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

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

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