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Course: Maternity Nursing

Topic: Substance Abuse and Neonatal Health

The Nurses International Community

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Module Goals

The learner will be able to:

Explain the risks to the newborn related to alcohol, tobacco and illicit drugs.
Discuss the nursing care of the infant of a mother who uses alcohol tobacco or illicit drugs.
Discuss teaching needs associated with alcohol, tobacco and illicit drugs.

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Newborn Health Risks

National Institute of Drug Abuse (2020b)

Use of tobacco, alcohol, or illicit drugs or misuse of prescription drugs by pregnant women may have severe health consequences for infants:

Many substances pass easily through the placenta, and growing fetus.

Estimates suggest that about 5 percent of pregnant women use one or more addictive substances.

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Alcohol, Tobacco, and Illicit Drugs:Newborn Health Risks

Alcohol, Tobacco consumption and using illegal drugs during pregnancy is associated with following newborn outcomes¹:

Double or even triple the risk of stillbirth
Neonatal abstinence syndrome (NAS)
Withdrawal symptoms at birth
Fetal Alcohol Spectrum Disorder (FASD)²

National Institute of Drug Abuse (2020b)
British Columbia (2019)

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Risks of Stillbirth from Substance Use in Pregnancy

Tobacco use: 1.8 to 2.8 times greater risk of stillbirth, with the highest risk found among the heaviest smokers.
Marijuana use: 2.3 times greater risk of stillbirth.
Evidence of any stimulant, marijuana, or prescription pain reliever use: 2.2 times greater risk of stillbirth.
Passive exposure to tobacco: 2.1 times greater risk of stillbirth.

Tobacco, drug use in pregnancy, 2013 from NIH, National Institute on Drug Abuse (2020b).

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Symptoms of Drug withdrawal in a Newborn

National Institute of Drug Abuse (2020b)

Symptoms can develop immediately or up to 14 days after birth and can include:

Blotchy skin coloring
Diarrhea
Excessive or high-pitched crying
Abnormal sucking reflex
Fever
Hyperactive reflexes
Increased muscle tone
Poor eating patterns

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Symptoms of Drug Withdrawal in a Newborn

National Institute of Drug Abuse (2020b)

Others symptoms include:

Irritability
Poor feeding
Rapid breathing
Seizures
Sleep problems
Slow weight gain
Stuffy nose and sneezing
Sweating
Trembling
Vomiting

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Critical Thinking Question/What Would a Nurse Do?:

A woman of 12 weeks with twin pregnancy is being assessed by a nurse. The nurse identifies that the mother is an alcoholic. While explaining to her about the effects of alcohol in the babies, the patient says “My babies are already affected, so why should I stop drinking alcohol now?”. What would be the most appropriate response by the nurse?

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Risks of Maternal Drug Abuse in a Newborn

Some drugs may have long-term or fatal effect on baby:

Birth defects
Low birth weight
Premature birth
Small head circumference
Sudden infant death syndrome (SIDS)

Children born to mothers who both drank alcohol and smoked tobacco beyond the first trimester of pregnancy have a twelve fold increased risk for (SIDS) compared to those unexposed or only exposed in the first trimester of pregnancy.

National Institute of Drug Abuse (2020b)

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Alcohol Effect in Newborn: FASD

British Columbia (2019)

Range of FASD effects of alcohol can include:

Distinctive facial features: have small head, flat face, and narrow eye openings, for instance

gets more obvious by age 2 or 3

Growth problems: May be smaller than other children of the same age
Learning and behaviour problems
Birth defects
Problems bonding or feeding as a newborn

Physical or mental problems may last all of his or her life.

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Tobacco Smoking Effect in Newborn

Newborns of smoking mothers also show signs of stress and drug withdrawal consistent with what has been reported in infants exposed to other drugs
Newborn exposure to secondhand smoke at greater risk for:

SIDS
Respiratory illnesses (asthma, respiratory infections,bronchitis)
Ear infections
Cavities
Increased medical visits and hospitalizations

National Institute of Drug Abuse (2020b)

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Critical Thinking Question/What Would a Nurse Do?:

A 32 years old mother at term has admitted in labor ward with a true labor pain. While nurse taking a history she found that the mother has been alcoholic and smoking throughout the pregnancy. What would the different symptoms a nurse would look in a baby after delivery? Select all that apply.

