Essay: What are the effects of non-pharmacologic management in infants diagnosed with Neonatal Abstinence Syndrome?

Introduction
This essay will focus on the efficacy of using non-pharmacologic management of Neonatal Abstinence Syndrome (NAS) specifically, skin-to-skin contact (SSC) or kangaroo care (KC) as a means of minimizing the signs and symptoms of NAS in a baby I cared for. The effects on infants and mothers shall be explored. A reflection of current available literature for managing NAS in comparison to the current treatment for NAS in the neonatal unit I work will be included, and the barriers that inhibit skin-to-skin contact as a treatment plan. In accordance to the Nursing Midwifery Council (2015) code of ethics which states that nurses have a duty to respect and ensure people’s right to privacy and confidentiality, the baby will be referred to as ‘Jo’. To summarize I will conclude with a recommendation of how to further on nursing care of infants with NAS using non-pharmacologic management on a daily basis.
Reporting
According to Kocherlakota (2014) Neonatal Abstinence Syndrome (NAS) is a clinical diagnosis for newborns as a result of their mothers suddenly discontinuing taking misused drugs during pregnancy, at the same time suddenly discontinuing exposure of these substances to their unborn infant. The most common signs and symptoms are tremors (trembling), irritability (excessive crying), sleep problems, high pitched cry, tight muscle tone, hyperactive reflexes, seizures, yawning, sweating, fever, stuffy nose and sneezing, poor feeding, vomiting and diarrhea (Stanfordchildrens.org. 2019). I took over the care of Jo who was born in good condition at 36 weeks old, delivered via spontaneous vaginal delivery at home, and presented irritability with high pitch cry, hyperactive reflexes, sneezing and sweating. His reason for admission was prematurity, low birth weight, suspected sepsis, and suspected Neonatal Abstinence Syndrome. His mother’s history revealed positive for cocaine exposure. Jo was 12 days old at the time I was caring for him and he was given morphine every 6 hours. I already gave Jo his due dose of morphine at 12:00pm when suddenly after just an hour and half he started crying excessively, becoming hyperactive and sweating profusely. His respiratory rate and heart rate also started going higher than normal and his oxygen saturation went down. After witnessing this, the doctor was about to decide with his colleague whether to increase the dose of morphine or not. But the mother who heard this said no and proposed that she can calm her baby down without the need of any more drugs. I was about to change Jo’s clothes and nappy when the mom immediately unbuttoned her shirt and said she’ll do skin to skin contact with her baby. Amazingly, this intervention calmed Jo. He suddenly stopped crying, started relaxing and his observations became stable.
My reason for choosing this topic is to emphasize the need to implement the non-pharmacologic management of babies with Neonatal Abstinence Syndrome instead of just depending on the pharmacologic treatment alone. The incident where the mother instinctively did skin-to-skin shows that there is definitely more to learn with the mother and child bond that should be promoted.
It concerned me as the patient’s advocate, that although the decision to increase the drug dose would have calmed Jo, could have also led him to becoming more dependent on the morphine. So instead of weaning Jo from the morphine, it might have aggravated his signs and symptoms and prolong his hospital stay. It is alarming that as the signs and symptoms increases, the usual plan of care is to increase the dose of morphine. After the incident, I asked my senior staff colleagues what the hospital’s protocol for the management of babies with neonatal abstinence syndrome was. The answers they gave me were the usage of the NAS score chart from the time of admission, and this chart will be used to determine the dose and frequency of morphine to be given. I asked them if they also consider the mother as a standard of care to help with the management for example doing skin-to-skin contact (SSC). They told me it can be done sometimes but only if the mother is mentally and physically stable. However, in most cases they are under social worker or safe guarding supervision and therefore some are not allowed to visit their babies while others refuse to keep the babies.
Relating:
In order to understand the effects of non-pharmacologic management in infants with Neonatal Abstinence Syndrome NAS, as a nurse it is good practice to learn from literature of current evidence based practice used in managing the syndrome. NAS is a series of symptoms of a newborn resulting from the abrupt discontinuation of opioids used by the mother during pregnancy (Perltz, Gary, 2015). These symptoms are multisystem disorders that frequently involves the central nervous system (CNS), gastrointestinal system (GI), autonomic system and respiratory system (Hamdan, Zanelli, 2017). In line with this, the current management of care for babies with NAS are dependent on minimizing its symptoms in order to decrease hospital stay and promote normal well-being.
According to Maguire (2014) the management guidance for NAS that was first described in the 1970s that is still prevalent today has little empirical evidence. Although several researches are available, more evidence is necessary to confirm which interventions are more effective.
Pharmacologic treatment is available for NAS infants to alleviate the withdrawal effects for the infant to experience comfort and recover from physical dependence (Maquire, 2014). The American Academy of Paediatrics (2012) recommends opioids morphine and methadone as the first- line drug therapy for infants with opioid-exposed mothers, while the second-line therapy are sedatives specifically, phenobarbital for infants with withdrawal seizures and polydrug exposure. The Finnegan Score chart is currently the most common assessment tool used to evaluate the severity and effectiveness of the symptoms, and determines the dose of drug necessary for the treatment (Wiles, et al, 2015).
