How to Assess and Management NAS using EBP

Introduction

Neonatal abstinence syndrome (NAS) is a group of conditions brought about by a baby’s withdrawal from drugs exposed during pregnancy. In some cases, these drugs can be medications prescribed for an illness, but the mother might be used for their pleasure in other cases. Pregnant ladies using addictive drugs expose the neonate to urogenital malformations, cerebrovascular complications, low birth weight, a smaller head circumference, seizures, respiratory problems, and in some cases, it might cause sudden infant death syndrome.

In the long run, NAS is associated with some conditions such as motor problems, where a baby has issues with their muscles and locomotion, stunted growth where the child fails to achieve their projected growth rate, they might also have behavioral and intellectual complications, speech difficulties, impaired vision, and ear infections. There is. However, research is being done to confirm these claims.

A neonate’s drug addiction signs depend on the dosage, length of the exposure period, the timing of exposure itself, the metabolic and excreting rate of the mother and fetus, how the drug was administered, and the drug itself. In most cases, NAS is caused by exposure to opioids, but other medications may also cause it. In most cases, these drugs are Benzodiazepines, Opiates, heroin, methadone, marijuana, and amphetamines (Butkus, 2015).

The signs in a neonate include seizures, poor feeding habits, vomiting and diarrhea, fever, a high-pitched cry, sleeping problems, irritability, sneezing, poor weight gain, nasal stuffiness, dehydration, and increased heart rate, among others. An increase in the number of cases of NAS diagnosis indicates that this is a problem whose solution should be found fast. Therefore, working to solve this problem is critical in reducing the present and future complications brought by NAS and, hence, improving the quality of care and patient safety.

Nursing Care and Management of NAS

Assessment

The modified Finnegan Abstinence Score Tool (NAST) assesses an infant’s drug withdrawal for those at risk. Nurses begin scoring immediately after admission, and then it’s done in three-hour intervals or four in some cases, depending on the frequency of how the infant is fed. The baby’s vital statistics are also monitored and generally cared for. If an infant appears hungry, they are provided half of the usual meal amount, and the score-taking proceeds (Cloherty & Stark, 2016). Suppose an infant has not been prescribed pharmacological care. In that case, their score is taken for four days, while those with prescribed pharmacological care are scored in the entire period of pharmacologic therapy and then for two or three days, depending on what the physician advises.

Management

The management care an infant receives depends on their NAST scores. The treatment commences with nonpharmacologic measures, but those that show more advanced withdrawal symptoms are aided with an opioid which in most cases is methadone or morphine. A newborn with no pharmacologic prescription, characterized by a NAST score of less than 8, begins a management plan that entails; the dimming of lights, noise, or touch to decrease stimulation, encouragement of pacifier use to aid the infant’s self-regulation, breastfeeding, skin to skin therapy, and motivation of a mothers presence (Cloherty & Stark, 2016).

If a newborn scores more than eight and is prescribed pharmacological care, interventions commence while continuing the nonpharmacologic care. This is done while monitoring the infant’s cardiac and respiratory activity to mitigate respiratory depression should it occur. A treatment and feeding schedule that achieves the prescribed 24-hour total dose is employed. The morphine dosage is adjusted depending on the score an infant attains, and until the dosage changes are made, it’s 0.05mg/kg of morphine. The infants that reach level four and continue to score more than eight or more are prescribed clonidine as an additional medication. According to Butkus (2015), reflexes, CNS, feeding and growth, vitals, and toxicology analysis should be monitored during this process.

The weaning is done by reducing doses rather than increasing the time between intervals. For infants prescribed morphine and clonidine, the morphine takes precedence in weaning. Weaning follows the pattern of a 10% reduction of the maximum for two days dose provided the infant scores less than eight in two consecutive days and then a faster wean after a day and the score is still below eight. Morphine is discontinued if the infant scores less than eight while receiving 75% of the maximum dose, and the scoring is done for two or three days. Clonidine is weaned off depending on the total dosage attained with the help of a pharmacist. It is also done after an infant has been weaned off morphine and the score is still below an eight (Cloherty & Stark, 2016).

Interprofessional Care and Collaboration

The clinician decides when to commence and stop morphine treatment for a child. They also decide when to begin clonidine dosage when it’s necessary. The attending doctor is the one who orders the one rescue dose of morphine, and if it has to be done again, they have to make the order. It’s a nurse’s job to link with the clinician and administer the medication as advised. The pharmacist helps the nurse obtain a plan to wean the infant off clonidine depending on the total dose taken by the infant. In addition, in some hospitals, they are the caretakers of the drugs to prevent misuse. They are therefore crucial when a pharmacological care plan is prescribed. The lactating specialists would work together with the nurses to determine whether the mother should breastfeed and if so, guide them to aid the faster recovery of the infants.

