Neonatal Abstinence Syndrome
Background of Neonatal Abstinence Syndrome
As the drug addiction epidemic is on the rise in the United States so is incidence of Neonatal Abstinence Syndrome (Johnson, 2017). NAS is better known by the public as an infant who is dealing with withdraw symptoms due to no longer being exposed to drugs outside of the uterus. From 2009 to 2013, in those four years alone, NAS infants nearly doubled from 3.4 per 1000 births to 5.8 per 1000 births, though more recent studies show that it has seen rose by nearly 400% with some states giving data of 30 per 1000 births (Radziewicz, Wright-Esber, Zupancic. Gargiulo, & Woodall 2018). Though not every fetus exposed to substances will be diagnosed with NAS, but every fetus exposed is at risk.
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Neonatal Abstinence Syndrome is due to maternal use of substances during pregnancy. While many people believe that this might just be illicit drugs this is not true. NAS can occur when any drug including prescribed medication transfers from the mother to the fetus via the placenta. The most common causes of NAS would be exposure to opioids, cocaine, barbiturates, benzodiazepines, Selective Secretion Reuptake Inhibitors (SSRIs), and alcohol (MacMullen, Dulski, & Blobaum, 2014) (McQueen, Murphy-Oikonen, & Desaulniers, 2015). Any drug that can pass from the mother’s blood through the placenta to the fetus can cause withdrawal symptoms, though it will depend greatly on the amount of use, the last time of use, and the actual drug of choice. The reason the infant with go through withdrawal is due to the fact that birth occurs, and the infant is no longer exposed to the drug.
Withdrawal symptoms tend to take place anywhere from 1-7 days post-delivery. Most infants, especially those who are withdrawing from opioids will start to show signs and symptoms roughly 1-3 days after delivery (Radziewicz, Wright-Esber, Zupancic. Gargiulo, & Woodall 2018). The reason for this time difference will be due to the half-life of the drugs being used. The reason the sign and symptoms will vary is also due to the specific drugs used and how it affects the body’s different systems. According to Clark & Rohan, 2015, NAS is a multisystem disorder, it will likely affect different systems throughout the body and each system will present signs and systems different. The signs and symptoms that an infant may show will vary greatly depending on which drug the child is no longer receiving. Though most common symptoms the infant will experience tend to be affected by the central nervous system, the gastrointestinal system, respiratory system, and autonomic nervous system. CNS symptoms would include things such as seizures, irritability, high-pitched or excessive crying, and inability to regulate their temperature. Gastrointestinal system symptoms will include diarrhea, vomiting, excessive sucking, and poor feeding. Respiratory symptoms include tachypnea and respiratory distress. Whereas autonomic nervous system symptoms will include hyperactivity, increased muscle tone, and sleep issues (MacMullen, Dulski, & Blobaum, 2014).
Diagnosis of Neonatal Abstinence Syndrome1
Neonatal Abstinence Syndrome is diagnosed by a few different factors. An important factor of diagnosis is a maternal drug test and a full history from the mother. The mother will be able to tell when the last usage was, how much was used, what drugs specifically were taken (McQueen, Murphy-Oikonen, & Dsaulniers, 2015). This gives a better outlook on what to expect. The mother may not be forth coming with such information. When there is suspicion of drug exposure to a fetus, once delivery takes place if a urine drug screen is to be done on the infant. Meconium can also be tested for drugs and may help disclose which drugs were used during pregnancy. Though it is also important to run other bloodwork to rule out any possible central nervous system disorders. Blood tests that should be ran are CBC, blood glucose, electrolyte panel, TSH, thyroxine, and triiodothyronine (Henry, McMichael, Johnson, DiStrasi, Roland, Wilford, & Barlow, page 184, 2016)
When looking at the results from the drug testing on the infant, it is possible to predict which signs and symptoms the infant may exhibit. The mother’s willingness to be upfront about her drug usage, as well as the drug testing, may also help predict when withdrawal may start occurring in the infant. Each drug class tends to have certain withdrawal symptoms that an infant may present with, though most do overlap. This compared with scoring tools will help give the infant the best possible care.
