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Neonatal Abstinence Syndrome

Courtney Moore

Delaware Technical and Community College

NUR 340
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Neonatal Abstinence Syndrome

Around 1875, doctors had identified an illness which they called “Congenital

Morphinism,” there were reports of several infants dying after being born to mothers’ dependent

on morphine (Gomez-Pomar & Finnegan, 2018). Congenital Morphinism was usually fatal as

there was a lack of knowledge, though in 1901 doctors began to see the connection and these

infants started to be treated with small amounts of opium (Gomez-Pomar & Finnegan, 2018).

At this time that it was also recognized that breastfeeding could help to minimize that symptoms

of withdrawal as low doses are passed through breast milk. Today we call this is called Neonatal

Abstinence Syndrome (NAS).

                                          Introduction

Infants born to mothers who used opioids during pregnancy have a 90% chance of

experiencing NAS. The complications can cause “deleterious symptoms and complications,

prolonged hospitalization, and extensive pharmacological therapy” (Adrian et al., 2020, p. 450).

NAS has increased 383% from 2002 to 2012, at an estimated cost of 1.5 billion dollars annually.

The average length of stay (LOS) for hospitalization is 16.9 days for these infants (Adrian et al.,

2020). The treatment, care and LOS of these infants depends on the severity of their symptoms.

Treatment includes both non-pharmacological and pharmacological interventions for the care of

these infants, several scoring tools are used to determine the appropriate treatment plan. Often

“Ineffective nursing interventions, inaccurate assessments, and insufficient utilization of

abstinence scoring tools contribute to unnecessary pharmacologic treatment”. The most used

scoring method if the Finnegan Abstinence Scoring System (FNASS) developed in

1975(Gomez-Pomar & Finnegan, 2018). Roughly 95% of institutions use the FNASS, other
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scales include: Lipsitz tool, MOTHER NAS scale, and The Eat, Sleep, Console (ESC) method

(Taylor & Maguire, 2020).

Statement of the Problem

NAS is significant for nursing, as it involves one of the most vulnerable patient

populations in our society. These infants are unable speak for themselves and rely on others to

get their needs met. Proper assessment is a vital to identify appropriate care and treatment. Much

the long-term effects of NAS not been researched as it is difficult to follow up with these

children for different reasons. In the hospital “Is a non-pharmacological (Eat, Sleep, Console)

approach more beneficial than pharmacological?” This is a newer approach that has focused on

less use of medication and increased parent involvement.

                                       Literature Review

The problem that currently exists in treatment of infants who experience NAS is that the

scoring is not universal, and it can often time be confusing and very subjective (Timpson et al.,

2018). The FNASS consists of 21 categories for scoring. “Clinically significant physiological

and behavioral symptoms include central nervous system (CNS) and vasomotor dysregulation

(pathophysiological cardiorespiratory instability, seizures, tremors, hyperthermia),

gastrointestinal dysfunction (vomiting, diarrhea, and poor feeding), and hyperirritability

(excessive movement, excoriation, crying, disturbed sleep)” (Timpson et al., 2018, p. 70) Many

of these symptoms can be considered normal newborn behaviors unrelated to withdrawal. The

FNASS has been studied and has had modifications done to help make it less cumbersome for

nursing staff to use and implement, but without the proper education and reeducation nurses
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could overrate infants affected with NAS, thus needlessly starting them on medication for their

symptoms (Timpson et al., 2018). 

The ESC approach to NAS infants is a new concept that was first introduced in 2017, it

was developed based of “observations of eating and sleeping being essential functions of a

newborn, and if these functions were not interrupted by withdrawal symptoms, then we could

consider the infants' withdrawal to be well managed” at Yale New Haven Children’s Hospital

(Grossman et al., 2017, p. 2). With the ESC model, the infant is considered well-fed if they are

able to eat greater or equal to 1 oz per feed, to sleep undisturbed for greater than or equal to one

hour, and if crying to be consoled within 10 minutes (Grossman et al., 2017). If any of these

goals were not met, then non-pharmacological interventions were modified, or medication was

initiated. Nonpharmacologic interventions (NPI) include swaddling, quiet and low stimulation

environments, skin to skin, rooming in and parental involvement, and positioning (Adrian et al.,

2020). “If a nurse is able to hold and sooth the baby and give the attention it needs to keep its

scores down, it can speed up the weaning process” (Adrian et al., 2020, p. 455). Appropriate

assessments and the ability to soothe the baby can help to get the rest they need, allow them to

eat and gain weight properly while avoiding unnecessary pharmacological treatment.

The use of these NPI are important treatment options for NAS infants, whether they are

being used with the FNASS or the ESC, these interventions can shorten the infants LOS.

Parental involvement is one of the NPI that can significantly improve care of a NAS infant,

though often can be difficult if the mother is not compliant with her drug treatment program or

feels that there will be punishment for her drug use. One goal of the ESC model is a “family-

integrated model of care’ in which building a trusting relationship between the mother and nurse

caring for the infant is of high importance (Shuman et al., 2020, p. 471). Continuity of care,
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consistent nursing staff, and empowering the parents can foster a trusting relationship between

parents and the nurses caring for these infants. Empowered parents are invested in educating

themselves and participating in treatment and care of their NAS infant and can initiate the NPI

by themselves (Smith et al., 2018). Even with strong parental involvement there can be barriers

to this important NPI, these barriers can be related to the mothers’ own treatment, transportation

issues, other children, and poverty (Shuman et al., 2020). This is when the nursing staff can

assist in finding the resources to help the family. It is important to the success of the ESC method

that prenatal counseling, NAS education and encouragement is available for these mothers prior

to delivery of their infant.

