What is Neonatal Abstinence Syndrome? Fifty years ago it was

What is Neonatal Abstinence Syndrome? Fifty years ago it was something that was almost unheard, but today it is a reality for nearly six infants out of one thousand births in Canada, that may not initially sound like very much, but that is triple what it was in 2003. NAS refers to a group of symptoms of substance withdrawal shown by an infant following separation from the mother’s placenta after birth. What is displayed by the NAS neonate is unpredictable, with each infant exhibiting different signs and symptom severity over time depending on what substance they were exposed to in utero (MacMullen, Dulsk& Blobaum, 2014).

NAS is not just a Canadian problem, with opioids use reaching epidemic levels across the world the incidences of infants being born with NAS is on a drastic and dangerous rise. Coinciding with this unfortunate reality is forced hand of health care to adapt to what they cannot change. The neonatal nursing role has had to evolve quickly to care for neonates affected by this epidemic, what are the benefits of adopting a universal approach to providing nursing care to infants with NAS?

Epidemiology

Canada has seen a drastic increase in neonates being born with NAS.

A study of the incidence of Neonatal Abstinence Syndrome in Canada and associated healthcare resource utilization found that cases of NAS in Canada tripled from 1.8 to 5.4 cases per 1000 live births, and all provinces studied, experienced significant increases overall. Predominantly Nova Scotia (eight-fold increase), Ontario and Manitoba ( five-fold increase), New Brunswick (nearly seven-fold increase), (Filteau, Coo,& Dow, 2018).

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With the observed drastic increase in births of NAS neonates, the financial impact on the health care system in Canada rises also. Costs associated with NAS neonates were 1.7 times higher in 2014 than they were in 2010 (Filteau et al., 2018). The surge in cost is due to the longer length of stay in the hospital for NAS neonates. What we have learned thus far in healthcare is that longer hospital stays do not equal better patient outcomes; this is also true for NAS neonates.

Clinical Manifestations/Finnegan scale

Neonatal abstinence syndrome occurs when the fetus is exposed to prolonged use of substances such as drugs or alcohol by the mother, transferred to the fetus through the placenta followed by abrupt discontinuation of fetal exposure when the infant is born (Raffaeli et al., 2017). What the neonate experiences following birth varies widely depending on what length of exposure and type of substance the mother used. NAS is associated with central and autonomic nervous system dysfunction and gastrointestinal disorders and life long lasting effects, though rarely fatal, NAS can cause substantial morbidity with varying degrees of disability such as cognitive and behavioural dysfunctions (Raffaeli et al., 2017). Common signs of withdrawal include tremors, difficulty feeding, hyperirritability and more see table one for a complete list of characteristic withdrawal symptoms and clinical manifestations (MacMullen et al., 2014).

Medical treatment for NAS is aimed at symptom management; the most common tool used to assess NAS is called the Finnegan Scale. The Finnegan Scale is a scoring system that rates infants on gastrointestinal symptoms, metabolic symptoms, respiratory symptoms and central nervous system symptoms shown in neonates experiencing withdrawal following birth, see table two for an example of a Finnegan Scale is a scoring system. Each symptom is rated numerically and then tallied up to create a score that is used to rate the severity of withdrawal, typically scores above eight are considered high and suggestive of neonatal withdrawal (Zimmermann, N?tzli, Rentsch,& Bucher, 2010). The Finnegan scale has been modified to several different versions over the years but still remains the most widely used NAS assessment tool. The biggest flaw with the Finnegan score is that it is based on human interpretation which can be ambiguous. Having a universal approach to nursing NAS can help reduce variables interfering with positive patient outcomes.

