Perinatal substance abuse: working with neonates and families

ACCORDING TO A NATIONAL survey on drug use during pregnancy, more than 5 percent of all neonates are exposed to illicit substancesin utero.1Five percent of births may not seem significant, but it represents 221,000 affected neonates each year. Cocaine and marijuana are the most frequently used illicit substances. In addition to illegal substances, we must also be concerned about the use of legal substances that can adversely affect the fetus—specifically, alcohol and tobacco. Annually, about 20 percent of fetuses are exposed to tobacco, which can adversely affect growth and result in an increased risk for low birth weight.1,2Additionally, approximately 20 percent of neonates are exposed to alcohol, a known teratogen.1,3

Neonatal drug exposure: assessing a specific population and services provided by visiting nurses

Historically, community health nurses have provided nursing services to infants who were exposed to licit and illicit drugs in utero and their mothers. The charts of 145 infants whose mothers had a history of drug and alcohol abuse and who were referred to a visiting nurse agency between 1988 and 1994 were reviewed for this study. Of the infants who were reported to have been exposed to drugs in utero, 69% were exposed to cocaine, 11% to heroin, and 6% to marijuana. The average age of the mothers was 26 years; 83.4% were single; 82.1% received Aid for Families of Dependent Children (AFDC); 92.4% were on Medicaid; and 95.9% were involved with child protective services. The most frequent nursing problems identified were (a) maternal-child attachment, (b) sleep patterns, (c) infant feeding, and (d) infant development. Nursing interventions included nutritional management, physical assessment, monitoring growth and development, and education in parenting skills. Fifty percent of the infants increased their weight by at least one percentile and 31% increased two percentiles. Resolution of nursing problems occurred in 50% of the cases.

Routine meconium screening versus drug screening per physician order: detecting the true incidence of drug-exposed infants

National statistics indicate that 11% of newborns are exposed to drugs of abuse in utero (Chasnoff, Burns, Schnoll, & Burns, 1985). From July through November of 1993, 0.2% (1/583) of infants in our hospital screened positive for exposure to drugs of abuse in utero, by blood and urine screens collected per physician's order. During the same 4 months in 1995, 0.2% (1/574) screened positive. In contrast, from July through November 1994, all newborns born at our institution were screened for in utero drug exposure using meconium samples; approximately 4.5% (22/493) were positive. Meconium screening of all infants, not just those per physician order, produced a dramatic increase in positive drug results. Of great concern in this study was that only two of the 22 mothers identified as having drug-screen positive babies during the 1994 meconium screening agreed to use rehabilitative services. This highlights the necessity of intervention through early educational programs stressing prevention.

Substance abuse: infant and childhood outcomes

Many children are born to women who consume drugs such as alcohol, cocaine, heroin, methadone, marijuana, and/or phencyclidine (PCP) during pregnancy. As a result, some children are growing up with both physical and developmental delays. Children with fetal alcohol syndrome have reported problems with growth, attention deficit disorder, and other medical problems. Impaired cognitive and neurologic functioning through the first 2 years of live has been documented for children exposed to methadone while in utero. Those children exposed to polydrug use including cocaine and marijuana seem to have difficulties with language development and verbal skills. Some of these deficiencies show improvement with early intervention and a nurturing environment, but in many cases the impairment continues throughout childhood. Because experimentation with drugs occurs at an early age, education related to drug prevention should begin early, possibly with school-aged children. Drug prevention education needs to be age and developmentally specific. The use of appropriate drug prevention strategies may help children make good decisions regarding drug use, especially during the teenage years when adolescent pregnancy may occur.

Born in the USA

How are newborn babies affected by their mothers' use of drugs nursed in specialist units the USA? A Nursing Times/Birmingham Hospitals Saturday Fund travel award allowed Karena Fellowes to find out.

Improving interactions between substance abusing mothers and their substance-exposed newborns

OBJECTIVE

To determine whether teaching comforting and interacting techniques within 24 hours of delivery to substance-abusing mothers will improve mother-infant interactions 48-72 hours after discharge.

DESIGN

An experimental three-group, random assignment, pretest-posttest design.

SETTING

Mothers attending a clinic serving a mostly indigent population.

PARTICIPANTS

Eighty-three women whose urine was positive for drug use were invited to participate. Sixty mother-newborn couplets completed the study.

INTERVENTIONS

Two observers, blind to the mothers' drug history, completed the Nursing Child Assessment Feeding Scale (NCAFS) of all participants within 24 hours of delivery. Mothers in the experimental group were given the intervention. The observers completed the NCAFS in the mothers' homes 48-72 hours after discharge.

