Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs - PowerPoint PPT Presentation


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Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs


Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs Dixie L. Morgese, BA, CAP, ICADC – PowerPoint PPT presentation

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Title: Handle With Care Therapeutic Approaches for Managing Babies Exposed to Alcohol and Other Drugs

Handle With Care Therapeutic Approaches for
Managing Babies Exposed to Alcohol and Other Drugs
  • Dixie L. Morgese, BA, CAP, ICADC

Learning Objectives
  • Identify terms associated with SENS
  • Learn common symptoms of drug exposed babies
  • Learn appropriate therapeutic handling of drug
    exposed newborns and babies
  • Understand scoring guide for babies with Neonatal
    Abstinence Syndrome
  • Understand fundamentals of conducting an Infant
  • Identify techniques for managing withdrawal

  • 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
    stimuli Moro
  • 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.
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

  • Medication is likely to be initiated in the
    following instances
  • NAS scores greater than 10 on 3 consecutive
    scoring intervals
  • The average of 3 consecutive scores is greater
    than 10
  • The score is greater than 12 on 2 consecutive
  • The average of 2 consecutive scores is greater
    than 12

Medication and NAS Scores
  • Tapered down based on NAS scores
  • Remains below 10 and infant tolerates medication
    decreases well
  • Medication can be decreased as quickly as 10 per
  • After medication discontinued, NAS scoring should
    be continued for at least five days,

Tools Needed
  • NAS Score Sheet
  • Watch or clock with a second hand
  • Thermometer
  • Stethoscope

System Signs Symptoms
Excessive High Pitched ( or other)
cry 2 Continuous
high pitched (or other) cry 3
Sleeps lt 1 hr after feeding 3
Sleeps lt 2hr after
feeding 2 Sleeps lt3 hr after
feeding 1 Hyperactive Moro Reflex 2
Hypersensitivity 3 M
arkedly hyperactive Moro Reflex 3
Mild tremors disturbed
Moderate-Severe tremors disturbed
2 Mild
Tremors Undisturbed
Moderate-Severe tremors Undisturbed
4 Increased muscle tone 2 Excoriation
(specific area) 1 Myoclonic
jerks 3 Convulsions/Seizures 5
Central Nervous System Disturbances
Assessment of the Infant
  • Crying
  • Sleep
  • Moro Reflex
  • Tremors
  • Increased Muscle Tone
  • Excoriation
  • Myoclonic Jerks
  • Generalized Convulsions/ Seizures

System Signs Symptoms Score Score
Sweating Sweating 2
Fever gt 101 (99-11.8F/37.2-38.2C) Fever gt 101 (99-11.8F/37.2-38.2C) 1
Fever gt 101 (38.4C or higher) Fever gt 101 (38.4C or higher) 2
Frequent Yawning (3-4 times/interval Frequent Yawning (3-4 times/interval 1
Mottling Mottling 1
Nasal Stuffiness Nasal Stuffiness 1
Sneezing (gt3-4 times/interval) Sneezing (gt3-4 times/interval) 1
Nasal Flaring Nasal Flaring 2
Respiratory Rategt60/min Respiratory Rategt60/min 1
Metabolic, Vasomotor, Respiratory Disturbances
  • Sweating forehead, upper lip, back of the head
  • Fever auxiliary temp
  • Frequent Yawning more than 3 per interval
  • Mottling marbling discoloration
  • Nasal Stuffiness noisy respirations due to
  • Sneezing more than 3 times per interval
  • Nasal Flaring
  • Respiratory Rate normal 30-60- breaths per

System Signs Symptoms Score
Disorganized Suck 3
Excessive Sucking 1
Flatus 1
Poor Feeding 2
Regurgitation 2
Projectile Vomiting 3
Loose Stools 2
Water Ring Stools 2
Watery Stools 3
Initials ? TOTAL SCORE
Gastrointestinal Disturbances
Gastrointestinal Disturbances
  • Disorganized Suck
  • Excessive Sucking
  • Flatus more than 3 hrs at a time
  • Poor Feeding minimum intake amount takes longer
    than 30-45 mins
  • Regurgitation 2 or more episodes during feeding
    (not associated with burping) or more than 5
    ccs or more between feedings
  • Projectile Vomiting forceful ejection
  • Loose Stools liquid or explosive
  • Water Ring Stools substance and water ring
    surrounding substance
  • Watery Stools liquid
  • Blood traces in the stool
  • Hypersensitivity oral feeds, touch, sound,
    smell, energy levels, surroundings, light, eye,
    contact, movement above and beyond normal scope
    of withdrawals.

Managing Initial Stages of Withdrawal
  • Swaddle with cotton thermal receiving blanket.
  • Curl infant body into C-position
  • Do not speak loudly into face
  • Sway rhythmically (do not jiggle)
  • Feed more frequently (due to calorie burning)
  • Cotton products are a must throughout
    withdrawal period
  • Do not remove clothes for increased temperature
    due to withdrawal

Managing Infants During Withdrawal 7 Steps
  • 1 Control Environment
  • 2 Learn babys cues
  • 3 Attempt to calm crying EARLY
  • 4 If difficulty regaining control swaddle
    vertical rock,
  • 5 Gradually introduce stimuli
  • 6 Gradually introduce AMOUNT of stimuli
  • 7 As infants ability to remain calm increases,
    unwrap for short periods of time

  • 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 SMA, Haven House, DMTC WIS,
    TOPWA other
  • 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

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