Substance Exposed Pregnant Women and their Babies

1. Substance Exposed Pregnant Women and their Babies Dixie L. Morgese, BA, CAP, ICADC

2. Premises • Every woman wants a healthy baby. • Every woman deserves a healthy baby. • Pregnancy is a finite period that can be the determinant for a child’s future. • Pre-pregnancy is the BEST time to address alcohol and drug use!

3. Learning Objectives • Identify three screening techniques for use with pregnant women who may be using alcohol or other drugs. • Gain an increased understanding of various classes of drugs and their effects on pregnant women, the developing fetus, and the newborn baby. • Identify five systems of care and their roles and responsibilities related to substance exposed pregnant women and their babies. • Learn a five point approach to effective multidisciplinary staffing and coordination.

4. Terms • SEN – Substance Exposed Newborn • CDN – Chemically Dependent Newborn • NAS – Neonatal Abstinence Syndrome • NAS* - Neonatal Abstinence Scoring • FASD – Fetal Alcohol Spectrum Disorder • FAS – Fetal Alcohol Syndrome • WIS – Women’s Intervention Specialist • FIS – Family Intervention Specialist • ATOD – Alcohol, Tobacco and Other Drugs • CNS – Central Nervous System

5. Terms • Hyperreflexia – Overactive reflexes – response to stimuli • Overstimulated – “overwhelmed” by stimulus • Philtrum – vertical groove on the median line of the upper lip. • Feeding intolerance – inability to suck, swallow or retain feedings.

6. Terms • Drug Endangered Infant/Child – a wide range of risk associated with exposure to alcohol and other drugs. • Marchman Act – petition that supports legal remedy regarding evaluation and intervention. • State Regulation – ability to adapt to external stimulation.

7. CNS Substances • Children of mothers who used drugs: • Stimulants – risk of preterm labor and abruption • Depressants – alcohol most damaging • Opiates – increasing numbers of cases • Marijuana • Hallucinogens • Tobacco* - low birth weight, SIDS Varying responses, particularly during infancy. Prognosis for other drugs is better than with FAS depending on term of pregnancy and environment.

8. Screening is IMPORTANT! • Find an approach that works for you. • Be non judgmental • Make it a routine part of care and conversation. • Know how to respond • Be positive • Follow up with other systems of care

9. The 5 A’s Framework

10. “5 A’s” • Ask about alcohol, tobacco or other drug use • Advise to quit – unless opiates/opioids are involved. If the woman is opiate/opioid dependent, gain consent and coordinate with health care providers. • Assess willingness to quit • Assist with support and referral • Arrange follow-up

11. Instruments Used for Screening • 5 P’s and 4 P’s Plus • CAGE AID • T-ACE

12. When Should You Screen? • Screening should be a routine part of care. • Look for physical and environmental indicators. (fingers, arms, eyes, paraphernalia, clothing, etc.) • Review life management issues. (personal hygiene, behavioral incidences, avoidance, etc.) • Use your senses and follow your instincts. • Intervene and Support – know what you will do next!

13. 5 P’s • Parents - Did any of your parents have a problem with alcohol or other drug use? • Peers - Do any of your friends have a problem with alcohol or other drug use? • Partner - Does your partner have a problem with alcohol or other drug use? • Past – Have you used alcohol or drugs in the past? • Present - In the past month, have you drunk any alcohol or used other drugs?

14. CAGE-AID • Have you ever felt you ought to cut down on your drinking or drug use? • Have people annoyed you by criticizing your drinking or drug use? • Have you felt bad or guilty about your drinking or drug use? • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? CAGE Source: Ewing 1984. CAGE-AID Source. Reprinted with permission from the Wisconsin Medial Journal Brown, R.L. and Rounds, LA Conjoint screening questionnaires for alcohol and drug abuse. Wisconsin Medical Journal 94: 135-140, 1995.

15. The T-ACE Questionnaire • TTolerance: How many drinks does it take to make you feel high? • A   Have people annoyed you by criticizing your drinking? • C   Have you ever felt you ought to cut down on your drinking? • EEye-opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? The T-ACE is considered to be positive with a score of 2 or more. Affirmative answers to the A, C, and E questions are each scored 1 point. A reply of more than two drinks to the T question is scored 2 points (Sokol et al. 1989).

16. How Do You Start the Conversation? • Be non-judgmental and build rapport. • Keep it Simple. • Use observable strengths. • When the door opens – be straight-forward. • Know your limitations. • Know your resources.

17. What Next? • Know your limitations and disclose them • Negotiate Consent for Release. • Develop a “short term contract.” • Be aware of timing and environment (conflict at home, day of the week, other children, etc.) • Seek supervision and coordination. • Consider resources and barriers.

18. Barriers • Dependence • Language/Culture – paradigm to a strength • Fear of system/outcomes • Partner – control or violence issues • Treatment access/residential availability • Family system/relationships and other children • Stressors • Depression • Economic Limitations

19. Systems of Care • Medical – CHD’s, CMS, hospitals, physicians, midwives • Treatment Centers – FADAA – WIS, TOPWA other – check directory. • Early Steps – screening of children • Child Welfare (DCF and Community Based Care) – legal, investigative, case management, wrap around services – use PNA • Healthy Start – care coordination and linkage to additional resources.

20. Other Possible Systems • Legal – drug court, probation, child support enforcement. • Workforce Development – economic self sufficiency for mother and partner. • Child Care/ELC – respite, structure, stability. • Others – Homeless Services, Domestic Violence support, HIV/TOPWA, Mental Health, Healthy Families, Insurance.

