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Drug dependency - infants born to drug dependent mothers

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Overview

The team is as follows:

  • Obstetrician 
  • Midwives: Betty Wilkings (Midwife), and midwifery staff of Tamaki Ward
  • Paediatricians: Dr Mariam Buksh and Dr Simon Rowley
  • Social Workers: ADAPT team social workers, or NICU Social Workers if baby in NICU

The baby is expected to be normal in all respects other than smaller than average for gestation. Maternal drug use alone is not an indication for delivery attendance - delivery will be attended by neonatal staff only if there are other fetal or maternal reasons for attendance. If NICU admission is necessary and there are no contraindications (e.g asphyxia, LBW) the baby may spend time with the parents before transfer. Naloxone should be avoided because of the likelihood of precipitating and intensifying withdrawal symptoms. 

The baby will be admitted to Tamaki Ward for observation. This could be for up to 7-10 days but may be for several weeks if medication is needed because of drug withdrawal.  Breastfeeding is encouraged, regardless of the drugs that have been taken by the mother. Parents are expected and will be encouraged to spend as much time as possible with their baby.

Drug dependency care may include:

  • Methadone maintenance during pregnancy. 
  • Methadone detoxification /benzodiazepine detoxification. 
  • Attendance at counselling agencies or therapeutic communities. 
  • Alcohol use. 
  • Other drugs including antipsychotic tranquillisers (prescribed or not). 

A file will be kept on Ward 32, including care plans and letters from Paediatricians which will also be filed in the maternal notes. These files are kept in strict confidence in the Charge Midwife office.

Exclusions from the plan to send babies direct to Ward 32 (i.e. indications for being nursed on the Newborn Intensive Care Unit):

  • Low birthweight, premature or unwell as for normal indications for admission to NICU. 
  • Polydrug abuse should be considered, particularly if there are confounding social factors but the methadone dose alone is not an exclusion criteria. 
  • Maternal and other social complicating factors. 

There is a need to ensure confidentiality for parents. A single room should be allocated if possible. The baby's history must not be discussed in front of other parents. The case notes and drug charts are to be kept in the office at all times. The baby's condition or reason for admission or length of stay is not to be discussed with anyone other than the parents. This includes grandparents. Visiting is the same as for all postnatal wards.

Medical and nursing care on the ward

There are a small group of primary midwives that will be dealing with the mother and baby.  It is important during the baby's stay in hospital that the mother has consistency in management, deals with as few staff as possible, i.e., one consultant or delegated junior staff member and one senior nursing staff member to be the information providers. 

Score sheets are to be kept in the office and maintained regularly.

It is not routine to send a urine sample for toxicology if the mother is well known to the ADAPT team and drug use is well documented. If a toxicology screen is required, the first urine from the baby is to be sent for toxicology. Meconium samples (which will give an indication of drug use over recent weeks rather than days) can be sent if indicated but need to be negotiated on an individual basis with Toxicology at LabPlus.

The Paediatric Consultant on service for the ADAPT team will visit as indicated and communicate with the parents and nursing staff. If the baby is on medication, then this will be daily. The Paediatric House Surgeon or Registrar should be called for any fever, vomiting, feeding problems or unstable temperature which may be the signs of a sick baby other than drug withdrawal. If the baby scores 8 or higher on the score chart then the Paediatric Registrar should be informed.

75% of mothers on the methadone programme are Hepatitis C positive. The infant will need antibody and RNA virus testing at 4-6 months if high risk, 15 months if mother is Hepatitis C positive.

Universal precautions

Gloves should be used for all nappy changes or for nursing staff changing the babies - and handling baby before initial bath.

Signs and symptoms of withdrawal

Tremors 95%
Irritability 80%
Hypertonicity and Hyperactivity (eg frantic sucking of fists) 80%
Vomiting 75%
High pitched cry 70%
Sneezing 65%
Respiratory distress 65%
Fever 50%
Diarrhoea 50%
Sweating 50%
Convulsions 2%

Few symptoms are specific for withdrawal but recurrent sneezing and yawning in infants should raise the possibility that the baby is withdrawing.

Treatment of withdrawal

Scoring of withdrawal should be done on the Neonatal Scoring Chart CR5664

This is managed by the Paediatric Consultant in conjunction with the Registrar and Charge Midwife and parents. Medications are started when the baby has several scores of >8 and after adequate consultation. The medication may only be changed by a Paediatric Consultant or Registrar.

The drug used is neonatal morphine solution 1mg/ml. Start at 0.5mg/kg/day in 4 divided doses (that is, 6-hourly) and reduce by 10-15% of the original dose every 2-3 days if possible. The infant may need increasing doses for stabilisation in the first few days.

Medication must be given strictly as charted given directly into baby's mouth by syringe. The drug must be given by a Registered Nurse/Midwife who checks the drug - not a parent. Medication times are not to be changed to fit in with baby's feeds times. This interferes with the withdrawal regime. Do not draw up milk into the syringe because dead space can lead to overdose of morphine.

If the medication time falls between feeds it is not necessary to wake the infant completely. It has been noted on past experience that babies take the medication well if the syringe is slipped into the mouth and medication is taken without any problems. The baby is then tucked back to sleep.

An alternative treatment is chlorpromazine 2.2mg/kg/24 hours given in four divided doses either orally or by injection. Full dosage should be given for two to four days then weaned at two day intervals if baby's condition, according to the clinical score, permits.

