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

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

The Statistics National Institute on Drug Abuse Washington State 500,000 – 700,000 affected babies annually in the United States Washington State 12,000 drug affected babies each year These numbers show that at some point in your career you will see or care for an infant that has been exposed to drugs and either suffering from withdrawal or at risk for developing symptoms. These figures are probably underestimated. A survey of infants delivered at a tertiary perinatal center showed 42% exposed to cocaine, heroin, or marijuana by meconium analysis in contrast to the 10.5% drug use obtained by maternal history. Women’s drug use varies among groups of women on socioeconomic, racial, and ethnic dimensions. Indications are that drug use occurs, to some degree, among all demographic groups of women. Only the drugs of choice vary.

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 In 2003, only 72% of providers screened their patients. We know that maternal admission to drug use is inaccurate and the affected newborn may appear normal at birth, so identification of the drug exposed infant requires a high index of suspicion. Screening and testing for substance abuse is a huge legal and ethical issue. Each state and every hospital in every state has its own guidelines. General consent for treatment vs special consent for testing In the infant, drug testing is necessary to document proof of the infant’s exposure to illicit drugs even if the mother admits to the use of illicit drugs. Various specimens used for drug testing are blood, urine, hair, meconium, gastric aspirate, and amniotic fluid. Blood is used more for forensic pathology. Urine is easy to collect and analyze. Drugs in the infant’s urine represent recent drug use by the mother. It has to be collected as close to birth as possible. Meconium testing shows recent and past exposure and can be collected 48-72 hours after birth. Meconium is present at 17 weeks gestation so the concentration of drugs in the meconium is r/t the amount of maternal drug exposure during pregnancy. Health professionals are mandated by law to report suspected or confirmed abuse or exposure of the maternal or neonatal patient to CPS. Who to test? We look for the maternal and neonatal characteristics that are known to be associated with drug use in pregnancy and use them as indications t screen for intrauterine drug exposure. We must have a protocol in place and signed consents. Consent should be obtained prior to sending any drug screen on the mother. The consent should include what will be done with the results (CPS) With respect to the baby, the general consent for care could cover a drug screen if it would have an impact on the infant’s care. We have a duty to protect the infant. The mother can speak/refuse for herself. Communication is essential. Tell her why you need it. These women know about CPS and they know that a + urine may mean their baby will be taken. Under those circumstances why would they consent? You could explain to her how the results will change her care. It will affect what and how much she receives for pain relief, the type of medication she could be give for high BP, the type of anesthesia she gets for a section. Be honest about testing the baby. Problems arise when patients feel that they were lied to or deceived or that information was withheld from them. If the mother knows that the baby will be tested anyway, she may be more willing to consent to her own urine test. Patient history/admission interview—physical signs, pick-n-poks, rotten teeth, track marks Significant other report Prenatal history—no prenatal care, entry into care >28 weeks, 2 or more unexplained missed prenatal visits, 3 or less total prenatal visits, IUGR by US, homelessness, history of preterm labor with undocumented cause CPS alert Newborn symptomology

Testing Mom Baby Risk Indicators Risk Indicators Consent Consent 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

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 Some of the effects associates with substance abuse are transient. Others are long lasting because of the teratogenic effects of the drugs themselves and other substances that are ingested with them. These teratogenic effects can be either dysmorphic or behavioral. Dysmorphism is a physical malformation that is recognized in the newborn period. Behavioral effects are more difficult to identify, presentation may be delayed and may not become evident until later in maturation and development (school age). In addition, some of the effects manifested by these exposed infants are caused by a combination of tow factors—the drugs taken and the life-style of the drug-abusing mother. Drug abuse during pregnancy is associates with significant perinatal complications such as MSAF, PROM, maternal hemorrhage, and fetal distress. In the neonate, the mortality and morbidity rate are increased due to asphyxia, prematurity, low birth weight, infections, cerbral infarction, drug withdrawal. Long term sequela are common and include delays in physical growth and mental development, SIDS, and learning disabilities. Maternal health—Many women who use these substances are not not healthy. They could be anemic and anorexic, have poor nutrition, and more infections. Poly drug use—is more common than single drug use. Some women use depressants & stimulants. Many smoke cigarettes or marijuana and drink alcohol along with their illicit drug use. These substances compound problems for the fetus and newborn. A lot of these substances cause decreased blood flow to the fetus so it doesn’t get enough nutrients and is exposed to chronic hypoxia. Gestational age—If she used when the cardiovascular system was developing, the infant could have cardiac anomalies. If used during the rapid growth phase of the CNS, the baby could have more CNS disturbances. Time used in relation to delivery—The severity of withdrawal depends on the last time that mom used. The closer to delivery, the worse the withdrawal.

