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Substance Exposed Pregnant Women and their Babies

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Substance Exposed Pregnant Women and their Babies Dixie L. Morgese, BA, CAP, ICADC Principle #4 Vertical Rock Best when baby is frantic and hard to calm Maintain C ... – PowerPoint PPT presentation

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Title: Substance Exposed Pregnant Women and their Babies


1
Substance Exposed Pregnant Women and their Babies
  • Dixie L. Morgese, BA, CAP, ICADC

2
Premises
  • Every woman wants a healthy baby.
  • Every woman deserves a healthy baby.
  • Pregnancy is a finite period that can be the
    determinant for a childs future.
  • Pre-pregnancy is the BEST time to address alcohol
    and drug use!

3
Learning Objectives
  • Identify three screening techniques for use with
    pregnant women who may be using alcohol or other
    drugs.
  • Gain an increased understanding of various
    classes of drugs and their effects on pregnant
    women, the developing fetus, and the newborn
    baby.
  • Identify five systems of care and their roles and
    responsibilities related to substance exposed
    pregnant women and their babies.
  • Learn a five point approach to effective
    multidisciplinary staffing and coordination.

4
Terms
  • SEN Substance Exposed Newborn
  • CDN Chemically Dependent Newborn
  • NAS Neonatal Abstinence Syndrome
  • NAS - Neonatal Abstinence Scoring
  • FASD Fetal Alcohol Spectrum Disorder
  • FAS Fetal Alcohol Syndrome
  • WIS Womens Intervention Specialist
  • FIS Family Intervention Specialist
  • ATOD Alcohol, Tobacco and Other Drugs
  • CNS Central Nervous System

5
Terms
  • Hyperreflexia Overactive reflexes response to
    stimuli
  • Overstimulated overwhelmed by stimulus
  • Philtrum vertical groove on the median line of
    the upper lip.
  • Feeding intolerance inability to suck, swallow
    or retain feedings.

6
Terms
  • Drug Endangered Infant/Child a wide range of
    risk associated with exposure to alcohol and
    other drugs.
  • Marchman Act petition that supports legal
    remedy regarding evaluation and intervention.
  • State Regulation ability to adapt to external
    stimulation.

7
CNS Substances
  • Children of mothers who used drugs
  • Stimulants risk of preterm labor and abruption
  • Depressants alcohol most damaging
  • Opiates increasing numbers of cases
  • Marijuana
  • Hallucinogens
  • Tobacco - low birth weight, SIDS

Varying responses, particularly during infancy.
Prognosis for other drugs is better than with FAS
depending on term of pregnancy and environment.
8
Screening is IMPORTANT!
  • Find an approach that works for you.
  • Be non judgmental
  • Make it a routine part of care and conversation.
  • Know how to respond
  • Be positive
  • Follow up with other systems of care

9
The 5 As Framework
10
5 As
  • Ask about alcohol, tobacco or other drug use
  • Advise to quit unless opiates/opioids are
    involved. If the woman is opiate/opioid
    dependent, gain consent and coordinate with
    health care providers.
  • Assess willingness to quit
  • Assist with support and referral
  • Arrange follow-up

11
Instruments Used for Screening
  • 5 Ps and 4 Ps Plus
  • CAGE AID
  • T-ACE

12
When Should You Screen?
  • Screening should be a routine part of care.
  • Look for physical and environmental indicators.
    (fingers, arms, eyes, paraphernalia, clothing,
    etc.)
  • Review life management issues. (personal hygiene,
    behavioral incidences, avoidance, etc.)
  • Use your senses and follow your instincts.
  • Intervene and Support know what you will do
    next!

13
5 Ps
  • Parents - Did any of your parents have a problem
    with alcohol or other drug use?
  • Peers - Do any of your friends have a problem
    with alcohol or other drug use?
  • Partner - Does your partner have a problem with
    alcohol or other drug use?
  • Past Have you used alcohol or drugs in the
    past?
  • Present - In the past month, have you drunk any
    alcohol or used other drugs?

14
CAGE-AID
  • Have you ever felt you ought to cut down on your
    drinking or drug use?
  • Have people annoyed you by criticizing your
    drinking or drug use?
  • Have you felt bad or guilty about your drinking
    or drug use?
  • Have you ever had a drink or used drugs first
    thing in the morning to steady your nerves or to
    get rid of a hangover (eye-opener)?

