Nurturing Neonatal Abstinence Syndrome

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Nurturing Neonatal Abstinence Syndrome

• Lynn Newton, R.N., BScN, MEd(s)
• RNAO Fellowship
• Clinical Educator NICU
• Kingston General Hospital

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Acknowledgments

• RNAO fellowship mentors Susan Jewell RN, MSc
  Carol Lynch RN, NP (EC)
• Street Health, Kingston, Ontario
• St-Michaels Hospital, Toronto, Ontario
• PRIMA-PSUP project, University of Toronto,
  Toronto, Ontario
• Neonatal Abstinence Syndrome working group, KGH
• Neonatal Joint practice committee, KGH
• Pediatric Joint practice committee, KGH

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Objectives

• Substance abuse in pregnancy
• Definition of Methadone
• Methadone in the community
• Women, pregnancy and Methadone
• Neonatal Abstinence Syndrome (NAS)
• Care of the infant with NAS
• Transition back to community

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Substance abuse in pregnancy

• Eighty-five percent of women that are substance
  abusers have mental health issues (CAMH, 2005)
• Eighty to ninety percent of these women have been
  abused as a child (CAMH, 2005)
• Methadone Maintenance Treatment (MMT) is based on
  a Harm Reduction model
• Helps develop a sense of hope
• We (society) did not look after this client
  population as children, it is our responsibility
  to care for them as adults Counselor from Street
  Health, Kingston

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Methadone

• Synthetically produced opioid
• Taken orally may also be called the juice
• Long lasting-used daily
• At a stable dose does not produce euphoria
  and allows a normal life
• Daily dispensing at local clinics
• Responsible may be eligible for carries-
• able to take a few doses home with them
• (in a locked box)

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Methadone
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How does methadone work?

• Replacement of other opioids
• Prevents withdrawal symptoms
• Reduces the effects of other opioids
• Goal is functionality!

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Assessment

• Comprehensive assessment completed at the clinics
  (including blood work)
• Some clinics have a wait time of 6 months to
  initiate treatment
• Pregnant women are able to initiate the program
  with 1 or 2 days
• All clients starting on this program have to
  sign a compliance form

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Women and methadone

• Methadone treatment of choice for opioid
  dependent pregnant women
• Methadone avoids peaks and troughs in blood
  levels
• Avoidance of exposure to contaminants including
  those that would be teratogenic/as well as blood
  born pathogens (Hep C)
• An opportunity to provide adequate prenatal care
  and primary care

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Pregnant women methadone

• Increased likelihood of having a term baby
• Fewer birth complications ( IUGR, premature
  delivery)
• Opportunities for medical care of infections such
  as HIV, Hep. B and C, TB and STDs
• Opportunities for management of high risk
  pregnancyyet not always deemed as high-risk

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Methadone doses in pregnancy

• Detoxification from methadone therapy during
  pregnancy is not recommended
• Healthier for mom to be on a consistent dosing
  rather than fluctuation of illicit drugs
• There is no compelling evidence to reduce
  maternal methadone dose in order to avoid
  neonatal abstinence syndrome (withdrawal)

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Care of mother post-delivery

• Mother is cared for as if she had a
  normal/uncomplicated pregnancy
• Labour may require more narcotics than the
  average women use of epidural preferable
• Breastfeeding is encouraged as appropriate
• Mother-baby contact, as appropriate
• Mothers dose of Methadone should be available
  daily while in hospital
• Narcan is contraindicated for the neonate in
  suspected/know opioid use _at_ delivery

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Case scenario

• 37 week gestation infant
• SVD
• No delivery complications
• Mat hx Mom on Methadone program at local clinic
• What is the potential diagnosis of this infant?

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Neonatal Abstinence Syndrome
(drug withdrawal)

• Up to 85 of neonates will exhibit NAS born to
  women on Methadone
• Neonatal withdrawal occurs in 4060 of infants
  born to women on opioids such as heroin
• The presentation of withdrawal depends on the
  timing of the mothers last dose of opioid before
  delivery
• Neonatal withdrawal can result in seizures and
  neonatal death if untreated

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Signs and symptoms of NAS

• There is no evidence of any long-term sequelae
• poor literature evidence to date
• not clear of the possible developmental delayis
  it related to the Methadone or is it the
  environment that they live in?

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Signs and symptoms of NAS

• Irritability, high-pitched cry
• Increased tone, tremors
• Poor feeding, vomiting, weight loss Sweating,
  hyperthermia, mottled skin
• Metabolic disturbances (hypoglycemia)

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Neonatal abstinence syndrome

• 2-14 days until the infant will exhibit signs of
  withdrawal (Methadone)
• Initial assessment includes
• Complete physical assessment
• Assess serology status (Hep. B or C)
• Drug screening- urine, meconium or hair
• Mat hx mothers taking street drugs, CAS,
  intoxication, ve hx of use of alcohol and drugs
• (T-ACE questionnaire)

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Management of infants at risk for NAS

• Admit all newborns at risk for or with diagnosed
  neonatal abstinence syndrome to the neonatal
  intensive care unit (NICU).
• In the event that a newborn is discharged home
  and neonatal abstinence syndrome is not
  identified until re-admission, these patients
  will be admitted to the pediatric unit.
• Monitor for signs of withdrawal, using Neonatal
  Abstinence Syndrome Score.
• Initiate scoring within 2 hrs of admission to the
  NICU or pediatric unit.
• Continue scoring every four hours up to five
  days, or as long as morphine treatment and
  weaning is necessary.

