Nursing Diagnoses for Neonatal Abstinence Syndrome

This final blog post will describe some of the problems (physiological, emotional, and social) that nurses look for when they are caring for mothers who are involved in substance use and infants who are diagnosed with NAS. 

Nursing Diagnoses
1. Ineffective Childbearing Process R/T Substance Abuse AEB lack of prenatal visits, mother does not report appropriate pre and postpartum lifestyle because of substance abuse, has limited support systems

This nursing diagnosis describes the mothers impaired ability to safely manage her pregnancy. This relates to her failure to obtain prenatal care before birth, her lifestyle of drug use that cannot safely support an infant, and the possibility that she is not well supported by friends, family or significant others. 

2. Risk for disturbed Maternal/Fetal Dyad R/T substance abuse AEB challenging feedings, mother unable to adequately care for her infant, involvement of social services
This nursing diagnosis describes the possible problems between the mother and infant that may occur after birth. Their relationship may be disrupted by the symptoms of NAS the infant will experience which can be very traumatic for both the baby and the mother. It also involves the mothers inability to provide the care the infant needs. Finally, the required involvement of social services may lead to removal of the infant from the mother's care. This can be traumatic for both the infant and the mother. Watch the video below to see an expectant mother's experience with NAS and her desire to get help for her next infant.

3. Ineffective breastfeeding R/T withdrawal symptoms, neonatal abstinence syndrome (NAS) AEB increased infant crying, infant crying at breast, failure to latch, infant irritability
This nursing diagnosis addresses the potential problems infants affected by NAS may have in breastfeeding. Often, the symptoms of NAS involve excessive crying, irritability and inability to self-calm which infants should normally be able to do in order to begin breastfeeding. Mothers of infants with NAS often have many challenges breastfeeding. Healthcare professionals must be available to help the mother and assist her with breastfeeding.

4. Disorganized infant behavior R/T prenatal substance abuse AEB tremors, jitteriness, hyperactivity, fever, sweating, nasal flaring, respiratory distress, poor feeding, myoclonic jerking, seizures, GI disturbances
This diagnosis describes the challenges the infant may have in adjusting to new life with the onset of traumatic withdrawal syndromes. The symptoms listed above could develop into dangerous conditions such as serious breathing complications, inability to self-regulate temperature, malnutrition, brain damage and extreme fatigue. For more information about symptoms of NAS click here for a link to an earlier blog post.

The challenges faced by the drug-addicted mother and her infant suffering from NAS are extensive and have emotional, physiological and social implications as explained above. Expectant mothers who are addicted to substances must seek support from their local birthing center, primary care provider, addiction support facilities, and other community resources to ensure safe pregnancy and delivery, and to ensure their newborn starts life with the highest quality care and attention.

Support Groups for Neonatal Abstinence Syndrome

This blog post contains some support groups and community resources for individuals or families affected by Neonatal Abstinence Syndrome (NAS). Click the titles of each organization/group to access their website!

For anyone with an infant affected by NAS:

Pediatric Interim Care Center

This organization located in Washington State provides short-term care for infants affected by NAS who require intermediate medical attention but are not ready to go home without medical supervision yet. Although these infants are no longer in need of intensive care in a NICU environment, they can still have dangerous symptoms that parents may not be equipped to handle. For parents, adjusting to caring for an infant is hard enough with out a NAS condition, so this program allows them to receive further support with this difficult change in their lives.

For parents of infants with NAS seeking treatment for substance abuse:
Methadone treatment centers

Women who abuse substances and have recently found out they are pregnant are not advised to "quit cold-turkey" because this is medically dangerous not only for the mother but also for the fetus. Withdrawal symptoms cannot be treated in unborn babies. An alternative for soon-to-be mothers seeking treatment is a methadone treatment program that weans the participant off of their opioid of choice with methadone which is a drug that is easier to eventually stop using. This site has links to methadone treatment centers by state. Don't wait, start now in finding treatment for yourself and your future child!

Drug/Alcohol rehabilitation centers

This website is a search engine for finding certified treatment centers for drug or alcohol abuse. Parents of children already diagnosed with NAS who want to change their lifestyle can search here for treatment programs. This step is extremely important in finding support going forward in your life and the life of your child. 

For adoptive parents of infants with NAS:
Adoptive parent support groups
New parents who have adopted a NAS-affected infant may find it challenging to accept their child's condition, or the situations that lead to it. Adoptive parent groups are incredible resources for adoptive parents to come together and share their experiences. Social events, encouragement, advice and support are often available in groups like these. Search with this website's engine to find a local adoptive parent group that fits your needs!

