Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome: Breaking the CycleSarah Stasik
Grand Valley State University
Neonatal Abstinence Syndrome: Breaking the CycleThe purpose of this paper is to examine the implications and nursing interventions that are used to prevent and treat Neonatal Abstinence Syndrome (NAS). The Centers for Disease Control (CDC) defines NAS as, “a drug withdrawal syndrome that most commonly occurs in infants after in utero exposure to opioids” (as cited in Ko et al., 2017, p. 242). The opioid epidemic that the United States is currently facing directly correlates to the rising number of infants born with NAS. In the year 2012, it was estimated that on average, one child with NAS was born in the United States every 25 minutes (Ko et al., 2017, p.242). This drug epidemic is particularly unique though, due to the fact that the patients that are struggling with addiction are generally upper middle-class, and well educated. This fact emphasizes the need to routinely question every childbearing woman about her drug usage, even if she does not fit the anticipated profile of someone who is addicted to drugs. Because NAS can increase complications in utero, and decrease positive postnatal outcomes, it is important that the healthcare team handles this disorder with diligence.
As the prevalence of infants experiencing Neonatal Abstinence Syndrome continues to climb, nurses are seeking ways to ensure that they are providing their patients with the most effective care available. The nursing scope of practice for NAS patients is centered around nonpharmacological interventions and adequate patient education; which is utilized in addition to the pharmacological regimens prescribed by physicians (MacMullen, Dulsk & Blobaum, 2017, p.171). Nurses play a pivotal role in alleviating withdrawal symptoms for neonates and focus on providing quality, evidence-based care to their patients. Topics discussed in this paper include: NAS causation, the application of nonpharmacological comfort measures and patient education for NAS management.

Exploring NAS Implications
Clinical Significance
Understanding the opioid epidemic, and its implications on NAS, are necessary to comprehending the complexities that NAS poses. NAS is frequently overlooked by many people and is viewed as a shrouded consequence of the opioid epidemic. In recent years, the opioid epidemic has come to the forefront of healthcare news and is the concern of many people living in the United States. Prescription opioids, which were originally intended for patients experiencing postsurgical pain, traumatic injury or a terminal illness, had been widely prescribed for conditions not warranting their use. This unnecessary over-medicating led to a surplus of opioid pain medication and resulted in a reliance on opioids in patients that did not require them in the first place (Pitt, Humphreys & Brandeau, 2018, p.1394). As the rate of opioid addicted adults increased, so did the rate of infants experiencing NAS. According to Keegan, Parva, Finnegan, Gerson and Belden, approximately 225,000 neonates in the United States are exposed to illicit substances each year (as cited in MacMullen et al., 2014, p.165). Though in recent years NAS awareness has increased, it is evident by the number of infants still experiencing this disorder that there is still more work that needs to be done.
The increasing number of infants hospitalized due to NAS is an important statistic, and one that should not be overlooked by hospital administration. Infants undergoing opioid withdrawal commonly experience difficulties with feeding, respiratory function, low-birth weight and seizures (Ko et al., 2017, p.242). By increasing the number of infants requiring specialized care and a longer hospitalization, there is an increased burden on the hospital and associated increased cost. It was estimated that in 2012, the cumulative hospital charges for all infants experiencing NAS totaled 1.5 billion dollars (Ko et al., 2017, p.242). It is in the best interest of the hospital to invest more money into preventative measures for NAS, so that the overall associated cost is lesser in the long-run.
Barriers to Care
Detecting opioid usage early on in pregnancy is associated with increased positive neonate outcomes, but due to fear of stigma and judgement from providers, many mothers do not seek help. (Nelson, 2013, p.40). Many women are afraid that if they self-report their opioid usage, they are going to be faced with the threat of criminal action or have their children taken away by Social Services. Being that each state varies so greatly on their treatment of opioid addicted mother, there is no clear-cut answer for what legal consequences may be. In some states women are entered into drug treatment programs, and in others using opioids during pregnancy is classified as child abuse (Ko et al., 2017, p.244). The varied ramifications of drug use causes mothers to feel uneasy about seeking treatment and creates an immense barrier to care. If mothers do choose to seek prenatal care though, the responsibility falls on the nurse to create a non-judgmental environment where the patient feels free sharing any and all information. The nurse plays an important role in the care of an infant, not only prenatally, but also in the acute setting after the child is born.

