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

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Presentation on theme: "Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs Dixie L. Morgese, BA, CAP, ICADC."— Presentation transcript:

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

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

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

4 Terms Hyperreflexia – Overactive reflexes – response to stimuli Moro Hyperreflexia – Overactive reflexes – response to stimuli Moro Overstimulated – overwhelmed by stimulus Overstimulated – overwhelmed by stimulus Philtrum – vertical groove on the median line of the upper lip. Philtrum – vertical groove on the median line of the upper lip. Feeding intolerance – inability to suck, swallow or retain feedings. 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. 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. Marchman Act – petition that supports legal remedy regarding evaluation and intervention. State Regulation – ability to adapt to external stimulation. State Regulation – ability to adapt to external stimulation.

6 CNS Substances Children of mothers who used drugs: 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 babys 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 One of the most common traits Little tolerance to stimuli Little tolerance to stimuli Swallowing, closeness, sound, can escalate baby into frantic state Swallowing, closeness, sound, can escalate baby into frantic state Babies need protection from overstimulation but should not be stimulus-deprived. Babies need protection from overstimulation but should not be stimulus-deprived.

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

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

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

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

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

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

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

16 Principle #3 Head to Toe Back and forth motions not recommended Back and forth motions not recommended Slow, rhythmic swaying following line from head to toe while swaddled and held in C position is comforting. 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. 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 Best when baby is frantic and hard to calm Maintain C position and hold directly in front of you and turned away. Maintain C position and hold directly in front of you and turned away. Slowly and rhythmically rock baby up and down – soothes neurological system. 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. Be aware of personal energy level – keep baby at a distance while rocking if necessary.

18 Principle #5 – Clapping Cup hand Cup hand Clap/pat babys blanketed bottom Clap/pat babys blanketed bottom Clap slow and rhythmically Clap slow and rhythmically Babys muscles may start to relax Babys muscles may start to relax This technique does not work with all babies – if baby does not respond, discontinue. 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 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 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. The key is to get baby relaxed enough to suck steadily in a low-stimulus environment. Baby should be swaddled and in C-position Baby should be swaddled and in C-position

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

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

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

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

24 NAS Scoring Tool Set of observed signs and symptoms in the infant Set of observed signs and symptoms in the infant Observed at regular intervals – every 3 hours Observed at regular intervals – every 3 hours Should reflect all symptoms observed since the last scoring Should reflect all symptoms observed since the last scoring High scores that are not lowered by therapeutic handling should be assessed for medical intervention 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: 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 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 NAS Score Sheet Watch or clock with a second hand Watch or clock with a second hand Thermometer Thermometer Stethoscope Stethoscope

28 System Signs & Symptoms Score Excessive High Pitched ( or other) cry2 Continuous high pitched (or other) cry3 Sleeps < 1 hr after feeding3 Sleeps < 2hr after feeding2 Sleeps <3 hr after feeding1 Hyperactive Moro Reflex2 Hypersensitivity3 Markedly hyperactive Moro Reflex3 Mild tremors disturbed 1 Moderate-Severe tremors disturbed 2 Mild Tremors Undisturbed 3 Moderate-Severe tremors Undisturbed 4 Increased muscle tone2 Excoriation (specific area)1 Myoclonic jerks3 Convulsions/Seizures5 Central Nervous System Disturbances

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

30 System Signs & Symptoms Score Sweating2 Fever > 101 ( F/ C) 1 Fever > 101 (38.4C or higher) 2 Frequent Yawning (3-4 times/interval 1 Mottling1 Nasal Stuffiness 1 Sneezing (>3-4 times/interval) 1 Nasal Flaring 2 Respiratory Rate>60/min 1 Metabolic, Vasomotor, Respiratory Disturbances

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

32 System Signs & Symptoms Score Disorganized Suck 3 Excessive Sucking 1 Flatus1 Poor Feeding 2 Regurgitation2 Projectile Vomiting 3 Loose Stools 2 Water Ring Stools 2 Watery Stools 3 Initials Initials TOTAL SCORE Gastrointestinal Disturbances

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

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

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

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

37 Systems of Care Medical – CHDs, CMS, hospitals, physicians, midwives Medical – CHDs, CMS, hospitals, physicians, midwives Treatment Centers – SMA, Haven House, DMTC – WIS, TOPWA other Treatment Centers – SMA, Haven House, DMTC – WIS, TOPWA other Early Steps – screening of children Early Steps – screening of children Child Welfare (DCF and Community Based Care) – legal, investigative, case management, wrap around services – use PNA 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. Healthy Start – care coordination and linkage to additional resources.

38 Other Possible Systems Legal – drug court, probation, child support enforcement. Legal – drug court, probation, child support enforcement. Workforce Development – economic self sufficiency for mother and partner. Workforce Development – economic self sufficiency for mother and partner. Child Care/ELC – respite, structure, stability. Child Care/ELC – respite, structure, stability. Others – Homeless Services, Domestic Violence support, HIV/TOPWA, Mental Health, Healthy Families, Insurance. 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. Identify key players – including and centering on the patient. Unify referral processes - identify the point person/entity. Unify referral processes - identify the point person/entity. Coordinate consent – Healthy Start screening form can support collaboration until further consent is obtained. 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.. Align policies and procedures – ensure systems have interagency agreements which delineate roles and responsibilities.. Utilize unified staffing forms. Utilize unified staffing forms.

40 Follow Up Identify additional staffing activities – establish dates, times. Identify additional staffing activities – establish dates, times. Key coordinator – typically case management or care coordination. Key coordinator – typically case management or care coordination. Ensure client completed referrals and verify subsequent appointments. Ensure client completed referrals and verify subsequent appointments. Prior to delivery, coordinate with hospital/birthing center. Prior to delivery, coordinate with hospital/birthing center. Provide documentation for pediatric follow up. Provide documentation for pediatric follow up. Identify who will provide ongoing education to the family. Identify who will provide ongoing education to the family. Establish family planning and interconceptional care plan. 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. 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. 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. Caregivers need to know how to handle SEN babies – ensure special instruction is provided and ongoing.

42 Questions?

43 Lets work together to keep them ALL safe, healthy, and happy!

44 Thank You!


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