Apps Related to Neonatal Abstinence Syndrome

The following apps may be useful for healthcare professionals who are working with infants suffering from Neonatal Abstinence Syndrome. The first two are related to scoring and determining treatment pathways based on published research. The second two could be recommended to parents who are dealing with NAS. The first is a feeding reminder and tracking app. Because treatment of withdrawal symptoms involves physical touch and comfort measures as well as medicine, it is important for parents to have reminders about feeding and comfort care. The last app may be helpful for parents who are seeking treatment or support during their recovery. Click the titles below to download each app!

Neonatal Drug Withdrawal Tools
FREE
Created by: Kyle Gunter PharmD BCPS
Category: Medical
"Neonatal Drug Withdrawal Syndrome also known as Neonatal Abstinence Syndrome (NAS) is an ever increasing problem among newborn infants. Recent studies have shown a three fold increase in NAS diagnosis over the past decade. The Neonatal Drug Withdrawal Tools App provides the busy clinician with a tool for treating NAS in a quick and intuitive manner. These protocols are based on published studies and provide an evidenced based method for treating neonatal drug withdrawal in newborns. This app is intended for Pediatricians, Neonatologists, Neonatal Nurse Practitioners, Pharmacists and other Pediatric Health Professionals."

Neonatal Abstinence Scoring Record Mobile App
FREE
Created by: Team Canvas
Category: Health Care & Social Services
"The Neonatal Abstinence Scoring Record mobile app allows hospitals and physicians to complete a medical Neonatal Abstinence Scoring Record using a Smartphone or Tablet. The app covers: System Signs and Symptoms for the Central Nervous System, Metabolic and Vascular Motor and Gastrointestinal. This app allows nurse to make notes and captures signature."

iBaby Feed Timer - Breastfeeding, Nursing, Bottle Feeding & Baby development log

$4.99

Created by: Fehners Software LLP

Category: Medical, Lifestyle

"Designed by and for breastfeeding mothers who want to track when and for how long their baby feeds, including a useful reminder for when a feed is due. It even tells you which breast to start on!

Baby Feed Timer does it all for you!
Tracks breastfeeds, bottle feeds, breast pumps, diapers, sleep, solid food, weight, length, notes and reminders(ideal for recording baby's temperature and medicine given)."

Addicaid

FREE
Created by: Twistor Labs, Inc.
Category: Medical
"Addicaid is a new way to begin or maintain your recovery. We cater to moderation management and sobriety. Find and rate meetings, track your progress with custom daily goals with the support of our intimate community. And when you're done clicking around there, you can stay inspired and motivated with our curated news, videos, and music feed. 

We have both 12-step and alternative support groups in our directory.

App features include:

Meetings
• List meetings so you can read them.
• Map out meetings so you can see them.
• Provides directions so you can get there.
• Save to calendar so you remember to go there.
• Check in to meetings so you can prove you were there.
• Favorite, comment, and tag meetings so people know what you think.

Social
• Comment on member goals to give and get community support.
• Add friends
• Public and private chats 
• SOS Alerts for times of need

Personal
• Journal entries
• Daily check-ins
• Custom goals with audio/text response

Resources
• Hotlines
• Inpatient treatment 
• Spending calculator 
• Eating regimen to reduce cravings 
• Relapse prevention tips"

Internet Resources for Neonatal Abstinence Syndrome

This post lists several informational websites that may be helpful for pregnant or recently pregnant mothers who either have infants at risk for Neonatal Abstinence Syndrome (NAS), or have an infant diagnosed with NAS. 

1. Medscape - NAS background (click here)
This website provides detailed information about the signs/symptoms, causes, and pathophysiology (or disease process) of NAS. The website conveniently lays out a common process of assessment, diagnosis, confirmation, and treatment of NAS. Parents who are interested in how this process works will find this website very helpful to explain some of the procedures or assessments done for their infant by healthcare professionals. 

2. March of Dimes - Risks of NAS (click here)
This website provides an overview of what NAS is, why it is a problem for infants, ways to prevent NAS, signs and symptoms that might indicate NAS, and how it is commonly treated in the hospital. This website specifically highlights some of the dangerous conditions infants can develop from NAS such as low birth weight, breastfeeding problems, seizures, and birth defects. It also emphasizes that quitting "cold turkey" is incredibly dangerous for both the mother and the infant.



3. Substance Abuse and Mental Health Services Administration - Treatment for the mother (click here)
This website is a portal that allows mothers or expectant mothers who are addicted to drug substances to search and find authorized treatment centers and facilities. This is essential in ensuring a healthy life and lifestyle for both the infant and the mother. The mother's health and ability to take care of her infant have incredible influences not only on how well her infant will grow and develop, but may even have an impact on whether she can keep her baby at all! If you are concerned about whether or not your infant may be at risk for NAS or if your infant is already diagnosed, please seek life-restoring treatment through this website to benefit both yourself and your child.

