Infants Exposed to Substance Abuse

8/10/2019 Infants Exposed to Substance Abuse

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K OS IR C HILD R EN S

N I C U

N o rt on S u bu rb a n H o sp it al

4001 Dutchmans Lane

Louisville, KY 40207

(502) 893-1000

N ort on Hea tth care 6 /11 KCH -46 00

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K O S IR C H ILD R E N S

NICU

N o rto n Suburban Hosp ita l

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r in for a Baby with

eonatal bstinence Syndrome

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Dear parents:

Thank you for entrusting uswith your baby's

care. Your baby will receive very good care

at Norton Suburban Hospital. This booklet

will address some of the questions you may

have about your baby and provide tips to

help you care for your baby while he or she is

recovering.

What to expect during your baby's

hospital stay

Your baby isbeing admit ted to the neonatal intensive care unit (NICU)

because he or she is withdrawing from drugs. This withdrawal is called

neonatal abstinence syndrome (NAS). Babies can become addicted to drugs

that the mother took while she was pregnant. Babies must be weaned slowly

from those drugs.

We understand that drug withdrawal is a sensitive issue. Our staff isnot

here to judge you. We are here to help your baby go through a safe and

medically supported drug withdrawal, which would not be safe to do at

home. Your baby may need medication to help him or her have an easier

time slowly withdrawing from the drugs.

To determine what medications are needed, your baby will get a score every

four hours based on his or her withdrawal symptoms. There is a list of 21

symptoms that nurses look for when scoring your infant. Wewill explain

these symptoms throughout this booklet.

Your baby will stay in the hospital until he or she does not need the

medication anymore and is well enough to be discharged.

All babies are different. No one, not even the doctor or nurse practi tioner,

knows exactly when your baby will be ready to go home with you. Drug

withdrawal can take as long as six to nine months. Your baby typically will

require medical t reatmentin the hospital for one to two months. Please talk

with your baby's nurse or caregiver ifyou have any questions.

Hospital chaplains and social workers can help you during this stressful

time. We also encourage you to ask family members or friends to help you

while your baby is in the hospital. We can help you best if you let us know:

Who you would like to receive information about your babys condition

when you are not at your baby's bedside

Who is it OK to talk in front ofwhen you are spending time with your

baby


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You are the most important person in your baby's li fe. We want you to

spend as much time with your baby as you can. It will help you get to know

your baby and help with bonding. Spending time with your baby also will

help you learn how to care for him or her.

We want you to understand that it is important for your baby to rest. Please

sit quietly by your baby's bed if he or she is asleep. One of your baby's

challenges will be getting restful sleep. It is important for you to participate

in your baby's withdrawal support by sit ting quietly rather than waking him

or her up.

Ways you can help your baby

Babies going through drug withdrawal need special care to keep them safe

and comfortable. It is important that you learn how to calm and comfort

your baby. This involves knowing how your baby is handled. You can help

your baby by using the t ips in this booklet and talking with your baby's

nurse about ways to calm and care for your baby.

Swaddling

Babies with NAShave a hard time doing different things at the same time.

They cannot focus on taking a bottle or sleeping ifthey are uncomfortable.

We can help your baby be calm by swaddling or wrapping your baby

snugly. This will help your baby control movements and provide comfort.

Babies and drug withdrawal

Babies who are withdrawing from drugs may act particularly different than

most newborn infants. These symptoms often begin within the first three

days after bir th. Sometimes withdrawal symptoms do not show up unti l

seven to 10 days after birth. Symptoms include:

Often crying for a long time

Being hard to calm

Having trouble sleeping

Tremors or being j ittery

Problems taking a bottle

The position

Holding your baby inthe C position will help him or her have more

control and be able to relax. Hold your baby securely and tuck the baby's

head and legs into a C shape. Your baby's chin should be resting near his

or her chest with arms near the center of the chest. Your baby's back should

be rounded with the legs tucked toward his or her bel ly.Wrap your baby

snugly in the blanket to help him or her s tay in this position. You also can

help your baby stay in the C position when laying him or her down. Jus t

place your swaddled baby on his or her side and use posit ioning devices

around your baby. Beginplacing your baby on his or her back for sleeping

as he or she slowly gets bet ter. The American Academy of Pediatrics

recommends this position when babies are sleeping to reduce the risk of

sudden infant death syndrome (SIDS).


