Nursing Treatment of Neonatal Abstinence Syndrome Ferris State University Kelly Geraghty, Tracy James, Kristen Lintjer, Sara Potes, Rikki Zissler

PICO Question “Are newborn infants with high neonatal abstinence syndrome scores (8 or above) more responsive when nurses treat them with pharmaceutical or non-pharmaceutical interventions?”

Definition of Withdrawal Neonatal Abstinence Syndrome (NAS) is a cluster of symptoms, exhibited by the baby, that indicates physiological response to the immediate withdrawal of maternal drug use.

There are two categories of NAS: NAS due to prenatal or maternal use of substances that result in withdrawal symptoms in the newborn Postnatal NAS secondary to discontinuation of medications such as fentanyl or morphine used for pain therapy in the newborn (Hamdan, 2010). We are focusing on the first category.

Drugs that are frequently associated with NAS are: Heroin Methadone Morphine cocaine alcohol nicotine An infant that has been exposed to alcohol and/or nicotine prenatally, doesn’t typically go through the same withdrawal process as the infant that has been exposed to one or more of the other more hard core drugs.

Methadone There has been a recent increase in our area in the amount of babies being born addicted to methadone which has been an approved form of therapy for opiate-addicted pregnant women. Clinics are becoming more available since this medication has shown to decrease addicted patients relapses

Withdrawal may occur as soon as 48 hours after birth and may appear up to 7-14 days after birth (Hamdan, 2010).

Signs and Symptoms of Withdrawal CNS Dysfunction GI Disturbances Metabolic, Vasomotor, & Respiratory Disturbances High pitch cry Excessive, frantic sucking or rooting Sweating Myoclonic jerks Poor feeding Fever Restlessness, sleep duration less than 1–3 hours after feeding Poor weight gain Respiratory rate greater than 60 without retractions, nasal flaring Hyperactive reflexes, hypertonia Regurgitation or projectile vomiting frequent yawning Jitteriness, tremors Loose or watery stools Sneezing Generalized convulsions Apnea Infants that are at a high risk for withdrawal need to be watched very closely for any of these signs or symptoms. If the infant begins to show any signs or symptoms scoring must be started immediately. (Hamdan, 2010)

Articles in Review

“Opiate treatment for opiate withdrawal in newborn infants”, Osborn, Jeffery, & Cole (2010). This study was done to “assess the effectiveness and safety of using an opiate compared to a sedative or non-pharmacological treatment for treatment of NAS due to withdrawal from opiates” (Osborn et al., p. 3-4). The studies enrolled 645 infants and there were nine studies done. It was found that there was no real difference in the failure of treatment between the infants receiving opiates to those receiving supportive care (Osborn et al., p. 3-4). This study also showed that infants that received opiates along with supportive care had a faster birth weight regain compared to infants that only received supportive care (Osborn et al., p. 8) The studies ranged from opiate versus supportive care to opiates versus phenobarbitone. Withdrawal from heroin usually presents at 24 hours after birth, where infants withdrawing from methadone usually show signs two to seven days after birth. This study shows that infants may need more than just supportive care.

“Neonatal Abstinence Syndrome” by Burgos and Burke (2009). It stated that the treatment of NAS should always begin with non-pharmacologic measures. (Burgos , Burke 2009) Non pharmacological measures include and should be in conjunction with pharmacological interventions. To reduce environmental stimulation suggestions include: Keep infant swaddled and contained when in sleeping state, and avoid waking from a deep sleep. Adequate nutrition since their nutritional needs may be greater than that of a normal newborn Breastfeeding should be encouraged and has been shown to reduce the severity of NAS. Pacifiers should be offered or hands for non-nutritive sucking. Physical and occupational therapy may be consulted for more ideas. Skin protection is highly recommended. Offer emotional support to the family. After the birth, encourage family to do as much care as possible and tell them that support will be available even after discharge from the hospital. Non pharmacological interventions should include gentle handling, ambient noise control, and an on demand feeding schedule. Reducing environmental stimulation suggestions include a quiet room, dim lighting, low activity level, and moving the infant away from the telephone, sink and other high traffic areas. The infant should be fed on demand with small frequent feedings with rest between. The infant should be burped frequently during a feeding. Adequate temperature and hydration should be maintained. Frequent diaper changes using a skin barrier to protect from frequent loose stools is recommended. Placing the infant on a pressure reduction mattress is also helpful.