Nurse’s Role

NICU nurses are faced with a new reality as the opioid epidemic spills over to the most vulnerable in our society. A study in the Journal of Advances In Neonatal Care examined the reality NICU nurses now face “Almost all of the nurses described the “high-pitched, neuro screaming” that characterizes these infants. “Something has to hurt,” stated one nurse. “Something has to hurt for them to scream like they do.” The cry was so familiar to the nurses that they could “walk into the room and look at them and you know what their diagnosis is.”. (Maguire, Webb, Passmore, Cline, & Catlin, 2012 pg 5). Signs of withdrawal can be very traumatic to both the infant experiencing it and those tasked with caring for them. Being unable to console an infant can be difficult to comprehend or cope with. Nurse’s caring for NAS neonates often describe feeling burnt out. This haunting truth creates moral and ethical dilemmas daily for the nurses caring for NAS neonates. The challenge is to move past the diagnosis and see the goal, a healthy future for the infant and their family. Evidence now shows that improving the health status of both the mother and the infant and not just the infant alone creates the best long term outcomes (Casper, Arbour, & Ikuta, 2014).

The first step of the nursing role in caring for infants with NAS begins with the importance of early screening. Early Screening of pregnant mothers to identify high-risk factors such as drug and alcohol use, increases positive outcomes for infants with Neonatal Abstinence Syndrome. Recognizing drug and alcohol use with the pregnant mother early in the pregnancy leads to better and safer patient outcomes. Infants classified as exhibiting signs of withdrawal will be scored every three to four hours using a scoring system such as the Finnegan scale and then administered medications to help wean the infant from the substance.

Health teaching is so crucial to NAS nursing, studies have shown that maternal-infant dyad care approach is best practice (Casper, et al., 2014). Standardized nursing approach to involving parents in care and teaching them to understand their newborn’s needs based on behaviours displayed will achieve this. Reinforcing the mother’s actions when the mother has an accurate interpretation of her newborn’s behaviour is also critical. These interventions may help the mother develop confidence in her parenting skills (Casper, et al., 2014). The nurse is an advocate for not just the infant but to the family as well, helping the parents become confident in providing care to the infant is one way to accomplish this. The needs of a neonate born with NAS are at the core the same as a child born without it; they need love, support and nourishment. The way in which they receive their needs varies, however. Noise, lights and other environmental factors over stimulate and hinder withdrawal management progress. A universal nursing approach to tailored to NAS nursing care would be beneficial to NAS neonates, creating a unique approach to care and environment, understanding the differences in care delivery needs.

Nonpharmacological Interventions

Arguably the most crucial intervention and treatment tool for NAS, nonpharmacological care delivery methods make a drastic impact on NAS neonates and their outcomes. Nurse’s should consider initiating nonpharmacological interventions on an admission of a newborn with already identified exposure to substances, regardless of the need for pharmacologic treatments (Casper, et al., 2014). With the Finnegan scale which determines the need for the pharmacological interventions being widely accepted and well known in the field of maternity nursing there comes a need for a care model that is equally recognized and resourceful for determining the need for nonpharmacological care.

Recently, a new model called Eat, Sleep, Console (ESC) has been developed that focuses on the comfort and care of these infants by maximizing nonpharmacologic methods, increasing family involvement in the treatment of their infant, (Grisham, et al., 2019). Eat, Sleep, Console assess an infant on their ability to perform basic functions such as eating and sleeping. When activities of daily life are interrupted by NAS, often they are managed by medications using the Finnegan scale, but if a nurse uses ESC in conjunction with other methods of NAS care management, it can significantly reduce the use of as needed medications and shorten the length of stay in the hospital.

ESC focus on several different nonpharmacological approaches to be tried first before the use of medications are selected, for example, Grisham, et al., writes “Console—Determine whether the newborn can be consoled within 10 minutes. If not, nonpharmacologic interventions should be increased including a second caregiver making attempts to console the newborn. If the newborn remains inconsolable, this would be an indication that the newborn may need pharmacologic treatment and the medical team should be notified” , (Grisham, et al., 2019 pg 45).

