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Neonatal Nursing Education Briefs

The Methadone-Exposed Neonate

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Purpose and Goal: CEARP #1094

  • Describe the risk factors associated with maternal methadone treatment.
  • Identify strategies that support the care of the infant and mother in the NICU.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored. 

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • January 2014 – January 2016

Learning Objectives

  • Describe the risks and benefits associated with maternal methadone treatment.
  • Identify at least two strategies for caring for infants with neonatal abstinence syndrome.

Substance Abuse

  • Drug abuse is a national problem.
  • Opioid addiction has dramatically increased.
  • 22 million Americans abuse opioids every year.
  • 3.1 million new Americans will become addicted every year.
  • Non-prescription opioids account for 14% of abuse.

Opioid Abuse

  • Opioids are extracted from the opium poppy.
  • More than 20 drugs have been developed.
  • Opioids produce supraspinal analgesia.
    • Morphine
    • Codeine
    • Heroin
    • Dilaudid
    • Fentanyl
    • Methadone
  • Acute effects include:
    • Sedation
    • Euphoria
  • Long-term use or abuse
    • Tolerance to effects
    • Physical dependency
    • Psychological dependency
  • Opioid addiction causes chemical changes in the brain.
    • No control over craving for opioid
    • Limited awareness of consequences of behavior
    • Can take up to two years to reverse changes
      • High rate of relapse
      • May require life-long treatment

Geographical Regions of Opioid Use

  • West 10.5%
  • Northeast 9.2%
  • Midwest 8.5%
  • South 7.5%
  • Highest in metropolitan counties (9.2%)
  • Lowest in rural counties (5.7%)

Drug Abuse in Pregnancy

  • Approximately 5% of pregnant women abuse opioids.
  • Reported rates of opioid use are most likely underestimated.
  • Highest rates of abuse
    • Women ages 15–17 (21%)
    • Women ages 18–25 (8%)
  • Opiates do not have known teratogenic or fetal effects.
  •  Maternal use of opioids can result in neonatal withdrawal.
    • Acute signs of toxicity
    • Acute signs of withdrawal
      • Risk of withdrawal 55–95%
    • Sustained signs of drug effect 

Methadone Treatment in Pregnancy

  • Methadone is a long-acting opioid.
  • Only FDA-approved drug for use in pregnancy
  • Treatment of choice for opioid abuse
    • Heroin use
    • Morphine use
    • Oxycodone use
    • Hydrocodone use

Advantages of Methadone

  • Reduces fluctuations of serum opiate levels
  • Protects fetus from repeated episodes of withdrawal
  • Associated with decreased drug abuse
  • Associated with increased maternal weight gain
  • Improves maternal physical and mental health
  • Improves compliance with prenatal care
  • Allows for anticipation of neonatal withdrawal

Disadvantages of Methadone

  • Withdrawal not recommended
    • Increased risk of fetal death
    • Increased risk of illicit drug abuse
  • Risk of fetal dependence
    • Risk of neonatal abstinence syndrome (NAS)
    • Prolonged course of NAS
    • Risk of NAS reported as 45–71%
    • Risk of NAS not dependent on methadone dose

Neonatal Abstinence Syndrome

  • Clinical presentation of opioid withdrawal varies.
  • Factors that influence NAS
    • Maternal drug history
    • Timing of drug use before delivery
    • Maternal, fetal, placental metabolism
    • Multiple drug use
      • Cocaine
      • Barbiturates
      • Hypnotics
      • Sedatives
      • Nicotine
  • Neonatal onset of withdrawal
    • Within first 24 hours of life
    • As late as 10–14 days of age
  • Duration of withdrawal
    • Acute signs first week of life
    • Sustained for 4–6 months

Signs and Symptoms of NAS

  • Neurologic excitability
    • Tremors
    • Irritability
    • Tachypnea
    • High-pitched cry
    • Frequent yawning
    • Frequent sneezing
    • Nasal stuffiness
    • Temperature instability
    • Increased wakefulness
    • Sleep disturbances
    • Increased muscle tone
    • Hyperactive Moro reflex
    • Seizures
  • Gastrointestinal dysfunction
    • Poor feeding
    • Excessive suck reflex
    • Vomiting
    • Diarrhea
    • Dehydration
    • Poor growth

Care of the Opioid-Affected Neonate

  • Goal is to minimize physiological effects of NAS
  • All NICU care should be coordinated with feeding times.
  • Excess environmental stimuli can exacerbate NAS.
    • Comfort measures
      • Swaddling
      • Quiet environment
      • Low light level
      • Minimal handling
      • Pacifier use
      • Vestibular stimulation
        • Patting
        • Rocking
        • Swing
        • Glider
  • Optimal nutritional intake is important.
    • Feeding behaviors may be impaired.
    • NAS produces a hyper-metabolic state.
    • High-calorie formula may be required.
    • Breastfeeding dependent on maternal drug use
      • Recommended for methadone use
        • Insignificant amounts of drug passed to baby
        • No adverse effects have been reported.
      • Not recommended for illicit drug use

Pharmacologic Management

  • Morphine is the current drug of choice.
    • Calms CNS symptoms
    • Reduces GI disturbances
    • Can be given with each feeding
    • Dosing easily adjusted as needed
  • Phenobarbital may be effective.
    • May impair feeding behaviors
    • Does not control diarrhea
  • Clonidine can be used in combination with morphine.
    • Blocks effects of neurologic excitability
    • Has long-acting analgesic properties
    • May allow faster weaning off morphine
    • May lead to decreased length of stay

Supportive Care of Mothers on Methadone

  • Support for opioid-addicted mothers is important.
    • Support in recovery efforts
    • Support in attempts to bond with infant
  • Positive reinforcement is crucial.
    • Balance maternal guilt
    • Balance maternal low self-esteem
    • Improve ability to read infant cues
    • Improve ability to comfort infant
    • Improve ability to successfully care for infant
  • Many drug addicts have a history of trauma.
    • Using trauma-informed care can be effective.
      • Recognize the need to respect trauma.
      • Adapt care around trauma triggers.
  • Motivational interviewing may also be effective. 
    • Strengthen motivation to change and parent.
      • Ask mothers about their motivation.
      • Ask mothers about their ideas on change.
      • Emphasize mothers' autonomy.
    • Recognize that only the mother can make change happen.
  • Therapeutic communication techniques
    • Empathy
    • Recognition of physical changes
    • Acceptance of mothers resistance
    • Supportive attitudes
    • Compassionate care
    • Supporting self-efficacy

References

  1. Maguire, D. Mothers on Methadone: Care in the NICU. 2013. Neonatal Network, 32 (6), p.409-415.
  2. Hudak, M.L. and Tan, R.C. Neonatal Drug Withdrawal. 2012. Pediatrics, 129 (2), p. 540-560.
  3. Greene, C. and Goodman, M.H. Neonatal Abstinence Syndrome: Strategies for Care of the Drug-Exposed Infant. 2003. Neonatal Network, 22 (4), p.14-24.
  4. Murphy-Oikonen, J, Brownlee, K., Montelpare, W. & Gerlach, K. The Experiences of NICU Nurses in Caring for Infants with Neonatal Abstinence Syndrome. 2010. Neonatal Network, 29 (5), p.307-313.
  5. Blunt, B. Supporting Mothers in Recovery. 2009. Neonatal Network, 28(4), p. 231-235.

Test and Evaluation

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