4. The Children's Hospital of Philadelphia - Treatment for the infant (click here)
This website lays out information about  the treatment pathway that would be followed in an NICU setting where an infant diagnosed with NAS would be treated. This provides vital information for parents who might be wondering about the specifics of how their infant will be treated, and what kinds of improvements are essential for discharge. By clicking on the highlighted links within the website, visitors can find additional information. While treatment pathways may not be the same for every facility, this is a common regimen that has been supported by research. Eventually, it may become a universally accepted treatment pathway for infants with NAS. 

References

1. emedicine.medscape.com/article/978763-treatment

2. www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx

3. findtreatment.samhsa.gov/

4. www.chop.edu/clinical-pathway/neonatal-abstinence-syndrome-clinical-pathway

Treatment of Neonatal Abstinence Syndrome

Treatment of opioid-induced Neonatal Abstinence Syndrome (NAS) has only recently been closely studied. Although it has become more standardized as more research is done on the subject, many hospitals still do not have standard protocols they follow to treat the newborns affected by NAS or they have only recently developed these guidelines. 

Research has discovered some treatment interventions that should be done, and some that shouldn't. For example, Naloxone, the medication used to reverse dangerous side effects of opiate overdose such as respiratory depression, is contraindicated for NAS-affected infants. It has been shown to exacerbated the symptoms of NAS and can bring on seizures in withdrawing infants (Kocherlakota, 2014). 

Non-Pharmacologic Treatment

Figure 1. Swaddling

These interventions do not involve drugs or medications and their goals include providing for adequate rest and nutrition, comfortably integrating the infant into their new social environment, and establishing a consistent pattern of growth. Some treatments include:
- Reducing environmental stimuli (dimming lights, turning down loud sounds)
- Avoiding self-stimulation (swaddling, careful/comfortable positioning, swaying, rocking)
- Responding to infant's physiologic needs (providing high-calorie formula or breast milk to stimulate growth)
(Hudak, Tan, The Committee on Drugs, & The Committee on Fetus and Newborn, 2012).

Pharmacological Treatment
The most effective pharmacological treatment regimen that has been researched is a weaning system involving either morphine or methadone. In the table below, these two front line medications are compared. 

Treatment	Dosage	Action	Notes	Cons
Morphine	0.05 mg/kg per day to 1.3 mg/kg per day	Decreases incidence of seizures, improves feeding, decreases irritability.	Most commonly used method of pharmacological treatment, solution is stable and easy to administer via oral route, the dosage is also easily titrated because of the short half-life of morphine	Increases length of hospital stay, must be administered every 3-4 hours because of the short half-life of morphine
Methadone	0.1mg/kg/12HRS with dose reduction of 10-20% per week	Similar to that of morphine	Well absorbed via oral route of administration, has a long half life which decreases the number of needed administrations	Difficult to titrate because of the long half-life of methadone
(Hudak, Tan, The Committee on Drugs, & The Committee on Fetus and Newborn, 2012), (Kocherlakota, 2014)

Treatment plans are heavily influenced by scores collected via the Neonatal Abstinence Syndrome Scoring System (click here). Based on a treatment plan like the one in Figure 2, using a standardized scoring system, a score of  ≥8 three time in a row, or 1 score of ≥12 triggers medication administration. At each reassessment of the neonate, medication dosing may increase or decrease based on the withdrawal symptoms shown by the infant. 

Figure 2. NAS Treatment Plan (Kocherlakota, 2014)
Click to enlarge

The ultimate goal of both pharmacological and non-pharmacological treatments is to reduce suffering and improve the infant's growth and entrance into their new life. It is essential to understand that each case is highly variable based on the addicting drug, the length and severity of addiction, the symptoms shown by the infant, and more. Advances are frequently followed by set-backs, and successful weaning could take weeks to months. Despite these giant hurdles, hope for recovery is found in the caring arms of nurses and physicians who are dedicated to providing relief from this challenging start to life (Hudak et al, 2012). 

References

Hudak, M., Tan, R., The Committee on Drugs, & The Committee on Fetus and Newborn. (2012) Neonatal drug withdrawal. Pediatrics, 129(2), 540-560. doi: 10.1542/peds.2011-3212.

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2), 547-561. doi: 10.1542/peds.2013-3524. 

Symptoms of Neonatal Abstinence Syndrome

Signs and symptoms of Neonatal Abstinence Syndrome (NAS) usually begin anywhere within 24 hours to 7 days after birth depending on what substance was used by the mother.

