Need tips on dealing with neonatal abstinence

grlgid · Apr 12, 2009

Our step-down unit is basically one big room.

*We try to place those babies away from each other as they seem to feed off each other once they start to cry.

*We try to have them as a 3 baby assignment whenever possible and only 1 withdrawing baby per nurse.

*We all take turns holding them it seems.

*Swings are our friends, bouncy seats used to be our friends until one of our neos lost her mind and now we can only use them in peds cribs, sigh.

*usually we seem to be giving morphine right around feeding time because we don't make these babies wait and if you give it too early they fall asleep and then they won't eat so you are faced with a lose/lose, win/win depending on how you look at it

all I can think of off the top of my head

Tina

Elvish, BSN, DNP, RN, NP · Apr 13, 2009

Our place keeps them in wellbaby and they don't get a NICU spot unless they start seizing. So, we house them in the nursery along with all the other screaming babies - cause it's so appropriate for them to have all that stimulation! :madface:

We do try to cluster their care - if they are due meds anytime close to when they are hungry, we go ahead and give them. Once they are asleep, we do NOT mess with them unless we absolutely have to, and we encourage parents to let them rest also. And considering they are with us for weeks/months we do NOT wake them up q3-4hrs just to feed. They can (and do) do just fine on their own schedule. Most are awake at least that often in the beginning anyway but once they get bigger we let them be and they do fine.

I've found that these kids have almost a perpetual tummyache - whether it's from the withdrawal process or from a slowed-down gut r/t morphine. And they will fight and claw and be miserable the whole time they're eating, and I think it's directly related to that. The best way I've found to get them to eat decently is to put them tummy-to-tummy with me and kind of wedge the burp cloth between them and me as they tend to be horridly messy eaters. And hold them fairly tightly...that pressure on their tummies seems to help the discomfort and when they are more comfy they eat better. They fight me less and eat better. And a full tummy = sleeping longer = happier baby = happier nurse!

We do everything we can to decrease stim for these kids. We use swings when we can, and we have a bouncy that kind of has cocoon over top that zips up. It kind of helps them feel enclosed and shields them from the mayhem. If there is a quiet corner of the nursery to be found where I can keep my eyes on them, I stick them over there. Our circ room is within sight distance of our nursery, so worst case scenario I put their cribs in there as it's cooler and dark (and obviously, not being used @ the moment). I can still see them but they are out of the way of the worst of the craziness.

I feel so bad for these kiddos. We have two right now.

UTVOL3 · Apr 20, 2009

I don't know the "correct" answers to your questions but I can tell you it varies kid to kid like anything else. I think it is best to put them in a three baby, but more importantly in my mind is giving the baby to the right nurse. Some nurses are just blessed with an incredible patience and can deal with a baby that screams all day and won't eat. The staff member that you know is spread very thin at work or home is not the nurse for those babies.

Sometimes we put them in an isolette on a very low setting and swaddle them to block out noise. Course sometimes elevated temp becomes an issue with that but if you can swaddle them in 1 blanket and just a diaper it helps. You can't leave them in the isolette with it off however. Apparently there is no way to circulate the air in there if it is turned off.

Also, be preemptive with the skin care. If you know they are NAS, the butt is going to get bad and a little ButtBalm or whatever your unit uses isn't going to hurt anything. I can't stand it when I come in and their little heiny is bleeding and no one has even gotten an order for butt cream.:angryfire Course I guess ABC's do take precedence over diaper rash, but if it gets out of control it is so hard to heal. You can also swaddle them arms only with their butts naked and in the air. That helps if you can get them to sleep like that for awhile.

IlovebabyfeetRN · Apr 20, 2009

We are a smaller unit, so we are often able to keep an NAS baby in an isolation room where it can be kept darker and quieter. Minimal stimulation is best. They very often need very few layers of clothing, blankets...but do best when they are tightly swaddled. Frequent issues are vomiting and sore hineys...I agree with the previous post...please do not make these babies wait until their butts are open...as soon as they start with the frequent stooling you should be putting some sort of barrier ointment on there. The withdrawal increases gastric motility which causes the diarrhea and the upset tummy.

I would not assign more than one withdrawing infant to a nurse because they can be trying even for the most patient and calm nurses. Accurate scoring and medication is important as well. If you get a lot of these infants, it would not be a bad idea for staff to be "refreshed" in NAS scoring and infant care on at least an annual basis.

Our hospital actually treats methadone withdrawal with methadone, which we have found decreases symptoms more quickly and leads to shorter hospital stays for these infants as they are better able to eat, etc. because their withdrawal is more quickly controlled. However, these babies need to be discharged with responsible and trustworthy caretaker and we have only two local pharmacies who will dispense the neonatal methadone.

http://emedicine.medscape.com/article/978763-overview (good mescape article on NAS...you have to sign up for medscape to access...but it is free and they have free nursing ceus)

Neonatal Network also usually has an updated article about NAS each year as well if you have access to that.

Elvish, BSN, DNP, RN, NP · Apr 20, 2009

It has to get really bad before we go the methadone route. Morphine and phenobarb are our drugs of choice, and most do fine, but I think they'd do better if they did methadone instead. We do encourage moms to pump/breastfeed if they're at all interested.

IlovebabyfeetRN · Apr 20, 2009

I think you would be surprised at how much more quickly their symptoms are controlled on methadone and they don't have to suffer the morphine/phenobarb trial and get "really bad" first. Plus, I was just reading an article about allowing methadone moms to breastfeed withdrawing infants. There is actually some studied evidence that it may be beneficial to the process. Of course, many of our meth moms are hep c positive, which is contraindicated for breastfeeding in the developed world. (if you can call us developed! ;-0 )

Elvish, BSN, DNP, RN, NP · Apr 21, 2009

I think you would be surprised at how much more quickly their symptoms are controlled on methadone and they don't have to suffer the morphine/phenobarb trial and get "really bad" first. Plus, I was just reading an article about allowing methadone moms to breastfeed withdrawing infants. There is actually some studied evidence that it may be beneficial to the process. Of course, many of our meth moms are hep c positive, which is contraindicated for breastfeeding in the developed world. (if you can call us developed! ;-0 )

Oh, I know they do so much better on methadone. I just wish we did it more! All the nurses do.

We currently have 2 withdrawers, one mom is pumping, the other is not. Guess which one is happier!

We do allow our HepC+ moms to BF.

UTVOL3 · Apr 21, 2009

We have done both with PO morphine being the first choice now. We all agree the methadone worked better. They gave us research to back up their choice to switch, but IRL experience sometimes differs.