Presentation on theme: "Dixie L. Morgese, BA, CAP, ICADC"— Presentation transcript:
1Dixie L. Morgese, BA, CAP, ICADC Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other DrugsDixie L. Morgese, BA, CAP, ICADC
2Learning Objectives Identify terms associated with SENS Learn common symptoms of drug exposed babiesLearn appropriate therapeutic handling of drug exposed newborns and babiesUnderstand scoring guide for babies with Neonatal Abstinence SyndromeUnderstand fundamentals of conducting an Infant AssessmentIdentify techniques for managing withdrawal
3Terms SEN – Substance Exposed Newborn CDN – Chemically Dependent NewbornNAS – Neonatal Abstinence SyndromeNAS* - Neonatal Abstinence ScoringFASD – Fetal Alcohol Spectrum DisorderFAS – Fetal Alcohol SyndromeWIS – Women’s Intervention SpecialistFIS – Family Intervention SpecialistATOD – Alcohol, Tobacco and Other DrugsCNS – Central Nervous System
4Terms Hyperreflexia – Overactive reflexes – response to stimuli “Moro” Overstimulated – “overwhelmed” by stimulusPhiltrum – vertical groove on the median line of the upper lip.Feeding intolerance – inability to suck, swallow or retain feedings.
5TermsDrug 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.
6CNS Substances Children of mothers who used drugs: Stimulants – risk of preterm labor and abruptionDepressants – alcohol most damaging*Opiates – increasing numbers of casesMarijuanaHallucinogensTobacco* - low birth weight, SIDSVarying responses, particularly during infancy. Prognosis for other drugs is better than with FAS depending on term of pregnancy and environment.
7Common Symptoms The drug that the baby was exposed to 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 toHow each individual baby metabolizes the drugThe baby’s own toleranceNo two babies will react exactly alike. It is the responsibility of the caregiver to carefully monitor and “read” the infant and the signs.
8Hypersensitivity to Stimuli One of the most common traitsLittle tolerance to stimuliSwallowing, closeness, sound, can escalate baby into “frantic” stateBabies need protection from overstimulation but should not be stimulus-deprived.
9Changes to Muscle Tone Muscle tone is the degree of stiffness Unusually limp or unusually stiffParticularly in limbs and neckStiffness may “come and go”Tremors, jerking, other signs of distress – sign of baby trying to control uncomfortable sensations.
10Gastrointestinal Problems Drugs attack gastric system – 12 mosWatery stool, explosive diarrhea, excoriated buttocks, gas, constipationNeed proper handling to prevent serious health concernsDistress and high stimulation can increaseDiarrhea can irritate fragile lining of the intestines and also lead to dehydration.
11Other Related Complications Chronic Ear InfectionUnexplained fever (opiates and opioids)Sleep/wake irregularityExtreme appetite (barbiturates)Hyperreflexia/Moro
12Therapeutic Handling Caregivers need appropriate training Comforting techniques are critical to management of withdrawing infantsEach type of drug exposure presents unique challengesBasic principles of handling apply to all
13Eight Principles Swaddling C-Position Head to Toe Movement Vertical RockClappingFeedingControlling the EnvironmentIntroducing Stimuli
14Principle #1 SwaddlingDrug exposed infants cannot do three things simultaneously – body, breathe, suckSwaddling provides comfort in helping them to control their bodiesAllows them to focus on breathing – then feeding with greater comfort.
15Principle #2 – C-Position Increases sense of control and ability to relaxHold baby firmly and curl head and legs into a CWhen laying down – place on side, wrap blanket into a role around body.Then introduce back position for sleeping as recommended by Academy of Pediatrics.
16Principle #3 “Head to Toe” Back and forth motions not recommendedSlow, 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.
17Principle #4 Vertical Rock Best when baby is frantic and hard to calmMaintain 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.
18Principle #5 – “Clapping” Cup handClap/pat baby’s blanketed bottomClap slow and rhythmicallyBaby’s muscles may start to relaxThis technique does not work with all babies – if baby does not respond, discontinue.
