SUBSTANCE ABUSE
The Drug-Exposed Infant
Authored by: Kathy McKee MS, RNC
OBJECTIVES
List three physiological or behavioral
signs of an infant exposed to drugs in
utero
 Describe use of Neonatal Abstinence
Scoring
 Discuss nursing interventions
appropriate for infants exposed to drugs
in utero
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The Statistics

National Institute on Drug Abuse
– 500,000 – 700,000 affected babies annually in
the United States
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Washington State
– 12,000 drug affected babies each year
Guidelines for Testing and
Reporting

Screening
– It is the responsibility of every practice to make sure that
all pregnant and postpartum women are screened for
substance use (WA State Dept of Health)

Testing
– Drug testing is based on specific criteria and medical
indicators
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Reporting
– Reports of prenatal substance exposure shall not be
construed to be child abuse or neglect and shall not
require prosecution of the mother
Testing

Mom
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– Risk Indicators
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No prenatal care
Previous unexplained
fetal demise
Precipitous labor
Abruptio placentae
Hypertensive episodes
Severe mood swings
Repeated spontaneous
abortions
– Consent
Baby
– Risk Indicators
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Jittery with normal
glucose level
Marked irritability
Preterm birth
Unexplained seizures
or apneic spells
Unexplained IUGR
Neurobehavioral
abnormalities
Congenital
abnormalities
Signs of NAS
– Consent
The Drug-exposed Infant
Transient effects
 Teratogenic effects

– Dysmorphic
– Behavioral
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Confounding variables
– Maternal health, socioeconomic status, lifestyle
– Drug used/Poly-drug use
– Use in relation to gestational age
– Time used prior to delivery
Common Findings in Drug
Exposed Infants
Hypersensitivity to stimuli
 Abnormal muscle tone
 Sleep Problems
 Feeding Problems
 GI Problems

Alcohol

Fetal Alcohol Spectrum Disorders/Alcohol
Related Birth Defects
– Growth Restriction
– Facial Dysmorphism
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Microcephaly
Short palpebral fissures
Hypoplastic philtrum
Thin upper lip
– CNS Dysfunction
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Neurological symptoms
Cognitive & behavioral signs
Nicotine
17% of pregnant women between
the ages of 15 and 44 smoke
 Adverse Effects

– Decreased blood flow through the
placenta
– Low birth weight
– Neurobehavioral impact
– Increased respiratory tract illnesses
– Sudden infant death syndrome
Cocaine

Stimulant
– Tachycardia
– Hypertension
– Decreased blood flow and oxygen delivery to
fetus
– Increased uterine contractions
Effect of Cocaine on the Infant
Irritability
 Poor feeding
 Decreased interaction
 Disorganization
 Sleep disturbances
 Tremors
 Sneezing
 Tone abnormalities
 High-pitched cry

Possible
association with:
–Congenital heart
defects
–Urinary
obstruction
defects
–Gastrointestinal
obstruction
Methamphetamine

Potent stimulant
– Vasoconstriction
– Increased heart rate
– Hyperthermia
– Decreased appetite in user
– Decreased oxygen and nutrient
delivery through placenta
– Prolonged circulation of drug in
fetal circulation
Effects of Methamphetamine
on the Infant
Associated
with:
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–Congenital brain
lesions
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–Cleft lip
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– Disorganized suck
– No suck
–Cardiac defects
–Low birth weight and
reduced OFC
–Hyperbilirubinemia
Poor state control
Lethargic
Poor feeding
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Irritable
Abnormal tone
Excoriated buttocks
Narcotics/Opiates
Morphine, Heroin, Methadone
 Continued use will lead to profound
physiologic and psychological addiction
 Neonatal Abstinence Syndrome

– Passive exposure in utero as a
consequence of maternal addiction.
– Iatrogenic exposure by the administration
of narcotic analgesics to the neonate
Neonatal Abstinence
Syndrome
Generalized disorder characterized by
21 symptoms most commonly seen in
withdrawing infants.
 2/3 of infants born to opiate-dependent
women will exhibit signs of NAS
 Time of onset varies
 Symptoms vary
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Neonatal Abstinence
Scoring
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Assists in the detection of
– Onset of withdrawal symptoms
– Severity of symptoms
– Response to intervention
– Resolution of symptoms
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Assess high risk infant
– 2 hours after birth
– Every 3-4 hours
NAS Scoring
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The Finnegan scale
– If score is 8 or greater
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Score every 2 hours for 24
hours
– Scores > 8 on three
consecutive scores
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Evaluate need for
medication
– If intervention not needed
by 72 hours
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Scoring may be
discontinued
System Disturbances
 Central
Nervous System
 Metabolic/Vasomotor/Respiratory
 Gastrointestinal
Central Nervous System
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Cry
Sleep pattern
Exaggerated Moro Reflex
Tremors
Muscle tone
Excoriation
Myoclonic jerks
Convulsions
Metabolic,Vasomotor,
Respiratory
Sweating
 Fever
 Yawning
 Mottling
 Nasal stuffiness
 Sneezing
 Nasal flaring
 Increased respiratory rate, retractions
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Gastrointestinal
Excessive sucking
 Poor feeding
 Regurgitation, projectile vomiting
 Loose stools, watery stools
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Medications for NAS
Morphine Sulfate
 Phenobarbital
 Ativan
 Other
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Nursing Care of the Drug
Exposed Infant
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Careful Assessment
NAS Scoring (if opiate exposure)
Control of the environment
Feeding techniques
Therapeutic Handling
–
–
–
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Swaddle
Clapping
Vertical rocking
C-position
Nursing Care of the Drug
Exposed Infant
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Dealing with the family
– Personal feelings
– Public health issue vs. Crime
– Involve in care—teach
Opportunities for changing the addicted
woman’s behavior and her view of health care
providers can be influenced by the care she
and her infant receive while hospitalized
Questions ?
References
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Askin, Debbie Frasier (2001). Cocaine: Effects of in utero
exposure on the fetus and neonate. The Journal of Perinatal
and Neonatal Nursing, 14 (4), 83-102
D’Apolito, Karen (2001). Prominence of withdrawal symptoms in
polydrug-exposed infants. The Journal of Perinatal and
Neonatal Nursing, 14 (4), 46-60.
Jorgensen, Katherine M. (1999). The drug-exposed infant:
Physiology, signs, and symptoms. Central Lines, 15 (2), 1-11.
Ostrea, Enrique M. (2001). Understanding drug testing in the
neonate and the role of meconium analysis. The Journal of
Perinatal and Neonatal Nursing, 14 (4), 61-82.
Tillett, Jackie & Osborne, Kathryn (2001). Substance abuse by
pregnant women: Legal and ethical concerns. The Journal of
Perinatal and Neonatal Nursing, 14 (4), 1-11.
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Weiner, Susan M. & Finnegan, Loretta P. (2002). Drug
withdrawal in the neonate. In Handbook of Neonatal Intensive
Care 5th Ed. St. Louis, Missouri, Mosby, Inc.
Wilbourne, Paula, Wallerstedt, Cheryl, Dorato, Veronica, &
Curet, Luis B. (2001). Clinical management of methadone
dependence during pregnancy. The Journal of Perinatal and
Neonatal Nursing, 14 (4), 26-45.
Guidelines for Testing and Reporting Drug Exposed Newborns in
Washington State. Washington State Department of Health,
2006.
Williams, Jill Schlabig (2006). The neurobehavioral legacy of
prenatal tobacco exposure. NIDA.