1. Caring for Substance Exposed Infants:
It Takes a Village
Nancy Forsyth MSN RN NNP
Beebe Healthcare
August 2017

2. Objectives Definitions:
Opioid
Substance Use Disorder
Substance Exposed Infant (SEI)
Neonatal Abstinence Syndrome (NAS)
Incidence and pattern of illicit drug use in the US
Drugs that cause withdrawal in the neonate
What does NAS look like?
Nursing and hospital care
Long term effects of drug exposure

3. Definitions
Opioid: Drug that acts on receptors in brain to cause morphine-like effects, which include pain relief and euphoria.
Substance use disorder (SUD): SUDs occur when the recurrent use of alcohol or other drugs (or both) causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.
Substance exposed infant (SEI): An infant less than one year of age born with or affected by intrauterine substance exposure or with withdrawal symptoms or with Fetal Alcohol Spectrum Disorder.

4. Neonatal Abstinence Syndrome (NAS)
Signs of withdrawal resulting from abrupt discontinuation of opioids after extended intrauterine exposure
Prescription or non-prescription drugs
Opioid drugs include:
Prescription medications: oxycodone, Percocet, Vicodin, morphine, fentanyl
Illicit drugs: heroin, fentanyl, designer drugs
Treatment drugs: methadone, buprenorphine (Subutex, Suboxone)
(Hudak & Tan, 2012; Johnson, 2012)

6. Scope of the problem: Illicit drug use

7. Scope of the problem: Overdose
Opioids were involved in 33,091 deaths in 2015
Opioid overdoses have quadrupled since 1999.
Nearly half of all U.S. opioid overdose deaths involve a prescription opioid.1 In 2015, more than 15,000 people died from overdoses involving prescription opioids.
Heroin-related overdose deaths have more than quadrupled since 2010, and increased 20.6% from
13,000 people died of heroin overdose in

8. 5-fold increase in NAS since 2000 >21,000 infants in 2012
Opioid use in pregnant women tripled from 2000 to 2009
50-94% of exposed infants develop NAS
FL and TN had 10-fold increase in this time

10. (

11. NAS: A multi-system disorder
Neurological
Irritability
Poor sleep
High-pitched cry
Tremors
Increased muscle tone
Frequent yawning
Frequent sneezing
Seizures
Gastrointestinal
Vomiting
Diarrhea
Dehydration
Poor weight gain
Poor feeding
Autonomic
Sweating
Nasal stuffiness
Fast breathing
Fever
Mottling
Other
Skin excoriation
Increased risk of SIDS
Impaired bonding

12. Withdrawal from opioid drugs
Onset
Duration
Heroin
24 – 48 hours
May be delayed 5 – 7 days
1 – 2 weeks
Methadone
2 – 7 days
Weeks to months
Buprenorphine
40 – 70 hours
Weeks to months. LOS may be shorter than with methadone.
Other opioids
48 – 72 hours

13. Methadone Benefits of methadone treatment
Maintains opioid concentration and prevents cravings
No euphoria
Counseling and monitoring for illicit drug use
Better nutrition and weight gain
More likely to have prenatal care
Less likely to have a preterm or LBW infant
Stable and predictable environment
Pregnant women on methadone are doing the best they can do for their unborn baby

14. Nursing management: Assessment

15. Care at Beebe Mother/baby room in whenever possible
Maintain low stimulation environment
Teach parents to console their infants
Read to baby
Encourage breastfeeding if no illicit drug use
Skin care
Practice Safe Sleep
Oral morphine for severe withdrawal

16. Discharging home Infant stable off medication and gaining weight
Evaluation for safe home environment
Pediatrician appointment scheduled
Home visiting: Smart Start Program, Parents as Teachers, home health nurse

17. Nurses’ concerns about discharge
“When you see what these babies go through, there is no way they cannot be affected in some way. There is just no way. The pain…like, oh God, the pain. If you ever saw that…” “These are kids that are going to have problems with attachment…Are they prone to addiction too, later on down the road?” “I was just afraid he was going to be screaming in the middle of the night and she was just going to drop him, throw him at a wall, you know, that’s what I thought...” “[I told her] This baby is going to cry and you’re not going to be able to stop him…You need to promise me right now that when that baby does that, you will put him in his crib, put the side rail up on the crib, and walk out of the room. I don’t want to read in the newspaper that you dropped him, that you threw him, that you drowned him, that you hurt him.”

