Quick background about myself: RN for seven years, pediatrics the whole time. Started in the local pedi hospital, switched to community health center work, now doing home visiting with families of children under age 3. The home visiting is not skilled nursing in nature- it's Department of Health funded and focuses on education and short-term case management for issues such as DV, mental health needs, homelessness, etc. Parental substance use and NAS are topics that I've dealt with throughout the years, including my current job. Today was a little different, though...

I visited an experienced foster family today and the latest arrival to their home: 3 week old born to a mother who was positive for opiates in her pregnancy. The substances included Subutex, not sure what else. Baby stayed in hospital for two weeks on a morphine wean. Day of d/c was completely off the morphine, supposedly doing very well with her NAS symptoms, but d/c records showed a dose of mag sulfate being given just before d/c home with foster family? I'm not familiar with this being done with neonates with NAS, especially not when they're supposed to be stable for discharge in a few hours.

Anyways, immediately upon saying hello to the foster mom and looking at the baby, it's clear baby's still in withdrawal. Awake, alert, calm, not crying, but shaking non-stop. Foster mom tells me about the severe diaper rash she has from the non-stop diarrhea she's experiencing, and then starts mentioning other NAS symptoms like sleeping 1-2 hours max between feeds, sweating profusely through her newborn hats, heightened Moro reflex....Finnegan scoring is not supposed to be part of my job, but I pulled up a copy and documented everything she was positive for. All in all, my composite score of my observations plus what the family reported was a 20. I know that there's more to Finnegan's than what I did, and I was mostly just trying to document everything baby was positive for in the very limited time I had, so maybe another person's score would have been slightly lower or better finessed, but still...baby clearly had sx present.

About a minute later, the PCP calls foster mom about the diaper rash. PCP is an NP, very nice- I've visited other patients of hers- but does not normally take NAS patients- they go to a pedi for management. She saw the baby once two days after d/c and didn't think baby was doing too bad at that time, though she did observe NAS symptom at the visit. I tell her about what I have just observed and discussed with the foster parents, and we make a plan. PCP is completely uncomfortable starting the baby on meds herself after baby has been home for almost a week med-free. PCP thought about referring to neuro, but had no idea how long an appointment might take to schedule. We decided on ER this afternoon at the children's hospital- neuro could consult in the ER, meds could be prescribed, baby could even be admitted for symptom management if needed. Foster family agreed with the plan, and I'm expecting to get an update tomorrow. In the meantime, I'm placing a referral to Early Intervention that probably should have been done before hospital d/c, but oh well- that's why I'm here!

I have two main questions. First, any thoughts on how I managed this visit? I've never encountered a neonate actively displaying signs of withdrawal before without some sort of medication being prescribed. I've especially never walked into someone's home in a pretty rural area to see this happening! Second, is there possibly a recent change in NAS management that I'm not aware of? Are meds being prescribed less for symptom management? It just seems cruel to me to let a newborn display so many symptoms with no medication to help control them.

I think you handled the visit fine. You advocated for the baby, collaborated with the PCP, and decided on a plan to best facilitate getting what the baby needs.

Our facility just updated our NAS policy based on most recent research/guidelines. I'm not at the bedside much now so I can't speak to the specifics of the policy, but I can get back to you in a few hours with an answer. I DO know that MgSO4 is NOT part of the protocol! But yes, we do still give meds, whether it's methadone or morphine.

We generally keep our kids for 48-72 hours after they are completely weaned. Scores under 8, they go home. Unless I see the previous scores and their weaning protocol it is hard to say. But if we have to give a break thru dose of morphine, not magnesium, then they are put back on the last dose they were on and we go from there as to whether we have to up the dose or start weaning again. We also do not send kids home on morphine, even with a foster. Sounds like maybe a fast wean and sent too quickly. Although, they will still exhibit signs, they always will.

They like to be held, did baby calm when held? I know it's a pain, but it comforts them, if you lay them down yes, many of them will cry. We have cuddlers to help. Also, bundling, no hat (they are little hot boxes) helps as does a swing. Many of them tremor for a long time. What formula is the baby on? We use Isomil, Alimentum or a sensitive tummy one They can have loose stools for a while. And they have a lot of GI issues. We also use Pepcid with many of them.

Are these experienced fosters who have taken drug kids? It sounds like maybe not. And it sounds like they didn't have great teaching. We have them in for at least a week prior to discharge so they see the baby's baseline.

I am so glad you spoke up for this little one! Believe it or not, we have had fosters and even extended family members call county and tell them they just can't care for these kids. They are trialing and very time consuming. I hope the baby got admitted and scores then treated!

The funny thing is, this is a foster family that has extensive history of caring for medically needy/fragile children, including NAS infants. However, this baby was discharged to the foster parents rather suddenly- no time to learn about the baby while still at the hospital- and the foster parents felt they were educated very poorly (really, not at all) about this baby's history. Foster mom is great and was absolutely doing everything to keep the baby calm while I was in the home, but symptoms were still persisting.

I spoke with foster mom this morning, and it turns out that right after arriving to the ER yesterday, the baby had a small seizure while in triage, and was admitted overnight for observation with a neuro consult today. Foster mom thinks the baby may have had two partial seizures earlier in the week as well. The admitting team didn't start baby on any meds- they were waiting for neuro's input. Also, phenobarb as an outpatient treatment for NAS infants is apparently becoming less popular due to phenobarb's possible impact on cognitive development- I didn't know this, and am very used to seeing NAS babies on phenobarb in my neck of the woods. This is what the hospital told foster mom. Anyways, it sounds like advocating for an ER trip sounded like the right call on my part!

Poor little one We only use phenobarb when we are maxed on morohine. That poor foster mom. I hope someone talks to the peds who released that baby.