The laboratory technicians come in handy in cases of NAS. When the attending physician orders a toxicology report when it is needed to evaluate if the mother has been using any substance in the past few days. The toxicology report is also required for those infants undergoing pharmacological care plans. The nurse acts as the liaison between the attending and the laboratory technologist (Cloherty & Stark, 2016).  Lastly, social services help is vital in taking care of the mother and infant outside the medical field. They are crucial in assessing the decision to discharge the patient, and they follow up on the family to make sure the mother is taking care of the child or reevaluating the parenting; the nurse helps with providing the vital information that might be needed on the medical field to aid the social worker in their decision making. In addition, the nurse links with the consulting medical doctors if there are other complications; they might be the surgeons or cardiologists, depending on the difficulty.

Evidence-Based Practice

In their study, Allen et al. (2018) advocated using a combination of less conventional laser acupuncture and pharmacological therapy for neonates as an intervention for neonatal abstinence syndrome. They claimed that the neonates subjected to this treatment combination had a 30% reduction in their time in the hospitals compared to the control group. Their report also advocated for breastfeeding, which is currently being used, at least for parents with no substance abuse problems; they also argued that parental presence aids in the treatment care. According to their study, the neonates who spent time with their mothers had a recovery period nine days shorter than the control group. Lastly, their study showed that soothing practices such as dimming of light, swaddling, and attention to nutrients boosted the recovery period of the neonates.

Education and Health Promotion

According to Cloherty and Stark (2016), the education intervention should come in some or all of the following ways. Firstly, the caregivers should be given verbal or written information about NAS. This claim is further supported by (Anbalagan & Mendes, 2021), who includes women in the childbearing age group in the suit. They argue that since NAS is a condition that can be stopped, educating women with aid in eradicating it. Hence, the women can be advised to abstain from substance abuse once or before becoming pregnant. In addition, this education would help identify the infant’s symptoms before it’s late.

The second is informing the parents and caregivers on the process being followed in the treatment strategies, the plan of care, and establishing a link between them and the social services. They both claim that education and a follow-up would be crucial in taking care of the infant after being discharged from the hospital. The education topics that should be prioritized are campaigns against substance abuse in general and advice for pregnant women who cannot discontinue their abuse abruptly to join a supervised medical program. Social media is one of the best potential tools to educate the population. The barriers anticipated are the unwillingness of people to learn and the process of mobilizing the funds to carry out a drive that raises awareness.

Improving Outcomes

To improve outcomes, interprofessional relationships are crucial, but the nurses have the most significant role to play. The responsibility of prescribing opioids, especially during pregnancy, is critical. The nurses have another vital role in mothers’ enrollment in supervised medical training when need be. Therefore, nurses should work together with the other medical personnel to ensure a continuous flow of information. As studies by the march of dimes (2022) indicate, breastfeeding aids in the reduction of time of recovery, and the nurses can play a role in guiding the parents. The nurses can also increase the outcome by contacting the social workers. This would help in avoiding readmissions. Lastly, the nurses being the people close to the patients, can help in their education to combat substance abuse.

Conclusion

            Neonatal abstinence syndrome is a condition that can be treated or avoided altogether. The nurses are on the frontlines of this war to eradicate this disease. They can aid this process by doing more research since they see it happen daily and consequently have more information; they also play a huge role in treatment care. From the point that an infant is admitted to the hospital, the prescribed plan of care all depends on the nurses. Being the liaison between all the other professions in the hospital, they are in a strategic position to combat this epidemic. They can and should follow up with the parents after discharge to avoid the readmission of these children.

References

Anbalagan S, Mendez MD. Neonatal Abstinence Syndrome. [Updated 2021 Jul 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551498/

Allen, N., Prunty, L., Babcock, C. C. K., Attarabeen, O., & Patel, I. (2018). Non-pharmacological interventions for neonatal abstinence syndrome. Addiction, 113(9), 1750–1751. https://doi.org/10.1111/add.14256

Mph, M. A. H. R., Md, E. E. C., Stark, A. R., & Md, C. M. R. (2016). Cloherty and Stark’s Manual of Neonatal Care (Eighth ed.). LWW.

Neonatal abstinence syndrome (NAS). (2022). Copyright 2022 March of Dimes. All Rights Reserved. Retrieved May 10, 2022, from https://www.marchofdimes.org/complications/neonatal-abstinence-syndrome-(nas).aspx#:%7E:text=What%20is%20neonatal%20abstinence%20syndrome,drugs%20called%20opioids%20during%20pregnancy.

Wilkins, W. L., Butkus, S. C., & Lippincott Williams & Wilkins. (2014). Maternal-Neonatal Nursing Made Incredibly Easy! Wolters Kluwer.

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