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Neonatal care in NICU

• Non- pharmacological
• Quiet envt-keep baby in incubator until a stable
  dose is established-then transfer to crib
• Swaddle
• Reduce noise and light
• Encourage breast-feeding (pump/BF 2-4hrs post
  methadone dosing)
• Dev. Care!!
• Consider primary care nursing
• Encourage mother-baby bonding

• Pharmacological
• Initiate oral Morphine if you have
• 2 consecutive scores of 12 and/or
• 3 consecutive scores of 8.

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Breastfeeding

• Women should be encouraged to breastfeed, if they
  desire to.
• Breast feeding should be consistent and have
  minimal interruptions.
• A collaborative plan should be in initiated and
  documented in order to aid in the success of
  breastfeeding and decrease the side effects of
  withdrawal.

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Parent education sheet
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Documentation

• Finnegan score
• Sequence- Finnegan score independent of dosing
• Do not wake the infant to score
• Score objectively after feed, diaper change,
  right before baby falls back asleep
• Do not dismiss Sepsis, hypoglycemia,
  hypocalcemia and/or IVH

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Preterm-fed q3h Sleeping score 1 if sleepslt2hrs
2 if sleepslt1hr
3 if does not sleep Gavage
feeding is not a 'poor feeder'
Scoring tips
Term baby-fed q4h Scoring 1/2-1hr after being fed
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Example schedule (scoring q4h)
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Neonatal Abstinence Syndrome Score
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• Administration of Morphine
• Morphine is not intended to be on a sliding
  scale
• When an average score of 8 for 3 consecutive
  readings is reached the oral morphine should be
  initiated within 2 - 4 hours.
• If score 12 for two consecutive intervals, or
  average of any two scores is 12, start treatment
  within 2- 4 hours.

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Morphine dosing
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Weaning of Morphine

• The neonate should continue on the dose of
  morphine required to keep the scores lt8 for 24
  48 hours before weaning commences
• Weaning is usually done by decreasing the dose by
  0.05 mg/kg per total daily dose, every 2 4
  days.
• Discontinuation of morphine can occur when the
  neonate is stable for 2 4 days on a dose of
  0.05 0.1 mg/kg/day.
• The duration of the weaning process can be as
  long as usually 4 8 weeks

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Neonatal care on Pediatrics

• Infants should be in private room near the
  nurses station
• Finnegan scoring will occur q4h unless otherwise
  indicated
• Infants/families will NOT have passes during the
  weaning process
• Parent(s) Methadone is/are not permitted on the
  pediatric unit.
• Neonatal Abstinence Syndrome scoring should occur
  3 days post discontinuation of Morphine

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Discharge education

• ADMISSION/DISCHARGE EDUCATION
• NICU Routines
• NICU Visiting Policy
• NICU Parent information sheet
• Educational Booklets 
• Directed Donation Pamphlet
• Blood Transfusion Consent Completed
• Retinopathy of Prematurity Eye Exam Consent
  Completed
• NICU Discharge Status form completed
• Community resource document (COPC, CDC, Health
  Unit)

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Care in the community

• Provide parents/guardian with the discharge
  education form
• Includes community contacts
• Emergency contacts
• Admission discharge checklist
• Community resources

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Street Health-Kingston

• Street Health Centre counselors are able to work
  with people on a variety of issues, including
• basic needs, referrals, life skills, support and
  personalized counseling on issues related to drug
  use, addictions, sexual health, mental health,
  practical needs.
• Staff from addictions and mental health agencies
  also work out of our clinic on a weekly basis and
  are available to work with clients of the Street
  Health Centre.
• Methadone maintenance is the standard of care for
  people living with opioid dependence. Our
  methadone clinic combines doctors, nurses,
  counselors and on-site medications
  administration. People using illicit opioids such
  as morphine, heroin, Dilaudid or Oxycontin have
  very high rates of morbidity and mortality.
  Methadone is a form of oral substitution
  treatment providing a safe, legal maintenance
  routine which, when combined with counseling and
  other medical care, dramatically improves health
  status and quality of life.

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Street Health

• Better Beginnings for Kingston Children offers
  programs and supports for families with children
  from 0-5 years living in north Kingston. Programs
  include prenatal education and support, home
  visiting, parent-child support groups, parenting
  programs, and school readiness programs.All of
  the services are free assistance with
  transportation and childcare are provided when
  needed.
• http//www.kchc.ca/betterbeginnings/index.html

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References

• http//www.camh.net/About_Addiction_Mental_Health/
  Drug_and_Addiction_Information/methadone_therapy.h
  tml
• http//www.cpso.on.ca/publications/MethadoneGuideN
  ov05.pdf
• http//www.childhealthnetwork.com/chn/pdfs/Guideli
  nes2020Transfer20Protocols20-20Management20
  of20Perinatal20Substance20Use20and20Abuse20-
  20June202002.pdf
• http//www.bcwomens.ca/Services/PregnancyBirthNewb
  orns/HospitalCare/SubstanceUsePregnancy.htm

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Thank you
newtonl_at_kgh.kari.net