Standardized care and compassion are key to successful treatment.

Takeaways

• Evidence-based standardized protocols are needed to provide the best treatment for the mother-infant dyad and improve outcomes for infants neonatal abstinence syndrome (NAS) and mothers with substance use disorders.
• Nurses must increase their awareness, establish trust, and support mothers who frequently feel judged and stigmatized because of drug use.
• An infant’s recovery from NAS depends on positive attachment to a mother who is able to respond effectively to her infant’s needs.
• To improve outcomes for infants with NAS and the mothers of these infants, a broader healthcare perspective is needed that recognizes that NAS isn’t an acute medical condition but requires a multidisciplinary team care approach.

Opioid use disorder in the United States is a public health emergency not only for adults, but also for newborns. Infants exposed to opioids in utero and who exhibit withdrawal signs after birth are diagnosed with neonatal abstinence syndrome (NAS). According to Winkelman and colleagues, NAS incidence has quadrupled within the last decade; as of 2014, the incidence was approximately 14.4 cases per 1,000 births. More recent reports indicate that the incidence continues to rise, suggesting rates as high as 20 cases per 1,000 live births. Throughout the United States, at least one newborn is affected by NAS every 15 minutes.

The standard of care for newborns with NAS includes an environment that supports physiologic stability by offering comforting interventions such as holding, swaddling, and decreasing excessive stimulation. Infants who don’t respond to this care may require pharmacologic treatment, most commonly with morphine or methadone. Pharmacologic intervention is associated with significantly longer lengths of stay, increased hospital stay costs, and the potential for mother and baby separation.

Clinical effects

Newborns are incapable of experiencing the psychological or relational components that define addiction in adults, so they shouldn’t be described as addicted. Maternal use of various drugs (opioids, barbiturates, benzodiazepines, nicotine) individually or combined can lead to NAS; however, clinical NAS most commonly results from in utero opioid exposure. Anywhere from 55% to 94% of infants who are exposed to opioids in utero develop NAS.

NAS commonly affects the neurologic, respiratory, and GI systems. (See NAS signs.) Clinical signs vary for each infant and are based on several factors, including the type and amount of drug exposure, the time of last maternal drug use, and the drug’s half-life.

For example, signs of NAS from in utero heroin exposure typically begin within 24 hours of birth, while signs of withdrawal from methadone usually begin between 24 to 72 hours after birth and in some cases may not manifest until 5 to 7 days after. The length and extent of withdrawal signs vary. An infant exposed to a drug with a shorter half-life (for example, hydrocodone, which has an average half-life of 4 hours) may be safely discharged if no withdrawal signs occur by 3 days after birth. However, an infant exposed to a drug with a prolonged half-life (for example, methadone, which has a half-life of 19 to 41 hours) should be observed for at least 5 to 7 days. The lasting effect of drug exposure on signs of withdrawal is unknown. A study by Patrick and colleagues indicates that infants exposed to drugs with prolonged half-lives may have NAS signs for 4 to 6 months.

In addition to in utero drug exposure, genetics, sex, birth weight, gestational age, infant metabolism, maternal tobacco use, and exposure to other prenatal medications play a role in the development and severity of withdrawal.

Diagnosis

Diagnosing an infant with NAS requires an accurate history of the mother’s drug use (including the last drug used and the time of consumption) and evidence of withdrawal. A scoring system can be used to aid diagnosis. Points are assigned based on the severity of each sign, and the total score helps determine the treatment plan. No strong evidence exists that one scoring tool is superior to another; however, research shows that a standard approach to diagnosis and treatment using a scoring tool improves outcomes and is recommended by the American Academy of Pediatrics.

Finnegan NAS scoring system

The Finnegan NAS scoring system, developed in 1975, is the seminal and most common tool used to guide pharmacologic NAS treatment. Nurses evaluate infants every 1 to 4 hours, based on their age, and score them on the presence and severity of common withdrawal signs, including central nervous system, metabolic vasomotor, respiratory, and GI disturbances. Pharmacologic treatment is recommended for any infant who receives a score ≥ 8 on three consecutive evaluations.

The Finnegan tool is long and complex, but a simplified short form recently was developed as a more efficient option. The short form allows for rapid assessment with limited items for scoring; however, although simpler to use, limited evidence exists to validate its use.

