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.

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

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

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