However, according to the research of Kocherlakota (2014) drug therapy is only required when (1) supportive therapy fails to control signs and symptoms, (2) withdrawal scores remain high, serious signs like seizures are present, and (3) when withdrawal is associated with severe gastrointestinal disturbances. If drug therapy is delayed, higher morbidity rate and longer hospital stay will result.
Moreover, since these drugs have complex withdrawal effects that still need further study, there is no uniformly accepted standardized pharmacological intervention for NAS (Kocherlakota, 2014). On the other hand, NAS is a complex condition with a significant variability in presentation for each infant diagnosed with the disease, and the onset of symptoms begins 24 to 48 hours after birth, and can last from 8 to 60 days (Wiles, et al, 2015). These findings then of current pharmacological treatment used for NAS are not guaranteed to be suitable or definite for all infants affected.
In the case Jo, no supportive therapy was applied when the doctor immediately started to decide to increase the morphine dose, and prior to the incident his withdrawal score chart was within the normal range. Jo did not even present any signs of seizures or gastrointestinal disturbances which would mimic the need to give more medication. The hospital I work in has no formal protocol of non-pharmacologic management specific for NAS infants; however, morphine is the drug given if the infant is exceeds the normal NAS withdrawal score chart limit, and if they’re positive for illegal drug exposure in their urine. Morphine maybe a recommended regimen according to the American Academy of Paediatrics that may alleviate withdrawal symptoms from the in-utero drug exposure, but at the same time it also has withdrawal effects that doesn’t always guarantee to improve their condition and still needs further study. With this, I believe doctors should emphasize the need of applying non-pharmacologic treatment first considering it is less harmful to the infant.
In literature, non-pharmacologic treatment is also available to infants with NAS. Although most clinical practice guidelines focus on pharmacologic treatment of NAS, according to Arora (2017) a researcher of Boston University ,non-pharmacological treatment are the first line treatment and crucial to recovery. Several of these treatment strategies of NAS have been adapted from standards set in the literature for treatment for preterm infants in the neonatal intensive care unit. It was discovered that preterm infants and infants with NAS share several similar vulnerabilities and early life obstacles, and these similarities include immature physiological development, extended hospital stays, additional requirements of extensive medical care, and limited direct contact with the mother after birth. The interventions used range from breastfeeding, non-nutritive sucking, swaddling, kangaroo care or skin-to-skin contact, and rocking promoting the parent-and-child bond (Maguire, 2014)
In a research done by Harris (2018), other hospitals provide music therapy, massage and non-oscillating water for the infants with the goal of lessening environmental stimulation. In his study, the central nervous system (CNS) is greatly affected; helping these infants have a non-stimulating environment will allow their CNS to function normally.
There is also another supportive treatment called “Rooming-in” which will allow the parents to have a private room and give the care their infant’s needs on their own. The goal is to promote parents and child bonding as a means of minimizing the symptoms (Harris, 2018). This intervention shows that parental presence provide important role to facilitate improvement of health (Allen et al., 2018). Evidently, infants with NAS who are roomed-in with their mothers have a 9-day shorter hospital stay and lesser dependence on medication as compared to babies with lesser or no parental presence according to a study done by the American Academy of Paediatrics (2012).
These supportive treatments can also be done in the neonatal unit I work in. However, starting from the time of the mother’s admission for delivery if the hospital is given information that the mother is revealed to have been taking illegal drugs, the gateway team takes control in deciding for the infant’s health and well-being ones born. If granted, the social service team will create a plan on how mothers can visit their babies; for instance with an allocated social worker. But the decision to keep their baby is as per court order. This is because the hospital follows the Nursing Midwifery Council (2015) code of ethics that states to keep to all relevant laws about mental capacity applied in the country practising, and make sure that the rights and best interests of those who lack capacity are still at the centre of the decision-making process. In infants with NAS, decisions will be under court order ensuring it will be for their best interest. Therefore, in the mothers’ absence, the nurses mainly provide the care. These include swaddling, cuddling, providing music therapy, and others. But in other cases, the social workers from the gateway team will provide these infants with trained foster moms that can take care of them. The good thing about the foster moms is that they can visit, swaddle and cuddle, and even do skin to skin contact (SSC) with the infants.
Nonetheless, with the incident that occurred with Jo when the doctor did not let the mother do a SSC first prior to deciding any medication orders, suggests that there are indeed barriers that need investigation in applying skin-to-skin contact as a non-pharmacologic treatment especially for cases of infants with NAS.
Firstly, one of these barriers is the mother’s presence. Because not all mothers are in good mental or physical state, the court will have to decide for the infant’s best interest and may not always allow mothers to visit the infant. According to Bridgeman (2017) these infants will be placed under Child Protection Register or sometimes called the ‘at risk register’ following the Children Act of 1989 to ensure they are in a safe custody and environment.
