Nursing Care of the NAS Infant. Lori Markham MSN, MBA, ARNP, NNP-BC

Transcription

1 Nursing Care of the NAS Infant Lori Markham MSN, MBA, ARNP, NNP-BC

2 Objectives Define neonatal abstinence syndrome Recognize the clinical presentation Identify non-pharmacologic and pharmacologic caregiver strategies for managing neonates with NAS Learn techniques to minimize neuroexcitation during withdrawal

3 NAS What is it? Infants born to mothers with antepartum opioid use which develop withdrawal symptoms following the postpartum cessation of in utero exposure to opioids Continuous drug exposure during pregnancy 50-90% in babies born to heroin-dependent mothers 60% in babies born to mothers on methadone

4 Incidence of NAS JAMA. 2012;307(18):

5 Drugs Associated with Symptoms in Newborns Opiates Heroin Methadone Buprenorphine Codeine OxyContin Percocet Dilaudid Fentanyl Benzodiazepines Valium Ativan Clonazepam Xanax Stimulants: Caffeine Nicotine Methamphetamine SSRI s: Prozac Celexa Paxil Zoloft Lexapro Barbiturates: Phenobarbital Luminal Marijuana Alcohol

6 NAS Facts! Infants with NAS are 2.5 times more likely as uncomplicated term infant to be readmitted within 30 days Statistically identical to the late preterm infant Shorter hospital stays for NAS patients are associated with rate of readmission < 1 week hospital stay has the highest risk Protracted signs of withdrawal have been described in adults and newborns

7 Keep in mind why! Drug addiction is an illness Drugs are also used for medical reasons every day Mental illness Seizure disorders Pain Diagnoses Fibromyalgia Sickle cell disease Arthritis Endometriosis

8 Issues in the Newborn Period Nicotine Marijuana Opiates Alcohol Cocaine Methamphet amine Fetal Growth Effect No effect Effect Strong effect Effect Effect Anomalies No consensus on effect No effect No effect Strong effect No effect No effect Withdrawal No effect No effect Strong effect Strong effect No effect * Neurobehavior Effect Effect Effect Effect Effect Effect

9 Onset of Symptoms Drug Signs Onset of signs Duration Alcohol Heroin Benzodiazepines Barbituates Methadone Buprenorphine Cocaine Hyperactivity, crying, irritability, poor suck, tremors CNS irritation, GI tract dysfunction, tone Irritability, tremors, excessive crying, tone CNS irritation, GI tract dysfunction, tone Hyperactive Moro, jitteriness, excessive sucking 3-12 hours 18 months Within 24 hours May not start until 2 weeks ~ 6-7 days Sub acute 4-6 months 4-6 months hours 7-14 days? 4 weeks Sub-acute 6 months hours Up to 7 days Nicotine Excitable and hypertonic???? Antidepressants CNS, motor, respiratory, GI symptoms, hypoglycemia Hours to days after birth 1 4 weeks Caffeine Jitteriness, vomiting, tachypnea At birth ~ 1 week of age

10 Nursing Assessment Maternal history risk behaviors Toxicology Newborn behaviors WITHDRAWAL assessment Finnegan scoring

11 Diagnosis History Most useful and least reliable Urine Reflects intake only few days before delivery Meconium Drugs may be found up to 3 days after delivery Hair The most sensitive Not widely available

12 Complications Withdrawal or toxicity signs and symptoms in neonate Congenital anomalies Fetal growth restriction Increased risk of preterm birth Impaired neurodevelopment

13 Co-Morbidities Differential Diagnosis No clinical signs should be attributed solely to withdrawal without appropriate assessment, evaluation, and diagnostic tests to rule out other cause Common neonatal disorders that mimic or compound NAS Milk intolerance Hypoglycemia Hypocalcemia Sepsis Meningitis Hypomagnesemia

