Implementing Trauma-Informed Strategies for Mothers of Infants with Neonatal Abstinence Syndrome

PURPOSE

To improve outcomes of infants with neonatal abstinence syndrome (NAS) by implementing an evidence-based approach to care.

METHODS

An interdisciplinary team developed and implemented an educational module about the elements and principles of trauma-informed care (TIC) and standardized education on NAS for mothers with substance use disorder (SUD). The team collaborated with community behavioral health professionals to secure the services of a certified recovery specialist. Primary outcome measures of average length of stay (LOS) and admissions to special care nursery (SCN) for NAS infants were analyzed.

RESULTS

Following health care team education on TIC and implementation of the standardized NAS brochure, average LOS decreased significantly from 6.5 to 5.1 days from baseline period (January-December 2019) to the implementation period (February-June 2020; p = 0.03). There was no difference in SCN admission from the baseline period (February-June 2019) to the implementation period (February-June 2020). Referrals to certified recovery specialists did not change.

CLINICAL IMPLICATIONS

Education on the impact of trauma on new mothers with SUD can promote collaboration between them and the neonatal team. Standardizing education for new mothers of infants with NAS can help to engage families of infants with NAS and improve clinical outcomes.

Postpartum Nurses' Experience Caring for Infants With Neonatal Abstinence Syndrome

OBJECTIVES

In previous years, otherwise healthy infants with neonatal abstinence syndrome (NAS) in our hospital were transferred to the NICU and frequently treated with medication. Currently, infants with NAS room-in with their mothers and rarely require medication. We sought to understand the lived experience of nurses on maternity and well-newborn units caring for infants with NAS.

METHODS

We conducted focus groups of registered nurses on postpartum units at 2 hospitals using qualitative methodology. Themes were identified through consensus, and the focus groups were stopped when no new themes were identified.

RESULTS

Seventeen postpartum nurses participated in 5 focus groups. The following major themes emerged: (1) managing the expectations of parents of newborns with NAS, (2) current NAS protocol (positive aspects of rooming-in and challenges with withdrawal scoring tool), (3) inconsistencies in care and communication, (4) perceived increase in nursing workload on the postpartum unit, and (5) nurses' emotional response to the care of infants with NAS.

CONCLUSIONS

We highlight the perspectives of nursing staff on the well-newborn unit who were previously unaccustomed to caring for infants with NAS. With increasing numbers of infants with NAS and longer stays on the well-newborn unit, hospitals must prepare to better support staff and implement protocols that offer consistency in practice.

Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA

OBJECTIVE

To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS.

DESIGN, SETTING AND PARTICIPANTS

This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded.

METHODS

A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution.

RESULTS

Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively.

CONCLUSION

The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.

NEONATAL ABSTINENCE SYNDROME AND THE ATTACHMENT RELATIONSHIP

Approximately 4.2% of pregnant women consume illicit drugs during pregnancy (AIHW, 2011). Drug exposed infants are more likely to be born small for gestational age, be pre-term, and be admitted to special care or intensive care nurseries (AIHW, 2007).

Supporting women with substance use issues: trauma-informed care as a foundation for practice in the NICU

Infants with neonatal abstinence syndrome and their mothers require extended support through health and social service systems. Practitioners are interested in exploring innovative approaches to caring for infants and mothers. There is now compelling evidence linking women's substance use to experiences of trauma and violence. A significant shift in the fields of addiction and mental health has been awareness of the impact of trauma and violence on infants and children, women, their families, and communities. In this article, the current state of knowledge of trauma-informed care is reviewed, in particular for application to practice within the NICU. Trauma survivors are at risk of being retraumatized because of health care providers' limited understanding of how to work effectively with them. Recognizing the impact of trauma and implementing evidence-based trauma-informed practices in the NICU holds promise for improving outcomes for women and their infants.

Evidence-based interventions for neonatal abstinence syndrome

This review aimed to determine best nursing practice by systematically and critically reviewing the appropriate literature and expert guidelines. Using keyword and literature databases, over 480 journal titles were reviewed. Twenty-four articles and three expert guidelines were chosen. The majority of articles selected as evidence were Level IV--opinions of respected authorities based clinical experiences, descriptive studies, case reports, or reports of experts. Two articles were Level I-II--experimental studies. Results of the review showed that traditional supportive interventions also have a body of evidence for their use. Although there is much research regarding neonatal abstinence syndrome (NAS), the majority of future research needs to be at a higher level of evidence. Nursing applications include obtaining evidence for best practice through diligent searches of the literature and expert guidelines.