Management of an unsettled, irritable baby

  • Check baby has dry napkin.
  • Baby may be hungry. These babies will often take extra feeds but may be difficult or sloppy feeders. They should not be tube fed unless there are other indications such as hypoglycaemia or scores are approaching treatment levels and being unduly influenced by symptoms of hunger. Dummies are very useful. Deep water bathing and massage often help relax the baby if needed. Many babies will settle well in the swinging cradle sling. A disposable napkin or incontinent pad must be used when nursing baby in the sling to protect the sling cover.
  • Frequent cuddling, walking with front pack, soothing music or quietness rather than loud music (individual variation).
  • When baby is stable, mother may take baby for a walk within the unit, if on NICU, or outside the ward if on Tamaki Ward. This is arranged between mother/charge midwife/nurse - times to be specific so that all staff are aware (the day nursery may be used). Later on, following negotiation with charge midwife, mother may take baby for a walk in the grounds. This is subject to permission on each occasion.
  • Midwives and nurses need to know the routine lines of communication when:
    • threatened with violence
    • parents are uplifting baby against medical advice
    • there is inappropriate behaviour from parents and/or visitors

Discharge planning

A meeting may be organised prior to discharge. The following people may be asked to attend:

  • Paediatrician
  • Charge Midwife/Nurse
  • Public Health Nurse or Plunket Nurse,
  • GP (if possible)
  • Parents
  • Liaison Midwife
  • Counsellor Methadone Services/CADS Unit
  • ADAPT S/W. (occasionally Oranga Tamariki personnel)

For short stay infants who have not had withdrawal symptoms, e.g. less than 10 days there should be adequate communication between GP, Social Worker, Paediatrician, Charge Midwife/Nurse with phone contact with other parties. Babies are not followed up by Neonatal Homecare unless they have other problems such as prematurity or low birthweight, that would normally be referred.

Medical follow up will be by the Paediatrician at clinic in 3-4 months or as necessary and we will offer a follow up appointment at one year. This is particularly important if mothers are Hepatitis C positive.

These infants have a higher incidence of Sudden Infant Death Syndrome and although this does not justify the use of monitors, the various community support networks must be alerted. Advice about reduction of risk factors (supine sleeping position, breast feeding, discouraging smoking, discouraging co-bedding) should be given. Monitors may be indicated for preterm infants.

Mother should attend teaching sessions for:

  • Home environment/clothing/when baby is sick.
  • Infant resuscitation classes.
  • Bathing.
  • Car seat needed.

The NICU Team Support Administrator makes Paediatric appointment at 3-4 months for Outpatient follow up. For infants discharged home from NICU, the Paediatric Registrar will write a discharge letter with a copy to the General Practitioner. Include follow up of HCV testing. NB: Note the privacy act and confidentiality.

Points of Interest

70% of babies born to mothers taking heroin or methadone will manifest signs of withdrawal. Some are only mildly affected. Babies born to methadone addicts show more frequent and severe signs than heroin addicted mothers.

The likelihood of the baby being affected is related to maternal consumption and the length of time addicted. However some babies born to heavily affected mothers may show no signs, while those born to 'light' users may show significant signs of withdrawal.

Although 70% will show signs of withdrawal, only about half of these will have signs severe enough to require treatment. 90% of these showing signs will start to have them within 48 hours. Initial signs of withdrawal are rare after 10 days of age.

About half of affected infants requiring treatment need it for 10 - 20 days and one third for up to 49 days after birth.

Mortality is said to be about 3% but with treatment should be virtually nil.

Narcotic depression in the newborn infant

This is manifest either at delivery when a baby needs resuscitation, or following delivery with behavioural changes in the infant. Narcotics given to the mother within 4 hours of birth can contribute to depression in an asphyxiated infant, or can result in depression without asphyxia. In this latter case, the baby usually has a normal heart rate initially, but depressed respiration.

Treatment of narcotic depression

DO NOT GIVE NALOXONE TO INFANTS AT RISK OF DRUG WITHDRAWAL, WHOSE MOTHERS HAVE BEEN TAKING OPIOID DRUGS.

  •  When indicated (which is rare), resuscitation must be instituted without delay, usually before naloxone administration.
  • Administration of Naloxone is not necessary as long as the baby can be adequately ventilated
  • Treat narcotic depression with naloxone (Narcan) intramuscularly.
    Dose 0.1mg/kg per dose, IM (0.25ml/kg of 0.4mg/ml).
    Naloxone comes in ampoules containing 0.4mg/ml.
    Intramuscular administration is preferable. The onset of action is almost as rapid as with IV administration, but the duration of action is much longer.

See Naloxone Drug Protocol for more details.

Observation and Documentation

The half life of intravenous naloxone is very short, and there is the potential its action will wear off before that of the opioid causing the depression. This appears not to be a problem with large intramuscular doses of naloxone (as recommended here).

There appears to be a depot effect of the IM injection. Measurable effects of naloxone have been seen up to 48 hours after the dose.

Babies needing resuscitation and/or naloxone at birth need observation afterwards. This need not necessarily be on NICU but can be with the mother in the delivery unit or post natal ward.

When administered in the delivery room, naloxone will often be given on the verbal order of the doctor or NS-ANP. This order should be written on the 'blue card' by the doctor/NS-ANP after the resuscitation.

References

  1. Committee on Drugs. American Academy of Pediatrics. Pediatrics 1989;83:803.
  2. Wiener PC et al. Br Med J 1977;2:228-31.
  3. Brice JEH et al. Arch Dis Child. 1979;54:356-61

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Document Control

  • Date last published: 06 August 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years