Common Findings in Drug Exposed Infants Hypersensitivity to stimuli Abnormal muscle tone Sleep Problems Feeding Problems GI Problems Hypersensitivity—bright lights, normal and loud noises, movement, touch, the human face, being exposed to more than one stimuli at a time Abnormal muscle tone—may be unusually limp or stiff. Stiffness, especially of the neck and limbs is caused by the baby’s attempt to control his body Sleep patterns—these babies don’t sleep well. They are fitful and restless, have less or absent REM sleep, have difficulty getting to sleep, or are so lethargic you can’t get them up to eat Feeding problems—include difficulty latching to nipple, a disorganized suck, difficulty coordinating sucking, swallowing, and breathing. Another problem is that so much energy is used reacting to the environment and trying to control tremors and other discomforts that they can’t take in enough calories GI problems—It is thought that some of the irritability in these babies may be from GI distress, watery stools, explosive diarrhea, constipation, gas, nausea/vomiting, and irritated/excoriated buttocks.

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 Alcohol has been shown to cause diminished DNA synthesis, disruption of protein synthesis, and impaired cellular growth, differentiation, and migration. Causes many of the same anomalies that are observed in cocaine exposed neonates. When marijuana is added, the incidence of delivering an infant with the features of FAS are increased nearly 5 fold. When cocaine and alcohol are used together, a unique metabolite is formed that is reported to be 10 times more potent than cocaine alone. 1 in 29 women who know they are pregnant drink alcohol. Leading cause of mental retardation-and only preventable cause of mental retardation.

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 2002 National Survey on Drug Use and Health Blood flow through placenta decreased by as much as 38% Cigarettes contain nicotine, tar, carbon monoxide, and cyanide. Nicotine causes vasoconstriction and increased heart rate in the mother and the fetus which decreases blood flow. Nicotine also targets neurotransmitter receptors in the fetal brain increasing cetecholamines which affect nervous system transmission and reduce cell division affecting long term cognitive function and increasing the risk of brain damage. Carbon monoxide reduces the amount of oxygen carried to the fetal tissues. Spontaneous abortion Placental abruption Placenta previa Fetus Vasoconstriction Carbon monoxide Stillbirth Placental complications Prematurity November 2006 TNT article…Moms who smoke before becoming pregnant or while pregnant or are exposed to second hand smoke are 60-80 times more likely to have infant with cardiac defect. Study by National Institute on Drug Abuse provides evidence of toxic effects of prenatal exposure to tobacco smoke on newborn neurobehavior. The study offers evidence of a dose-response relationship between maternal smoking during pregnancy and newborn neurobehavior. Infants prenatally exposed to tobacco were highly aroused and reactive, with more rigid muscles than non-exposed infants. They also scored higher on markers of stress or drug withdrawal consistent with what has been reported in infants exposed to other drugs. Exposed infants showed significant CNS, GI, and visual effects They also required more handling to keep them in a quiet and alert state.

Cocaine Stimulant Tachycardia Hypertension Decreased blood flow and oxygen delivery to fetus Increased uterine contractions Stimulant Increase in circulating catecholamines and serotonin Vasoconstriction Increase in circulating norepinephrine Tachycardia and hypertension in fetus and user Increase in uterine contractions Spontaneous abortion, abruption, preterm delivery

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 Vomiting and diarrhea An abstinence syndrome for cocaine exposed infants has not been identified. It is believed these behaviors are linked to the effect of the drug itself/toxic effects of the drug, rather than to the effect of withdrawal from the drug. The treatment of these findings in the cocaine-exposed infant is one of support. The effects cannot be eliminated with the use of pharmacologic intervention. The infant will require environmental support and consistent caregiving to decrease the overstimulation which contributes to disorganization. Cocaine produces a depressant rather than hyperactive state. Do not receive the message to the brain that they are hungry so will not wake to feed and when they do feed they have difficulty eating because of poor suck/swallow coordination. Longer term effects include shorter attention span, restlessness, delayed motor skills, language delays, difficulty focusing, and difficulty with self-regulation and impulse control.