“Neonatal abstinence syndrome: assessment and pharmacotherapy” Finnegan (1990) The Finnegan scoring system is the most widely used even though it is 21 years old. It lists 21 symptoms that are most frequently observed in opiate-exposed infants (Finnegan, 1990, p. 2). The symptoms are rated by severity and the total is calculated for that period of time (Finnegan, p. 2). This tool was designed to be used with term infants therefore it may need to be modified for preterm infants. The Finnegan scoring system is the most widely used even though it is 21 years old. (Hamdan, 2010). This scale assesses 21 of the most common signs of neonatal drug withdrawal syndrome and is scored on the basis of pathological significance and severity of the adverse symptoms (Hamdan, 2010). If an infant receives three consecutive scores of 8 or higher, treatment for withdrawal is started.

The study included 450 infants and data was collected on 437. :Maternal Methadone use in pregnancy factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources”. Dryden, C., Young, D., Hepburn, M and Mactier, H. (2009) The study included 450 infants and data was collected on 437. Of the infants in the study, 45.5% of received pharmacological treatment for NAS. Duration of oral morphine was from 1-44 days. Half were discharged to home on Phenobarbital and therapy ranged from 2-140 days. As high as 93% of infants requiring Phenobarbital were exposed to poly-drug use in utero. Breastfeeding was initiated in 27.7% of these infants and 48.8% of these infants were admitted to the NICU. (Dryden et al 2009) Stays in hospital ranged from 1-108 days and 40% of these were admitted due to NAS.(Dryden et al) Breastfeeding for greater than 48 hours was independently associated with halving the odds of the infant receiving pharmacological treatment for NAS. This article contains information about infants born to drug-misusing mothers. These infants are recognized to be at risk of preterm delivery, poor intrauterine growth, and development of neonatal abstinence syndrome There has been some association with increased rate of NAS and longer hospital stay in infants born to mothers with poly-drug use. There is also a correlation between a higher methadone use and decrease in the amount of poly-drug. This suggests a higher dose of methadone reduces poly-drug use and side effects to the infant. In this study the woman were provided with substitute therapy of methadone and social work services. Standard methadone treatment is to prescribe enough methadone to eliminate physical withdrawal symptoms. The act of breastfeeding soothes agitated infants and drugs taken by the mother are excreted in varying amounts in breast milk which reduces the effects of withdrawal. The average rate of drug using mothers who breastfeed is 35% by day 5. It is the impression of this study that the majority of drug-misusing mothers, who do not choose to breastfeed, do so because of deeply engrained social prejudice and not because of poly-drug misuse. It is recommended that all drug-misusing mothers be encouraged to breastfeed their infants and rooming in helps to facilitate this.(Dryden et al)

Assessment tool for NAS

Finnegan Scale This scale assesses 21 of the most common signs of neonatal drug withdrawal syndrome and is scored on the basis of pathological significance and severity of the adverse symptoms (Hamdan, 2010). If an infant receives three consecutive scores of 8 or higher, treatment for withdrawal is started.

Typical scoring chart (Finnegan, 1990, p. 2) Irritability NA 1 Restless even after intervention 2 Crying or frantic fist sucking 3 Fresh excoriation of limbs 4 Continuous cry Startle Hyperactive Tremors When undisturbed When disturbed Hyper tonicity Hyper tonicity present Reguritation Regurgitation Loose or watery stools Loose watery stools Yawning or Sneezing More than 2 a session Sweating or Mottling Sweating or mottling present Sleep cycle Less than 2hr Less than 1hr Does not sleep between feeds Ideally the first score should be two hours after birth or on admission to the nursery. This is the baseline score (Finnegan, 1990, p. 2). The infant should be scored every four hours unless the score is greater than or equal to eight. If the score is greater than or equal to eight the infant should be scored every two hours. Scoring continues until the score is consistently less than eight for at least three days after the discontinuing of any pharmacotherapy. (Finnegan, 1990, p. 2)

Supportive Therapy

Non-Pharmacologic Interventions 1. Decrease environmental stimulation Quiet room Dimming lights Low activity level Nurses should use slow movements and avoid talking at the bedside Keep the infant tightly swaddled while sleeping Don’t wake the infant from a sleeping state

2. Ensure adequate nutrition Nutritional needs may be higher due to increased activity and stress that comes from withdrawal. Breastfeeding should be encouraged and can help decrease the severity of NAS. Swaddling will help the infant control their body and help with feeding The infant should be offered the pacifier for non-nutritive sucking when possible. Breastfeeding for greater than 48 hours was independently associated with halving the odds of the infant receiving pharmacological treatment for NAS. The act of breastfeeding soothes agitated infants and drugs taken by the mother are excreted in varying amounts in breast milk which reduces the effects of withdrawal.