RESULTS

At the home visit, couplets in the treatment group showed significant improvement in their total NCAFS score (F = 5.18; p = .008). When analyzed separately, only maternal scores showed a significant difference between the treatment and control groups at the home visit (F = 6.48; p = .0029).

CONCLUSIONS

Nurses, by demonstrating caregiving behavior, can help mothers recognize and respond to newborns' behavioral cues, thus enhancing mother-newborn interactions.

Adverse reactions to the withdrawal of opioids and benzodiazepines in paediatric intensive care

The aim of this study was to examine adverse reactions to the withdrawal of opioids and benzodiazepines among critically ill children. Although withdrawal reactions have been well documented in relation to substance abusers and their newborn infants, there has been little study of this phenomenon as an iatrogenic problem. We developed a graphical case study method for examining patterns over time, and applied this to five cases referred to us by the nursing staff of a 10-bed paediatric intensive care unit. A striking pattern of behavioural distress was clearly associated with the diminution of opioids and benzodiazepines. These adverse reactions were characterized by various combinations of inconsolable crying, tremors, jitteriness, irritability, gagging, vomiting, and feeding problems. These signs appeared as early as 1 h and as late as 24 h following a significant reduction in opioid and benzodiazepine infusion rates, sometimes following very short-term therapy. We elaborate an interpretation of this distress, in light of the multiple disruptions undergone by critically ill children, and conclude by outlining our recommendations for preventing/minimizing these adverse reactions.

Pharmacologic management of neonatal abstinence syndrome

Substance abuse among pregnant women has become a national health issue. As a result of the increase in maternal consumption of illicit drugs during pregnancy, many more infants are experiencing signs and symptoms of withdrawal during the immediate newborn period. In many instances, pharmacologic management is required to alleviate the signs and symptoms of withdrawal experienced by these infants. The article provides a review of the common drugs of abuse consumed by women during pregnancy, identifies the common signs and symptoms of infant withdrawal, describes the onset and duration of these symptoms, and discusses potential pharmacologic agents that can be used to treat infant withdrawal or neonatal abstinence syndrome.

Neonatal nurses' knowledge of and attitudes toward caring for cocaine-exposed infants and their mothers

The knowledge, attitudes, and backgrounds of 215 nurses employed in the nurseries of six hospitals were studied by means of a questionnaire survey. The nurses' attitudes toward the mothers of cocaine-addicted infants were found to be generally negative and/or judgmental and their knowledge to be low. More experience with nursing cocaine-addicted infants and greater acuity of the neonatal unit in which the nurse worked correlated with more positive attitudes toward the infants but not toward their mothers. Knowledge and attitude correlated positively with formal education, inservice education, and self-education, but the correlations were weak.

Examining the feasibility of hospital-based intervention for mothers and their drug-exposed neonates

PURPOSE

To examine the effects of an educational intervention that teaches specialized newborn, care to substance-abusing mothers.

METHOD

A quasi-experimental design included an educational intervention for a group of mothers whose babies had positive meconium stains for cocaine. Outcomes were to be assessed by the Brazelton Neonatal Behavioral Assessment Scale and Nursing Child Assessment Feeding Scale.

FINDINGS

Due to a change in the hospital's discharge policy resulting in early discharge, recruitment difficulties occurred.

CONCLUSION

The ramifications of this change in discharge policy are discussed.

Assessment and management of opioid withdrawal in ill neonates

Neonatal physical dependence on opioids occurs in two ways: (1) through passive exposure in utero from maternal ingestion of drugs such as heroin or methadone or (2) through the administration of opioids such as morphine, fentanyl, or methadone for analgesia and sedation in the NICU. This article provides a comprehensive review of the mechanisms of opioid tolerance, physical dependence, and withdrawal specific to the neonate. Particular emphasis is given to the assessment of iatrogenic neonatal abstinence syndrome in the ill neonate and to its prevention and management in the NICU.

Therapeutic handling techniques for the infant affected by cocaine

The effects of maternal cocaine abuse can be manifested in infants as physiologic, psychologic, cognitive, and developmental deficits. The effects of cocaine disrupt the sleep and wake cycles, which may cause the infant to be difficult to handle or unresponsive to parents or caregivers. Assessments of sleep/wake states and interventions to aid these infants are described. Cocaine-affected infants can also present with hypertonic or hypotonic muscle tone disorders. Interventions to improve muscle tone are included in the discussion.

