Caring for Substance Exposed Infants It Takes a

Caring for Substance Exposed Infants: It Takes a Village Nancy Forsyth MSN RN NNP Beebe Healthcare August 2017 nforsyth@beebehealthcare. org

Objectives • Definitions: • Opioid • Substance Use Disorder • Substance Exposed Infant (SEI) • Neonatal Abstinence Syndrome (NAS) • • • Incidence and pattern of illicit drug use in the US Drugs that cause withdrawal in the neonate What does NAS look like? Nursing and hospital care Long term effects of drug exposure

Definitions • Opioid: Drug that acts on receptors in brain to cause morphine-like effects, which include pain relief and euphoria. • Substance use disorder (SUD): SUDs occur when the recurrent use of alcohol or other drugs (or both) causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. • Substance exposed infant (SEI): An infant less than one year of age born with or affected by intrauterine substance exposure or withdrawal symptoms or with Fetal Alcohol Spectrum Disorder.

Neonatal Abstinence Syndrome (NAS) • Signs of withdrawal resulting from abrupt discontinuation of opioids after extended intrauterine exposure • Prescription or non-prescription drugs • Opioid drugs include: • Prescription medications: oxycodone, Percocet, Vicodin, morphine, fentanyl • Illicit drugs: heroin, fentanyl, designer drugs • Treatment drugs: methadone, buprenorphine (Subutex, Suboxone) (Hudak & Tan, 2012; Johnson, 2012)

Scope of the problem: Illicit drug use

Scope of the problem: Overdose • Opioids were involved in 33, 091 deaths in 2015 • Opioid overdoses have quadrupled since 1999. • Nearly half of all U. S. opioid overdose deaths involve a prescription opioid. 1 In 2015, more than 15, 000 people died from overdoses involving prescription opioids. • Heroin-related overdose deaths have more than quadrupled since 2010, and increased 20. 6% from 2014 -2015. • 13, 000 people died of heroin overdose in 2015.

5 -fold increase in NAS since 2000 >21, 000 infants in 2012 Opioid use in pregnant women tripled from 2000 to 2009 50 -94% of exposed infants develop NAS FL and TN had 10 -fold increase in this time http: //www. drugabuse. gov/related-topics/trends-statistics/infographics/maternal-opiate-use-newborns-suffering-opiate-withdrawal-are-rise-in-us

(http: //drugline. org/ail/pathography/708/)

NAS: A multi-system disorder Neurological Gastrointestinal Autonomic • Irritability • Poor sleep • High-pitched cry • Tremors • Increased muscle tone • Frequent yawning • Frequent sneezing • Seizures • Vomiting • Diarrhea • Dehydration • Poor weight gain • Poor feeding • Sweating • Nasal stuffiness • Fast breathing • Fever • Mottling Other • Skin excoriation • Increased risk of SIDS • Impaired bonding

Withdrawal from opioid drugs Drug Onset Duration Heroin 24 – 48 hours May be delayed 5 – 7 days 1 – 2 weeks Methadone 2 – 7 days May be delayed 5 – 7 days Weeks to months Buprenorphine 40 – 70 hours Weeks to months. LOS may be shorter than with methadone. Other opioids 48 – 72 hours Weeks to months

Methadone Benefits of methadone treatment • Maintains opioid concentration and prevents cravings • No euphoria • Counseling and monitoring for illicit drug use • Better nutrition and weight gain • More likely to have prenatal care • Less likely to have a preterm or LBW infant • Stable and predictable environment • Pregnant women on methadone are doing the best they can do for their unborn baby

Nursing management: Assessment

Care at Beebe • Mother/baby room in whenever possible • Maintain low stimulation environment • Teach parents to console their infants • Read to baby • Encourage breastfeeding if no illicit drug use • Skin care • Practice Safe Sleep • Oral morphine for severe withdrawal

Discharging home • Infant stable off medication and gaining weight • Evaluation for safe home environment • Pediatrician appointment scheduled • Home visiting: Smart Start Program, Parents as Teachers, home health nurse

Nurses’ concerns about discharge “When you see what these babies go through, there is no way they cannot be affected in some way. There is just no way. The pain…like, oh God, the pain. If you ever saw that…” “These are kids that are going to have problems with attachment…Are they prone to addiction too, later on down the road? ” “I was just afraid he was going to be screaming in the middle of the night and she was just going to drop him, throw him at a wall, you know, that’s what I thought. . . ” “[I told her] This baby is going to cry and you’re not going to be able to stop him…You need to promise me right now that when that baby does that, you will put him in his crib, put the side rail up on the crib, and walk out of the room. I don’t want to read in the newspaper that you dropped him, that you threw him, that you drowned him, that you hurt him. ”

Fetal effects Teratogenic Altered brain development and organization Altered growth Altered placental blood flow Altered maternal behaviors: nutrition, healthcare, violence, mental illness Developmental outcomes Growth Behavior Cognition Language Motor Achievement Drug use? Neonatal effects Teratogenic Growth Withdrawal Drug toxicity Neurobehavioral Nutrition Social factors Impaired bonding Impaired parenting Altered family environment Unstable home *