19Principle #6 - FeedingWithdrawal may adversely affect sucking – babies may suck frantically or have disorganized suckMakes it difficult for them to take in enough formula or to breastfeedThe key is to get baby relaxed enough to suck steadily in a low-stimulus environment.Baby should be swaddled and in C-position
20Principle #7 – Controlling the Environment Limit number of caregiversOffer calm surroundingsMinimize any loud noise – music and voices should be low volumeKeep lights lowCaregiver should have calm presenceRoutine is beneficial
21Neonatal AbstinenceNeonatal Abstinence – term given to the condition of an infant born to a drug affected mother – withdrawalWithdrawal – set of symptoms as the body attempts to remove an addictive substanceMust be accurately assessedMay be controlled by using therapeutic measures and often medication
23Neonatal Abstinence Scoring Determines the level of therapeutic intervention necessaryHelps to determine the effectiveness of interventions being usedAssesses symptomsOriginally developed by Loretta Finnegan
24NAS Scoring Tool Set of observed signs and symptoms in the infant Observed at regular intervals – every 3 hoursShould reflect all symptoms observed since the last scoringHigh scores that are not lowered by therapeutic handling should be assessed for medical intervention
25MedicationMedication is likely to be initiated in the following instances:NAS scores greater than 10 on 3 consecutive scoring intervalsThe average of 3 consecutive scores is greater than 10The score is greater than 12 on 2 consecutive scoresThe average of 2 consecutive scores is greater than 12
26Medication and NAS Scores Tapered down based on NAS scoresRemains below 10 and infant tolerates medication decreases wellMedication can be decreased as quickly as 10% per dayAfter medication discontinued, NAS scoring should be continued for at least five days,
27Tools Needed NAS Score Sheet Watch or clock with a second hand ThermometerStethoscope
28Central Nervous System Disturbances System Signs & Symptoms ScoreExcessive High Pitched ( or other) cry 2Continuous high pitched (or other) cry 3Sleeps < 1 hr after feeding 3Sleeps < 2hr after feeding 2Sleeps <3 hr after feeding 1Hyperactive Moro Reflex 2Hypersensitivity 3Markedly hyperactive Moro Reflex 3Mild tremors disturbedModerate-Severe tremors disturbedMild Tremors UndisturbedModerate-Severe tremors UndisturbedIncreased muscle tone 2Excoriation (specific area) 1Myoclonic jerks 3Convulsions/Seizures 5Central Nervous System Disturbances
29Assessment of the Infant CryingSleepMoro ReflexTremorsIncreased Muscle ToneExcoriationMyoclonic JerksGeneralized Convulsions/ Seizures
31Assessment Sweating – forehead, upper lip, back of the head* Fever – auxiliary tempFrequent Yawning – more than 3 per intervalMottling – “marbling” discoloration*Nasal Stuffiness – noisy respirations due to mucousSneezing – more than 3 times per intervalNasal FlaringRespiratory Rate – normal: breaths per minute
33Gastrointestinal Disturbances Disorganized SuckExcessive SuckingFlatus – more than 3 hrs at a timePoor Feeding – minimum intake amount takes longer than minsRegurgitation – 2 or more episodes during feeding (not associated with burping) or more than cc’s or more between feedingsProjectile Vomiting – forceful ejectionLoose Stools – liquid or explosiveWater Ring Stools – substance and water ring surrounding substanceWatery Stools – liquidBlood traces in the stoolHypersensitivity – oral feeds, touch, sound, smell, energy levels, surroundings, light, eye, contact, movement above and beyond normal scope of withdrawals.
34Managing Initial Stages of Withdrawal Swaddle with cotton thermal receiving blanket.Curl infant body into C-positionDo not speak loudly into faceSway rhythmically (do not jiggle)Feed more frequently (due to calorie burning)Cotton products are a ‘must’ throughout withdrawal periodDo not remove clothes for increased temperature due to withdrawal
35Managing Infants During Withdrawal – 7 Steps #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
36Barriers Dependence Language/Culture – paradigm to a strength Fear of system/outcomesPartner – control or violence issuesTreatment access/residential availabilityFamily system/relationships and other childrenStressorsDepressionEconomic Limitations
37Systems of Care Medical – CHD’s, CMS, hospitals, physicians, midwives Treatment Centers – SMA, Haven House, DMTC – WIS, TOPWA otherEarly Steps – screening of childrenChild Welfare (DCF and Community Based Care) – legal, investigative, case management, wrap around services – use PNAHealthy Start – care coordination and linkage to additional resources.
38Other 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.
39Five Point ApproachIdentify 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.
40Follow UpIdentify 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.
41Points to RememberSEN 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.