Nursing Diagnosis

Interrupted breastfeeding r/t infant illness AEB infant diagnosis of Neonatal Abstinence Syndrome (Ackley, & Ladwig, 2014).
Breast feeding would be difficult with infants who are inconsolable, those infants who are going through withdrawal wont necessarily want to eat because of the pain. Education will be needed to assist the new mom on how to breast feed. It will assist in the baby's withdrawal because if the mother is still on narcotics some will come through the breast milk to assist in symptoms. It will be an important step forward to have appropriate breast feedings to assist the newborn bond with mom and build a trusting relationship.

Acute pain for infant r/t chemical injury agent AEB delivery from mother who is addicted to narcotics (Ackley, & Ladwig, 2014).
These infants will be suffering from pain from withdrawal. It is important to acknowledge what the infants are going through to assist in any way the medical staff can. Whether the intervention be medications, low stimuli environment or swaddling.

Maternal deficient knowledge r/t lack of interest in learning AEB addiction to narcotics while pregnant (Ackley, & Ladwig, 2014).
If the mother is addicted to narcotics it is highly probable that pre-natal health and education was neglected by the mother. Meaning education is needed to assist the mom in taking care of her infant and her own needs.

Maternal self neglect r/t substance abuse AEB continued use of substance that does harm (Ackley, & Ladwig, 2014).
Adding onto the diagnosis above, the mother might not know what to do for her infant or herself after delivery. Education is very important to set the infant and mom up for the best situation even if pregnancy was not planned. 

(Nurses NANDA, 2009)

 References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. Maryland Heights, MO: Elsevier. 

Nurses NANDA. (2009). Nurses Nanda. Retrieved March 28, 2016, from http://www.nursesnanda.com/2015/09/newborn-priority-nursing-diagnosis-and.html 

Support Groups

(Support Group, 2016)

It is important for mothers who are addicted to narcotics to know there is support that they can turn to for assistance through pregnancy and post delivery. It will depend on the mother on what type of support will work well for her and her infant with Neonatal Abstinence Syndrome (NAS).

After finding out a woman is pregnant and is also addicted to narcotics, it is important to learn about what all can be passed to their new growing infant. This website is full of information of frequently asked questions of pregnant women. There is also a feature to email and chat with experts about questions related to narcotics transferring to the fetus and then newborn through both the umbilical cord and breast milk (MotherToBaby, 2014).

http://mothertobaby.org

For mothers who want to work toward being narcotic free, but it may be too dangerous to detox while pregnant, there is a possibility of looking to methadone clinics. This allows the mother to get on a methadone regimen that is monitored by the methadone clinic in her area. This gives the mother peace of mind to know she will not be going through withdrawal. Along with medication monitoring, there is counseling individualized for the mother to work on herself so she can be prepared for her soon coming infant (Methadone.US, 2016)

http://www.methadone.us/counseling-and-addiction-recovery/

For mothers who need more assistance after delivering their infant, there are facilities that take both the mother and infant and assist the mother through detox and learning to become a mom. An example is Good Shepherd Rehabilitation, this is an inpatient facility that works with mothers who need more hands on care with medication management with an infant with NAS. The criteria are that the mother is medically stable and the infant can maintain appropriate body temperature in an open crib (Good Shepherd Rehabilitation Network, 2016).

http://www.goodshepherdrehab.org/neonatal-abstinence-syndrome-program

After becoming sober, the mothers can go to groups for support in continuing on their journey of staying clean. Mothers can go to Narcotics Anonymous (NA). These meetings focus on the disease of addiction, not just a specific drug of choice. This way the attendees address their addiction, not just a particular drug that he or she took for a limited about of time (NA World Services, Inc, 2016).

https://www.na.org/

References

Good Shepherd Rehabilitation Network. (2016). Neonatal Abstinence Syndrome Program. Retrieved March 14, 2016, from http://www.goodshepherdrehab.org/neonatal-abstinence-syndrome-program

Methadone.US. (2016). Counseling and Recovery, Addiction Recovery, Methadone.US. Retrieved March 14, 2016 from http://www.methadone.us/counseling-and-addiction-recovery/

MotherToBaby (2014). Home. Retrieved March 14, 2016, from http://mothertobaby.org

NA World Services, Inc. (2016). NA. Retrieved March 14, 2016 from https://www.na.org/

Support Group. (2016). Retrieved March 14, 2016, from https://www.google.com/search?q=supportgroup

Apps to Recommend to Patients

While there are no apps that focus on Neonatal Abstinence Syndrome (NAS), there are some with links that can assist pregnant women who are trying to make it through their pregnancy.