NAS Nursing Interventions
Non-pharmacological Comfort Measures
With NAS, the neonate is undergoing an immense amount of stress caused by the immediate withdrawal of opioids after delivery. Because of this nurses, are tasked with providing non-pharmacologic comfort measures to alleviate theses stressors. Relying on evidence-based practice, the use of non-pharmacological means to comfort neonates is the most commonly accepted NAS nursing intervention utilized by nurses. The American Academy of Pediatrics (AAP) states that for NAS infants, their goals are “minimizing environmental stimuli, promoting adequate rest and sleep, and providing sufficient caloric intake to establish weight gain (as cited in Nelson, 2013, p.40). To achieve sensory minimization and promote sleep, this, nurses will conduct a number of interventions such as, darkening the room, talking in hushed tones, and rocking the infants to calm them down (Nelson, 2013, p.40). Infants have a difficult time achieving adequate nutrition due to impaired feeding ability. Poor weight gain occurs from behaviors including: “excessive sucking, poor feeding, regurgitation, and diarrhea”. Adequate weight gain is necessary for the neonates to overcome many of the negative effects of NAS. Overall, the key to promoting growth and rest in neonates is to promote comfort.
Patient Education
The most important patient education that a nurse can give to parents of an NAS baby is to facilitate bonding. There are numerous ways to facilitate bonding, such as skin-to-skin contact or sleeping in room with baby, but the best way is breastfeeding. If the mother is no longer taking opioid medication, breastfeeding is the best option for nutrition and comfort for the neonate. Breastfeeding facilitates bonding between the mother and infant, and gives them extra resiliency to fight through withdrawal symptoms. In a systematic literary review conducted by MacMullen et al., it was established that breastfeeding may decrease the severity of NAS and could potentially decrease the need for any pharmacological intervention (2014, p.170). Each baby affected by NAS should be treated individually because each case of addiction is unique. Although nurses have a set interventions they generally use for NAS infants, each case is unique and not every intervention will be used for every child. Nurses simply use a trial and error system and test the effectiveness of each specific intervention by measuring the patients corresponding outcome. Unfortunately, with many NAS infants the patients are not involved in the care, so the task of providing comfort falls solely on the nurse (MacMullen et al., 2014, p.170). Hospitals though will sometimes help to alleviate this burden by bringing in volunteers and community support to help hold, rock and feed NAS infants. Taking care of an NAS infant is truly a team effort and requires the healthcare team to work as an interdisciplinary unit to provide quality care.
Application
Being that I would like to work within the realm of women’s health when I graduate, this topic is something that I am especially passionate about. In my current role as a student nurse, I believe that the greatest way to apply NAS knowledge to my repertoire is through my education. By staying up to date on all the new ways to manage and prevent NAS, I am better preparing myself to give my patients the highest quality of care. On a hospital wide scale, I feel that it would be beneficial for the interdisciplinary healthcare team to conduct semi-annual seminars where they re-evaluate and revise their protocol for managing NAS infants. By ensuring that the whole healthcare team is up to date with the newest scientific research, the hospital is doing everything in their power to maximize positive outcomes while simultaneously minimizing hospital costs. In addition to this, by having a standardized treatment plan for all neonates affected by NAS nurses will be more confident in their interventions, thus promoting self-efficacy. Neonatal Abstinence Syndrome is 100% preventable and I believe that with informed acute care and community health nurses leading the way, we will be able to eradicate this unfortunate consequence of opioid addiction.
References
Ko, J. Y., Wolicki, S., Barfield, W. D., Patrick, S. W., Broussard, C. S., Yonkers, K. A., … Iskander, J. (2017). CDC grand rounds: Public health strategies to prevent neonatal abstinence syndrome. MMWR: Morbidity ; Mortality Weekly Report, 66(9), 242-245.

MacMullen, N. J., Dulsk, L. A., ; Blobaum, P. (2014). Evidence-based interventions for neonatal abstinence syndrome. Pediatric Nursing, 40(4), 165-203.

Nelson, M. M. (2013). Neonatal abstinence syndrome: The nurse’s role. International Journal of Childbirth Education, 28(1), 38-42.
Pitt, A. L., Humphreys, K., & Brandeau, M. L. (2018). Modeling health benefits and harms of public policy responses to the US opioid epidemic. American Journal of Public Health, 108(10), 1394-1400.