Treating Newborns in Opioid Withdrawal: A Nursing-First Approach

Neonatal abstinence syndrome (NAS) is a treatable condition that newborns may experience as a result of prenatal exposure to certain substances, most often opioids. Read on to learn how to treat newborns with NAS.

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Treating Newborns in Opioid Withdrawal: A Nursing-First Approach

Neonatal Abstinence Syndrome was recognized over 40 years ago at Harlem Hospital. NY where they pioneered many treatment approaches: quiet non-stimulating environment, swaddeling, low voices, skin-to-skin contact, and the use of volunteer cuddlers.  They were one of the first to use Morphine to ease symptoms in infants with severe withdrawal symptoms inconsolable by swaddeling,  intolerable to touch, difficulty feeding, etc.

Neonatal abstinence syndrome (NAS) is a treatable condition that newborns may experience as a result of prenatal exposure to certain substances, most often opioids. Neonatal opioid withdrawal syndrome (NOWS) is a related term used today that refers to the symptoms that infants may experience as a result of exposure to opioids specifically.

The Four Categories For Pregnant Women Who May Use Opioids:

  1. Those taking medication for pain due to a medical condition who are being monitored by a physician and are not addicted.
  2. Those on medication-assisted treatment (MAT) who are in recovery from a substance use disorder and are managed by a physician.
  3. Those misusing opioid pain medications with or without a prescription and who are addicted.
  4. Those using illicit opioids (e.g., heroin) and who are addicted.

Prior to birth, engaging pregnant women with opioid use and other substance use disorders  in substance use treatment and other services during prenatal care can decrease or prevent negative birth outcomes associated with NAS and NOWS.   A supportive, nonjudgemental attitude with support from Social Work staff as part of a treatment team and nursing follow-up post hospital discharge leads to better outcomes.

Symptoms of NAS and NOWS

The signs a newborn has NAS depend on what drugs the mother used, how much and how often she took them during pregnancy. One or more of the following can be signs of withdrawal:

  • High-pitched cry
  • Shaky, tremors
  • Cranky, restless
  • Hard to get or keep asleep
  • Feeding problems
  • Overactive sucking
  • Diarrhea or frequent stools
  • Vomiting
  • Fever
  • Dehydration
  • Severe diaper  rash
  • Stuffy nose or sneezing
  • Sweating
  • Seizures (convulsions)
  • Skin irritation of face, heels
  • Stiff baby
  • Yawning
  • Poor weight gain
  • Patchy color of skin 

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 Image  from the American Nurse: Caring for infants and families affected by neonatal abstinence syndrome 

The onset of the symptoms varies.  Newborns exposed to heroin or other short-acting opioids will typically show symptoms within the first 48–72 hours after birth. Those exposed to methadone or buprenorphine, which are longer acting opioids, will often present symptoms later than 72 hours, but usually within the first 4 days. The severity and duration of the withdrawal symptoms can be influenced by exposure to other substances, including tobacco and barbiturates along with poly-substance use.

Pathophysiology of Neonatal Opioid Withdrawal

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From: FDA ADVISORY COMMITTEE: Neonatal Opioid Withdrawal Syndrome

 Infants with NAS and NOWS are treated through non-pharmacological methods (such as rooming-in with mothers after birth, breastfeeding, swaddling, skin-to-skin time, and minimizing stimuli in the environment), as well as pharmacologic methods (medication) when warranted.  There are numerous scoring systems to help identify severity NAS and guide medication treatment:  Finnegan NAS -most extensively used, Lipsitz Neonatal Drug-Withdrawal, Neonatal Narcotic With­drawal Index, Neonatal With­drawal Inventory, and MOTHER NAS Scale.   A new  Eat, Sleep, Console (ESC) NAS assessment scoring method  has been introduced using regular assessments of the infant's ability to eat, sleep, and be consoled to determine the need for pharmacologic treatment, a family friendly approach.

Substance use contributes to parenting challenges and has the risk of impeding development of the nurturing parent-child relationships. At the extreme, NAS can lead to infant abuse due to a parent being overwhelmed with a screaming, unconsolable infant.   In the U.S.,  the National Rate of NAS per 1,000 Newborn Hospitalizations in 2017  ( lists rate per state)  was  7.3, while in my state - PA,  the rate is more than doubled to 14.8.   

