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.

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.

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