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 release of norepinephrine, dopamine, and serotonin According to the National Survey on Drug Use and Health, in 2002 12.4 million Americans age 12 and older have used methamphetamine—5.3% of the population—with a majority of users between 18 an d34 years of age. Meth has similar effects as cocaine but there are some major differences. Manmade vs plant derived (may contain lead, battery acid, ammoinia) High lasts 8-24 hours vs 20-30 minutes 50% of drug removed from body in 12 hours vs 1 hour January 2005 article in the TNT states that meth labs and dump sites are up 16% from last year. In 2004, 541 meth labs and dump sites were reported. Brain lesions-hemorrhage and infarction

Effects of Methamphetamine on the Infant Associated with: Congenital brain lesions Cleft lip Cardiac defects Low birth weight and reduced OFC Hyperbilirubinemia Poor state control Lethargic Poor feeding Disorganized suck No suck Irritable Abnormal tone Excoriated buttocks Aggressive behavior and peer related problems at 4-8 years of age

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 Methadone is an opiate antagonist that prevents the symptoms of opiate withdrawal without causing the high associated with heroin. Methadone treatment reduces illicit substance use, illegal drug-seeking activity, overdoses, exposure to toxins in impure street drugs, and needle-related infections.. Goals of methadone maintencance during pregnancy are to prevent abstinence syndrome, reduce or eliminate drug cravings, and block the euphoric effects of narcotic drugs in order to reduce illicit drug use. Methadone maintenance provides a steady state of opiate levels, thus reducing the risk of constant withdrawal. It can be taken orally, lacks impurities, costs less, and allows for contact with a healthcare provider. Women in methadone programs receive more prenatal care and have babies with higher birth weights and fewer complications. While methadone administration reduces many of the risks associated with heroin use, it has also been associated with longer and more severe NAS than heroin exposure due to its longer half life. Neither heroin or methadone have been associated with congenital malformations of a specific dysmorphic syndrome. Prescription drugs—Tylenol 3, Percocet

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 You cannot predict which infants will develop NAS or how severe it will be. Time of onset and symptoms vary based on the half-life of the substance. Heroine withdrawal begins within the first day. Methadone after three days, alcohol 3-12 hours after delivery, sedatives and barbiturate withdrawal between three and seven days. It also depends on the last time mom used in relation to the delivery. The closer to delivery, the worse the withdrawal.

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 Finnegan scoring sheet.

NAS Scoring The Finnegan scale If score is 8 or greater Score every 2 hours for 24 hours Scores > 8 on three consecutive scores Evaluate need for medication If intervention not needed by 72 hours Scoring may be discontinued The Finnegan Scale is a well-known neonatal abstinence scoring system. It was developed by Dr. Loretta Finnegan to help determine the severity of the infant’s symptoms, its response to nursing care strategies and medication, and resolution of symptoms. Symptoms within each system are rated on a one to five point scale based on the symptom’s clinical significance. It was developed for use on term infants exposed to opiates and nonopiate CNS depressants. Base your assessment and score on the entire interval between scoring—not just what you see at the time of assessment.

System Disturbances Central Nervous System Metabolic/Vasomotor/Respiratory Gastrointestinal The three systems affected by opiate withdrawal are the CNS, the metabolic/vasomotor/respiratory, and the gastrointestinal systems. Some of the behaviors and symptoms are caused by an increased excitability of body functions that were previously depressed by the effect of the drug. Others are caused by the effect of the drug on the developing systems of the fetus.