                                                Analysis

The studies used for this paper were both qualitative and quantitative in nature, one of

which was a mixed method study. NAS as a topic allows for both methods to be used during

research as NAS has data and numbers than as treatment and effectiveness of that treatment, but

also the perceptions regarding treatment, the ethical and legal aspects that occur in this

population. 

The findings from this research support the ESC method for treatment of NAS infants. It

has shown to reduce LOS and reduce the use of pharmacological interventions in patients. “The

ESC approach resulted in morphine initiation for 6 infants (12%) compared with 31 infants

(62%) who would have had morphine initiated using the FNASS approach (P<.001).” (Grossman

et al., 2017, p. 4) The ESC method also showed that there were 30 patients (60%) where this

approach led to no change or a decrease in the morphine dosage, where using the FNASS would

have resulted in an increase in the morphine dose. This particular occurrence of difference in

methods happened on 78 total days or 26.4 % (Grossman et al., 2017). The research does not
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show that there are any adverse effects for these infants, nor were any of them readmitted within

30 days for withdrawal symptoms using the ESC. What it does show is that average length of

stay for these infants to be shortened and the number of infants requiring pharmacological

therapy is less (Grisham et al., 2019).

                                                Recommendations

Future research is required on a larger scale, more infants involved in these types of

studies. The ESC method is a beneficial approach that reduces the time that an infant would need

to be away from their caregivers, as well as decreasing the need to be on medication if that

would even be needed. Starting the ESC method by doing prenatal counseling, the easiest area to

accomplish this is for those mothers already involved in a treatment program can be identified

and asked to participate in this research to see if starting the education prenatally has any effect

on the parental involvement after the infant is born. This future research study can employ a

questionnaire during the prenatal stage, after birth while the infant is inpatient, and then after

discharge as a follow up. This would be for both the mother and the staff to gauge their

knowledge on NAS, and parental engagement, and experience with NAS for the mothers (seeing

if they have had a previous NAS infant and if medication was required), and the knowledge of

NPI. There can be a group that participated prenatally, and a group that was seen in hospital that

was not involved in the prenatal education.  Along with the surveys data can be collected on how

often parents visited, how often the initiated NPI treatments, was the prenatal education effective

in helping the parents to feel more comfortable with the post-natal period. A possible title for this

future research study could be “Effects of prenatal education on parental involvement in babies

with Neonatal Abstinence Syndrome”. 

This type of study and the ones that have been done for babies with NAS have

implications in relation to the treatment of this population as this is an ever-growing population

with the opioid epidemic continuing to grow every day. Unfortunately, this is not something that

can be pushed to the side, these children are being born every day in all corners of the country

and the long-term effects of in utero exposure to poly- drug use in not fully understood, but the

treatment that these infants can receive after they are born can be studied. If these studies can

show a better way to care for these infants that decrease the LOS in the hospital and may even

decrease the amount of medication required while still relieving symptoms it should be studied. 
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Reference

Adrian, A., Newman, S., Mueller, M., & Phillips, S. (2020). A mixed-methods study to

investigate barriers and enablers to nurses' implementation of nonpharmacological

interventions for infants with neonatal abstinence syndrome. Advances in Neonatal Care,

20(6), 450–463. https://doi.org/10.1097/anc.0000000000000794

Gomez-Pomar, E., & Finnegan, L. P. (2018). The epidemic of neonatal abstinence syndrome,

historical references of its’ origins, assessment, and management. Frontiers in Pediatrics,

6, 1–8. https://doi.org/10.3389/fped.2018.00033

Grisham, L. M., Stephen, M. M., Coykendall, M. R., Kane, M. F., Maurer, J. A., & Bader, M. Y.

(2019). Eat, sleep, console approach. Advances in Neonatal Care, 19(2), 138–144.

https://doi.org/10.1097/anc.0000000000000581

Grossman, M. R., Lipshaw, M. J., Osborn, R. R., & Berkwitt, A. K. (2017). A novel approach to

assessing infants with neonatal abstinence syndrome. Hospital Pediatrics, 8(1), 1–6.

https://doi.org/10.1542/hpeds.2017-0128

Shuman, C. J., Weber, A., VanAntwerp, K., & Wilson, R. (2020). Engaging mothers to

implement nonpharmacological care for infants with neonatal abstinence syndrome.

Advances in Neonatal Care, 20(6), 464–472.

https://doi.org/10.1097/anc.0000000000000812

Smith, J. G., Rogowski, J. A., Schoenauer, K. M., & Lake, E. T. (2018). Infants in drug

withdrawal. Journal of Perinatal & Neonatal Nursing, 32(1), 72–79.

https://doi.org/10.1097/jpn.0000000000000309
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Taylor, K., & Maguire, D. (2020). A review of feeding practices in infants with neonatal

abstinence syndrome. Advances in Neonatal Care, 20(6), 430–439.

https://doi.org/10.1097/anc.0000000000000780

Timpson, W., Killoran, C., Maranda, L., Picarillo, A., & Bloch-Salisbury, E. (2018). A quality

improvement initiative to increase scoring consistency and accuracy of the finnegan tool.

Advances in Neonatal Care, 18(1), 70–78.

https://doi.org/10.1097/anc.0000000000000441