 

For moms who need to stay on their narcotics, like those who are on Methadone treatment, an app that is a pill monitor would be very helpful. These types of apps educate their users on the type of medications and have reminders to take medications. It is a type of list that communicates to the user to make sure and finish everything throughout the day (Pill Monitor – Medication Reminders and Logs on the App Store, 2015).

https://itunes.apple.com/us/app/pill-monitor-medication-reminders/id477666512?mt=8

For those who stop taking their narcotics, there is an app called Relax Now. This app assists in reducing stress and anxiety by being a sort of pocket hypnotherapy. For moms who are trying to stay off the narcotic of choice or cut down on use, their anxiety will be high with possible insomnia. Stress relief will be important (Connolly, 2011).
https://itunes.apple.com/us/app/relax-now-hd/id415130280?mt=8 

To assist with the pregnancy, it will be important for the mothers to keep track of what she eats. There are several apps that assist in keeping track of proper nutrients the mother needs. An example is Health Plus. This will assist the mother in keeping up her nutrition, especially if she is still taking the narcotics, to get the proper nutrients to the fetus (ABCOM Information, 2011).
https://itunes.apple.com/us/app/health-plus/id426336271?mt=12

Finally, to assist with life after the birth of their infant, an app that will assist is Baby Connect. This app allows the parents to keep track of the infants habits, learn about important behaviors of their infant and can assist in calming down the infant. This will assist the new parents to care for the infant and stay organized, as much as they possibly can, for a smooth transition (Baby Connect, 2016)
https://www.baby-connect.com/

References

ABCOM Information. (2011). Health Plus on the Mac App Store. Retrieved March 07, 2016, from https://itunes.apple.com/us/app/health-plus/id426336271?mt=12 

Baby Connect: Baby tracker and log for Android, iPhone, iPad, Windows Phone and for the web. (2016). Retrieved March 07, 2016, from https://www.baby-connect.com/ 

Connolly, T. (2011). Relax Now HD on the App Store. Retrieved March 07, 2016, from https://itunes.apple.com/us/app/relax-now-hd/id415130280?mt=8 

Pill Monitor – Medication Reminders and Logs on the App Store. (2015). Retrieved March 07, 2016, from https://itunes.apple.com/us/app/pill-monitor-medication-reminders/id477666512?mt=8  

Websites to Recommend

All information is at the fingertips of everyone with an internet connection. This allows the population to learn about different syndromes that are not talked about in normal conversation. An example of this is Neonatal Abstinence Syndrome (NAS). While more information needs to be done to look at long term effects of a child diagnosed with NAS, people can learn about what NAS is and what goes on in the infant. 

To learn about what NAS is and to learn the basics about the syndrome, visit the website below. Stanford Children's Health goes over the basics of what the syndrome is, how the infant is diagnosed and how the infant will be treated. To start learning about what NAS is, this is a great resource to learn the basics (Neonatal Abstinence Syndrome, 2016).
http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387

To learn about specific symptoms and treatment visit the website below. This website lists common signs and symptoms of NAS. Then it explains what tests can be done to diagnose NAS and what is done to treat those infants (Lee, 2014).
https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm

To learn about how the infants are scored based on their symptoms, visit the website below. This resource allows people who don't regularly take care of infants with NAS to learn and understand how infants are scored on severity of NAS and how pharmacological intervention is reviewed. (Withdrawal Scoring Sheet, 2016). 
http://newborns.stanford.edu/ScoringSheet.html

To learn about possible short and long term effects of a fetus exposed to drugs while in the womb visit the website below. This website goes more in depth on what effects specific drugs can have on infants. The long term effects need to be studied more, but with the prevalence of NAS increasing, the medical world will start to learn what happens to those children born with NAS (Behnke, & Smith, 2013).
http://pediatrics.aappublications.org/content/131/3/e1009

References

Behnke, M., & Smith, V. (2013). Prenatal substance abuse: Short-and long-term effects on the exposed fetus. Retrieved from http://pediatrics.aappublications.org/content/131/3/e1009 

Lee, K. (2014). Neonatal abstinence syndrome: MedlinePlus Medical Encyclopedia. Retrieved February 29, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm 

Neonatal Abstinence Syndrome. (2016). Retrieved February 29, 2016, from http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387 

Withdrawal Scoring Sheet. (2016). Retrieved February 29, 2016, from http://newborns.stanford.edu/ScoringSheet.html 