Experiences of mothers of infants with neonatal abstinence syndrome in the neonatal intensive care unit

OBJECTIVE

To describe the experiences of mothers of infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU).

DESIGN

Qualitative description.

SETTING

We recruited participants from community-based, out-patient, addiction treatment facilities in a large urban city in the southwestern region of the United States.

PARTICIPANTS

A convenience sample of 15 Hispanic, substance addicted mothers of infants with NAS participated.

METHODS

We conducted semistructured, individual, interviews and analyzed the data using qualitative content analysis. First, we analyzed the data independently and then discussed the themes until a consensus was reached.

RESULTS

We identified four themes: (a) understanding addiction, (b) watching the infant withdraw, (c) judging, and (d) trusting the nurses. The participants felt there was a lack of understanding concerning addiction that was particularly noted when interacting with the nurses. They shared their feelings of guilt and shame when observing their infants withdrawing. The participants felt judged by the nurses for having used illicit drugs during pregnancy. Feeling judged interfered with the participants' ability to trust the nurses.

CONCLUSION

These findings provide nurses with a better understanding of the experiences of mothers who have addiction problems and may lead to more customized nursing care for this high-risk population of mothers and their infants.

[Nursing management of neonatal opiate abstinence syndrome]

Caring for infants with neonatal opiate abstinence syndrome is a challenge for nursing staff. These infants are at high risk for many complications. Nurses should be aware of the influences on neonates of maternal opium addiction during pregnancy. This article discusses clinical manifestations of neonatal opiate abstinence syndrome, common assessment tools for neonatal abstinence syndrome, and a variety of medical treatments and nursing interventions. In order to obtain adequate medical care for the neonates and safely alleviate their neonatal abstinence system, nurses should develop a comprehensive discharge plan and seek community support for the neonate's family.

A model program: neonatal nurse practitioners providing community health care for high-risk infants

Perinatal drug exposure costs our communities millions of dollars each year in hospital fees and in services such as foster care, child protection, and drug treatment. Infants and their families in this group require substantial long-term health care and community resources. Neonatal health care providers should take an active role in developing and implementing home visitation programs to support early hospital discharge and continuity of care for these high-risk infants and their families. Neonatal nurse practitioners should prepare in the future to practice not only in secondary-- and tertiary--level neonatal centers, but also in follow-up clinics, long-term developmental centers, and the community This article describes a home intervention program delivered by neonatal nurse practitioners for high-risk infants and their mothers. The target population is infants exposed prenatally to drugs and/or alcohol.

Caring, chaos and the vulnerable family: experiences in caring for newborns of drug-dependent parents

BACKGROUND

Infants exposed to intrauterine drugs present a number of challenging features with which the new mother is faced. They can be irritable, unresponsive, and unpredictable. Available treatments require specialised neonatal care for the first four to six weeks of life; a critical time for the parent-infant attachment relationship to develop. Neonatal nurses have the opportunity to promote this development and ameliorate the effect of other developmental risk factors the baby is likely to experience.

OBJECTIVES

The aim of this study was to explore neonatal nurses' experiences of providing care to drug-exposed newborns and their parents throughout treatment for neonatal abstinence syndrome (NAS).

DESIGN, SETTING AND PARTICIPANTS

This study used interpretive methods by conducting group interviews with eight neonatal nurses in each of four Special Care Nursery Units in South-East Queensland, Australia.

RESULTS

Barriers to promoting the parent-infant attachment relationship were found to be both attitudinal and organisational. These barriers were significant, and were seen to impact negatively on optimal care delivery to this vulnerable population.

CONCLUSIONS

Unfortunately, the results of this study indicated that management of these babies and their parents is compromised by a range of attitudinal and organisational factors. There is a need to address these barriers to optimise care delivery and improve the way in which neonatal nurses impact on parent-infant relationships.