CAGE Source Ewing 1984. CAGE-AID Source.
Reprinted with permission from the Wisconsin
Medial Journal Brown, R.L. and Rounds, LA
Conjoint screening questionnaires for alcohol and
drug abuse. Wisconsin Medical Journal 94
135-140, 1995.
15
The T-ACE Questionnaire
  • T   Tolerance How many drinks does it take to
    make you feel high?
  • A   Have people annoyed you by criticizing your
    drinking?
  • C   Have you ever felt you ought to cut down on
    your drinking?
  • E   Eye-opener Have you ever had a drink first
    thing in the morning to steady your nerves or get
    rid of a hangover?

The T-ACE is considered to be positive with a
score of 2 or more. Affirmative answers to the A,
C, and E questions are each scored 1 point. A
reply of more than two drinks to the T question
is scored 2 points (Sokol et al. 1989).
16
How Do You Start the Conversation?
  • Be non-judgmental and build rapport.
  • Keep it Simple.
  • Use observable strengths.
  • When the door opens be straight-forward.
  • Know your limitations.
  • Know your resources.

17
What Next?
  • Know your limitations and disclose them
  • Negotiate Consent for Release.
  • Develop a short term contract.
  • Be aware of timing and environment (conflict at
    home, day of the week, other children, etc.)
  • Seek supervision and coordination.
  • Consider resources and barriers.

18
Barriers
  • Dependence
  • Language/Culture paradigm to a strength
  • Fear of system/outcomes
  • Partner control or violence issues
  • Treatment access/residential availability
  • Family system/relationships and other children
  • Stressors
  • Depression
  • Economic Limitations

19
Systems of Care
  • Medical CHDs, CMS, hospitals, physicians,
    midwives
  • Treatment Centers FADAA WIS, TOPWA other
    check directory.
  • Early Steps screening of children
  • Child Welfare (DCF and Community Based Care)
    legal, investigative, case management, wrap
    around services use PNA
  • Healthy Start care coordination and linkage to
    additional resources.

20
Other Possible Systems
  • Legal drug court, probation, child support
    enforcement.
  • Workforce Development economic self sufficiency
    for mother and partner.
  • Child Care/ELC respite, structure, stability.
  • Others Homeless Services, Domestic Violence
    support, HIV/TOPWA, Mental Health, Healthy
    Families, Insurance.

21
Five Point Approach
  • Identify key players including and centering on
    the patient.
  • Unify referral processes - identify the point
    person/entity.
  • Coordinate consent Healthy Start screening form
    can support collaboration until further consent
    is obtained.
  • Align policies and procedures ensure systems
    have interagency agreements which delineate roles
    and responsibilities..
  • Utilize unified staffing forms.

22
Follow Up
  • Identify additional staffing activities
    establish dates, times.
  • Key coordinator typically case management or
    care coordination.
  • Ensure client completed referrals and verify
    subsequent appointments.
  • Prior to delivery, coordinate with
    hospital/birthing center.
  • Provide documentation for pediatric follow up.
  • Identify who will provide ongoing education to
    the family.
  • Establish family planning and interconceptional
    care plan.

23
Points to Remember
  • SEN babies are at elevated risk for SUIDS
    ensure family has safe sleeping environment.
  • Mothers at elevated risk for PPD or relapse
    identify support system.
  • Caregivers need to know how to handle SEN babies
    ensure special instruction is provided and
    ongoing.

24
Common Symptoms
  • There are characteristics and symptoms that drug
    exposed babies will have in common. The nature
    of these their frequency and timing will depend
    on factors such as
  • The drug that the baby was exposed to
  • How each individual baby metabolizes the drug
  • The babys own tolerance
  • No two babies will react exactly alike. It is
    the responsibility of the caregiver to carefully
    monitor and read the infant and the signs.

25
Hypersensitivity to Stimuli
  • One of the most common traits
  • Little tolerance to stimuli
  • Swallowing, closeness, sound, can escalate baby
    into frantic state
  • Babies need protection from overstimulation but
    should not be stimulus-deprived.

26
Changes to Muscle Tone
  • Muscle tone is the degree of stiffness
  • Unusually limp or unusually stiff
  • Particularly in limbs and neck
  • Stiffness may come and go
  • Tremors, jerking, other signs of distress sign
    of baby trying to control uncomfortable
    sensations.