21. Five Point Approach • Identify key players – including and centering on the patient. • Unify referral processes - identify the point person/entity. • Coordinate consent – Healthy Start screening form can support collaboration until further consent is obtained. • Align policies and procedures – ensure systems have interagency agreements which delineate roles and responsibilities.. • Utilize unified staffing forms.

22. Follow Up • Identify additional staffing activities – establish dates, times. • Key coordinator – typically case management or care coordination. • Ensure client completed referrals and verify subsequent appointments. • Prior to delivery, coordinate with hospital/birthing center. • Provide documentation for pediatric follow up. • Identify who will provide ongoing education to the family. • Establish family planning and interconceptional care plan.

23. Points to Remember • SEN babies are at elevated risk for SUIDS – ensure family has safe sleeping environment. • Mothers at elevated risk for PPD or relapse – identify support system. • Caregivers need to know how to handle SEN babies – ensure special instruction is provided and ongoing.

24. Common Symptoms • There are characteristics and symptoms that drug exposed babies will have in common. The nature of these – their frequency and timing will depend on factors such as: • The drug that the baby was exposed to • How each individual baby metabolizes the drug • The baby’s own tolerance • No two babies will react exactly alike. It is the responsibility of the caregiver to carefully monitor and “read” the infant and the signs.

25. Hypersensitivity to Stimuli One of the most common traits Little tolerance to stimuli Swallowing, closeness, sound, can escalate baby into “frantic” state Babies need protection from overstimulation but should not be stimulus-deprived.

26. Changes to Muscle Tone Muscle tone is the degree of stiffness Unusually limp or unusually stiff Particularly in limbs and neck Stiffness may “come and go” Tremors, jerking, other signs of distress – sign of baby trying to control uncomfortable sensations.

27. Gastrointestinal Problems Drugs attack gastric system – 12 mos Watery stool, explosive diarrhea, excoriated buttocks, gas, constipation Need proper handling to prevent serious health concerns Distress and high stimulation can increase Diarrhea can irritate fragile lining of the intestines and also lead to dehydration.

28. Other Related Complications Chronic Ear Infection Unexplained fever (opiates and opioids) Sleep/wake irregularity Extreme appetite (barbiturates) Hyperreflexia/Moro

29. Therapeutic Handling Caregivers need appropriate training Comforting techniques are critical to management of withdrawing infants Each type of drug exposure presents unique challenges Basic principles of handling apply to all

30. Eight Principles Swaddling C-Position Head to Toe Movement Vertical Rock Clapping Feeding Controlling the Environment Introducing Stimuli

31. Principle #1 Swaddling Drug exposed infants cannot do three things simultaneously – body, breathe, suck Swaddling provides comfort in helping them to control their bodies Allows them to focus on breathing – then feeding with greater comfort.

32. Principle #2 – C-Position Increases sense of control and ability to relax Hold baby firmly and curl head and legs into a C When laying down – place on side, wrap blanket into a role around body. Then introduce back position for sleeping as recommended by Academy of Pediatrics.

33. Principle #3 “Head to Toe” Back and forth motions not recommended Slow, rhythmic swaying following line from head to toe while swaddled and held in C position is comforting. Keeping movement slow and rhythmic will help relax and settle the infant.

34. Principle #4 Vertical Rock Best when baby is frantic and hard to calm Maintain C position and hold directly in front of you and turned away. Slowly and rhythmically rock baby up and down – soothes neurological system. Be aware of personal energy level – keep baby at a distance while rocking if necessary.

35. Principle #5 – “Clapping” Cup hand Clap/pat baby’s blanketed bottom Clap slow and rhythmically Baby’s muscles may start to relax This technique does not work with all babies – if baby does not respond, discontinue.

36. Principle #6 - Feeding Withdrawal may adversely affect sucking – babies may suck frantically or have disorganized suck Makes it difficult for them to take in enough formula or to breastfeed The key is to get baby relaxed enough to suck steadily in a low-stimulus environment. Baby should be swaddled and in C-position

37. Principle #7 – Controlling the Environment Limit number of caregivers Offer calm surroundings Minimize any loud noise – music and voices should be low volume Keep lights low Caregiver should have calm presence Routine is beneficial

38. Neonatal Abstinence Neonatal Abstinence – term given to the condition of an infant born to a drug affected mother – withdrawal Withdrawal – set of symptoms as the body attempts to remove an addictive substance Must be accurately assessed May be controlled by using therapeutic measures and often medication

39. Neonatal Abstinence Symptoms(not exhaustive) Hyper-irritability Respiratory distress Gastrointestinal distress Sleep disturbances

40. Neonatal Abstinence Scoring Determines the level of therapeutic intervention necessary Helps to determine the effectiveness of interventions being used Assesses symptoms Originally developed by Loretta Finnegan

41. NAS Scoring Tool Set of observed signs and symptoms in the infant Observed at regular intervals – every 3 hours Should reflect all symptoms observed since the last scoring High scores that are not lowered by therapeutic handling should be assessed for medical intervention

42. New Concerns • High rates of prescription drug use and opioids in high doses may result in longer observation periods being required for NAS. • Home visitors and other support staff may be unaware of symptoms. • Misdiagnosis by health professionals who do not have history on mother.

43. Recommendations • Statewide data collection about nature and scope of the problem. • Staff development protocols for maternal and child support staff. • Policy changes to help medical staff better manage opiate/opioid dependent women during pregnancy. • Multi-disciplinary approaches to protocol development in medical, child welfare, child development, and substance abuse treatment disciplines.

44. Questions?

45. Let’s work together to keep them ALL safe, healthy, and happy!

46. Thank You!