Questions about neonate drug withdrawal management

  1. 1
    Mom had one prenatal visit (total) at 38 weeks, in which she was prescribed tylenol 3. She had a prior script for Norco (from another Dr.) but was told not to take both. Well, baby is in withdrawal. We are a level II/well baby and our docs are mostly family medicine and don't get much exposure to these poor kiddos. There were no orders given on this baby except routine care. This baby shows lots of signs of withdrawal. From mild-moderate tremors, temp 100.1, high pitched cry (didn't sleep the entire first day for more that 5 minutes), sneezing, vomitting constantly, weight loss >10% on day one, etc. So, I started NAS scores.. At 26 hours of age the first score was 19! The nurse in charge of his care didn't want to wake the docs (who were aware of possible withdrawal). The Dr. pulled a pharmacy report and it was 3 pages long! ER's from all over town, pharmacies too. Mostly tylenol 3 and Norco. This is since the beginning of pregnancy. So, last night I asked the Dr. about the POC. I suggested considering morphine and he was floored! He said he would only go that route if the baby started seizing. I did more research and gave him a copy and he gladly read it. He's a resident, so I understand he is still learning (as am I). He called his attending and they decided to still refrain from interventions.
    What would be the standard of care in this situation? Am I off base with the morphine? I have some NICU experience, but not enough withdrawal experience to back this up with just my brain cells. But I do know when I worked the NICU, that when babies were in withdrawal they had NAS scores ordered and morphine (for opiates) to get them through it (titrated with the scores).
    Thanks for anything you can throw my way.
    Last edit by Race Mom on Jan 29, '09
    Jarnaes likes this.
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  4. 14 Comments so far...

  5. 1
    Yikes! No you are not off base. I take it an early tox screen was not collected on baby?
    That kiddo should be transferred if he cannot get the care he needs at your facility. Why would you wait for a baby to seize before treating?
    Race Mom likes this.
  6. 1
    You are right on base with the morphine! Most recent evidence based practice show this to be effective. Kuddos for really advocating proper withdrawl managment. I see withdrawl both iatrogenic and maternally induced frequently. It is intolerable and negligent to wait until the baby seizes to intervene.
    Race Mom likes this.
  7. 0
    Yes, a urine tox screen was done and showed "H" for opiates, mec was sent-no results yet (but, unfortunately the nurse that sent the mec sent it after the 1st stool). The docs here seem afraid to send babes out. The nurses that have been on the unit for many, many years said they can only recall one baby that was put on Morphine for withdrawals. I'm afraid when I get back to work tonight, that they will have d/c'd this baby to mom (who by the way has only held babe for 15 mins since birth). She was offered a "guest" status so she can stay at the hospital with her kiddo. She decided she was in too much pain (3 days PP/tubal) to stay and would call to check up on him (never did). The nurses on my unit admit they are too afraid to question the docs. I'm not. I will advocate for the babies till my head pops off. Unfortunately, I haven't been the "nursery" nurse the last 2 nights, but most likely will be tonight.
    The docs are concerned about lengthening the stay of the baby. Why, I don't know. The baby needs extended care. He is not a "well baby" that can just go home in 24 hours.
  8. 1
    The baby scored a 19? Poor, poor baby. In the level three nursery where I work, we get drug withdrawal babies all the time. We would have started a baby with a score of 9 on morphine! And it can take weeks to withdraw the baby when he's had constant exposure to narcotics in utero.

    You did all the right things, (bravo!) but you doctor needs to follow up with someone who is more experienced in this sort of thing. That baby will need to stay in the ICN for a while, and if he is sent home with mom, could be a set-up for child abuse. A drug mom with a screaming baby who doesn't sleep and frantically eats could be a disaster.

