SUBSTANCE ABUSE The Drug-Exposed Infant

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SUBSTANCE ABUSE The Drug-Exposed Infant
Authored by Kathy McKee MS, RNC
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OBJECTIVES

• List three physiological or behavioral signs of
  an infant exposed to drugs in utero
• Describe use of Neonatal Abstinence Scoring
• Discuss nursing interventions appropriate for
  infants exposed to drugs in utero

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The Statistics

• National Institute on Drug Abuse
• 500,000 700,000 affected babies annually in the
  United States
• Washington State
• 12,000 drug affected babies each year

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Guidelines for Testing and Reporting

• Screening
• It is the responsibility of every practice to
  make sure that all pregnant and postpartum women
  are screened for substance use (WA State Dept of
  Health)
• Testing
• Drug testing is based on specific criteria and
  medical indicators
• Reporting
• Reports of prenatal substance exposure shall not
  be construed to be child abuse or neglect and
  shall not require prosecution of the mother

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Testing

• Mom
• Risk Indicators
• No prenatal care
• Previous unexplained fetal demise
• Precipitous labor
• Abruptio placentae
• Hypertensive episodes
• Severe mood swings
• Repeated spontaneous abortions
• Consent

• Baby
• Risk Indicators
• Jittery with normal glucose level
• Marked irritability
• Preterm birth
• Unexplained seizures or apneic spells
• Unexplained IUGR
• Neurobehavioral abnormalities
• Congenital abnormalities
• Signs of NAS
• Consent

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The Drug-exposed Infant

• Transient effects
• Teratogenic effects
• Dysmorphic
• Behavioral
• Confounding variables
• Maternal health, socioeconomic status, lifestyle
• Drug used/Poly-drug use
• Use in relation to gestational age
• Time used prior to delivery

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Common Findings in Drug Exposed Infants

• Hypersensitivity to stimuli
• Abnormal muscle tone
• Sleep Problems
• Feeding Problems
• GI Problems

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Alcohol

• Fetal Alcohol Spectrum Disorders/Alcohol Related
  Birth Defects
• Growth Restriction
• Facial Dysmorphism
• Microcephaly
• Short palpebral fissures
• Hypoplastic philtrum
• Thin upper lip
• CNS Dysfunction
• Neurological symptoms
• Cognitive behavioral signs

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Nicotine

• 17 of pregnant women between the ages of 15 and
  44 smoke
• Adverse Effects
• Decreased blood flow through the placenta
• Low birth weight
• Neurobehavioral impact
• Increased respiratory tract illnesses
• Sudden infant death syndrome

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Cocaine

• Stimulant
• Tachycardia
• Hypertension
• Decreased blood flow and oxygen delivery to fetus
• Increased uterine contractions

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Effect of Cocaine on the Infant

• Irritability
• Poor feeding
• Decreased interaction
• Disorganization
• Sleep disturbances
• Tremors
• Sneezing
• Tone abnormalities
• High-pitched cry

• Possible association with
• Congenital heart defects
• Urinary obstruction defects
• Gastrointestinal obstruction

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Methamphetamine

• Potent stimulant
• Vasoconstriction
• Increased heart rate
• Hyperthermia
• Decreased appetite in user
• Decreased oxygen and nutrient delivery through
  placenta
• Prolonged circulation of drug in fetal
  circulation

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Effects of Methamphetamine on the Infant

• Poor state control
• Lethargic
• Poor feeding
• Disorganized suck
• No suck
• Irritable
• Abnormal tone
• Excoriated buttocks

• Associated with
• Congenital brain lesions
• Cleft lip
• Cardiac defects
• Low birth weight and reduced OFC
• Hyperbilirubinemia

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Narcotics/Opiates

• Morphine, Heroin, Methadone
• Continued use will lead to profound physiologic
  and psychological addiction
• Neonatal Abstinence Syndrome
• Passive exposure in utero as a consequence of
  maternal addiction.
• Iatrogenic exposure by the administration of
  narcotic analgesics to the neonate