Medical Treatment Options

The treatment for Neonatal Abstinence Syndrome (NAS) is to assist the infant through detox as painless as possible. First, knowing what type of drug the mother is on is very important. On average, if the mother is on a narcotic with a short half life, like Hydrocodone, the infant could be discharged at age 3 days if no withdrawal symptoms occur. If the mother is on a narcotic with a long half life, such as Methadone, the infant needs to be observed until age 5 to 7 days and then can be discharged if no withdrawal symptoms occur (Hamdan, 2016). Then appropriate follow up care is needed. 
After an infant is diagnosed with NAS the infant is sent to the NICU, which is better equipped to treat such a diagnosis. Nonpharmacologic interventions include assessing the infant closely with sleeping habits, feeding patterns, weight gain and any signs of withdrawal. Minimizing stimuli in the room is very important along with swaddling, non-nutritive sucking with a pacifier and frequent small feedings of hypercaloric formula (Hamdan, 2016).

(Kocherlakota, 2014)

Pharmacologic therapy should only be used for supportive therapy because it can prolong hospitalization and expose infants to more agents that are not necessary. Approximately 30-91% of infants who are diagnosed with NAS receive pharmacological treatment. This treatment allows the infants to feed, sleep, gain weight and interact with caregivers. The most common treatment is  oral morphine solution, followed by methadone and even clonidine (Hamdan, 2016).

 (Kocherlakota, 2014)

The chart above explains the types of medication used to assist the infant through detox. As the infant grows older and symptoms decrease, weaning of the pharmacological intervention is started. The goal is to get the infant off all medications. Side effects that are the most concerning are sedation and longer treatment. Types of medications were stopped if the infant was not responding well to them, mainly not getting comfortable with the type of medication. Luckily medication is given on a schedule of on average every four hour. This allows medical staff to step in if any worsening side effects occur, but the main objective is to keep the infant comfortable (Kocherlakota, 2014).

References

Hamdan, A. (2016). Neonatal Abstinence Syndrome Treatment & Management. Retrieved February 23, 2016, from http://emedicine.medscape.com/article/978763-treatment 

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

 

Signs and Symptoms

Signs and symptoms of Neonatal Abstinence Syndrome (NAS), are very similar to the signs and symptoms of drug detox in adults. The most common symptoms include tremors, irritability, excessive crying and diarrhea. Seizures can occur in about 2% to 11% of newborns born with NAS. Those listed are considered the initial phase.  The chart below illustrates the onset, frequency and duration of this syndrome depending on the type of drug the mother is using (Kocherlakota, 2014)

(Kocherlakota, 2014)

The duration of time the drug is in the infant depends on the last time of dose, how long the fetus was exposed and what type of drug being used. Different drugs have a different half-life and that also attributes to how long or short detox can be. When the infant goes through detox, the initial symptoms decline in frequency and intensity. However, after the initial phase, that can last weeks to months, the infant can go through long chronic and relapsing hyperirritability sleep disturbances, hyperphagia and other neurologic and autonomic signs (Kocherlakota, 2014). The symptoms that contribute most to the discomfort of the infants are the irritability, tremors and excessive crying. The infant is going through severe detox and will feel bad, the only thing that can help is proper medical care and time. (Doctors, 2011)

(Doctors, 2011)

The video above goes over common symptoms of NAS, what they look and sound like. The medical staff does what they can to decrease intensity of symptoms, but the infants need to clear there system before the effects of detox stop.

References

Doctors. (2011). Struggles of Drug Addicted Babies. Retrieved February 18, 2016, from

            https://www.youtube.com/watch?v=c07RnhNYsPk

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

Diagnosis

When diagnosing Neonatal Abstinence Syndrome (NAS) it is always important to consult with the infant's doctor because signs and symptoms of NAS can look like other medical problems. It is important to know what drugs the mother is on, and when the last use was for each substance. A maternal drug test would be beneficial to see exactly what is in the mother's system and at what strength. To make a true diagnosis in the infant, toxicological confirmation is necessary, as this confirms what narcotics are in the infants system (Trevino, 2016).


A scoring system is used to measure how severe the infants symptoms are, which allows a systematic, objective, periodic and thorough evaluation of the newborn of the progression of NAS (Jansson,  Velez, & Harrow, 2009). There are a few different scoring sheets that can be used, a common model is the  Modified Finnegan Neonatal Abstinence Score Sheet. This model allows the medical staff to assess 31 items to quantify the severity of NAS, this is repeated every four hours. Other scoring systems that are used in the medical setting include  The Lipsitz Neonatal Drug-Withdrawal Scoring System, The Neonatal Withdrawal Inventory, and The Neonatal Narcotic Withdrawal Index, the later two being simplified versions of the Finnegan scoring tool (Jansson, Velez, & Harrow, 2009).