    Dawn
    Race Mom likes this.
  9. 1
    no nicu experience to offer re drug treatment but offering advice from homecare referrals received and care our mom baby program provides.

    a. social work referral needed if not already done to assess home situation and preparation for infant.
    b. mom would be referred to children and youth protective services re lack of prenatal care and possitive drug
    screen in child.
    they would check if any problems with mom before, intervene/followup if needed or place child with another person if significant issues.
    c. appointment setup for mom for outpt services: pain center and drug counseling --miss appointments and baby not discharged to home.
    d. baby kept detained until stable--often 3-6 weeks or more.
    e. home care referral for maternal child visit to assess home situation, parental bonding, care followup and
    community linkage. 2-3 visits would be done-- they can find the mother.

    bowingpur:bowingpur thank you for being an advocate for this child. please kick this situation up the chain of command "to prevent a crtical incident" and suggest this as good education topic for next staff inservice.


    articles:

    from new zewland: nw newborn clinical guideline - drug dependent mothers
    infants born to drug dependent mothers


    treatment of withdrawal
    • this is managed by the paediatric consultant in conjunction with the registrar and charge midwife and parents. medications are started when the baby has several scores of >8 and after adequate consultation.
    • the medication may only be changed by a paediatric consultant or registrar.
    • the drug used is neonatal morphine solution 1mg/ml.
      • start at 0.5mg/kg/day in 4 divided doses (that is, 6-hourly) and reduce by 10-15% of the original dose every 2-3 days if possible. the infant may need increasing doses for stabilisation in the first few days.
    • medication must be given strictly as charted given directly into baby's mouth by syringe. the drug must be given by a registered nurse/midwife who checks the drug - not a parent.
    • medication times are not to be changed to fit in with baby's feeds times. this interferes with the withdrawal regime. do not draw up milk into the syringe because dead space can lead to overdose of morphine.
    • if the medication time falls between feeds it is not necessary to wake the infant completely. it has been noted on past experience that babies take the medication well if the syringe is slipped into the mouth and medication is taken without any problems. the baby is then tucked back to sleep.
    • it is always a help if identification is on the left as this disturbs the baby less when noting identification.
    • an alternative treatment is chlorpromazine 2.2mg/kg/24 hours given in four divided doses either orally or by injection. full dosage should be given for two to four days then tried to decrease at two day intervals if baby's condition, according to the clinical score, permits.
    neonatal abstinence syndrome: treatment & medication - emedicine
    medications should be considered when supportive measures fail to ameliorate the infant's withdrawal. this may be manifested early on as difficulty with feeding, extreme irritability, and poor sleeping. if a scoring system is used, pharmacological treatment is commonly started when the average of 3 scores is 8 or more on the finnegan scale[color=#006699]6 or 4 or more on the lipsitz scale.

    many pharmacological agents have been used to treat neonatal abstinence syndrome (nas). however, few randomized trials have compared the efficacy of the various pharmacological treatments. a recent us survey reported that opioid medications are the most commonly used medications for the treatment of both opioid and polydrug withdrawal.[color=#006699]9 diluted tincture of opium (dto) is recommended by the american academy of pediatrics for the treatment of nas due to opioid withdrawal.[color=#006699]10 many neonatal units use proprietary oral or intravenous morphine solutions, and methadone is also used.

    currently, many infants are exposed to polydrug abuse. unfortunately, evidence from randomized studies is insufficient to determine the best management for these patients. in 2 randomized trials, phenobarbital, rather than diazepam or paregoric, was best at controlling symptoms in infants exposed to polydrugs. the results of another study suggested that the combination of phenobarbital with dto may be more effective than dto alone because the combination was associated with a shorter hospital stay.[color=#006699]8
    journal of infusion nursing:volume 28(3)may/june 2005p 159-167 identification and management of neonatal abstinence syndrome

    advances in neonatal care - fulltext: public health nursing ... home intervention for in utero drug-exposed infants

    uk: a survey of the management of neonatal opiate withdrawal in ...