Other assessment tools to guide pharmacologic NAS treatment include the 11-item Lipsitz Neonatal Drug-Withdrawal Scoring Sys­tem, the seven-item Neonatal Narcotic With­drawal Index, the seven-item Neonatal With­drawal Inventory, and the 19-item MOTHER NAS Scale. These tools haven’t been as widely adopted as the Finnegan tool.

Eat, Sleep, Console scoring tool

The new Eat, Sleep, Console (ESC) NAS assessment scoring method uses regular assessments of the infant’s ability to eat, sleep, and be consoled to determine the need for pharmacologic treatment. (See Eat, Sleep, Console.) Several studies of the ESC approach report decreased lengths of stay, less unnecessary exposure to pharmacologic treatments, and lowered care costs.

Treatment

The standard of care for infants with NAS, first described in the 1970s, includes holding, nonnutritive sucking, swaddling, pressure, rubbing, swaying, rocking, and reducing external stimulation. Infants with NAS who require hospitalization traditionally have been admitted to special care nurseries or the neonatal intensive care unit (NICU).

For babies who have persistent scores indicating withdrawal and who aren’t responsive to initial interventions, a typical pharmacologic treatment plan includes opioid administration (usually oral morphine or methadone). Approximately 50% to 80% of infants exposed to opiates in utero receive pharmacologic management.

In response to the rise in NAS incidence, recognition of its complexity, and the impact of social factors, such as education, socioeconomic status, and living situation (social determinants of health), evaluation and treatment are being revisited. Newer evidence-based approaches strongly recommend a comprehensive and holistic approach that includes addressing the mother’s psychosocial needs, evaluating the impact of social determinants of health, and taking advantage of community resources.

Challenges

Nurses encounter many challenges when considering appropriate evaluation, diagnosis, and treatment for infants with NAS.

Challenge 1: Rising incidence

Increased incidence of NAS has improved awareness and highlighted the number of healthcare resources required to care for these patients. Infants with NAS have complex physiologic and behavioral states that demand increased nursing care and unit resources. Nurses’ primary responsibility is to provide care and support for the infant, but they also must support the mother, who in addition to a history of substance use disorder also may have complex psychosocial situations that complicate her care of a newborn. To meet the needs of each infant with NAS and support his or her mother, appropriate nurse staffing and adequate support and resources for families are essential.

Challenge 2: Care variation

Care of infants with NAS varies widely because no consensus exists on the best diagnostic or treatment strategy. Variations in care and using a subjective, rather than objective, scoring tool increase the potential for unnecessary exposure to pharmacologic treatment. Lack of standardization, inconsistent care plans, and pharmacologic treatment are associated with longer lengths of stay, unnecessary separation of the mother and infant, and poor long-term developmental outcomes. Evidence of improved outcomes supports local improvement efforts that focus on standardizing care. (See Follow a standard.)

Challenge 3: Care complexity

Many women with a substance use disorder also experience mental illness, trauma, economic hardship, intimate partner violence, unintended pregnancy, and housing instability. Each of these circumstances complicate efforts to decrease and eliminate substance use during pregnancy and after birth and may negatively impact the NAS treatment plan. Caring for an infant is challenging even for healthy mothers with stable support systems, but those with a substance use disorder may have strained relationships with family and friends, leading to a lack of support as well as no access to transportation to receive care. These women also face significant social stigma within the community and healthcare system.

Training and education for healthcare pro­viders focused on the care of these women is limited, and perceptions are often negative. Such attitudes and unconscious (or conscious) bias reinforce stigma, contribute to inequi­table treatment, disempower these mothers, and decrease trust in healthcare providers, all of which are associated with poor mother and infant outcomes.

An infant’s recovery from NAS depends on positive attachment to a mother who can respond effectively to her infant’s needs. A mother’s ability to bond and respond appropriately is determined in large part by the type and quality of support she has. Healthcare teams must acknowledge existing biases and provide equitable and quality care that addresses and supports mothers’ complex social needs.

