Author: Goins, Maggie
Date published: July 1, 2010
Journal code: PDFP
In today's world, those working in health care know that careful screening of pregnant women and good prenatal care result in healthier babies by identifying those who may have a difficult start. Knowing the mother was taking prescription or illicit drugs can be helpful in the baby's first days. Sometimes, though, the mother denies her drug use and the baby shows signs of problems, of drug withdrawal.
Newborn drug withdrawal is known in the medical world as neonatal abstinence syndrome, or NAS. This is the physical process the baby goes through once not receiving a medication anymore. A baby going through withdrawal may have tense muscles, tremors, frequent sneezing/yawning/hiccups, sweaty and mottled skin, vomiting and loose stools, and may be very restless, often unable to stop crying frantically.
There are two causes for NAS: mother's prenatal drug use and drugs prescribed to the baby once born, such as fentanyl for pain control.
Withdrawal from Prenatal Drug Use
Sometimes a woman may have chronic pain due to an injury, and her doctor prescribes her an opiate such as oxycodone or Vicodin. Or a woman may be depressed or anxious and is prescribed a SSRI (selective serotonin reuptake inhibitor) such as Celexa or Zoloft.
Opiates and SSRIs are not bad medications. In fact, they are very helpful to many women, and not every baby has withdrawal symptoms because its mother took them. But, according to a 1998 American Academy of Pediatrics (AAP) Committee on Drugs policy statement, 55-94% of newborns exposed to opiates in utero will show signs of withdrawal at birth.
Withdrawal from Postnatal Drug Use
Babies who are born with an infection or breathing difficulties may need the help of a respirator for a while. As important as this may be to their recovery, the baby may be in some pain. And, just like a bigger person, a baby will be better able to handle the treatment that will make her well if she can rest comfortably. But unfortunately, once the baby no longer needs the pain medication, sometimes she experiences withdrawal symptoms once the medication stops.
Tests and Tools
According to the AAP, testing a new baby's urine for drugs gives many false positives. They recommend using the baby's meconium, the first stool made up of everything the baby swallowed in the womb. Not only does meconium testing show drug use, but also it identifies which drugs the mother took.
Obviously not all restless and fussy neonates are going through drug withdrawal, so one way to evaluate a difficult newborn for drug withdrawal is with the Neonatal Withdrawal Inventory (NWI). Neonatal nurse practitioner Carol Wallman uses this screening method routinely in her practice.
"The NWI has been researched and determined to be accurate, and I think it is an effective tool to use," she says. The NWI is a checklist of signs and symptoms done every 3-4 hours by the nurse taking care of the baby. A point system evaluates several of the baby's behaviors. A physician or nurse practitioner is called for a score of greater than eight out of 10 so that treatment may be decided.
Types of Treatment
Once a newborn has been determined to be going through drug withdrawal, treatment begins. The AAP recommends trying supportive care first. A baby with NAS can expend a lot of calories through constant crying, little sleep, vomiting, drooling or diarrhea.
Supportive care includes slow rocking, swaddling, creating a soothing environment, giving a pacifier, and frequent small feedings with extra calories. If the baby doesn't do better with support, then the next step is to treat with medication, which will keep the baby in the hospital longer.
After the decision to treat the baby with medication, further treatment can be complicated. According to Wallman, "I think the most challenging aspect is achieving the optimal dose... We want the baby comfortable while withdrawing but not too sleepy to eat the amount he or she needs to grow."
How do parents feel about treating their newborn's drug withdrawal with drugs? Wallman says, "I find most parents do accept the treatment their baby needs for NAS. They really do want the best for their baby and when they see the comfort that the treatment offers their baby, they readily accept it. What I think they find surprising and have a hard time accepting is the length of time the treatment takes to resolve the physical symptoms of NAS. They can become frustrated with the unexpected length of hospital stay that is required and the fact that many of the babies need to continue receiving medications after discharge from the hospital."
What Can a Mother Do?
A woman who is pregnant orthinking about starting a family has many things in her life to consider. Taking a drug may not have been an issue when only she was taking it, but once she becomes pregnant she has her developing fetus to also think about.
Jeremy Dubin, DO, ASAM, ABIHM, the Medical Director of the Rocky Mountain Treatment Centers/North Colorado Behavioral Health of Fort Collins, CO, is part of the answer to this problem. He states, "As a family physician and addiction medicine specialist, I can assist obstetricians and psychiatrists with the evaluation of the patient for addiction and if the benefits outweigh the risks to keep certain people on their opiates, or controlled substances, etc."
There is no "right" time to discuss drug use and pregnancy, but Dubin says it should be "ideally before getting pregnant, in other words, if we suspect illicit use of opiates or addiction, or someone is maintained on chronic opiate therapy and chemically dependent, and [she is] of child-bearing age, that conversation should be included every time we write for a controlled substance."
Dubin advises that if a woman wants to stop taking her prescription medications during her pregnancy, then it "should always be done in discussion with her physician and/or medical provider, and best if with the prescribing provider. Usually, third trimester you will see the least developmental problems but you can face premature delivery or increased problems in utero if you detox off opiates during pregnancy... According to ACOG (American College Of Obstetrics And Gynecology), any pregnant female who is battling opiate addiction needs to be stabilized in a methadone maintenance program."
In some cases, a drug-addicted pregnant woman's family and caregivers may be judgmental and unsupportive of her experience. Dubin recommends, "Alanon or Naranon are great tools for families learning about addiction with a loved one. It is almost always necessary for successful long-term recovery."
Decisions and Outcomes
A woman who knows the facts and has open discussions with health care providers is vital in decisions about how to handle prescription use before or during a pregnancy. The woman and her baby's health and well-being depend on striving to do what's best for them both.
Maggie Coins is a registered nurse in a neonatal intensive care unit. She is passionate about the health and safety of babies and children. Maggie writes an educational blog at http://www.InternetSafety Central, com.