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NAS

scoring

We must be able to correctly assess you babys symptoms due to drug

withdrawal. It will help us know how to take care of your baby. The NAS

scoring tool was created to make this possible. The NAS scoring tool is a

set of 21 signs and symptoms that your baby may have. We look at these

symptoms every four hours. Each symptom has a score, and the total of

these scores helps us plan the best treatment for your baby. This score is a

very important number. If the score is less than eight, your baby is having

an easier t ime with the drug withdrawal. Low scores tell us that your baby

may be weaned from the medications sooner. High scores tell us that your

baby is having a harder time with the drug withdrawal. I t means your baby

will be weaned slower from the medications and may stay in the hospital

longer. The score can change quickly from high to low. It also can change

from day to day.

Medication is started when your baby's scores are high and he or she does

not respond to the traditional comfort methods (as discussed earlier in this

hooklet) . Morphine, methadone and sometimes phenobarbital may be given

to your baby. The amount of medication isbased on your babys scores.

Medication is started when:

Three scores in a row are greater than or equal to 8

Two

scores in a row are greater than or equal to 12

Or, one score is greater than or equal to 15

Medications are increased/added until your baby's scores remain mostly

less than 8. We begin decreasing the medications 72 hours after your baby 's

average daily score is less than or equal to 8. (Your babys doctor or nurse

prncritioner wil l take al l the scores from the pas t 24 hours and average

111I:nl into one score t.ohelp determine when

wean your baby from the medicat ion.) It

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important for the scores to be correct.

YUill' babys nurse has been t rained touse this

f~l'l\l'lngoo l, Below is the set of symptoms

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h n b y : - ; nurse wi ll look for when scoring

yntll' I ll Ihy.

Assessing your baby's symptoms

E xc es si ve h ig h-p itc he d o r o th er ) c ry

Continuous or irregular crying for up to fiveminutes, even with attempts to

calm your baby. This symptom will be scored ifi t is observed in your baby.

Your baby will not be scored for excessive crying if i t happens right before a

feeding and he or she calms with the feeding.

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Continuous crying for more than five minutes, even with attempts to

calm your baby. This symptom will be scored ifi t is noted with your baby.

Newborn infants typically do not need to be held constantly to stay

calm or soothe themselves. We encourage you to hold your baby if it

helps to comfort him or her. We want you to understand that your

baby wil l be scored if he or she needs excessive help from you or

others to stay calm.

It is normal for a baby at two to three months of age to cry for a short

period of time as he or she learns how to soothe himlherself. I t isnot

necessary to pick your baby up as soon as he or she begins to cry because i t

can interfere with your baby's learning of this very important skill. However,

your baby should not be left. to cry for long periods of time without any

help. We do not score your baby for this type ofcry because it is different

from the excessive cry of a baby going through drug withdrawal.

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Sleeping

Sleeps less than one hour after feeding

Sleeps less than two hours after feeding

Sleeps less than three hours after feeding

Your baby will be scored based on longest length of time that he or she slept

during the scoring period. We do not score ifyour baby is disturbed by the

doctors, nurse practitioners or nurses for procedures or other reasons. The

doctors and nurse practit ioners won't wake your baby up for an assessment;.

they wi ll wait unt il the baby wakes up on his or her own.


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We want you to understand that newborns usually eat and then go

right to sleep.

They wake up when they need to eat again, which is around

three to four hours later. They will gradually begin to stay awake for longer

periods of time as they get older.

M o ra r efle x

This is a normal reflex that all babies are born with. We evaluate it by

gently lifting your baby slightly off the mattress by the wrists. The baby will

straighten his or her arms and move them out at the elbows.