Low Birth weight
Macrosomia
High pitched cry
Abnormal sucking reflex
Hypertonic reflexes
Seizures

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Alcohol/Tobacco/Illicit Drugs Effects on Breastfeeding

Nicotine in breast milk and passive smoking can cause respiratory infections, vomiting, diarrhoea and irritability in babies¹
Alcohol consumption above moderate level while breastfeeding² :

Interfere with the milk ejection reflex (letdown)
Decreased milk production
Damaging to an infant’s development, growth, and sleep patterns

Illicit drug pass to breast milk leading to³:

Irritable baby
Dependency on drugs
Drowsiness and poor feeding habits

The Royal Women’s Hospital (n.d.,a)
Center for Disease Control and Prevention (2021)
Queensland Government (2017)

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Infant of a Substance Abusing Mother: Treatment

The baby’s treatment depends on the drugs the mother used

Treatment may involve:

Limiting noise and bright lights
Maximizing "TLC" (tender loving care) including skin-to-skin care and breastfeeding with mothers who are in treatment/no longer using illicit substances, including marijuana
Using medicines (some cases)

In the case of babies whose mothers used narcotic:

The baby is initially given small doses of a narcotic to ease withdrawl
Dose is slowly adjusted as the baby is weaned off of the substance over days to weeks
Sometimes sedatives are used

Medline Plus (2021)

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Infant of a Substance Abusing Mother: Treatment

Medline Plus (2021)

Infants with organ damage, birth defects or developmental issues may need:

Medical or surgical therapy
long-term therapies

Infants are likely to grow up in homes that do not promote healthy, emotional, and mental development.
The infant and family need long-term support.

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Infant of a Substance Abusing Mother: Treatment

Mothers should stop drug use only with medical assistance:

Mother, suddenly withdrawing from addictive substance without medical assistance, could put fetus at risk

Monitor newborns for withdrawal and provide proper treatment if necessary
FDA has not approved medications to treat opioid-dependent pregnant women,

but methadone or buprenorphine can improve many of the adverse outcomes associated with untreated opioid use disorder

National Institute of Drug Abuse (2020c)

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Education/Counselling to Substance Abuse Mothers

Mother, family/support person must be counselled on:

Assessing for signs of withdrawal in baby right after birth to 14 days after birth.

Inform them withdrawal symptoms in baby

If signs of withdrawal present, use non pharmacological techniques:

Skin to skin contact, tender loving care
Breastfeeding who are in treatment
Limit bright light and noise

If symptoms do not resolve, seek medical care as soon as possible

National Institute of Drug Abuse (2020c)

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Education/Counselling to Substance Abuse Mothers

continued…..

Buprenorphine, for opioid use disorder taken during pregnancy should be aware that the amount of buprenorphine passed through breast milk may be inadequate to prevent opioid withdrawal in their infant and treatment of the infant may be required.
Even if mother is in treatment, they should monitor the baby for drowsiness, inadequate weight gain, and failure to meet developmental milestones—especially in younger, exclusively breastfed infants.

National Institute of Drug Abuse (2020c)

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Education/Counselling to Substance Abuse Mothers

National Institute of Drug Abuse (2020c)

continued…..

If a breastfed baby of a woman on buprenorphine, shows signs of increased sleepiness, difficulty feeding or breathing, or limpness, a health care provider should be contacted immediately
Infants should be observed for withdrawal signs if breastfeeding is abruptly stopped

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Patient Education: Tobacco/Smoking and Breastfeeding

Smoking can have harmful effects on babies and reduce the amount of breastmilk production.
It is better to breastfeed and smoke than not to breastfeed at all.
If decided to smoke:

Smoke after breastfeeding, away from the baby.
Avoid smoking for half an hour before breastfeeding.

