Maternity and Paediatrics 1

Practical Nursing Theory 302

Kim King/500059566

Arlene Bissette/PNUR2003

October 25, 2010

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Neonatal Abstinence Syndrome

Neonatal abstinence syndrome is described as a withdrawal symptoms experience by a

neonate that includes signs and symptoms of the central nervous system hyperirritability, body

tremors, gastrointestinal dysfunction and respiratory distress. Along with vague autonomic

symptoms that include yawning, sneezing, mottling and fever. This syndrome usually begins

within 72 hours, but may appear up to two weeks after birth. [ CITATION Pri05 \l 4105 ] This

happens while the fetus is in utero and is exposed to drugs such as opiates, amphetamines,

tranquilizers or multiple illicit drugs because these drugs cross the placenta barrier affecting the

fetus.

There are two major types of neonatal abstinence syndrome (NAS) related to prenatal

exposure, and postnatal abstinence syndrome related to secondary discontinuation of drugs used

for pain therapy in newborns. Fentanyl and morphine used for critically ill newborns would show

withdrawal symptoms that may occur after five days or more of continuous infusions.[ CITATION

Jaq10 \l 4105 ]

The neonatal abstinence syndrome and postnatal abstinence syndrome treatment would be the

same. A difference between the two is the neonatal abstinence syndrome is the most preventable;

however three percent of the 4.1 million women of child-bearing age who abuse drugs are

believed to continue drug use during pregnancy.[ CITATION Jaq10 \l 4105 ] With this fact I can see

the importance of education for women about neonatal abstinence syndrome (NAS). Another

problem arises with this population in how to deal with addiction to illicit drugs and how to stop

or prevent drug use during pregnancy.

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The pathophysiology of neonatal abstinence syndrome begins when an illicit drug substance

crosses from maternal to fetal circulation. What happens is the drugs will accumulate in the fetus

because of the immaturity of the renal function and the enzymes used for metabolizing drugs.

Therefore the distribution of the drugs happens at birth resulting in withdrawal symptoms.

Common signs and symptoms in neonatal exposed to opiates included low birth weight,

prematurity, and intrauterine growth retardation.

Mothers using methadone therapy for opiate addictions improve prenatal care and obstetric

outcomes but the infant still experiences withdrawal and the neonate is at increased risk fetal

distress, death, impaired growth, and risk of sudden infant death syndrome. Signs and symptoms

of neonates exposed to cocaine include hyperactive Moro reflex, jitteriness, and excessive

sucking. With behavioural issues there have been no findings between neonates that have been

exposed to cocaine and those who were not.

For moms that like their coffee or other caffeine substances the drug methylxanthine will

accumulate in the blood of breastfed babies. Smoking while pregnant; I always reflect on the

campaign advertisement of a pregnant woman smoking and the words come up in the ad, ‘At

least you can leave the room.’ The nicotine may reach fifteen percent higher in utero than the

maternal blood levels of an expecting mother. A side effect for the neonate is a lower birth

weight of about 150-250 grams from mothers that smoke cigarettes compared to a non-smoker.

Infants who have been exposed to tobacco have been found to be more excitable and hypertonic

and demonstrate more stress and abstinence signs.[ CITATION Jaq10 \l 4105 ]
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The neonatal abstinence syndrome does not happen with maternal use of marijuana. Other

factors associated with the use of marijuana include hypoglycemia, hypocalcemia, sepsis,

hypoxic encephalopathy, intracranial hemorrhage, and jitteriness.[ CITATION Jaq10 \l 4105 ] Effects

on the fetus depend on how much marijuana the mother would consume. With heavier users

intrauterine growth retardation was the greatest risk. Signs also include nicotine toxicity, such as

tachycardia, poor perfusion, irritability, and poor feeding. The neonates would be of smaller

weight, length, and head circumference but would catch up within the first year in each growth

category. Cognitive function would also be affected in the first five years.

Antidepressants during pregnancy also increase the risk of neonatal abstinence syndrome.

Signs and symptoms for the neonate consist of irritability, agitation, tremors, increased

respiratory rate, nasal congestion, emesis, and diarrhea.

Death is rare just from withdrawal alone but other combing factors of infection, prematurity,

and perinatal asphyxia may lead to death. Sudden infant death syndrome is the greatest risk

factor compare to infants with no exposure to opiates. Another risk factor for infants is a

compromised home environment with mothers that are drug addicted.

White women and Hispanic women had a lower rate of drug use than black women, but

cigarette smoking is higher with white women than any other race.
 Age is another contributing factor towards drug use with pregnant women aged 15-20 years

more likely to use illicit drugs than any other group of pregnant women. In this group teens of

15-17 years were the greatest risk for using illicit drugs.

