1. Dixie L. Morgese, BA, CAP, ICADC
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
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 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 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. Central Nervous System Disturbances
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
Moderate-Severe tremors disturbed
Mild Tremors Undisturbed
Moderate-Severe tremors Undisturbed
Increased muscle tone 2
Excoriation (specific area) 1
Myoclonic jerks 3
Convulsions/Seizures 5
Central Nervous System Disturbances

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

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

31. Assessment 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: breaths per minute

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

33. Gastrointestinal Disturbances
Disorganized Suck
Excessive Sucking
Flatus – more than 3 hrs at a time
Poor Feeding – minimum intake amount takes longer than mins
Regurgitation – 2 or more episodes during feeding (not associated with burping) or more than 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.

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. Managing 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

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!