    israel: a four year survey of neonatal narcotic withdrawal: evaluation and ...
    Race Mom likes this.
  10. 0
    Thank you everyone! Unfortunately, they sent baby home with mom by 10am yesterday. Barely 2 hours after I left the hospital. I heard mom looked like crap when she came in (like a drug abuser). Now they are both in an awful position.
    One of the docs who was NOT involved, but comes from the same practice called the dayshift nursery nurse to offer up their "reasoning" for not aiding this kiddo in withdrawal. (Hey, at least they felt they needed to explain--which they did need to!) Their reason is the oddest thing I've ever heard....
    They didn't want to start the baby on morphine then send him HOME ON MORPHINE for the mother to administer. They were afraid she would take the drops.
    Well, um, yeah, she probably would...that's why THE KIDDO NEEDED TO BE MANAGED BY THE STAFF! I don't know whats more scary...the fact that they sent the baby home with mom or that they even had the fleeting idea that a baby could be sent home on morphine drops.
    At discharge: his resps were 68, his NAS score was 12.
    I'm sick.
  11. 1
    I would be sick too, Woogy. When I worked in an inner city level II nursery years ago we had a lot of withdrawing babies. We had a protocol for managing symptoms, phenobarbital 20 mg per Kg load then maintenance 5 mg per Kg q8h. Scoring was q2h until there were four in a row <8 then q4h. After 72 hours with no score >8 we would then go to q12h maintenance for 2 doses then a single dose then d/c it. It worked well. No baby with NAS went home with mom until they were off phenobarbital. Most were apprehended, at least in the short term.
    Race Mom likes this.
  12. 2
    since you feel so strongly about this, file an incident report with risk management office to doccument you served notice on the facility of a practice issue.

    this case is ripe for review of professional standards of care....which these doctors have not met from what has been reported and the articles i've posted. in pa, we are mandated by law since 2006 to report pregnancy related possitive drug tests or withdrawl symptoms resulting from perinatal drug exposure.
    see pg 2 bottom: office of children, youth and families bulletin

    mandated reporters in pa are

    pennsylvania law encourages everyone to report any suspicions of child abuse or neglect in order to protect the children. certain professionals are required to report. any person, while in the course of their employment, occupation or practice of their profession, who comes into contact with children, is a mandated reporter. these mandated reporters include but are not limited to:
    physicians
    school teachers
    dentists
    medical examiners
    nurses
    day care workers
    optometrists
    social services workers
    coroners
    law enforcement officers
    http://www.co.delaware.pa.us/humanse...hildyouth.html
    please check your states standards, also your nurse practice act. if poor outcome occurs, net will be cast for all that cared for this child....if nurse practice act has reporting language you are sos if lawsuit filed. remember suit can be brought within first 21 years of life for birth issues.

    hope your malpractice policy is active too or application in the mail.
    UTVOL3 and Race Mom like this.
  13. 0
    Thanks for all the terrific websites Karen! This mother was reported. Child protective services and the police visited the mom in the hospital. Social services was involved. I guess CPS has already dealt with this mom (not sure why). She has a home health visit coming on Monday.
    I wasn't ever assigned to this baby or mom. Babies are my passion, so I frequently poke my head in to see what's going on in the nursery. Of course, you can tell a withdrawal baby from across the unit, which is why I poked my head in.
    I am still educating myself on this subject, so anymore words of wisdom about this subject will help. Now that I have a few days off, I can print out the info you Karen gave me and put it to work.
    I am a newer nurse, been working for a year. I'm not afraid of doctors, I'm not afraid of advocating for my patients. But, I am intimidated by my lack of nursing years/experience. I work in a smaller community hospital, where it's not unusual to only have 2 nurses on at night, 4 at the most. We deliver 30ish a month. Most of the nurses I work with have been in this particular unit for 10-30 years. Which really saddens me that they aren't more proactive and knowledgable. They do great with the well babies but the unit lacks skills for the Level II designation.
    If I do an incident report, what happens from there?


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