The Neonatal Abstinence Syndrome Scoring System (click here) lists signs and symptoms that are monitored to score the severity of NAS. The percentage of infants that experience specific symptoms is poorly reported as research on this condition has only recently received focused attention. However, more severe symptoms have been more closely monitored and it is reported that 2-11% of infants with NAS experiencing seizures and over 30% experiencing ECG abnormalities.While individual infant responses to NAS may vary on the type(s) of drugs used by the mother, some of the most common include tremors, irritability (difficulty being comfortable), excessive crying, high pitched crying, sleep problems, vomiting, diarrhea and poor feeding (Hudak, Tan, The Committee on Drugs, & The Committee on Fetus and Newborn, 2012). Below are video examples of some of these common symptoms.

Tremors - these are sometimes mistaken as shivering, but notice the infants often pull their hands to their mouths while their legs show a kicking action.

Cry- While all babies cry, the NAS cry is very distinct because it is usually high-pitched and often occurs even when the babies are being consoled by swaddling, feeding, or holding. 

Overall, these symptoms show that infants experiencing NAS suffer greatly during their withdrawal. The majority of these symptoms can have dangerous effects on the infant. Decreased sleep, ineffective feeding, seizures, fever, abnormal respiratory rate, vomiting and diarrhea all can have severe negative outcomes for the infant as they begin the first few days of their new life. As was mentioned in earlier posts, most infants diagnosed with NAS end up staying in the NICU during recovery, and their length of stay is on average longer than infants who stay in the NICU for other reasons (Tolia, Patrick, Bennett, Murthy, Sousa, Smith, Clark, & Spitzer, 2015). Supervised recovery under the care of medial professionals is the only safe way to help an infant through these dangerous symptoms. Next week's blog will go into more detail on what NAS recovery looks like.

References

Hudak, M., Tan, R., The Committee on Drugs, & The Committee on Fetus and Newborn. (2012) Neonatal drug withdrawal. Pediatrics, 129(2), 540-560. doi: 10.1542/peds.2011-3212

Tolia, V., Patrick, S., Bennett, M., Murthy, K., Sousa, J., Smith, B., Clark, R., & Spitzer, A. (2015). Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. The New England Journal of Medicine, 372(22), 2118-2126.

Diagnosing Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome is identified and diagnosed through the use of several tools including clinical presentation scoring, maternal history, and toxicology screening of tissue samples.

Figure 1. Neonatal Abstinence Scoring System.

Clinical Presentation
After birth during the first few hours/days of life, a newborn is frequently assessed by nurses, pediatricians and other medical professionals. While there are many expected behaviors from newborns such as crying, fussing, acting hungry, etc. there are some behaviors that are abnormal and may mean there is a problem. Signs and symptoms of NAS will be further discussed in another blog post, but a scoring system (Figure 1) is used to standardize documentation of

concerning behaviors that may indicate NAS (Hudak, Tan, The Committee on Drugs, & The Committee on Fetus and Newborn, 2012).

Maternal History
Questions and information about drug use history is part of almost every single hospital admission assessment. Questions about current drug use, past drug use, and drug use by partners, family, and friends are all included in an intake assessment of the mother. However, drug use is frequently under-reported so clinicians also take into account a history of unexplained term fetal demise, severe mood swing, and inconsistency in prenatal care. Additionally, toxicology screenings are done if there is suspicion of drug use based on clinical presentation or history (Hudak, et al, 2012).

Figure 2. Urine Drug Screening 

Toxicology Screenings
There has been a movement to increase the analysis of the baby’s meconium (first bowel movement) to screen for drug substances. This method of screening provides a more longitudinal look at what kinds of substances might have been used even showing substances that were used as early as the second trimester. Baby and mother urine drug screenings are extremely popular but they usually only detect substances used within the last 24-72 hours. Additional samples can be taken from maternal hair, neonatal hair, and even umbilical tissue. These are less popular because of the relatively new technology required to perform and process the screening (Murphy-Oikonen, Montelpare, Southon, Bertoldo, & Persichino, 2010).

There are many factors that contribute to the diagnosis of NAS, and medical professionals are extremely careful to use a range of objective and subjective data to confirm this diagnosis. 

References

Hudak, M., Tan, R., The Committee on Drugs, & The Committee on Fetus and Newborn. (2012) Neonatal drug withdrawal. Pediatrics, 129(2), 540-560. doi: 10.1542/peds.2011-3212

Murphy-Oikonen, J., Montelpare, W., Southon, S., Bertoldo, L., Persichino, N. (2010). Identifying infants at risk for neonatal abstinence syndrome: A retrospective cohort comparison study of 3 screening approaches. Journal of Perinatal & Neonatal Nursing, 24(4), 366-372. doi: 10.1097/JPN.0b013e3181fa13ea

Figure 1 retrieved from http://img.medscape.com/pi/emed/ckb/pediatrics_cardiac/973235-978492-156.jpg 

Figure 2 retrieved from https://www.premierintegrity.com/Images/Protocols_445.jpg