27
Gastrointestinal Problems
  • Drugs attack gastric system 12 mos
  • Watery stool, explosive diarrhea, excoriated
    buttocks, gas, constipation
  • Need proper handling to prevent serious health
    concerns
  • Distress and high stimulation can increase
  • Diarrhea can irritate fragile lining of the
    intestines and also lead to dehydration.

28
Other Related Complications
  • Chronic Ear Infection
  • Unexplained fever (opiates and opioids)
  • Sleep/wake irregularity
  • Extreme appetite (barbiturates)
  • Hyperreflexia/Moro

29
Therapeutic Handling
  • Caregivers need appropriate training
  • Comforting techniques are critical to management
    of withdrawing infants
  • Each type of drug exposure presents unique
    challenges
  • Basic principles of handling apply to all

30
Eight Principles
  • Swaddling
  • C-Position
  • Head to Toe Movement
  • Vertical Rock
  • Clapping
  • Feeding
  • Controlling the Environment
  • Introducing Stimuli

31
Principle 1 Swaddling
  • Drug exposed infants cannot do three things
    simultaneously body, breathe, suck
  • Swaddling provides comfort in helping them to
    control their bodies
  • Allows them to focus on breathing then feeding
    with greater comfort.

32
Principle 2 C-Position
  • Increases sense of control and ability to relax
  • Hold baby firmly and curl head and legs into a C
  • When laying down place on side, wrap blanket
    into a role around body.
  • Then introduce back position for sleeping as
    recommended by Academy of Pediatrics.

33
Principle 3 Head to Toe
  • Back and forth motions not recommended
  • Slow, rhythmic swaying following line from head
    to toe while swaddled and held in C position is
    comforting.
  • Keeping movement slow and rhythmic will help
    relax and settle the infant.

34
Principle 4 Vertical Rock
  • Best when baby is frantic and hard to calm
  • Maintain C position and hold directly in front of
    you and turned away.
  • Slowly and rhythmically rock baby up and down
    soothes neurological system.
  • Be aware of personal energy level keep baby at
    a distance while rocking if necessary.

35
Principle 5 Clapping
  • Cup hand
  • Clap/pat babys blanketed bottom
  • Clap slow and rhythmically
  • Babys muscles may start to relax
  • This technique does not work with all babies if
    baby does not respond, discontinue.

36
Principle 6 - Feeding
  • Withdrawal may adversely affect sucking babies
    may suck frantically or have disorganized suck
  • Makes it difficult for them to take in enough
    formula or to breastfeed
  • The key is to get baby relaxed enough to suck
    steadily in a low-stimulus environment.
  • Baby should be swaddled and in C-position

37
Principle 7 Controlling the Environment
  • Limit number of caregivers
  • Offer calm surroundings
  • Minimize any loud noise music and voices should
    be low volume
  • Keep lights low
  • Caregiver should have calm presence
  • Routine is beneficial

38
Neonatal Abstinence
  • Neonatal Abstinence term given to the condition
    of an infant born to a drug affected mother
    withdrawal
  • Withdrawal set of symptoms as the body attempts
    to remove an addictive substance
  • Must be accurately assessed
  • May be controlled by using therapeutic measures
    and often medication

39
Neonatal Abstinence Symptoms (not exhaustive)
  • Hyper-irritability
  • Respiratory distress
  • Gastrointestinal distress
  • Sleep disturbances

40
Neonatal Abstinence Scoring
  • Determines the level of therapeutic intervention
    necessary
  • Helps to determine the effectiveness of
    interventions being used
  • Assesses symptoms
  • Originally developed by Loretta Finnegan

41
NAS Scoring Tool
  • Set of observed signs and symptoms in the infant
  • Observed at regular intervals every 3 hours
  • Should reflect all symptoms observed since the
    last scoring
  • High scores that are not lowered by therapeutic
    handling should be assessed for medical
    intervention

42
New Concerns
  • High rates of prescription drug use and opioids
    in high doses may result in longer observation
    periods being required for NAS.
  • Home visitors and other support staff may be
    unaware of symptoms.
  • Misdiagnosis by health professionals who do not
    have history on mother.

43
Recommendations
  • Statewide data collection about nature and scope
    of the problem.
  • Staff development protocols for maternal and
    child support staff.
  • Policy changes to help medical staff better
    manage opiate/opioid dependent women during
    pregnancy.
  • Multi-disciplinary approaches to protocol
    development in medical, child welfare, child
    development, and substance abuse treatment
    disciplines.

44
Questions?
45
Lets work together to keep them ALL safe,
healthy, and happy!
46
Thank You!
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