Any newborn that NAS is suspected should also be assessed with a Neonatal Abstinence Syndrome Scoring tool. The most commonly used scoring tool within the United States is the modified Finnegan score. Newborns should be assessed every few hours. The Finnegan scoring tool assesses the central nervous system, gastrointestinal system, respiratory system, and the autonomic systems. “There are 21 to 31 items on the scoring tool that have various scores available for each item. Scores are totaled every 3 to 4 hours. … An abnormal total score, indicated significant withdrawal, is 8 or greater” (Radziewicz, Wright-Esber, Zupancic, Gargiulo, & Woodall, 2018). This score will help determine if a newborn is at need for nonpharmacological, pharmacological, or a combination treatment.
Treatment of Neonatal Abstinence Syndrome. There are different options for treatment of a newborn suffering from NAS. They can be treated in nonpharmacological ways which include things such as swaddling, breastfeeding, skin to skin, and placing the child in an environmental area with minimal stimulation and distraction. When possible placing the newborn in room with mother will also help the infant improve symptoms. Pharmacological interventions are used when nonpharmacological interventions are responding in the manner in which is in favor of the infant. These interventions are also used when an infant is suffering from moderate-to-severe signs and to prevent further complications (Clark & Rohan, 2015). The pharmacological interventions will depend on the drug in which the newborn was exposed to in utero. Medications for opioid exposure would include morphine or methadone as first choice. Second line drugs, such as Phenobarbital, are used when the infant has been exposed to other drugs along with opioids, such as benzodiazepines (Maguire, 2014).
Nursing Care Plan for Neonatal Abstinence Syndrome. When caring for an infant in distress due to NAS there are a few key problems that should be of concern. Respiratory issues are an issue that could take a turn at any point during treatment. It is important to monitor the infants respiratory rate and rhythm, lung sounds, pulse ox, and overall use of accessory muscles. Infants diagnosed with NAS due to the mother’s use of SSRI’s can suffer from respiratory distress (MacMullen, Dulski, and Blohaum, 2014). These newborns may require oxygen if their saturation levels drop, yet some infants my require more help, such as a c-pap or even a ventilator if they are unable to breath on their own, though these interventions will require a doctor’s order. The other common problem that NAS infants will suffer from is a problem with comfort. These infants struggle with tremors, hyperirritability, and impaired sleep. Nonpharmacological interventions such as swaddling can help maintain regulation and also help the infant tolerate stimulation (Clark & Rohan, 2015). Reducing environmental stimuli, such as low lighting and noise control, can help promote comfort and a decrease in sleep disturbances (Maguire, 2014). Another way to promote comfort, is to encourage breastfeeding. Breastfeeding in situations where it is not contraindicated, when the mother is on maintance medications and does not have ongoing illicit drug use, HIV, or on antiretroviral medications, will provide comfort and also improve the bonding and attachment between the mother and the infant and will in turn provide the infant with a better outcome (Clark & Rohan, 2015). The other important problem that these infants may suffer from is impaired nutrition. According to Maternal-Child page 731, the poor suck and swallow coordination of NAS infants can interfer with their caloric intake, yet due to their excessive activity they burn more calories. It is suggested that infants be swaddled during feedings to prevent excessive movement. This may help them with their coordination (Maternal-Child, page 731). More frequent feedings is also indicated to help the infant achieve a higher caloric intake that is needed (Maternal-Child, page 731). Most importantly encouraging breastfeeding for these infants, breastfeeding will help procide optimal nutrition for eac h individual infant (MacMullen, Dulski, and Blobaum, 2014).
Radziewicz, R. M., Wright-Esber, S., Zupancic, J., Gargiulo, D., & Woodall, P. (2018). Safety of Reiki Therapy for Newborns at Risk for Neonatal Abstinence Syndrome. Holistic Nursing Practice, 32(2), -.
Identifying and Assessing the Substance-Exposed Infant. (2015). MCN, The American Journal of Maternal/Child Nursing, 40(2), E7-E8.
McQueen, K., Murphy-Oikonen, A., & Desaulniers, J. (2015). Maternal Substance Use and Neonatal Abstinence Syndrome: A Descriptive Study. Maternal and Child Health Journal, 19(8), 1756-1765.
Care of the Infant with Neonatal Abstinence Syndrome: Strength of the Evidence. (2014). The Journal of Perinatal & Neonatal Nursing, 28(3), E3-E4.
Johnson, B. (2017). Neonatal abstinence syndrome. Pediatric Nursing, 43(4), 206-207.
MacMullen, Nancy J., Dulski, Laura A., & Blobaum, Paul. (2014). Evidence-based interventions for neonatal abstinence syndrome. Pediatric Nursing, 40(4), 165-172,203.
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