However, for Jo his mother was readily available at the time he became very unsettled. No medication was necessary to increase in dosage when Jo settled down after he experienced his mother’s touch from the SSC. The intervention wasn’t complex nor was it harmful. It comforted him, it reassured his mother, and a bond was established. It was easily done but it makes me wonder what other reasons could be stopping medical professionals in applying the intervention as a management.
In a systematic review, out of 1264 article publications, four frequent barriers for initiating SSC was discovered and these were issues with the environmental facility or resources, low awareness or idea about SSC, negative impressions and interactions with staff, and lack of help in assisting how SSC is done (Seidman, G., et, al, 2015). Unfortunately, I do agree that these can be true. As a staff nurse, there are times due to busy working and poor staffing conditions that I tend to overlook mothers who need help. I feel bad as well because when baby Jo became unsettled the first thing I had in mind was that Jo might be uncomfortable and needs a clean nappy and clothes, but I did not consider in letting the mother help with the situation. I can imagine how Jo’s mom would have felt when nobody was asking or consulting her for help when she is the mother. It’s bad enough that her baby got affected from a substance she was exposed to that she can’t do anything to make Jo feel better.
In a survey done by Cleveland and Bonugli (2017), they discovered that most mothers of NAS infants felt guilt and shame when observing their infants withdrawing. They also felt judged by nurses for having used illicit drugs during pregnancy. I believe these barriers should be cut down by empowering mothers to do what they can to help for example doing SSC. In this way, they will not feel as if they are left out in the picture.
Seidman et., al, (2015) proposes that the top enablers to practice SSC that includes ‘mother-infant attachment’ and ‘support from family, friends, and others. These findings suggest that if hospitals emphasize SSC in the management of NAS, not only will it benefit the infant but also the mother.
Reasoning:
Skin to skin contact (SSC) or Kangaroo care (KC) is a method of placing an infant naked under a mother’s bare skin most commonly on the chest that can take place soon after birth and should take place immediately after birth as it has been shown to have several benefits(Alenchery et al., 2018). In the scenario where the mother instinctively provided SSC suggests the need to explore the Importance of SSC as a calming measure for babies with NAS.
As defined earlier, infants with NAS have difficulties with sleeping, regulating body temperature, and communicating others in expressing needs. However, SSC aims at meeting these needs. In a study done by Ludington and Abouelfettoh (2015), it was revealed that continuous SSC of infants with NAS with their mothers led to a decreased NAS withdrawal score charts, and results were even more favourable for those infants who spent 3 or more hours of SSC. Originally, SSC was first applied in Borgia Columbia as a means of keeping infants warm due to incubator shortage in the 1970s (Arora, 2017). The method was found out to integrate rhythmic, thermal and sensory stimulation that help infants increase their ability in maintaining body temperature, stabilize cardiac function and improve sleep organization, resulting in increased quiet sleep and longer sleep cycles.
Skin-to-skin contact also reduces the amount of procedural pain on infants. In a pilot study done, 26 preterm infants who were in SSC for 15 to 30 minutes appeared to have a lesser autonomic pain response during a heel prick procedure as opposed to infants who were maintained in incubators (Cong et al., 2009). Infants with NAS should likewise have the same intervention as they are also subjected to several pain procedures as heel prick due to morphine administrations. The study shows that even short durations of SSC helps decrease stress that would initiate a big impact on NAS babies with disturbed neurological behaviors.
The intervention also aids in neurological development. In a research done by Ludington and Abouenlfettoh (2015), preterm infants who experienced SSC had better brain functioning than those infants placed in incubators. This is because SSC provides longer resting and calming environment and eliminates stress thus, brain development is better.
In terms of practicality, SSC is cost effective. It is inexpensive, readily available, and a non-invasive therapy that has become a standard in the US for newborns (Arora, 2017).
Nevertheless, the most important benefit SSC provides is establishing the parent and child bonding. Early SSC as soon as the infant is born facilitates in the development of mothering behaviors and newborn adaptation to extra uterine life as it gives mothers the sense of accepting the babies (Boyd, 2017). This is in line with the psychosocial benefits of SSC that includes increased bonding, observation time, and availability of the mother to provide for the needs of her baby. According to Harris (2018) SSC may improve the stigma surrounding drug addicted mothers who feel shameful, guilty, and distant from their infant. Mentioned as well in the article was a nurse from Cleveland who stated that one of the mothers told her she felt her baby was forgiving her as she was doing SSC. It was as if the feeling of guilt and shame was going away. At the same time, SSC also helps reduce postpartum depression. During the activity, oxytocin is released that decreases maternal anxiety and promote attachment (Fetters, Mcginnis, 2018)
These evidence-based findings have great benefits that need consideration to propose SSC as a standard treatment for NAS babies. The intervention not only helps the infant with NAS but also the mothers affected by the situation physically and emotionally.
(importance of skin to skin:benefits,challenges(if mom not ther))
Recommendation:
(Implications stopping moms on substance abuse to bond with babies)
To further increase my understanding I will be exploring on evidenced based studies on skin to skin on babies.>>> Henderson on importance of fam presence and baby needs
References:
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