Care of substance-exposed infants: the current state of practice in Canadian hospitals

Substance Use During Pregnancy: A Comparative Review of Major Guidelines

Importance

Substance use during pregnancy is a major health issue for both the mother and the fetus, but it also represents an important public health concern.

Objective

The aim of this review was to summarize and compare recommendations from recently published guidelines on substance use during pregnancy and especially regarding alcohol, smoking, and drug use.

Evidence Acquisition

A descriptive review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the World Health Organization (WHO), the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on substance use was conducted. Regarding the term "substance use," the most recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition substances were used.

Results

All the reviewed guidelines recommend appropriate counseling and screening women regarding alcohol, smoking, and drug use during the antenatal period, while the management options vary. More specifically, the prompt management of alcohol dependence is emphasized by all the guidelines except from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, which makes no recommendation upon. The use of alcohol during breastfeeding should be avoided. Regarding smoking cessation, all guidelines recommend the use of certain psychosocial, behavioral interventions, and pharmacotherapy. All the guidelines, except the one from the WHO, suggest screening drug users for coexistent sexually transmitted infections. Brief interventions are considered beneficial, while a gradual decrease in benzodiazepines is suggested, as well as the discontinuation of marijuana and methamphetamine use. However, there is controversy regarding breastfeeding in those women as the WHO recommends in favor, whereas the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists recommend against this practice. Finally, all the guidelines state that, following delivery, close monitoring of the neonate is needed.

Conclusions

The diversity of guidelines' recommendations concerning substance use reflects the different ways of the management of pregnant women during routine antenatal care due to absence of strong evidence. More research in the areas of dispute may allow the adoption of an international consensus, in order to early detect and appropriately manage pregnant women with harmful addictions.

The Infant Cuddler Study: Evaluating the effectiveness of volunteer cuddling in infants with neonatal abstinence syndrome

Objectives

St. Michael's Hospital launched a volunteer cuddling program for all infants admitted into the neonatal intensive care unit in October 2015. The program utilizes trained volunteers to cuddle infants when caregivers are not available. This was a pilot study to assess the impact of a volunteer cuddle program on length of stay (LOS) and feasibility of implementation of the program.

Methods

A mixed methods approach was utilized to measure both quantitative and qualitative impact. A pilot cohort study with a retrospective control group assessed the feasibility of implementing a volunteer cuddling program for infants with neonatal abstinence syndrome (NAS). Length of stay was used as a surrogate marker to measure the impact of cuddling on infants being treated for Neonatal Abstinence Syndrome. Focus groups using semi-structured interviews were conducted with volunteers and nurses at the end of the pilot study.

Results

LOS was reduced by 6.36 days (U=34, P=0.072) for infants with NAS in the volunteer cuddling program. Focus groups with both bedside nurses and program volunteers described a positive impact of cuddling programs on infants, families, staff, and volunteers alike.

Conclusions

The study results suggest that the volunteer cuddling program may reduce LOS in infants with NAS and have potential economic savings on hospital resources. However, larger prospective cohort studies are needed to confirm these results.

Survey of Neonatal Intensive Care Unit Nurses' Use of a Motion/Sound Infant Seat

BACKGROUND

Perinatal substance exposure is an increasing concern in infants being cared for in neonatal intensive care units. Current recommendations support nonpharmacologic treatments for this population of infants. Multimodal (motion, sound) seats are often employed to soothe infants.

PURPOSE

The purpose of this study was to survey neonatal intensive care unit nurses on their practices regarding the use of a motion/sound infant seat.

METHODS

Sixty-six nurses (52% of 126 total nurses) completed the survey about their self-disclosed practices that included (1) reasons for use; (2) rationale for choice of settings of motion and sound; (3) duration of time infants spent in seat in one session; (4) perception of positive infant response; (5) who places infants in the seat; and (6) nursing instructions dispensed prior to use.

RESULTS

Chief reasons for use were infant state, lack of persons to hold infants, and a diagnosis of neonatal abstinence syndrome. Rationale for choice of motion and sound settings included trial and error, prior settings, personal preferences/patterns, assumptions, and random selection. Nurse responses regarding the amount of time the infant was placed in the seat in a single session ranged from 10 to 360 minutes, with determining factors of infant cues, sleeping, feeding, and someone else to hold the infant.

IMPLICATIONS FOR PRACTICE

As nonpharmacologic treatments evolve, nurses need guidelines for safe, effective interventions to care for infants.

IMPLICATIONS FOR RESEARCH

Further research is necessary to ascertain the responses of withdrawing infants and to establish guidelines and education for use of the motion/sound infant seat.

