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Substance Exposed Pregnant Women and their Babies


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

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

  • 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!

Learning Objectives
  • Identify three screening techniques for use with
    pregnant women who may be using alcohol or other
  • Gain an increased understanding of various
    classes of drugs and their effects on pregnant
    women, the developing fetus, and the newborn
  • 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.

  • 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

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

  • 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

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.
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

The 5 As Framework
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

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

When Should You Screen?
  • Screening should be a routine part of care.
  • Look for physical and environmental indicators.
    (fingers, arms, eyes, paraphernalia, clothing,
  • 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

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
  • Present - In the past month, have you drunk any
    alcohol or used other drugs?

  • 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.
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
  • 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).
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.

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.

  • 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

Systems of Care
  • Medical CHDs, CMS, hospitals, physicians,
  • 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.

Other Possible Systems
  • Legal drug court, probation, child support
  • 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.

Five Point Approach
  • Identify key players including and centering on
    the patient.
  • Unify referral processes - identify the point
  • 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.

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.

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

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.

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.

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

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

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

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

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

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.

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.

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
  • Keeping movement slow and rhythmic will help
    relax and settle the infant.

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.

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.

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

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

Neonatal Abstinence
  • Neonatal Abstinence term given to the condition
    of an infant born to a drug affected mother
  • 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

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

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

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

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.

  • 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
  • Multi-disciplinary approaches to protocol
    development in medical, child welfare, child
    development, and substance abuse treatment

Lets work together to keep them ALL safe,
healthy, and happy!
Thank You!