivers need appropriate training
• Comforting techniques are critical to management
  of withdrawing infants
• Each type of drug exposure presents unique
  challenges
• Basic principles of handling apply to all

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Eight Principles

• Swaddling
• C-Position
• Head to Toe Movement
• Vertical Rock
• Clapping
• Feeding
• Controlling the Environment
• Introducing Stimuli

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Principle 1 Swaddling

• Drug exposed infants cannot do three things
  simultaneously body, breathe, suck
• Swaddling provides comfort in helping them to
  control their bodies
• Allows them to focus on breathing then feeding
  with greater comfort.

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Principle 2 C-Position

• Increases sense of control and ability to relax
• Hold baby firmly and curl head and legs into a C
• When laying down place on side, wrap blanket
  into a role around body.
• Then introduce back position for sleeping as
  recommended by Academy of Pediatrics.

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Principle 3 Head to Toe

• Back and forth motions not recommended
• Slow, rhythmic swaying following line from head
  to toe while swaddled and held in C position is
  comforting.
• Keeping movement slow and rhythmic will help
  relax and settle the infant.

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Principle 4 Vertical Rock

• Best when baby is frantic and hard to calm
• Maintain C position and hold directly in front of
  you and turned away.
• Slowly and rhythmically rock baby up and down
  soothes neurological system.
• Be aware of personal energy level keep baby at
  a distance while rocking if necessary.

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Principle 5 Clapping

• Cup hand
• Clap/pat babys blanketed bottom
• Clap slow and rhythmically
• Babys muscles may start to relax
• This technique does not work with all babies if
  baby does not respond, discontinue.

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Principle 6 - Feeding

• Withdrawal may adversely affect sucking babies
  may suck frantically or have disorganized suck
• Makes it difficult for them to take in enough
  formula or to breastfeed
• The key is to get baby relaxed enough to suck
  steadily in a low-stimulus environment.
• Baby should be swaddled and in C-position

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Principle 7 Controlling the Environment

• Limit number of caregivers
• Offer calm surroundings
• Minimize any loud noise music and voices should
  be low volume
• Keep lights low
• Caregiver should have calm presence
• Routine is beneficial

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Neonatal Abstinence

• Neonatal Abstinence term given to the condition
  of an infant born to a drug affected mother
  withdrawal
• Withdrawal set of symptoms as the body attempts
  to remove an addictive substance
• Must be accurately assessed
• May be controlled by using therapeutic measures
  and often medication

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Neonatal Abstinence Symptoms(not exhaustive)

• Hyper-irritability
• Respiratory distress
• Gastrointestinal distress
• Sleep disturbances

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Neonatal Abstinence Scoring

• Determines the level of therapeutic intervention
  necessary
• Helps to determine the effectiveness of
  interventions being used
• Assesses symptoms
• Originally developed by Loretta Finnegan

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NAS Scoring Tool

• Set of observed signs and symptoms in the infant
• Observed at regular intervals every 3 hours
• Should reflect all symptoms observed since the
  last scoring
• High scores that are not lowered by therapeutic
  handling should be assessed for medical
  intervention

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New Concerns

• High rates of prescription drug use and opioids
  in high doses may result in longer observation
  periods being required for NAS.
• Home visitors and other support staff may be
  unaware of symptoms.
• Misdiagnosis by health professionals who do not
  have history on mother.

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Recommendations

• Statewide data collection about nature and scope
  of the problem.
• Staff development protocols for maternal and
  child support staff.
• Policy changes to help medical staff better
  manage opiate/opioid dependent women during
  pregnancy.
• Multi-disciplinary approaches to protocol
  development in medical, child welfare, child
  development, and substance abuse treatment
  disciplines.

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Questions?
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Lets work together to keep them ALL safe,
healthy, and happy!
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Thank You!