Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs

1. Handle With CareTherapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs Dixie L. Morgese, BA, CAP, ICADC

2. Learning Objectives • Identify terms associated with SENS • Learn common symptoms of drug exposed babies • Learn appropriate therapeutic handling of drug exposed newborns and babies • Understand scoring guide for babies with Neonatal Abstinence Syndrome • Understand fundamentals of conducting an Infant Assessment • Identify techniques for managing withdrawal

3. 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

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

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

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

12. 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

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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. Medication • Medication is likely to be initiated in the following instances: • NAS scores greater than 10 on 3 consecutive scoring intervals • The average of 3 consecutive scores is greater than 10 • The score is greater than 12 on 2 consecutive scores • The average of 2 consecutive scores is greater than 12

26. Medication and NAS Scores • Tapered down based on NAS scores • Remains below 10 and infant tolerates medication decreases well • Medication can be decreased as quickly as 10% per day • After medication discontinued, NAS scoring should be continued for at least five days,

27. Tools Needed • NAS Score Sheet • Watch or clock with a second hand • Thermometer • Stethoscope

28. System Signs & Symptoms Score Excessive High Pitched ( or other) cry 2 Continuous high pitched (or other) cry 3 Sleeps < 1 hr after feeding 3 Sleeps < 2hr after feeding 2 Sleeps <3 hr after feeding 1 Hyperactive Moro Reflex 2 Hypersensitivity 3 Markedly hyperactive Moro Reflex 3 Mild tremors disturbed 1 Moderate-Severe tremors disturbed 2 Mild Tremors Undisturbed 3 Moderate-Severe tremors Undisturbed 4 Increased muscle tone 2 Excoriation (specific area) 1 Myoclonic jerks 3 Convulsions/Seizures 5 Central Nervous System Disturbances

29. Crying Sleep Moro Reflex Tremors Increased Muscle Tone Excoriation Myoclonic Jerks Generalized Convulsions/ Seizures Assessment of the Infant

30. Metabolic, Vasomotor, Respiratory Disturbances

31. Sweating – forehead, upper lip, back of the head* Fever – auxiliary temp Frequent Yawning – more than 3 per interval Mottling – “marbling” discoloration* Nasal Stuffiness – noisy respirations due to mucous Sneezing – more than 3 times per interval Nasal Flaring Respiratory Rate – normal: 30-60- breaths per minute Assessment

32. Gastrointestinal Disturbances

33. Disorganized Suck Excessive Sucking Flatus – more than 3 hrs at a time Poor Feeding – minimum intake amount takes longer than 30-45 mins Regurgitation – 2 or more episodes during feeding (not associated with burping) or more than 5 cc’s or more between feedings Projectile Vomiting – forceful ejection Loose Stools – liquid or explosive Water Ring Stools – substance and water ring surrounding substance Watery Stools – liquid Blood traces in the stool Hypersensitivity – oral feeds, touch, sound, smell, energy levels, surroundings, light, eye, contact, movement above and beyond normal scope of withdrawals. Gastrointestinal Disturbances

34. Managing Initial Stages of Withdrawal • Swaddle with cotton thermal receiving blanket. • Curl infant body into C-position • Do not speak loudly into face • Sway rhythmically (do not jiggle) • Feed more frequently (due to calorie burning) • Cotton products are a ‘must’ throughout withdrawal period • Do not remove clothes for increased temperature due to withdrawal

35. #1 – Control Environment #2 – Learn baby’s cues #3 – Attempt to calm crying EARLY #4 – If difficulty regaining control –swaddle & vertical rock, #5 – Gradually introduce stimuli #6 – Gradually introduce AMOUNT of stimuli #7 As infant’s ability to remain calm increases, unwrap for short periods of time Managing Infants During Withdrawal – 7 Steps

36. 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

37. Systems of Care • Medical – CHD’s, CMS, hospitals, physicians, midwives • Treatment Centers – SMA, Haven House, DMTC – WIS, TOPWA other • 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. Questions?

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

44. Thank You!