Parent-infant interaction during perinatal addiction treatment

Studies of parent-child interactions during perinatal addiction treatment are needed to offer insights into the nature of child development outcomes for this population. A purposeful sample of 17 women in a drug and alcohol addiction treatment program and their infants was studied over the course of their first year in the program. The purpose of this naturalistic field study was to examine parent-child interactions during addiction treatment. The following research question guided the inquiry: What is the nature of parent-infant interaction during the first year in a perinatal addiction treatment program? This study combined grounded theory methodology with the quantitative methods of descriptive and differential statistics. Open-coding of interviews, field notes, and the treatment records followed grounded theory methodology. A time-sampling procedure was used to examine stability of interactions at the beginning of program participation, again when each infant was 6 months old, and when each infant was 12 months. Results are used to describe parent-child interactions across samples and over time. Chi-square procedures were performed on number of children in each family, length of time in the program, sobriety, and mutual enjoyment of interaction. A significant difference in interaction by length of time in the program (chi 2 = 7.0801, df = 1, p < .00) as well as in interaction by percent sobriety (chi 2 = 4.1538, df = 1, p < .04) was evident. Behaviors of the infants reflected the emotional tone and parenting responses of their mothers. Dyads whose interactions showed a pattern of mutuality were more likely to continue in the treatment program and to maintain sobriety. The ability of a mother to enjoy her infant seemed to be the one factor that made the most difference in child behaviors. Results can be used by clinicians to guide the choice of treatment approaches that support the parent-child relationship during addiction treatment.

Drug withdrawal symptoms in children after continuous infusions of fentanyl

The purpose of this research was to determine the extent to which critically ill infants exhibited signs and symptoms of narcotic withdrawal after receiving continuous infusions of fentanyl. The convenience sample consisted of 12 pediatric intensive care unit (PICU) patients under 25 months of age who received fentanyl infusions for at least 24 hours. Drug withdrawal symptoms were monitored using the Neonatal Abstinence Score Tool (NAST), which assigns a score to each behavior indicative of withdrawal. A score of 8 or greater indicates Neonatal Abstinence Syndrome (NAS). Scoring began 4 hours after discontinuation of fentanyl and was conducted once per hour for 8 hours. Six subjects had a NAST score exceeding 8; these infants frequently exhibited tremors with or without stimulation, increased muscle tone, insomnia, and increased respiratory rate and effort. There were significant correlations between fentanyl dosage and NAST score (r = .76, p < 0.01), between length of infusion of fentanyl and NAST score (r = .70, p < 0.05), and between chloral hydrate dosage and NAST score (r = .62, p < 0.05). These findings suggest the need for an observation protocol and a possible weaning regimen after fentanyl is discontinued.

The cocaine-exposed infant, Part I: Identification and assessment

The incidence of cocaine use among women of childbearing years is rapidly increasing. The identification and assessment of the cocaine-exposed infant provides a challenge to the nurse practitioner. This article, the first of two parts, describes identification and assessment techniques. Part two will discuss intervention and teaching methods.

The cocaine-exposed infant, Part II: Intervention and teaching

The incidence of cocaine use among women of child-bearing years is increasing at an alarming rate. Part I of this article described techniques for identifying and assessing the cocaine-exposed infant. Part II discusses techniques of intervention and treatment of these infants.

Perinatal substance abuse: assessment and management of the pregnant woman and her children

The use and abuse of alcohol and other drugs by women during the childbearing years continues to be an area of concern. Knowledge of the effects of drugs on the developing fetus and the child postnatally is essential for the NP. This report presents information on the assessment and screening of the pregnant woman who abuses substances. Interventions for mothers and children affected by perinatal substance abuse are also offered.

Deciding what to do when the patient can't speak: a preliminary analysis of an ethnographic study of professional nurses in the neonatal intensive care unit

The role of patient advocate is not easily implemented with infants in the neonatal intensive care unit because there is no way of knowing what the infant would wish to be done. Many of the nurse's actions are based on the concept of the "best interests of the infant." However, although widely used, this concept is rarely defined or described for the neonatal population. The purpose of this qualitative study was to identify themes related to the professional nurse's interpretation of the concept of advocacy. A case study design and inductive data analysis consisting of constant comparison and triangulation methodologies were used. This research resulted in multiple perspectives of a single phenomenon based on the similarities and differences in the nurse's perspective related to the concept of interest.