NCP The Infant of an Addicted Mother

Although abuse of alcohol, heroin, and marijuana has remained relatively stable, cocaine and crack use is growing dramatically, affecting approximately 1 in 10 pregnancies (higher in urban areas). In addition to alcohol and illicit drugs, abuse of prescription medications also occurs and use of multiple substances is common. From 80%–90% of infants born to addicted mothers are physiologically addicted and experience passive signs of drug withdrawal, commonly referred to as neonatal withdrawal syndrome or neonatal abstinence syndrome. It is estimated that cocaine use alone impacts 30,000–50,000 infants born annually. An additional 3000–5000 infants yearly are determined to be suffering from FAS. This plan of care is to be used in conjunction with the previous newborn plans of care. Refer also to CPs: The Preterm Infant and Deviations in Growth Patterns, as appropriate.

NEONATAL ASSESSMENT DATA BASE

Severity and time of onset of symptoms are related to substance(s) abused, duration of use, and maternal drug level at birth.

Activity/Rest

High-pitched cry, wakefulness, short or unquiet sleep patterns, yawning
Difficulty maintaining alert states

Circulation

Tachycardia
Hypertension

Ego Integrity

Poor state organization (cocaine use)

Elimination

Diarrhea
Hyperactive bowel sounds (hypermotility)

Food/Fluid

May be LBW or SGA infant; may have IUGR (maternal use of heroin, alcohol, or cocaine, or maternal malnutrition); or may be higher-birth-weight/LGA infant (maternal use of methadone)
Poor feeding with uncoordinated frantic sucking, hyperphagia, drooling, hiccups, possible cleft lip
Weight decrease or failure to gain weight
Vomiting/regurgitation
Dry mucous membranes, poor skin turgor, sunken fontanels
Abdominal distension, changes in bowel sounds, dilation of bowel (paralytic ileus, NEC)

Neurosensory

Apgar score may be low (e.g., intrauterine asphyxia or medication given to mother during intrapartal period).
Small head circumference/SGA (nicotine); microcephaly (FAS, cocaine use, toxic vapor abuse); facial abnormalities (FAS, toxic vapor abuse).
Hyperirritability (including increased startle response), hyperactivity, poor state organization; hypertonicity may be present.
Hyperacusis (abnormal sensitivity to sound), difficulty attending to/actively engaging in auditory and visual stimuli.
Tremors, persistent or rhythmic myoclonic jerks, or seizure activity may be noted.
Increased or exaggerated reflexes (e.g., gag, sucking, rooting, deep tendon, and Moro reflex) may be noted; absent or poor reflexes; poor muscle tone/limpness (perinatal infarcts).
Dilated/tortuous vessels of the iris.

Respiration

Periods of apnea (cocaine), transient tachypnea (heroin).
Increased tearing, rhinorrhea, stuffy nose, yawning, or sneezing may be present.
Signs of respiratory distress; green-tinged mucus (meconium aspiration) (heroin).
Tracheoepiglottal abnormalities (FAS).

Safety

Temperature variations.
Sweating, mottling, and flushing may be seen.
Rub marks on face and knees related to constant “mouthing/crawling” motions pressure-point abrasions.
Sclera, skin may be jaundiced.
Congenital anomalies (associated with cardiovascular or genitourinary systems) may be present.
Signs of infection or sepsis (acquired in utero), history of premature rupture of membrane, impaired immunologic mechanisms (marijuana).

Social Interaction

May exhibit poor tolerance for being held, decreased interactive behavior (difficulty responding to human voice/face, environmental stimuli), gaze aversion.

Sexuality

Female more commonly affected, ratio 2:1 (FAS)
Genital abnormalities in females (FAS)
Teaching/Learning
May be premature.
Mother may have received no prenatal care (literature suggests that 75% of women who abuse drugs during pregnancy do not seek prenatal care until the onset of labor), or may report prenatal problems associated with preterm labor, abruptio placentae, or placenta previa (placental insufficiency/fetal asphxia); infections such as pneumonia, endocarditis, STD, or hepatitis; PIH; and anemia.

DIAGNOSTIC STUDIES

Toxicology or Drug Screen (maternal/infant blood and urine, and fetal meconium): Identifies current substance exposure. Cocaine metabolites may persist in urine for 4–7 days after use, or even longer in infant.
Serum Electrolytes: Vomiting/diarrhea resulting in electrolyte imbalances.
Serum Glucose: May be decreased (increased metabolic rate, poor feeding, limited nutritional reserves [FAS]).
CBCD and Blood Cultures: For differential diagnosis associated with sepsis. GBS is becoming one of the most insidious and lethal infections of the newborn.
Platelet Count: May be decreased (tranquilizers or infectious process).
Serologic Tests: Determine presence of STDs, e.g., syphilis, hepatitis B, HIV.
Bilirubin Levels: Increased risk of jaundice (especially in infant of methadone user).
Electroencephalogram (EEG): May be abnormal, demonstrating cerebral irritation, in cocaine-exposed infant. Normalization of EEG noted by 3–12 mo of age.
Lumbar Puncture: Determines presence of white cells/bacteria, specific GBS antigens.

NURSING PRIORITIES

1. Facilitate and support drug withdrawal in infant.
2. Detection of infectious process.
3. Prevent injury, and reduce risk of short- and long-term complications.
4. Foster parent-infant interaction and attachment.
5. Provide information and support to parent(s) during rehabilitation process.

DISCHARGE GOALS

1. Gaining weight appropriately.
2. Free of injury, complications resolving.
3. Parent-infant interactions progressing satisfactorily.
4. Parent(s)/caregiver understand infant’s present condition, prognosis, and needs.
5. Parent(s)/caregiver participate in care and use available resources.
6. Plan in place to meet ongoing needs after discharge.