Maternity nurses are often not experienced or trained in addictions; unintentional stigma passed to the mother may hinder the development of a bond between mother and child. Focusing on creating a nonjudgemental environment for care is vital to positive outcomes. Current standards for care delivery for NAS often results in separation from the mother causing impaired maternal-infant bonding and extended neonatal opiate exposure (Boucher, Harris-Haman & Zukowsky, 2017). Rooming-in is another example of a nonpharmacologic intervention that has been proven to decrease the need for pharmaceuticals. Rooming-in is when the infant receives care in the same room as the mother instead of the traditional NICU. Nurses are responsible for removing their preconceived notions and moving past the traditional care delivery to embrace the new science surrounding NAS. Doing so will achieve the best patient outcomes by supporting the mother-child bond, encouraging breastfeeding and a more holistic care approach that focuses on both the short and long term goals for the infant.

Goals

Goals of care for infants with Neonatal Abstinence Syndrome include both short and long term interventions. Short term goals include successfully weaning the neonate from the substance they were exposed to in utero, to achieve this a multidisciplinary team, as well as the parents, must work in unison. Nurses can help the infant accomplish the best possible outcomes by encouraging the parents to be an active participant in care planning and delivery. Examples of ways this can be accomplished would be promoting rooming-in and supporting breastfeeding. Studies have shown that mothers with NAS who breastfeed have increased self-esteem and greater confidence in handling their infant’s withdrawal symptoms (Crook, Brandon, Dowling, Thibeau,2017).

Long term goals are multifaceted; they include reducing the likelihood of long term morbidity associated with fetal substance exposure, heightening of mother-infant bond, social structure improvement, infant nutrition and increasing community awareness of the impact of NAS on health care (Raffaeli et al., 2017). Community follow up is essential to ensuring NAS infants continue to thrive after leaving the hospital. Nursing staff can advocate for the patients to be referred to outside support systems and community resources following discharge.

Discussion

Open dialogue surrounding addictions is beginning to be evident in society, media and news outlets are bringing to light the reality of drug use affecting people of all walks of life. Addiction does not discriminate, the poor, the rich, Caucasian, Native American, no race, colour or creed has not been affected by addiction at some point in the world, infants are no different..

Antepartum assessment and early intervention can help reduce NAS severity; examples of which are methadone drug replacement therapy for the mother. Methadone use under strict physician monitoring and administration is a safer option than unregulated or non-physician controlled opiate use.

Nursing care for NAS presents a complex set of social and moral issues. While dialogue is increasing among healthcare professionals about NAS, there is a lack of specific education and training provided to nurses regarding the care of these neonates. Many nurses felt role clashes between caring for the typical NICU neonate and caring for an infant with NAS (Romisher et al., 2018). Gaps in education for nurses caring for NAS, as well as conflict with the parents due to lack of understanding of addiction, and frustration towards the mother for using drugs while pregnant are just some examples of many factors that lead to inconsistencies in scoring withdrawal signs for the infant (Romisher et al., 2018). Further research and focus needs to be done as well on the importance of nonpharmacological interventions such as the Eat, Sleep, Console model that directly reduces the need for drug therapy. Additional exploration on whether preterm vs full-term babies must be scored using separate modified Finnegan scales as early studies have shown that preterm babies will have poorer responses and score higher despite not necessarily needing pharmacological intervention ( Zimmermann-Baer, et al., 2010).

Summary

In summary, creating a standardized approach to nursing NAS infants vs traditional NICU infants would produce the best short and long term outcomes as well as reduce the role conflict nurses report feeling while providing care. Care needs vary so too should the way in which we deliver care. Early introduction of nonpharmacological interventions has been proven to reduce the need for medication administration for NAS infants.

Addiction teaching for NICU nurses would work to decrease stigma and help break down barriers to a successful nurse-patient relationship as well as reduce inaccuracies in scoring NAS infants decreasing the need instances of pharmacological interventions. Mother’s who report feeling supported by the nursing staff were more likely to bond with the infant and feel confident in caring for their infants which is shown to shorten the length of stay in the hospital for the NAS neonate.

Holistic care delivery using a maternal-infant care dyad designed to specifically to NAS can help reduce the impact the opiate and addiction epidemic is having on the most vulnerable in our society, helping ensure a better future for the infant, the mother.