The scoring sheets work well with treating the infants because with the score, it lets the medical staff know when medications need to be used to cut down the severity of symptoms. But keep in mind, no scoring system is perfect, these measuring tools are subject to observer variability and simplified versions of longer measuring tools have had little success. 

This syndrome progresses in the infant, and expresses itself through detox symptoms, which include tremors, high pitch crying, and not being able to get comfortable. The nursing staff keeps the infant comfortable through the symptoms by weaning the infant off the narcotic and healthy enough to go home (Kocherlakota, 2014).

References

Jansson, L. M., Velez, M., & Harrow, C. (2009). The Opioid Exposed Newborn: Assessment and Pharmacologic Management. Journal of Opioid Management, 5(1), 47–55.

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2).

Trevino, H. (2016). University of Rochester Medical Center. Retrieved February 11, 2016, from https://www.urmc.rochester.edu/Encyclopedia/Content.aspx?ContentTypeID=90

Etiology and Pathophysiology

The etiology of Neonatal Abstinence Syndrome (NAS) is when the mother uses and is addicted to opiate drugs while pregnant. The type of narcotics include heroin, codeine, oxycodone, Oxycontin, methadone and buprenorphine. The narcotic goes into the mother and into the fetus through the placenta (Lee, 2014). Huestis and Choo (2002) explain the mechanisms of transfer from mother to fetus, these include, active transport which requires energy, passive diffusion requiring no energy, and pinocytosis which moves fluids by creating a cavity of cell membranes. Along with the mechanisms of transport, it is also important on the size of the drug molecule, because equilibrium will always be reached across the placenta membrane, meaning mother and fetus will be on the same substances (Huestis & Choo, 2002). The cause of NAS is substance abuse and dependence, which is a growing problem especially in women. The treatment of addiction takes time and is different for every individual. Plus with the availability of opiate narcotics increasing, this contributes to the morbidity of NAS (Huestis & Choo, 2002).

(ABC News, 2012)

The mother in this video was seeking drug abuse treatment when she found out she was pregnant. Since she was still dependent on methadone, the baby became addicted and had to go through withdrawal after being born. The progression of NAS is illustrated above, the mother of this infant, while under methadone treatment, passed the drug onto her fetus and once the infant was born, detox started. Then all the mother could do is watch, while her infant was treated for withdrawal off a narcotic that the infant had no choice in. Resulting in harsh symptoms and more medications to wean the infant off the narcotic and try and ease the symptoms of detox.

 References

ABC News (2012). Drug-Dependent Infants Detox at Tenn. NICU. Retrieved February 05, 2016, from https://www.youtube.com/watch?v=2eP5EnFSG0c

Huestis, M.A., & Choo, R.E. (2002). Drug abuse’s smallest victims: In utero drug exposure. Forensic Science International, 128, 20-30.

 Lee, K. (2014). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Retrieved February 05, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm 

Epidemiology

The distribution of increased incidence positively correlates with the increase of prescription drug use. The map below represents the cases of Neonatal Abstinence Syndrome in each state. This was based off of the analysis of the Kids' Inpatient Sample 2012 (Vanderbilt, 2012).

 (Vanderbilt, 2012)

When looking at the map above, Kentucky, Tennessee, Mississippi, and Alabama are the states with the highest incidence of Neonatal Abstinence Syndrome at 16.2 births per 1000 births. This correlates with the amount of Opiate medications being subscribed by medical professionals within the same time frame. The image below represents prescribing rates per 100 persons, in quartiles, by state and drug type during 2012; the south region had the highest rates of prescribing opioid pain relievers and benzodiazepines (Paulozzi, Mack & Hockenberry, 2014).

(Paulozzi, Mack & Hockenberry, 2014)

Over the last five years, Neonatal Abstinence Syndrome (NAS) has increased in the United States. From 2000 to 2012, there was a five-fold increase of infants born with NAS (National Institute on Drug Abuse, 2015). More often than not, people who are addicted to a substance are using multiple. This brings even more risk to the infant who could need numerous detox regimens. NAS is rarely fatal because the infants are taken into critical care and are given the appropriate measures when diagnosed (Kocherlakota, 2014). In an experiment based in Florida, mothers with infants diagnosed with NAS, were on a combination of Opioids, Benzodiazepines, Tobacco, Marijuana, Cocaine, Antidepressants, Barbiturates, Methamphetamine, and Alcohol (Lind, Petersen, Lederer, Phillips-Bell, Perrine, Li, . . . Anjohrin, 2015). When focusing on the Opiate use, the mothers shared different reasons for using, these included; illicit use, drug abuse treatment, chronic pain or unknown (Lind et al., 2015). Populations at greater risk for abusing drugs include: those treating chronic pain, seeking thrill, or treating their tolerance (Women's Health Care Physicians, 2012). When looking at the research study, ethnically the majority of mothers identified as White, non-Hispanic, then followed Hispanic, Black, non-Hispanic and other (Lind et al., 2015). The results in this study are limited to Florida, but it gives a good picture of what is going on with the mothers with infants diagnosed with Neonatal Abstinence Syndrome. 