3. Protect the skin 4. Encourage Attachment Use frequent diaper changes using barrier cream to avoid damage from frequent loose stools. Consider placing the infant on a pressure reduction mattress. 4. Encourage Attachment After the birth, encourage family to do as much care as possible and tell them that support will be available even after discharge from the hospital. Nurses should be prepared to be empathetic and nonjudgmental

Say yes to the breast Breast feeding should be encouraged. Many moms choose not to breastfeed, not due to the drugs, but due to social prejudice. It is important for nurses to understand that the excreted medication in the mothers milk will most likely provide enough medication to the infant to help calm the side effects of withdrawal. Mothers must be educated that providing breast milk for the first few weeks will actually benefit and not harm their child.

Pharmacological Intervention Morphine- commonly used to reduce neural activity which ultimately decreases withdrawal symptoms. Clonidine- has seen in some studies to decrease the affects of opiate withdrawal, and decreases the inhibitory effects on noradrenaline which is released in the locus ceruleus Phenobarbital – works nonspecifically on symptoms to NAS. Methadone-activates the opiate receptors in the locus ceruleus. The locus ceruleus is one of the major clusters of noradrenergic cells in the brain. Many times an infant will ultimately need pharmacological intervention to help with the withdrawal symptoms. Hospital stays will be longer when medications are used. Many infants will also be discharged home with morphine or methadone. They are followed very closely after discharge, and are very slowly weaned off the medication. (Gereda et al, 2003

Nursing Care Even though a doctors order must be obtained before any medication is given, NAS scoring takes nursing assessment and skills. Many institutions will implement pharmaceutical interventions when an infant has scored 8 or above in 3 consecutive scores. Nurses must exhaust all possibilities of non-pharmaceutical interventions prior to seeking medication therapy Nurses may start scoring on any infant that the suspect may be withdrawing. As nurses we need to do everything that we can to decrease the need for medication intervention. Caring for a withdrawal infant can be very difficult, but good nursing interventions can be very helpful to the infant.

References A. (1998). Neonatal Drug Withdrawal. Pediatrics, 101(6), 1079-1086. Burgos, A. E., & Burke, B. L. (2009). Neonatal Abstinence Syndrome. NeoReviews, 10(5), E222-E229. doi: 10.1542/neo.10-5-e222. Dryden, C., Young, D., Hepburn, M and Mactier, H. (2009), Maternal methadone use in pregnancy: Factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG: An International Journal of Obstetrics and Gynaecology, 116: 665-671. Doi: 10.1111/j.1471-0528.2008.02073.x. Finnegan LP. Neonatal abstinence syndrome: assessment and pharmacotherapy. In: Nelson N, editor.Current therapy in neonatal-perinatal medicine. 2 ed. Ontario: BC Decker; 1990. Gerada, C., Greenough, A., Johnson, K,.(2003) Treatment of Neonatal Abstinence Syndrome. Arch Dis Child Fetal Neonatal Ed. 88:F2–F5 Hamdan, A. H. (2010, March 3). Neonatal Abstinence Syndrome. EMedicine Pediatrics. Retrieved March 5, 2011, from emedicine.medscape.com/article/978763-overview

Johnson, K. , Gerada, C. , & Greenough, A. (2003) Johnson, K., Gerada, C., & Greenough, A. (2003). Treatment of neonatal abstinence syndrome. Archives of Disease in Childhood: Fetal & Neonatal Ed, 88(1):F2-F5. Doi 10.1136/fn.88.1.F2. Oei, J., & Lui, K. (2007). Management of the newborn infant affected by maternal opiates and other drugs of dependency. Journal of Pediatrics and Child Health, 43(1-2), 9-18. Osborn, D. A., Jeffery, H. E., & Cole, M. J. (2010). Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database of Systematic Reviews, 10, 1-55. Doi: 10.1002/14651858.CD002059.pub3. Schub, E., & Davidson, H. A. (2010, March 5). Evidence Based Care Sheet, Neonatal Abstinence Syndrome. Retrieved March 1, 2011, from http://www.cinahl.com