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.

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"

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.

Disease Process of Neonatal Abstinence Syndrome

The exact cause of Neonatal Abstinence Syndrome is the sudden discontinuation of infant exposure of to substances that were used by mothers during pregnancy. The most common substance that causes NAS is opioids such as heroin, codeine, oxycodone, methadone, or buprenorphine. Birth initiates the cessation from whatever substance is being used by the mother and allows the onset of a dangerous withdrawal period.

Figure 1. Transfer of opioids across the placenta 

(Neonatal Abstinence Syndrome, 2010).

The pathophysiology of NAS is not completely understood, but it definitely involves multiple body systems and could have still unknown effects on the long-term health and quality of life of the infant. The drug substance makes its entry into the bloodstream of the newborn via the placenta (Figure 1). Opiates are water soluble, low molecular weight substances that can easily cross this otherwise protective barrier between the bloodstream of the mother and fetus. As the fetus grows and demands more nutrients from mom, this transfer of opioids increases.

Figure 2. Mechanism of opioid withdrawal in neonates (Kocherlakota, 2014)

All opioids act primarily on opioid receptors in the central nervous system, peripheral nervous system, and the gastrointestinal system among others. As the substance abuse continues throughout birth, the fetus's body becomes accustomed to this receptor stimulation. When the stimulation of these opioid receptors is abruptly stopped by birth, a chain reaction is triggered in the newborn body. 

The absence of opioids triggers the production of norepinepherine, acetylcholine and corticotrophin. Additionally, the production of dopamine decreases during this withdrawal period. The ability of the autonomic and peripheral nervous systems and the gastrointestinal system to work properly is also affected after extended exposure to the opioids. See a complete diagram explaining the cascade to the left (Figure 2). Next week's blog will discuss how these different neurotransmitter and hormone changes cause dangerous responses in the newborn. 

References

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

Neonatal Abstinence Syndrome. (2010). Retrieved from http://images.walgreens.com/marketing/library/contents.jsp?docid=19888&doctype=2

Trends in Neonatal Abstinence Syndrome

The numbers are hard to ignore. The incidence of Neonatal Abstinence Syndrome (NAS) has persistently risen over the past decade and seems to be projected to continue to increase.

Figure 1. NICU admissions for Neonatal Abstinence Syndrome from 2004-2013

The biggest indicator of this trend is that Neonatal Intensive Care Unit (NICU) admissions attributed to NAS have increased from 7/1000 to 27/1000 NICU cases over 2009-2014 (Figure 1). Admission to the NICU indicates that the newborn is in need of advanced medical attention, close monitoring, or specialized nursing care (Stanford Children's Hospital). Unfortunately, this rate of increase is significantly steeper than the rate of increase from 2004-2008 (Figure 1). Additionally, from 2009 to 2014, the length of stay in a NICU facility because of NAS diagnosis increased from an average of 13 days to an average of 19 (Tolia, Patrick, Bennett, Murthy, Sousa, Smith, Clark, & Spitzer, 2015). On average, newborns who are born addicted are more likely to be admitted to the NICU than those who are not, and will spend significantly more time in the NICU than newborns who need intensive care for other conditions. This also has implications on the cost of the hospital stay which was an average of 19 times more expensive for newborns with NAS than those without in a 2012 study (Figure 2).

Figure 2. Infographic from the National Institutes of Health.

Studies have also shown that a shift has occurred in the distribution of NAS among various ethnic groups. Compared to a measurement in 2004-2005 when 64% of mothers were of white race, there has been a significant increase to 76% of mothers being of white race in a 2012-2014 sample. At the same time, proportions of mothers from black races and Hispanic ethnic groups have correspondingly decreased (Tolia, et al, 2015). 

Geographically, the highest incidence rates of NAS at 16.2 cases per 1000 hospital births occur in the East South Central Division including the states of Kentucky, Tennessee, Mississippi and Alabama. New England holds the second highest incidence rate in the US at 13.7 cases for every 1000 hospital births (Patrick, Davis, Lehmann, & Cooper, 2015). 

Together, these statistics show an alarming increase in the incidence of NAS and the need for more intensive treatments in newborns affected by NAS. Dramatic efforts must be made to decrease the incidence of this risky condition. 

References

National Institutes of Health. (2015). Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. Retrieved from www.drugabuse.gov.

Patrick, S., Davis, M., Lehmann, C., & Cooper, W. (2015). Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatology, 35(8), 650-655. doi:10.1038/jp.2015.36.

Stanford Children's Hospital. (2016). The Neonatal Intensive Care Unit (NICU). Retrieved from www.stanfordchildrens.org.

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.

Search terms: epidemiology, neonatal abstinence syndrome, neonate, withdrawal, opioid, incidence, geographic, NICU

Prenatal Drug Exposure and Neonatal Abstinence Syndrome

Although every newborn faces incredible changes at the moment of birth, those that experience Neonatal Abstinence Syndrome (NAS) are faced with an extra challenge. NAS is defined as “a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb” (MedlinePlus, 2014). Prenatal exposure to opiates, narcotics, and other drugs can create unwitting newborn addicts whose bodies have become physiologically dependent on their mother’s drug(s) of choice. For these newborns at the moment of birth, even as their heart takes sole responsibility for circulating blood, and their lungs learn to suck in air instead of amniotic fluid, their entire body is wracked by dangerous withdrawals.

Image retrieved from www.medscape.com/viewarticle/840696

Unfortunately the sad reality is that these newborns are facing the harsh consequences of actions well beyond their control. While information about the risks of drug use during pregnancy is easily accessible and commonly shared by healthcare providers, many mothers still use or abuse dangerous drugs during pregnancy (Bersani, Corsello, Mastandrea, Patacchiola, Voligno, Garofalo, & Dotta). Besides the physiological implications of NAS, there are also social and legal implications of drug use during pregnancy. Any physician who identifies NAS or other symptoms of drug exposure in a newborn is required by the 2003 Keeping Children and Families Safe Act to report the findings to their state Child Protective Services. Procedures and guidelines for responding to these reports vary from state to state. But as of 2006, 13 states and the District of Columbia identify prenatal drug exposure as a form of child abuse or neglect which can have implications on the mother's ability to keep her baby after birth (U.S. Department of Health and Human Services, 2009).

The impact of prenatal drug exposure ranges from physiological, to social, and beyond. Healthcare providers must understand the challenges faced by both the mother and the baby when NAS or other symptoms of drug exposure occur in a newborn. Physicians, nurses, midwives, and others involved in the birthing process must know how to intervene effectively and respond compassionately when babies are born addicted.

References

Bersani, I., Corsello, M., Mastandrea, M., Patacchiola, V., Foligno, S., Garofalo, V., & Dotta, A. (2013). Neonatal abstinence syndrome. Early Human Development 89(4) S85-S87.

MedlinePlus. U.S. National Library of Medicine. (2014). Neonatal abstinence syndrome. Retrieved from www.nlm.nih.gov/medlineplus/ency/article/007313.htm

U.S. Department of Health and Human Services. (2009). Protecting children in families affected by substance use disorders. Child Abuse and Neglect User Manuel Series. Retrieved from www.childwelfare.gov/pubPDFs/substanceuse.pdf#page=51&view=CHAPTER 6 The Role of Child Protective Services When Substance Use Disorders AreIdentified