14 Differential Diagnosis - Research Prematurity can increase or decrease score Finnegan tool was not designed for preemies Older NAS babies do not sleep three hours between feeds Trisomy 21 infant with major heart defects: large dose due to tachypnea, sweating and poor feeding some symptoms due to heart failure and genetics NAS baby scoring for fever and excoriation necrotizing fasciitis

15 Basic Supportive Care

16 Family Centered Care Leave your bias outside the door The family is a unit, these are the parents the baby has Meet your patient/family where they are. Build on their strengths and set them up for success A person s actions make sense in their context 16

17 Promote Bonding Engage the parents in the care point out behaviors to watch for that will help them be more responsive to their infant s needs Encourage parent visits praise their efforts to be at the bedside no matter what time it is Score infant with Mom present when possible explain behaviors and scores eliciting family participation promotes a team approach, and better understanding and bonding

18 Pediatric Therapy Services Advocate for Peds Therapy specialists to be involved Experts on sensory/motor behaviors Can help parents bond more effectively by explaining behaviors displayed by infants They bring additional tools to the bedside to enhance the infant s successful transition There is NO contraindication to their involvement

19 Environment - Handling Prepare everything prior to disturbing infant to minimize handling Use slow, modulated, gentle movements when handling infant Kangaroo care! Encourage parents to do this as it can drastically reduce Finnegan scores! A measure that can immediately quiet an infant is the Vertical Rock in care-giver s arms. Slowly, in a C position, rock up and down for just a few revolutions. It helps infant switch gears Utilize Cuddlers! Instruct them to hold infants close to their body gently, but firmly

20 Vertical Rock

21 C-Position

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23 Clap and Sway

24 Devices and Therapies Use pacifiers liberally Baths Can be for cleanliness as well as therapeutic. No limit on therapeutic baths! Utilize swaddling and plenty of water when bathing for optimum therapeutic effect! Utilize large tubs filled with enough water to submerge infant up to his/her shoulders Use blankets to bolster infant if a second pair of hands is not available Infant Massage It will quiet and calm your infant for hours can be done during a bath to intensify the therapeutic effect

25 Skin Care Diaper/Skin care be proactive always, every diaper change, use protective barrier Utilize a first line ointment as a protectant barrier; no friction cleaning A quick rinse with peri bottle of warm water keeps bottom clean and skin free of friction pat dry apply barrier

26 Non-pharmacologic Intervention

27 Non-pharmacologic Intervention Swaddling Rocking Minimal sensory or environmental stimulation Light and sound Maintaining temperature stability Breastfeeding Increasing the frequency of feeds May require 150 to 250 kcal/kg/day

28 Swaddling swaddle so infant can still move his/her arms and have hands to mouth for comfort utilize blanket rolls under the infant s thighs for support of extensor muscles use a C position if it is quieting for them explain swaddling measures and blanket rolls to parents Don t give mixed messages 28

29 Swaddling

30 Side-Lying with Boundaries Do Don t

31 Swings Swings should be used only as a last option Use slowest motion setting, use setting that most closely achieves front to back motion-it helps with vestibular maturation Mamaroos most therapeutic settings are car ride and Kangaroo. Adjust the swing to its most horizontal setting, place infant into swing on either side, not face forward, in order to achieve the best vestibular position while swing is in motion Music is not recommended for these infants, however, the ocean wave sounds do appear to soothe and deflect other noise When infant cries in a swing, it may be time to stop!

32 Environment Noise Maintain a quiet room, dim lighting, positive energy field, slow mindful movement Be conscientious in reducing noise when closing fridge door, bedside module drawers, and moving nutrition carts Avoid talking at or over bedsides when infants are sleeping, or feeding Leave normal to loud voice levels, laughter, and peripheral visiting outside the nurseries Maintain quiet even in the hallways outside the nurseries ADVOCATE for your babies! Remind personnel as necessary! Normal voice tones are loud inside quiet nurseries!