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Infants that are suspected of having neonatal abstinence syndrome may exhibit any of the

following signs related to the body systems including:

 CNS dysfunction

o High-pitched cry

o Restlessness, with sleep duration less than 1-3 hours after feeding

o Hyperactive reflexes

o Jitteriness

o Tremors

o Hypertonia

o Myoclonic jerks

o Generalized convulsions

 Metabolic, vasomotor, and respiratory disturbances

o Sweating

o Fever

o Mottling

o Frequent yawning

o Sneezing (>3 times per interval)

 o Nasal flaring

o Respiratory rate greater than 60 breaths per minute without retractions

o Apnea

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 GI dysfunction

o Excessive (frantic) sucking or rooting

o Poor feeding

o Hyperphagia, usually associated with poor weight gain

o Regurgitation or projectile vomiting

o Loose or watery stools

 Alcohol-specific symptoms

o Withdrawal that presents within the first 24 hours of life is reported among infants

with the dysmorphic (birth defect) features of fetal alcohol syndrome.

o Neonates also exhibit irritability, tremors, seizures, opisthotonus(body arching

backwards until heels nearly touch the head), and abdominal distention.

 Lysergic acid (LSD) symptoms

o The effect of LSD on the fetus is clouded by the high incidence of polydrug

abuse.

o Withdrawal symptoms manifest as hypertonia, tremors, poor feeding, and

abnormal feeding patterns.

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 Other symptoms

o Nicotine may produce withdrawal symptoms in infants, including increased

excitability and hypertonicity.

o Caffeine withdrawal includes feeding difficulties, vomiting, excessive crying,

irritability, and poor sleep patterns. Onset of symptoms may occur as long as 5

days after birth and persist for weeks or months.[ CITATION Jaq10 \l 4105 ]

When identify this syndrome; collecting hair samples of neonate is useful in detecting

narcotics, marijuana, and cocaine. Blood and urine can also detect drug use but the result will

show only small amount of drugs in the system because the body of the neonate as already

started to metabolize the drugs. Meconium analysis is currently considered the best method for

detecting drug exposure in pregnancy. Reliable for detecting opioid and cocaine exposure after

the first trimester and can be used to detect a range of other illicit and prescribed medications.

[ CITATION Jaq10 \l 4105 ]

The mother’s lifestyle needs to be assessed for unsafe sexual practice and intravenous drug

use because of the risk of hepatitis B and C, and sexually transmitted diseases including human
immunodeficiency virus should be included in providing prenatal and hospital care for mother

and baby.

Medical treatment for neonatal abstinence syndrome involves the use of naloxone in the

delivery room. This is given to the neonate to prevent seizures from abrupt drug withdrawal but

may also be given to neonate whose mother just received a narcotic to assist in delivery of baby.

Maternity and Paediatrics 8

The primary treatment of NAS is the use of morphine administration this involves lengthy

hospital stays for neonate which can interfere with the natural bonding between mom and baby.

As a registered practical nurse when caring for a neonate with neonatal abstinence syndrome

the best practise would be to allow the neonate to feed, sleep, gain weight, and interact with care

givers. Assess daily for withdrawal, sleeping habits, feeding patterns, and weight gain. Reduce

excessive lighting, noise, unnecessary handling, and provide swaddling for settling neonate.

Provide high calorie formula with small frequent meals.

The education process has been limited in the hospital. Adequate resources and tools had not

been established for health care providers to learn about the processes in caring for families and

infants of the methadone program.[ CITATION Reg07 \l 4105 ] To decrease expecting moms’

anxiety levels it is helpful to give them a tour of the neonatal intensive care unit and let them

know about the possibility of a lengthy hospital stay. Mothers that are addicted to illicit drugs

and want to breast feed their babies need to be counselled about the drug entering into the breast

milk and that they should consider using formula. If money is a problem educate moms about the

local food bank as a good resource to get formula.

 Steps that should be taken by the community are to recognize who needs to get help with their

addictions. If we can get these moms to accept help and get them the care that they need there is

a decrease risk of fetal death or neonatal death. Make expecting mothers aware of methadone

clinics and how they [ CITATION Jaq \l 4105 ]can help them and also provide some extra

prenatal care. Postnatal care will involve in home visits with community health nurse and regular

physician appointments. I believe the only thing as a nurse is to be supportive of mother and

child with their needs.

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Neonatal Abstinence Syndrome Scoring Form

Table 1[ CITATION Jaq10 \l 4105 ]
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References

Belik, J. Neonatal Abstinence Syndrome Scoring Form. Neonatal Abstinence Syndrome Table 1.

Elsevier Science Publishers.

Jaques Belik, M. a. (1994-2010). eMedicine from Web MD. Retrieved 10 12, 2010, from

eMedicine: http://emedicine.medscape.com/article/978763-overview

Leifer. (2003). Introduction to Maternity and Pediatric Nursing. St. Louis: Saunders.

Ontario, R. N. (2007, January 30). Nurturing Neonatal Abstinence Syndrome . Retrieved October

21, 2010, from rnao.org: http://www.rnao.org/Page.asp?

PageID=122&ContentID=2381&SiteNodeID=397

Partnerships, P. H. (2005, February 25). Neonatal Abstinence Syndrome Guidelines. Retrieved

October 15, 2010, from nsw.gov.au:

http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_494.pdf