Trends in incidence of neonatal abstinence syndrome in Canada and associated healthcare resource utilization

BACKGROUND

Neonatal abstinence syndrome (NAS) is a collection of symptoms that occurs primarily due to antenatal opioid exposure. National data on incidence, hospital resource utilization, and demographic features of NAS have not been previously described for Canada.

METHODS

Secondary analysis was performed with data from hospitals in all Canadian provinces and territories, excluding Quebec. Infants with NAS were identified by searching for ICD-10-CA code P96.1 in the Canadian Institute for Health Information's discharge abstract database. We examined incidence, hospital beds occupied per day, length of stay (fiscal 2003-2014), hospital costs, and demographic features (due to data availability, limited to fiscal 2010-2014).

RESULTS

The incidence of NAS in Canada tripled between 2003 and 2014 (1.8-5.4 per 1000 live births), with an average annual increase of 0.33 cases per 1000 live births (95% CI 0.31, 0.34). Provincial incidence in 2014 ranged from 2.7 (Alberta) to 9.7 (New Brunswick) per 1000 live births. Between 2010 and 2014 total and mean per-patient costs rose from $15.7 to $26.9 million CAD and $14,629 to $17,367 CAD, respectively, with substantial inter-provincial variation in expenditure. Mean length of stay was 14.4 days in 2003 and 14.8 days in 2014, and beds occupied per day rose from 19.7 in 2003 to 69.4 in 2014.

CONCLUSIONS

The incidence of NAS is increasing in Canada with associated rise in healthcare resource utilization. Inter-provincial variability in incidence and resource utilization underscores the need to further explore best practices for cost-effective prevention and management of NAS.

No. 349-Substance Use in Pregnancy

OBJECTIVES

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

No 349 - Consommation de substances psychoactives pendant la grossesse

OBJECTIFS

Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins.

OPTIONS

La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse.

ISSUES

Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement.

RECHERCHE DOCUMENTAIRE

La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy », « electronic cigarettes », « tobacco use cessation products », « buprenorphine » et « methadone ». Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références.

VALEURS

La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.

NICU Culture of Care for Infants with Neonatal Abstinence Syndrome: A Focused Ethnography

PURPOSE

The purpose of this focused ethnography was to describe the culture of care and nonpharmacologic nursing interventions performed by NICU nurses for infants with neonatal abstinence syndrome (NAS).

METHOD

Roper and Shapira's framework for the analysis included participant observation, individual interviews, and examination of existing documents.

SAMPLE

Twelve full-time nurses were observed and interviewed.

RESULTS

Results described the culture of care provided to infants with NAS by NICU nurses as evidenced by six themes: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer/comforter, becoming an expert), grief, making a difference (wonderful insanity, critical to them), and education and care of the mother.

A National Survey of the Nursing Care of Infants With Prenatal Substance Exposure in Canadian NICUs

BACKGROUND

Many communities are reporting increases in the number of infants requiring NICU care. Practices continue to vary and there is limited available evidence about nursing care.

PURPOSE

The purpose of this study was to describe current nursing care practices for infants with prenatal substance exposure in the NICU setting and during transition to the community. Findings from this study were compared with an earlier Canadian survey (by Marcellus in 2002) to identify shifts in clinical nursing practice for this population.

METHODS

This was a cross-sectional descriptive survey design. A 68-item survey composed of multiple-choice and open-ended questions was administered through FluidSurveys online software. A convenience sample of 62 clinical managers or clinical educators in hospitals with active maternal-infant clinical units with 500 deliveries or more annually and/or pediatric hospitals with a separate designated neonatal service (ie, Level 2 and 3 units) was chosen.

RESULTS

A greater number of NICUs are using clinical guidelines to support the standardization of quality care. Improvements in nursing practice were identified and these included the consistent use of a withdrawal scoring tool and provision of education for team members in orientation. A decline in routine discharge planning meetings and routine parent teaching plans was discovered.

IMPLICATIONS FOR PRACTICE

This survey has improved understanding of the current state of nursing care for infants with prenatal substance exposure and their families during this critical time of transition. The purpose of the survey was to compare findings with the 2002 study by Marcellus to identify any improved practices and describe current state nursing care practices in the NICU. Practice changes over the last decade have included keeping mothers and infants together, expanding concepts of the team, integrating programs and services across hospital and community settings, and creating opportunities for NICU teams to learn more about substance use, mental health, violence, and trauma.

IMPLICATIONS FOR RESEARCH

Focus on discharge planning, parent teaching, and creation and implementation of national/hospital guidelines is essential for consistent evidence-based quality patient care.

SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Substance use in pregnancy

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B).

Identifying infants at risk for neonatal abstinence syndrome: a retrospective cohort comparison study of 3 screening approaches

OBJECTIVE

The main objective of this study was to analyze the consistency in using a standardized newborn toxicology screening protocol to identify infants at risk of developing neonatal abstinence syndrome (NAS).

DESIGN

A retrospective cohort comparison design was approved by the institutional review board at the regional hospital and used to gather data from the infants' medical records during the study period.

SETTING

The data were collected for a period of 1 year from a regional hospital serving 100,000 patients per annum.

PATIENTS/PARTICIPANTS

Data were based on expectant mothers who delivered between March 2006 and March 2007.

METHOD

Data of maternal self-reported substance use, and urine toxicology results and meconium results were obtained through retrospective chart review of infants exhibiting signs of NAS as noted by nurses on the Finnegan Scoring Tool.

RESULTS

In the absence of accurate prenatal screening, this study lends positively to support the use of toxicology screening protocols at birth to adequately assess and treat infants exposed to illicit substances. Toxicology screening in not intrusive and despite emotional discomfort experienced by mothers of the infants tested, the benefits of attaining accurate information regarding substance exposure is critical for the well-being of the infant.

CONCLUSION

The use of a toxicology screening protocol at birth appears beneficial in determining the need for identifying infants with NAS. Early detection of substance exposure in newborns leads to timely assessment for NAS and subsequent treatment to reduce symptoms in newborns.

(Ad)ministering love: providing family foster care to infants with prenatal substance exposure

A significant percentage of children in foster care in North America are younger than 1 year of age and are in foster care because of parental substance use and other social challenges. Infants might present with specific health and behavioral issues that are challenging to manage within the foster family home environment; foster families require specialized skills and knowledge to manage these issues. In this article, the author describes a constructivist grounded theory of the process of becoming and providing family foster caregiving in the context of caring for infants with prenatal alcohol and/or drug exposure. The basic social process of (ad)ministering love was identified. The author further describes the three phases of this process and the core concepts within each phase.

Neonatal abstinence syndrome: reconstructing the evidence

Neonatal abstinence syndrome (NAS) is the term used to describe the presence of withdrawal symptoms in neonates exposed prenatally to opiates. Much of what is known about NAS is based on the biomedical model of illness. There is less consideration of the social, historical, and political influences on knowledge development about the NAS phenomenon. Social construction presents an alternate framework within which to consider the diagnosis of NAS and on which to strengthen theoretical foundations, expand research programs, and improve practice.

Caring, chaos and the vulnerable family: experiences in caring for newborns of drug-dependent parents

BACKGROUND

Infants exposed to intrauterine drugs present a number of challenging features with which the new mother is faced. They can be irritable, unresponsive, and unpredictable. Available treatments require specialised neonatal care for the first four to six weeks of life; a critical time for the parent-infant attachment relationship to develop. Neonatal nurses have the opportunity to promote this development and ameliorate the effect of other developmental risk factors the baby is likely to experience.

OBJECTIVES

The aim of this study was to explore neonatal nurses' experiences of providing care to drug-exposed newborns and their parents throughout treatment for neonatal abstinence syndrome (NAS).

DESIGN, SETTING AND PARTICIPANTS

This study used interpretive methods by conducting group interviews with eight neonatal nurses in each of four Special Care Nursery Units in South-East Queensland, Australia.

RESULTS

Barriers to promoting the parent-infant attachment relationship were found to be both attitudinal and organisational. These barriers were significant, and were seen to impact negatively on optimal care delivery to this vulnerable population.

CONCLUSIONS

Unfortunately, the results of this study indicated that management of these babies and their parents is compromised by a range of attitudinal and organisational factors. There is a need to address these barriers to optimise care delivery and improve the way in which neonatal nurses impact on parent-infant relationships.

Foster families who care for infants with prenatal drug exposure: support during the transition from NICU to home

Infants exposed prenatally to drugs and alcohol tend to enter the child welfare system at a younger age than many other foster children and often directly from the hospital following birth. This article examines three concepts from the postpartum family adaptation literature: transition to parenthood, maternal and paternal role identities, and attachment. It applies these concepts to the experiences of foster parents who care for infants with prenatal drug and alcohol exposure. Also reviewed are recommended strategies to promote development of the foster parent-infant relationship and to increase parental knowledge within the NICU setting and during the period of transition from hospital to home. Nurses within the NICU have a unique knowledge and experience of caring for infants in withdrawal. This knowledge needs to be shared beyond the hospital with community professionals, who may have limited training in infant health, mental health, or development.