18. * Fetal effects Teratogenic Altered brain development and organization
Altered growth
Altered placental blood flow
Altered maternal behaviors:
nutrition, healthcare,violence, mental illness
Neonatal effects
Teratogenic
Growth
Withdrawal
Drug toxicity
Neurobehavioral
Nutrition
Developmental outcomes
Growth
Behavior
Cognition
Language
Motor
Achievement
Drug use?
Research on long-term effects of pain…what about pain and suffering from withdrawal?
Social factors
Impaired bonding
Impaired parenting
Altered family environment
Unstable home *

19. Long term outcome Lower scores on developmental assessments
Higher rate of foster home placement
Children lost to follow-up
Increased risk of substance abuse?
However, infants in a stable home environment will have developmental assessments comparable to non-drug-exposed peers
(Hunt, Tzioumi, Collins, Jeffery, 2008)

20. Caring for drug-addicted patients
“Addiction is the one disease that you are criminalized for having.”
It’s a disease with no ongoing relationship with a health care provider.
Drug addiction is multifactorial
Physical and/or emotional trauma
Self-medication with drugs or alcohol
Addiction is a primary disease requiring specialized treatment to achieve recovery.
The threat of criminal prosecution prevents many women from seeking prenatal care and treatment for substance abuse.
(Catlin, 2012; Marcellus, 2012)

21. It takes a village Treatment programs Improving maternal nutrition
Case management to access services
Build parenting skills
Strengthen supportive social networks
Reading
Early intervention

22. References
Academy of Breastfeeding Medicine Protocol Committee (2009). ABM clinical protocol #21: guidelines for breastfeeding and the drug-dependent woman. Breastfeeding Medicine, 4 (4),
American Academy of Pediatrics Section on Breastfeeding (2012). Breastfeeding and the use of human milk. Pediatrics, 129, e827.
American Nurses Association. Non-punitive alcohol and drug treatment for pregnant and breastfeeding women and their exposed children Published Accessed November 8, 2012.
Bio LL, Siu A, Poon CY (2011). Update on the pharmacologic management of neonatal abstinence syndrome. Journal of Perinatology. Doi: /jp
Catlin, A. (2012). Call for improved care for the substance-positive mother. Advances in Neonatal Care, 12, (5),
CDC and the Substance Abuse and Mental Health Services Administration. (2011). Vital signs: Overdoses of prescription opioid pain relievers—United States, Morbidity and Mortality Weekly Report, 60, (43), Nov 4, 2011
CDC (2016). Drug Overdose Data.
D’Apolito, K. & Finnegan, L. (2010). Assessing Signs and Symptoms of Neonatal Abstinence Using the Finnegan Scoring Tool: An Inter-Observer Reliability Program (2nd ed.). NeoAdvances, LLC.

23. References
Hanna, D.R. (2005). The lived experience of moral distress: Nurses who assisted with elective abortions. Research and Theory for Nursing Practice: An International Journal, 19 (1), [Cited by Johnson, T., 2012]
Hudak ML & Tan RC. American Academy of Pediatrics Committee on Drugs & Committee on Fetus and Newborn (2012). Neonatal drug withdrawal clinical report. Pediatrics. Doi: 10,1542/peds
Hunt, R.W., Tzioumi, D., Collins, E., Jeffery, H.E. (2008). Adverse neurological outcome of infants exposed to opiate in-utero. Early Human Development, 84 (1),
Johnson, T. (2012). Double jeopardy: intrauterine substance exposure impact on mothers and babies. Presented at the Thruway Conference for Advanced Practice Nursing, May 16, 2012, Syracuse, New York.
Jones, HE, Johnson, RE, Jasinski, DR, O’Grady, KE, Chisholm, CA, Choo, RE, Crocetti, M, Dudas, R, Harrow, C, Huestis, MA, Jansson, LM, Lantz, M, Lester, BM, Milio, L (2005). Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: Effects on the neonatal abstinence syndrome. Drug and Alcohol Dependence, 79, 1-10.

24. References
Kaltenbach, K. (2013). Lessons from the MOTHER study: Methadone vs. buprenorphine and beyond. Presented at VON Collaborative Controversies in the Care of Infants and Families Affected by Neonatal Abstinence Syndrome. Newark, DE 3/6/13.
Maguire, D, Webb, M, Passmore, D, Cline, G. (2012). NICU nurses’ lived experience: Caring for infants with neonatal abstinence syndrome. Advances in Neonatal Care, 12, (5),
Marcellus, L. (2013). Principles of trauma-informed care: Considerations for the NICU context. Presented at VON Collaborative Controversies in the Care of Infants and Families Affected by Neonatal Abstinence Syndrome. Newark, DE 3/6/13.
National Institutes of Health, National Institute on Drug Abuse (2012). opiate-use-newborns-suffering-opiate-withdrawal-are-rise-in-us. Accessed 2/11/13.
Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. U.S. Department of Health and Human Services, Substance Abuse and Mental Services Administration, Center for Behavioral Health Statistics and Quality Accessed November 8, 2012
Results from the 2014 National Survey on Drug Use and Health: Summary of National Findings. U.S. Department of Health and Human Services, Substance Abuse and Mental Services Administration, Center for Behavioral Health Statistics and Quality /NSDUH-FRR pdf.