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Neonatal Abstinence Syndrome

• Generalized disorder characterized by 21
  symptoms most commonly seen in withdrawing
  infants.
• 2/3 of infants born to opiate-dependent women
  will exhibit signs of NAS
• Time of onset varies
• Symptoms vary

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Neonatal Abstinence Scoring

• Assists in the detection of
• Onset of withdrawal symptoms
• Severity of symptoms
• Response to intervention
• Resolution of symptoms
• Assess high risk infant
• 2 hours after birth
• Every 3-4 hours

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NAS Scoring

• The Finnegan scale
• If score is 8 or greater
• Score every 2 hours for 24 hours
• Scores gt 8 on three consecutive scores
• Evaluate need for medication
• If intervention not needed by 72 hours
• Scoring may be discontinued

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System Disturbances

• Central Nervous System
• Metabolic/Vasomotor/Respiratory
• Gastrointestinal

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Central Nervous System

• Cry
• Sleep pattern
• Exaggerated Moro Reflex
• Tremors
• Muscle tone
• Excoriation
• Myoclonic jerks
• Convulsions

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Metabolic,Vasomotor, Respiratory

• Sweating
• Fever
• Yawning
• Mottling
• Nasal stuffiness
• Sneezing
• Nasal flaring
• Increased respiratory rate, retractions

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Gastrointestinal

• Excessive sucking
• Poor feeding
• Regurgitation, projectile vomiting
• Loose stools, watery stools

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Medications for NAS

• Morphine Sulfate
• Phenobarbital
• Ativan
• Other

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Nursing Care of the Drug Exposed Infant

• Careful Assessment
• NAS Scoring (if opiate exposure)
• Control of the environment
• Feeding techniques
• Therapeutic Handling
• Swaddle
• Clapping
• Vertical rocking
• C-position

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Nursing Care of the Drug Exposed Infant

• Dealing with the family
• Personal feelings
• Public health issue vs. Crime
• Involve in careteach
• Opportunities for changing the addicted
  womans behavior and her view of health care
  providers can be influenced by the care she and
  her infant receive while hospitalized

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Questions ?
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References

• Askin, Debbie Frasier (2001). Cocaine Effects
  of in utero exposure on the fetus and neonate.
  The Journal of Perinatal and Neonatal Nursing, 14
  (4), 83-102
• DApolito, Karen (2001). Prominence of
  withdrawal symptoms in polydrug-exposed infants.
  The Journal of Perinatal and Neonatal Nursing, 14
  (4), 46-60.
• Jorgensen, Katherine M. (1999). The drug-exposed
  infant Physiology, signs, and symptoms. Central
  Lines, 15 (2), 1-11.
• Ostrea, Enrique M. (2001). Understanding drug
  testing in the neonate and the role of meconium
  analysis. The Journal of Perinatal and Neonatal
  Nursing, 14 (4), 61-82.
• Tillett, Jackie Osborne, Kathryn (2001).
  Substance abuse by pregnant women Legal and
  ethical concerns. The Journal of Perinatal and
  Neonatal Nursing, 14 (4), 1-11.

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• Weiner, Susan M. Finnegan, Loretta P. (2002).
  Drug withdrawal in the neonate. In Handbook of
  Neonatal Intensive Care 5th Ed. St. Louis,
  Missouri, Mosby, Inc.
• Wilbourne, Paula, Wallerstedt, Cheryl, Dorato,
  Veronica, Curet, Luis B. (2001). Clinical
  management of methadone dependence during
  pregnancy. The Journal of Perinatal and Neonatal
  Nursing, 14 (4), 26-45.
• Guidelines for Testing and Reporting Drug Exposed
  Newborns in Washington State. Washington State
  Department of Health, 2006.
• Williams, Jill Schlabig (2006). The
  neurobehavioral legacy of prenatal tobacco
  exposure. NIDA.