By Nadine Salmon, BSN, IBCLC, Clinical Content Specialist, AMN Healthcare
An unfortunate reality is that a percentage of expectant mothers abuse drugs, without considering the consequences. The effect of recreational drugs on fetal development have only been seriously studied over the past 30 years (Wang & Rosenkrantz, 2012), yet it is a growing problem that healthcare professionals (HCPs) should be trained to recognize and put into practice. Neonatal Withdrawal Syndrome (NWS), is a medical condition that can seriously impact the health behavior of a newborn. Therefore, it is important for HCPs to understand what NWS is and how to recognize it in newborns under their care (Coles, 2002).
According to Coles (2002), NWS (also known as NAS or Neonatal Abstinence Syndrome), occurs in newborns whose mothers abuse drugs during pregnancy. Only certain kinds of drugs cause NWS, particularly drugs that depress the central nervous system (CNS). The most common drugs associated with NWS are narcotics like heroin, methadone, morphine and other opiates, both natural and synthetic (Coles, 2002). Alcohol is also considered a depressant drug and is associated with newborn withdrawal. Understanding and recognizing the subtle signs and symptoms of NWS can make the first few days of life easier for the infant.
Drugs that are classified as "stimulants," such as cocaine and methamphetamine do not cause NWS because their action on the Central Nervous System (CNS) is very different. However, these types of substances can cause the newborn to develop a physical tolerance to the drug(s) (Coles, 2002).
The American Academy of Pediatrics (AAP) released an updated clinical report on neonatal drug withdrawal in February 2012. The report outlines the steps that clinicians can take to identify and monitor infants exposed to opioids and other drugs of addiction. The report also updates information from the medical literature about current treatment, options for neonatal opioid withdrawal. The report also highlights the need for further research to develop treatments that are safer and more effective, requiring shorter treatment periods and time in the hospital (AAP, 2012).
Intrauterine exposure to certain drugs may cause congenital anomalies and/or fetal growth restriction, increase the risk of preterm birth, produce signs of withdrawal or toxicity in the neonate, or impair normal neurodevelopment (Lester, 1998 in Wang & Rosenkrantz, 2012). Fetal exposure to marijuana, the illicit drug most commonly used by pregnant women, does not cause clinically important neonatal withdrawal signs, but may have subtle effects on long-term neurobehavioral outcomes (Ebrahim et al., 2003 in Wang & Rosenkrantz, 2012).
The modified Neonatal Abstinence Scoring System is the predominant tool used in the United States (Hudack & Tan, 2012). This tool assigns a cumulative score based on the interval observation of 21 items relating to signs of neonatal withdrawal. Infants at risk for NAS should be carefully monitored in the hospital for the development of signs consistent with withdrawal. These signs and symptoms may include irritability, hyperactivity, tremors, high-pitched crying and excessive sucking.
Initial treatment of infants who develop early signs of withdrawal is directed at minimizing environmental stimuli (both light and sound), by placing the infant in a dark, quiet environment; avoiding auto-stimulation by careful swaddling; responding early to an infant’s signals; adopting appropriate infant positioning and comforting techniques (swaying, rocking), and by frequently providing small volumes of high-caloric formula or human milk to allow for adequate growth (Hudack & Tan, 2012). The infant needs to be carefully observed to recognize early signs of fever, dehydration, or weight loss. The goals of therapy are to ensure that the infant achieves adequate sleep and nutrition to establish a consistent pattern of weight gain. Drug therapy may be indicated to relieve moderate-to-severe signs of NAS and to prevent complications such as fever, weight loss, and seizures if an infant does not respond to a committed program of non-pharmacologic support (Wang & Rosenkrantz, 2012).
Every NICU caring for infants with neonatal withdrawal should develop a protocol that defines indications and procedures for screening for maternal substance abuse (Wang & Rosenkrantz, 2012). In addition, each unit should develop and adhere to a standardized plan for patient evaluation and treatment.
American Academy of Pediatrics [AAP]. (2012). How Pediatricians Can Help Babies Exposed to Drugs. Retrieved from http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/How-Pediatricians-Can-Help-Babi es-Exposed-to-Drugs.aspx
Coles, C. (2002). Neonatal Withdrawal Syndrome. MSA Newsline, 2 (3). Retrieved from http://www.psychiatry.emory.edu/PROGRAMS/GADrug/Newslines/Neonatal%20Withdrawal.pdf
Hudak, M. & Tan, R. (2012). Neonatal Drug Withdrawal, Pediatrics 2012; 129; e540. Retrieved from http://pediatrics.aappublications.org/content/129/2/e540.full.pdf+html
Wang, M. & Rosenkrantz, T. (2012). Perinatal Drug Abuse and Neonatal Drug Withdrawal Differential Diagnoses. Medscape Reference. Retrieved from http://emedicine.medscape.com/article/978492-differential © 2012. AMN Healthcare, Inc. All Rights Reserved.
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