The wrists go into a C shape. The arms then return to the chest in a

resting position. A baby may cry during this evaluation. It is important to

check this reflex when your baby is calm.

Hyperactive Moro

Your baby will be scored in this area ifhe or she

has a noticeable jitteriness of the hands during or at the end of the

Mora reflex.

Markedly hyperactive Moro

Your baby will be scored in this area

if jitteriness and jerking of the hand and/or arms or feet are noticed

during or after the reflex.

Tremors

Tremors and jitteriness are the same thing. They are involuntary movements

that are rhythmic and occur in the arms, legs, hands or feet. Some jitteriness

in sleep is normal and is not scored. Tremors are based on how severe they

are, from mild to severe. They also are scored depending on when they

occur.

Your baby will get a higher score if tremors are noticed when

he or she is not being disturbed.

In cre ase d m u scle to ne

Tone is the ability of the muscles to resist movement. Muscle tone is

assessed when your baby is awake and calm. Your baby is s cored for an

increase in tone when he or she has no head lag. It also is scored if your

baby is stiff or arching.

Sk in b re a kd own

Your baby's skin can break down when it is rubbed repeatedly against a

flat surface. Some areas of the skin that may break down include the chin,

knees, cheeks, elbows, toes and fingers. Your baby's bottom also can break

down because of frequent bowel movements.

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Myo cl on ic je rk s

These are involuntary spasms of the muscle. They are quick and jerky, and

do not last long. They can occur in the face, arms or legs. They may occur

as a single jerk or many jerks. They are different from tremors because they

are quick, jerky movements of one arm or leg. This symptom is scored if

your baby has them.

Sweat ing

This symptom is scored if there is wetness on your babys forehead, upper

lip or the back of the neck. It will not be scored if it happens because your

baby is swaddled snugly.

Fever

Your baby will be scored if his or her temperature is between 99F to

lOO.SF.

He or she will get a higher score if the temperature is higher

than 101F.

Your babys temperature is taken under the arm.

Gene ra l iz ed convu l si on s s e izu re s

Seizure activity is sometimes hard to notice. It can include:

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Quick movements of the eyes that your baby cannot control

Chewing

Rowing motion of the upper arms, or bicycling of the legs

Back arching

Fist clenching

Please let a nurse know if you see your baby doing any of these

things. The nurse will examine your baby to be sure he or she is OK.

Generalized convulsions/seizures are scored.

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Yawn ing

This symptom is scored ifyour baby has frequent yawning, which is more

than three times during the scoring interval.

Mott l ing

Mott ling is a change in the color ofyour baby's skin, making i t look

splotchy. It usually is seen on the chest, trunk, arms or legs. This symptom

will be scored if it is noticed with your baby. Mott ling also can be seen if

your baby is cold. Your baby wil l not be scored if mottled for this reason.

Na sa l s tu ffi ne ss

Nasal stuffiness occurs when the nostrils are partially blocked with mucus.

It usually causes noisy breathing. This symptom wil l be scored ifyour baby

has nasal stuffiness that persists after initial suctioning, even if it cannot be

seen.

Sneez ing

This symptom is scored ifyour baby sneezes more than three or four t imes

during the scoring interval.

Na sa l f la ri ng

Nasal flaring is the outward spreading of the nostrils during breathing. This

symptom is scored when it is seen in your baby.

R esp ir ato ry r ate

Babies normally breathe between 30 to 60 times every minute. A

retraction

is a sign that tells us your baby is working hard to breathe. He or she will

have a sucking in of the chest wall above or around the rib cage. Your baby's

breathing rate will be counted for a full minute when he or she is content.

Your baby will be scored in this area if he or she is breathing more than

60 times a minute.

Your baby will get a higher score ifhe or she also has retract ions while

breathing more than 60 times a minute.

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Ex ce ss iv e s u ck in g

Excessive sucking is what happens when your baby is sucking on the

nipple so strongly that there will be a need to break the seal to release it. It

also means sucking on a pacifier frantically or almost all the time between

feedings. Your baby will he scored if this activity is noticed.