33 Nutrition Promote Breast Feeding! Refer to Lactation as needed- caution parents that abrupt cessation of BF may increase withdrawal signs and symptoms Ad Lib Demand Feeds Be careful not to over-feed at any one feeding Most term newborns do not go 4 hours between feedings, much more common to feed every 2-3 hours Feed on early hunger cues - decreases escalation of agitation, allows capture of quiet alert state which decreases energy usage 33

34 Tips for Feeding Swaddle infant snugly during feeds with hands forward but contained Infants are trying to do 4 things at once, 3 of those are breathing, sucking and swallowing which we as caregivers can t do for them; the 4th we can do! Control their environment so they can focus! Refrain from unnecessary conversation while feeding infant- it distracts their focus 34

35 Breastfeeding Guidelines Mother in residential or outpatient treatment adhering to treatment requirements has had negative urine screens and adequate prenatal care for at least 2 weeks prior to delivery Mother not in formal treatment program no use of cocaine, methamphetamines, PCP, or other drugs contraindicated in breastfeeding for at least one month prior to delivery has signed a release allowing the infant s care team to continue to review her toxicology screen results No other maternal contraindications Mother is HIV-negative and TB-negative Mothers are counseled not to use marijuana, tobacco, or alcohol while breastfeeding

36 Pharmacologic Intervention

37 When to start medication? AAP recommends starting when non-pharmacologic measures are not enough Relieve moderate to severe signs of NAS Prevent complications such as fever, weight loss and seizures No standard and thresholds vary Finnegan scale 8 x 3 scores Benefit: short-term amelioration of clinical signs Disadvantages: prolongs drug exposure and duration of hospitalization; may affect maternal-infant bonding

38 Morphine Most frequently used Oral morphine versus supportive care No significant effect of morphine on treatment failure rate Increased duration of treatment and length of hospital stay (LOS) Decreased number of days required to regain birth weight and duration of supportive care Widely variable pharmacokinetics Various formulations Neofax recommends 0.4 mg/ml dilution from concentrated oral morphine sulfate solution

39 Buprenorphine More recently investigated Primarily used in adults for withdrawal Partial mu opioid receptor agonist/antagonist Blocks the binding of other mu agonists Metabolism CYP 3A4 to an active metabolite, norbuprenorphine Available as sublingual tablets Extemporaneous compound available

40 Phenobarbital Place in therapy Drug of choice for nonnarcotic-related withdrawal Adjunctive therapy Benefits Modifies hyperactive behavior related to narcotic withdrawal Disadvantages Does not relieve gastrointestinal signs May depress the CNS Impairs suck reflex Delays bonding between mother and infant Long half life Drug interactions (inducer) Rapid tolerance to sedative effect Alcohol (13.5%)

41 Clonidine Centrally acting alpha2-adrenergic receptor agonist Used as adjunct therapy in opioid withdrawal in children and adults Inhibits CNS sympathetic outflow Ameliorates autonomic over-activity Tachycardia, hypertension, diaphoresis, restlessness, diarrhea May experience rebound autonomic activity Limited trials in NAS

42 Medication Morphine Starting dose (oral) Dosages 0.05 mg/kg every 3 hours (increase by 0.02 mg/kg) Tincture of opium 0.1 ml/kg (2 drops/kg) every 4 hours Methadone mg/kg every 6-24 hours Phenobarbital 16 mg/kg loading dose, followed by 1-4 mg/kg every 12 hours as maintenance Clonidine 0.15 mcg/kg every 6 hours

43 Summary A standardized process should be developed for identification, evaluation, treatment and discharge management of infants with NAS Primary treatment for NAS consists of opioid replacement therapy Adjunctive agents may be considered Large, well-designed clinical trials are needed to optimize evidence-based treatment for these babies

44 References Maguire D. et. Al. NICU Nurses Lived Experience: Caring for Infants with Neonatal Abstinence Syndrome Advances in Neonatal Care 12(5):