Central Nervous System Cry Sleep pattern Exaggerated Moro Reflex Tremors Muscle tone Excoriation Myoclonic jerks Convulsions Central nervous system disturbances include… Excessive high pitched crying, decreased sleep intervals May have pronounced jitteriness and repetitive jerking Tremors when being handles to tremors while not being handled Increased muscle tone—rigid Excoriation in areas other than diaper such as chin, knees, elbows, hands and feet Jerks different from tremors which are quivering and rhythmical

Metabolic,Vasomotor, Respiratory Sweating Fever Yawning Mottling Nasal stuffiness Sneezing Nasal flaring Increased respiratory rate, retractions Metabolic, vasomotor, and respiratory disturbances include… Sweating is not normal in newborns Temperature ranges—normal, 99-101, >101 Yawns more than 3 times during scoring period Breathing is noisy Sneezes more than 3 times during scoring period

Gastrointestinal Excessive sucking Poor feeding Regurgitation, projectile vomiting Loose stools, watery stools GI system disturbances include… Frantic or disorganized suck, unable to latch onto nipple or close mouth, shaking head, mouthing nipple, dribbling Grasps the nipple so strongly that caregiver must break seal to release, exagerated rooting reflex Loose stool appears curdy, or runny without a water ring Water stools has little substance and had water ring surrounding it.

Medications for NAS Morphine Sulfate Phenobarbital Ativan Other As with using an abstinence scoring tool for opiate exposure, medication is also almost always used for only opiate withdrawal. The decision to start drug therapy is based on the severity of withdrawal symptoms. Severity is based on the scores obtained by the scoring system, or if the GI disturbances are resulting in excessive weight loss, the infant is unable to sleep, or the infant is having seizures. A variety of pharmacologic agents are used to treat the opiate exposed infant. Some have been studies more than others and each one has advantages and disadvantages Morphine—inhibits bowel motility, causes low level sedation, improves effectiveness of sucking, improves nutrient intake, oral morphine contains no additives or alcohol, has a long tapering period, can cause respiratory depression, urinary retention Phenobarbital—eases hyperactivity, controls irritability and insomnia, good if multiple drugs used, does not control vomiting or diarrhea, causes respiratory and CNS depression in high doses, impairs sucking reflex, need to monitor serum levels Ativan Other drugs are paragoric tincture of opium, diazepam, chlorpromazine, clonidine, and methadone. These either have not been widely used in neonates or contain additives that have potential toxic effects. Never use Narcan—can cause acute withdrawal and seizures

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 Treatment consists of nursing interventions that focus on comfort, sleep, and nutrition. These nursing interventions can be used on newborns exposed to any type of drug. Assessment—Starts upon admission of the laboring patient. Drug use in pregnancy crosses all socioeconomic and racial boundaries. Red flags are physical evidence of use, late or no prenatal care, history of missed appointments, precipitous labor and delivery, preterm labor without a documented cause, IUGR, history of STDs, homelessness. All newborns should be assessed for exposure. NAS scoring—accurate/objective scoring is essential for making sure these babies get the care they need. Control the environment—dim the lights, control noise, decrease amount of stimuli baby is exposed to at a time. Feeding techniques—feed with lights dimmed, don’t talk to or rock while feeding, offer small frequent feeds, sometimes need to use higher calorie formula. You learn very quickly how to hold these babies while feeding and burping so you don’t get sprayed when they vomit. Therapeutic handling—Instead of trying to explain there methods of therapeutic handling, I am going to show you a short video that was made by the Pediatric Interim Care Center in Kent. They specialize in caring for infants who were exposed to illicit drugs.

Nursing Care of the Drug Exposed Infant Dealing with the family Personal feelings Public health issue vs. Crime 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 Another difficult aspect of caring for these babies is dealing with the family. You do need to personally separate the negative aspects of the mother’s addictive behavior from her right to respect and support. Many organizations such as the AAP, ANA, March of Dimes, ACOG view substance abuse during pregnancy as a public health issue rather than a crime. We don’t want to alienate these families from their source of healthcare—our goal is to improve the outcomes for these families. These families need to be involved in the care of the infant and need to be taught how their babies differ from babies that were not exposed to drugs. Many of these babies go home with their mothers or with other family members or are returned to their parents before they are fully recovered from withdrawal.

Questions ?

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 D’Apolito, 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.

Weiner, Susan M. & Finnegan, Loretta P. (2002) 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.