Excess ive sucking does not always mean that your baby is hungry.

This can lead to overfeeding your baby. Your baby should eat

every three to four hours and use the pacifier for comfort between

feedings.

L oo se s to ols

This symptom will be scored ifyour babys stools are seedy or runny, unless

they are breast milk stools.

W a te ry s to ols

This symptom wil lbe scored ifyour babys stool is liquid and/or explosive.

Poo r f ee d in g

Your baby will be scored for poor feeding ifhe or she is not able to take the

amount needed within 30 minutes. Yourbaby wil l. use more calories than

he or she takes in when allowed to eat longer than 30 minutes. Using more

calories can lead to weight loss and possibly a longer hospital stay.A poor

feeding also is scored if your baby cannot take his or her bottle without a lot

ofhelp, such as:

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Chin/cheek support

Manipulating the

honk

Repositioning

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Changing your postt ton


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Vomiting

T his s ym pto m w ill b e s co re d if:

Y our b aby vo mits tw o o r m ore tim es during a feeding th at i s n ot

a ss o ci at ed w i th b ur pi ng

Y our baby vom its 5 cc or mo re b etw ee n f ee di ng s

Y ou r b ab y w ill re ceiv e a h igh er s co re if h e o r sh e fo rc efu lly v omits dur ing o r

a ft e r a f e ed i ng .

Introducing stimulation

Ba bi es n ee d s ti mul at io n f or h e al th y d ev el op men t.

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b ab y g oi ng t hr ou gh d ru g

w ith dr aw al n ee ds to h av e s ti mu la ti on i n s ma ll d os es. I t m ust o ccur w hen h e

or sh e is able to h andle it.

It

is best to go slo wly and try o ne th ing at a tim e,

l ik e i nt ro du ci ng l ig h t, s o un d, t ou ch , voice, et c. Y ou m igh t try to s ee h ow y our

b aby acts w hen h e or sh e is no t sw addled as snugly. T hen y ou m ay tr y g entle

r oc ki ng o r t al ki ng. S to p a nd sw ad dle y ou r b ab y ag ain if h e o r s he b eco me s

s tr es sed . I t w i ll tak e tim e a nd p atie nc e fr om y ou . W atc h fo r h ow y ou r b ab y

reacts and h is or h er cues. Y our b ab y w ill let y ou kno w w hat h e or sh e can

h andle. R each o ut to yo ur baby w hen h e o r sh e is ready and aler t, no t w hen it

is m or e co nv enie nt fo r y ou.

Babies recovering from

NAS

will tend to not make eye contact. Your

baby may only brief ly look into your eyes or gaze upon yonr face and

then turn away from you. This is normal. This does not mean your

baby is not bonding with yon. This will get better with time.

Going home

Tomake sure you have developed the skins needed to care for your

baby at home you will need to do an of the care for your baby in the

hospi tal for 24 hours before your baby can be discharged.

W e w a nt th e tra nslt lo u 1(1 hom e 10 h( it sm oo th one for you and y our b aby.

You r baby w il l he d is l ilO lrl .l l 1 when hr III she is complet ely wea ned from

th e medi cati on . Your

baby

may sttll bc very irri tab le at lim es due to drug

w ithdr awal.

ir runbiltty

[iucriucss and ex cessive s uc ki ng can c on tinu e fo r as

l on g a s s ix to ni ne mon th s. These symptom s can b e m anaged w ith th e com for t

m ea su re s t ha t were di scus sed in th e ways yo u c an h el p y ou r b ab y s ec ti on a t

t h e b eg in ni ng o f t h is b o ok le t.

You r baby w i ll b e f ol lo w ed u p i n a n eo na ta l d ev el op me nt al c li ni c a t le as t e ve ry

three m on th s du ring h is o r h er fir st y ea r o f l ife. T his is to ev alu ate h ow w ell

y ou r baby is m ee t in g h is o r h e r d ev el op men ta l m i le st on es .

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Infants Exposed to Substance Abuse

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