Long term outcome • Lower scores on developmental assessments • Higher rate of foster home placement • Children lost to follow-up • Increased risk of substance abuse? • However, infants in a stable home environment will have developmental assessments comparable to non-drug-exposed peers (Hunt, Tzioumi, Collins, Jeffery, 2008)

Caring for drug-addicted patients • “Addiction is the one disease that you are criminalized for having. ” • It’s a disease with no ongoing relationship with a health care provider. • Drug addiction is multifactorial • Physical and/or emotional trauma • Self-medication with drugs or alcohol • Addiction is a primary disease requiring specialized treatment to achieve recovery. • The threat of criminal prosecution prevents many women from seeking prenatal care and treatment for substance abuse. (Catlin, 2012; Marcellus, 2012)

It takes a village • • Treatment programs Improving maternal nutrition Case management to access services Build parenting skills Strengthen supportive social networks Reading Early intervention

References • Academy of Breastfeeding Medicine Protocol Committee (2009). ABM clinical protocol #21: guidelines for breastfeeding and the drug-dependent woman. Breastfeeding Medicine, 4 (4), 225 -228. • American Academy of Pediatrics Section on Breastfeeding (2012). Breastfeeding and the use of human milk. Pediatrics, 129, e 827. • American Nurses Association. Non-punitive alcohol and drug treatment for pregnant and breastfeeding women and their exposed children. http: //www. nursingworld. org. Published 2011. Accessed November 8, 2012. • Bio LL, Siu A, Poon CY (2011). Update on the pharmacologic management of neonatal abstinence syndrome. Journal of Perinatology. Doi: 10. 1038/jp. 2011. 116 • Catlin, A. (2012). Call for improved care for the substance-positive mother. Advances in Neonatal Care, 12, (5), 286 -291 • CDC and the Substance Abuse and Mental Health Services Administration. (2011). Vital signs: Overdoses of prescription opioid pain relievers—United States, 19992008. Morbidity and Mortality Weekly Report, 60, (43), Nov 4, 2011 • CDC (2016). Drug Overdose Data. https: //www. cdc. gov/drugoverdose/data/statedeaths. html • D’Apolito, K. & Finnegan, L. (2010). Assessing Signs and Symptoms of Neonatal Abstinence Using the Finnegan Scoring Tool: An Inter-Observer Reliability Program (2 nd ed. ). Neo. Advances, LLC.

References • Hanna, D. R. (2005). The lived experience of moral distress: Nurses who assisted with elective abortions. Research and Theory for Nursing Practice: An International Journal, 19 (1), 95 -124. [Cited by Johnson, T. , 2012] • Hudak ML & Tan RC. American Academy of Pediatrics Committee on Drugs & Committee on Fetus and Newborn (2012). Neonatal drug withdrawal clinical report. Pediatrics. Doi: 10, 1542/peds 2011 -3212 • Hunt, R. W. , Tzioumi, D. , Collins, E. , Jeffery, H. E. (2008). Adverse neurological outcome of infants exposed to opiate in-utero. Early Human Development, 84 (1), 29 -35. • Johnson, T. (2012). Double jeopardy: intrauterine substance exposure impact on mothers and babies. Presented at the Thruway Conference for Advanced Practice Nursing, May 16, 2012, Syracuse, New York. • Jones, HE, Johnson, RE, Jasinski, DR, O’Grady, KE, Chisholm, CA, Choo, RE, Crocetti, M, Dudas, R, Harrow, C, Huestis, MA, Jansson, LM, Lantz, M, Lester, BM, Milio, L (2005). Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: Effects on the neonatal abstinence syndrome. Drug and Alcohol Dependence, 79, 1 -10.

References • Kaltenbach, K. (2013). Lessons from the MOTHER study: Methadone vs. buprenorphine and beyond. Presented at VON Collaborative Controversies in the Care of Infants and Families Affected by Neonatal Abstinence Syndrome. Newark, DE 3/6/13. • Maguire, D, Webb, M, Passmore, D, Cline, G. (2012). NICU nurses’ lived experience: Caring for infants with neonatal abstinence syndrome. Advances in Neonatal Care, 12, (5), 281 -285. • Marcellus, L. (2013). Principles of trauma-informed care: Considerations for the NICU context. Presented at VON Collaborative Controversies in the Care of Infants and Families Affected by Neonatal Abstinence Syndrome. Newark, DE 3/6/13. • National Institutes of Health, National Institute on Drug Abuse (2012). http: //www. drugabuse. gov/related-topics/trends-statistics/infographics/maternalopiate-use-newborns-suffering-opiate-withdrawal-are-rise-in-us. Accessed 2/11/13. • Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. U. S. Department of Health and Human Services, Substance Abuse and Mental Services Administration, Center for Behavioral Health Statistics and Quality. http: //oas. samhsa. gov/NSDUH/2 k 10 Results. pdf. Accessed November 8, 2012 • Results from the 2014 National Survey on Drug Use and Health: Summary of National Findings. U. S. Department of Health and Human Services, Substance Abuse and Mental Services Administration, Center for Behavioral Health Statistics and Quality. https: //www. samhsa. gov/data/sites/default/files/NSDUHFRR 1 -2014/NSDUH-FRR 1 -2014. pdf.