 Search terms: Neonatal Abstinence Syndrome, Epidemiology, Nationwide

 References

Kocherlakota, P. (2014). Neonatal Abstinence Syndrome. Pediatrics, 134(2). 

Lind, J., Petersen, E., Lederer, P., Phillips-Bell, G., Perrine, C., Li, R., . . . Anjohrin, S. (2015). Infant and Maternal Characteristics in Neonatal Abstinence Syndrome — Selected Hospitals in Florida, 2010–2011. Morbidity and Mortality Weekly Report, 64(8), 213-216.

National Institute on Drug Abuse (2015). Dramatic increases in maternal opioid use and neonatal abstinence syndrome.  Retrieved January 20, 2016, from http://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

Paulozzi, L. J., Mack, K. A., & Hockenberry, J. M. (2014). Variation among states in prescribing of opioid pain relievers and benzodiazepines — United States, 2012. Journal of Safety Research, 51, 125-129.

Vanderbilt. (2012). Neonatal Abstinence Syndrome. Retrieved January 26, 2016, from https://medschool.vanderbilt.edu/nas/

Women's Health Care Physicians. (2012). Retrieved January 26, 2016, from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy

What is Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome (NAS) occurs in newborns when the mother uses and is addicted to opiate drugs while pregnant. The problems arise when the narcotics pass through the placenta to the fetus, resulting in the fetus obtaining the drug effects and eventually becoming addicted like the mother (Lee, 2014). While in the womb, the fetus is receiving the narcotic whenever the mother takes the drug, ensuring no detox symptoms occurring. 
 
(Narconon News, 2011)                                            (Lee, 2014)

The effects of withdrawal start in the newborn after birth because the narcotics are no longer being supplied. Newborn babies have to go through many different changes, and adding detox to those changes only hurts the newborn. The symptoms of detox that can be present in the newborn after birth include; tremors, irritability, high pitched cries, sleep problems, tight muscle tone, seizures, poor appetite, vomiting, diarrhea, sweating, and unstable temperature (Neonatal Abstinence Syndrome, 2016). Along with the effects of detox that these newborns are going through, there are other problems that are at an increased risk including; poor intrauterine growth, premature birth, seizures and birth defects (Neonatal Abstinence Syndrome, 2016). These symptoms of detox and higher risk problems put terrible stress on the infants system, which is brand new to the world as is and trying to figure out how to function outside the womb.

(Wall Street Journal, 2012)

Over the years, there has been an increase of maternal opioid use and from that, there has been a rise in Neonatal Abstinence Syndrome. From the year 2000 to 2012 there was a five-fold increase of newborns being diagnosed with Neonatal Abstinence Syndrome, leading to an estimated 21,732 infants born with NAS in that time span (National Institute on Drug Abuse, 2015). To break it down further, the amount of newborns born with NAS is the same as one baby suffering from opiate withdrawal every twenty-five minutes (National Institute on Drug Abuse, 2015). With the amount of cases of Neonatal Abstinence Syndrome on the rise, there needs to be more attention brought to the severity of this prognosis and more research to provide a more effective treatment for those newborns who are diagnosed.

 References

Lee, K. (2014). Neonatal abstinence syndrome: MedlinePlus medical encyclopedia. Retrieved January 20, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm

Narconon News. (2011). Retrieved January 20, 2016, from http://www.narconon-news.org/blog/2012/11/more-on-neonatal-abstinence-syndrome-and-babies-born-addicted/  

National Institute on Drug Abuse (2015). Dramatic increases in maternal opioid use and neonatal abstinence syndrome.  Retrieved January 20, 2016, from http://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

Neonatal Abstinence Syndrome. (2016). Retrieved January 20, 2016, from http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387

Wall Street Journal. (2012). Born addicted: Treating drug-dependent babies. Retrieved January 20, 2016, from https://www.youtube.com/watch?v=tmgOiHMpENw