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.