Challenge 4: NICU environment

Most infants who require hospitalization for NAS are admitted to the NICU, which frequently is loud and chaotic and may exacerbate signs of the condition. The physical space also usually separates the mother-infant dyad. A calm, nurturing environment conducive to mother-child bonding is best for infants with NAS.

Evidence-based care models facilitate concurrent care for mothers and infants and support rooming-in and breastfeeding. In NICUs that can’t support this model, other hospital units, including pediatric units, are used. Nurses on these units must be adequately educated to understand the needs of infants with NAS and mothers with a substance use disorder. Comprehensive, multidisciplinary supportive care, regardless of the hospital unit, requires resources such as breastfeeding support, social work, volunteer cuddler programs, and pharmacists.

Challenge 5: Social implications

To adequately address the social needs of infants with NAS and their mothers, nurses must collaborate with social workers, case managers, and community-based organizations. Syvertsen and colleagues propose a framework that considers NAS management a “cascade of care” that begins with prevention, prenatal care, and drug treatment for the mother, extends throughout hospitalization from labor and delivery to the NICU, and continues after discharge as the mother and infant transition to their home and community. This approach requires a multidisciplinary team that includes physicians, nurses, social workers, occupational therapists, and case managers who provide care to the mother and infant during the hospital stay and connect them with resources after discharge.

Intervention from state child protective services may be appropriate for some infants with NAS to ensure they’re safe and that their families have the necessary support to care for their new babies. Although some states still criminalize pregnant women with a substance use disorder, the American Academy of Nursing (and many other professional organizations) calls for an end to this practice and supports a public health response that provides care and support.

Nursing implications

Studies have identified the benefit of prenatal care screening and early intervention, but barriers to care may mean that NICU and other nurses are the first sustained contact that mothers of infants with NAS have with the healthcare system. Nurses have an opportunity to encourage and facilitate integrated, comprehensive, multidisciplinary care; establish trust; empathize with mothers to increase maternal-infant bonding; understand the context of substance use and effective treatment strategies; and encourage harm reduction. (See 3 key takeaways.)

Achieving these outcomes requires education for nurses and self-reflection about substance use assumptions and biases.

Education

Nurse distress and frustration when caring for infants with NAS frequently is linked to lack of knowledge and understanding about mental illness and substance use, as well as the accompanying social complexities (poverty, homelessness, and trauma). Organizations should offer education that helps nurses build trusting partnerships with mothers with mothers affected by substance use disorder.

Self-assessment

Nurses can prepare to care for infants with NAS and their mothers by examining any implicit biases they may have about substance use that might affect their ability to develop rapport and establish trust. Substance use disorders frequently are linked to trauma, and nurses must provide care that acknowledges the trauma and safeguards against it.

Similar to the universal precautions approach, nurses should assume that all parents of NICU patients have a history of trauma and then seek to understand and address their psychosocial needs. This approach decreases the potential for bias and ensures more consistent care. It also allows for understanding when mothers of infants with NAS show signs of defensiveness, anger, and frustration, and why a mother might be absent, distant, or depressed. Viewing each mother’s behavior through this lens creates an opportunity to gain understanding of her broader life circumstances and to address the barriers and challenges she faces to provide a stable and secure home environment. This understanding allows for the provision of equitable care and the ability to identify appropriate support and resources.

Foster respect and compassion

Providing standardized care for infants with NAS must be accompanied by equal care and support of the mother. Fostering a respectful and compassionate environment and establishing a nonjudgmental, trusting relationship with mothers will help them learn to interpret and manage signs of NAS in their infants.

Nursing assessment and critical thinking skills are instrumental to recognizing signs of infant withdrawal and facilitating diagnosis and treatment. Nurses should collaborate with hospital leadership, community partners, and elected representatives to advocate for policy change that supports and protects infants with NAS and their mothers and facilitates better access to care and resources related to substance use disorders. (See Nursing best practices.)

Elizabeth Schierholz is a neonatal nurse practitioner at Children’s Hospital of Colorado in Aurora, and a research fellow in data science to patient values at the University of Colorado School of Medicine in Aurora. Rachel French is a predoctoral research fellow at the University of Pennsylvania School of Nursing in Philadelphia. Anne-Marie Boucher is a neonatal nurse practitioner at C.S. Mott Children’s Hospital in Ann Arbor, Michigan.

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