As  a prior Home Health Central Intake Manager serving the Philadelphia 5 county area, my staff processed 300+ Maternal Child referrals monthly with ~ 50 having + drug screens on referral.  Our Mom Baby nurses were successful in teaching parents how to care for their infants; few required rehospitalization. Registered Nurses link moms and babies for followup at OB and Pediatrician appointments along with other resources as needed: free cribs, diapers, formula, shelter resources and counseling through Philadelphia's Maternity Care Coalition.

The Michael Smerconish daily newsletter 5/25/21, published  the following article whose authors  are Registered Nurses associated with the School of Nursing at the University of Pennsylvania.  They recommend a Nursing First Approach to caring for infants with NAS.

Treating Newborns in Opioid Withdrawal: A Nursing-First Approach

Quote

...Baby Anna and other newborns with NAS suffer from a range of withdrawal symptoms. Some of these symptoms include difficulty feeding, forceful spitting up, difficulty keeping any milk in their system (putting them at risk for dehydration), and constant loose diarrhea that excoriates their skin (a severe diaper rash). Baby Anna also has developed neurologic symptoms requiring careful monitoring, including jerky body movements, being hard to console, and a piercing cry.

Previously, there was a heavy reliance on treating these babies' withdrawal symptoms with medication. Now we are learning that fundamental nursing care leads to a decreased need for, and therefore use of, opioid medication, such as morphine. Nursing care includes facilitating mother/infant bonding and parent education. There is a lovely reciprocity that occurs when we focus on fundamental nursing care first. By focusing first on bonding and the parent caring for the infant, less medication is needed. When a baby receives less medication, the baby is more capable of participating in interactions with the parents, the mother and baby experience more bonding, and more breastfeeding. The mother is empowered to care for the infant....

...Beyond healthcare institutions, recommended targets include public policy, media portrayals, and representation of nurses on decision-making bodies. Public policy should support appropriate nurse staffing. The media plays an important role in how the opioid epidemic is portrayed generally, but when it comes to nursing care, it should accurately portray nurses' contributions to patients' wellbeing. We should all expect and require that nurses are in decision-making roles on professional and governmental bodies where their knowledge and expertise can be utilized to advance health. For example, the Department of Health and Human Services recently convened an expert panel to develop standardized NAS definitions. Just one of 19 panel members was a nurse. Despite nurses being on the frontline of COVID-19 care, President Biden's COVID-19 taskforce did not include nurses until a petition in November 2020 resulted in a single nurse being appointed....

Further reading:

National Center on Substance Abuse and Child Welfare: Neonatal Abstinence Syndrome

Caring for infants and families affected by neonatal abstinence syndrome

Neonatal Abstinence Syndrome (NAS) Toolkit

Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants  - able to download.

HRSA's Home Visiting Program: Supporting Families Impacted by Opioid Use and Neonatal Abstinence Syndrome

Video: Advances in Neonatal Care -EBP Brief on Eat, Sleep, Console

EATING, SLEEPING, CONSOLING NEONATAL ABSTINENCE SYNDROME CARE TOOL

 

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NRSKarenRN

About NRSKarenRN, BSN, RN

Home Health Columnist / Guide

NRSKarenRN has over 40 years of nursing experience specializing in bedside Adult Respiratory Care, Hospice, and over 30 years Home Health (HH) Visiting Nursing.

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Specializes in CRNA, Finally retired.

Thank you for your article.  As a CASA in family court, this is something we see often in newborns placed in foster care.  My last case before Covid ended happily when my little one was adopted by the original and only foster family she knew.  It took almost a year of gentle mothering and lots of MD visits but I got to watch her convert from a cranky, easily aroused infant to a confident and competent toddler. Parent visitation was a constant setback every week.  Mom was in prison and a sweet but totally incompetent father sued for custody but eventually, he lost.  So it isn't all doom and gloom!  Nuture works and nurses are the natural "best" practitioners to get these parents through the journey of that stressful first year.  We will just have to get more aggressive about advocating for ourselves in statehouses as well as in D.C.

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Subee, thanks for sharing your experience. 

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Specializes in NICU.
On 5/25/2021 at 8:27 PM, NRSKarenRN said:

Nursing care includes facilitating mother/infant bonding and parent education. There is a lovely reciprocity that occurs when we focus on fundamental nursing care first. By focusing first on bonding and the parent caring for the infant, less medication is needed.

The fundamental flaw in that approach is that the mothers barely come in to spend time with their infant. It is difficult to initiate mother/infant bonding if the mother is absent throughout the infant's hospitalization.

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