Follow-up of infants prenatally exposed to cocaine

Maternal cocaine use during pregnancy continues to be of great concern for health care professionals. Research in this area has increased as investigators examine the effects of prenatal cocaine exposure in the infant/young child. This paper will critically review the literature, identify the primary care needs of infants and young children with a known history of prenatal cocaine exposure, and present guidelines for the primary care practitioner to monitor the infant's physiologic and developmental sequelae during the first 3 years of life. Findings in the literature demonstrate inconsistencies in regard to the physiologic and developmental outcomes of infants/young children prenatally exposed to cocaine. Further research is warranted, as it is evident from studies that not all investigators are controlling for confounding variables such as poly-drug use, which is necessary in isolating cocaine's effects. Subtle effects, however, have been reported from well-controlled studies and, thus, particular attention needs to be paid to early identification and interventions by primary care practitioners to prevent negative health outcomes. The guidelines proposed assist the practitioner with a thorough and focused approach to assessing the physiologic and developmental effects that are currently known to occur in the infant/young child prenatally exposed to cocaine.

Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients

The purposes of this prospective repeated measures study were to: (a) describe the occurrence of withdrawal symptoms with the use of a standardised protocol to slowly taper opioids and benzodiazepines; and (b) to test the predictive validity of an opioid and benzodiazepine withdrawal assessment scoring tool in critically ill infants and young children after prolonged opioid and benzodiazepine therapy. Fifteen children (6 weeks-28 months of age) with complex congenital heart disease and/or respiratory failure who received opioids and benzodiazepines for 4 days or greater were evaluated for withdrawal symptoms using a standardized assessment tool. Thirteen children showed moderate to severe withdrawal symptoms a median 3 days after commencement of tapering. Symptom intensity was not related to prior opioid or benzodiazepine exposure, extracorporeal membrane oxygenation (ECMO) therapy or length of tapering. Children who received fentanyl in addition to morphine more often exhibited signs of withdrawal. This study demonstrated that significant withdrawal symptoms occur in critically ill children even with the use of a standardised assessment tool and tapering management protocol. The predictive validity and utility of the Opioid and Benzodiazepine Withdrawal Score (OBWS) was adequate for clinical use, but areas for further improvement of the tool were identified. Problems with the clinical withdrawal prevention and management guidelines were also identified. More research is needed to establish the optimal methods for prevention and management of iatrogenic opioid and benzodiazepine withdrawal in paediatric critical care.

Behavioral responses of substance-exposed newborns: a retrospective study

This study assessed the behavior of infants whose mothers had a drug history by using the Neonatal Behavioral Assessment Scale. Data were collected via retrospective chart review (N = 103). Urine testing was only reported for 66 mothers during pregnancy and at birth. Infants performed within normally expected ranges for all items, except consolability and self-quieting. These findings support the use of NBAS in assessing newborn behavior because the information gained assists the parent in providing a supportive care giving environment that will not only help the infant recover but also enhance interaction between infant and parent.

Prenatal cocaine exposure and neonatal/infant outcomes

Illegal drug use throughout the nation is a problem of epidemic proportion. Of particular concern is drug use among pregnant women. In most cases, these women have little hope of achieving a better life for themselves or their children. Illegal drugs, cocaine in particular, can have devastating effects on the neonate. These effects can last well into childhood and can exhibit themselves in academic, social, and family situations. Challenges for the neonatal nurse include early identification of these infants and use of available resources. This article addresses prenatal cocaine use and support services for drug-dependent women, effects of cocaine during the neonatal period, possible neonatal and infant outcomes, and implications for nursing practice.

Care of substance-exposed infants: the current state of practice in Canadian hospitals

Many practices related to care of infants exposed to drugs and alcohol during th e prenatal period have been developed on an anecdotal basis. There are few available research studies to validate these interventions. This study describes current practices used in daily care, discharge planning, and community support for drug- and alcohol-exposed infants, their families, and alternate caregivers in one country. A survey of Canadian hospitals with annual birth rates of greater than 500 was conducted with a 51% return rate. Variations were noted in the perception of the importance of the issue of perinatal substance use, nursery care, discharge planning, and community support. Nurses are encouraged to consider these results within the context of their own communities to evaluate and develop standards of practice for substance-exposed infants and their families and caregivers.

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.

Teaching Infant CPR to Mothers of Cocaine-Positive Infants

Cocaine abuse, a major problem in our society, has increased in women of childbearing age. Because cocaine-positive infants are at greater risk for apnea/sudden infant death syndrome (SIDS), their mothers need to be instructed in infant CPR. This study compared the use of a computerized interactive video learning system to the traditional infant CPR teaching method (lecture, video, and return demonstration) to determine the most effective method. This study indicated that mothers of cocaine-exposed infants can learn infant CPR in the immediate postpartum period and that the traditional method was found to be more effective. One unexpected positive outcome was the increase in these mothers' self-esteem.