If using nicotine gum:

breastfeed first then chew the gum after so there is less nicotine in the breast milk.

Try not to breastfeed while smelling of cigarette smoke.

The Royal Women’s Hospital (n.d.,a)

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Critical Thinking Question/What Would a Nurse Do?:

A 37 weeks pregnant mother told the nurse that she was an opioid drug user and she is recently taking Buprenorphine, for opioid use disorder. The mother asked the nurse whether the treatment with a Buprenorphine will prevent the baby having Neonatal withdrawal symptoms. What should nurse reply?

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Patient Education: Alcoholism and Breastfeeding

Alcohol passes into breast milk and may remain in milk for hours
Avoid drinking alcohol altogether
If decided to drink alcohol:

Avoid drinking in first month, to establish good breastfeeding
Limit to 2 standard drinks per day
Breastfeed or express and store breast milk before drinking
Wait 2 hours after each standard drink before breastfeeding
Express breastmilk in advance if possible, if plan to drink

If plan to continue drinking alcohol, talk to your doctor or breastfeeding-trained health professional about minimising the harm to your baby

Queensland Government (2017)

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Patient Education: Illicit Drug Use and Breastfeeding

Many drugs pass to breast milk and harm the baby
Inhalants are not safe to use while breastfeeding
Not safe to breastfeed if still injecting drugs

Sharing or re-using injecting equipment can lead to blood-borne infection like HIV, that can be passed on through breast milk

If drugs such as amphetamines or heroin are used as a one-off, express breast milk in the 24 hours afterwards and throw it away before breastfeeding again
While on illicit drugs, do not breastfeed baby

Risk of dropping or smothering the baby

The Royal Women’s Hospital (n.d.,b)

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What role do you think nurses play in the care of the babies belonging to mothers with history of substance abuse?

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Nursing Management

Be aware of mother’s history of substance abuse.
Assessment, identification and appropriate management of related side-effects or withdrawal in babies.
Assessment of growth and developmental milestones in babies at every visit.
Assist in making appropriate referrals to:

Substance abuse management programs
Breastfeeding consultants
Support groups, services, resources available in the community

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Nursing Management

Patient/family teaching on:

Related danger sign/symptoms in babies
When to seek care.
Importance of breastfeeding for babies.

Proper breastfeeding techniques in relation to alcohol/tobacco consumption and illicit drugs use.

Need for family members to assist mother in taking care baby.
About normal growth and development milestones in babies, and seeking medical advice if deviation from the norm.

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Red Flags

Look for sign/symptoms on the baby:

Blotchy skin coloring
Diarrhea
Excessive or high-pitched crying
Abnormal sucking reflex
Fever
Hyperactive reflexes
Poor feeding and poor weight gain
Seizures

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References:

Center for Disease Control and Prevention (2021). Breastfeeding: Alcohol. Retrieved 27 May 2020 from: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/alcohol.html

Gunatilake, R., & Patil, A. V. (2021). Women’s Health Issues: Drug during Pregnancy. Merk manual. Retrieved on 26th of May 2021 from https://www.merckmanuals.com/home/women-s-health-issues/drug-use-during-pregnancy/drug-use-during-pregnancy

HealthLink BC (2019). Alcohol effects on a fetus. Accessed from: https://www.healthlinkbc.ca/health-topics/tk3598

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References:

Medline Plus (2021). Infant of Substance Using Mothers. Accessed from: https://medlineplus.gov/ency/article/007238.htm#:~:text=Babies%20born%20to%20substance%2Dabusing,on%20which%20substances%20were%20used

National Institute on Drug Abuse (2020a). Drugs, Brains, and Behavior: The Science of Addiction: Addiction and Health. Accessed from: https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/addiction-health

Contact info: info@nursesinternational.org

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References:

National Institute of Drug Abuse (2020b). Substance Use in Women Research Report: Substance Use While Pregnant and Breastfeeding. Accessed from : https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-pregnant-breastfeeding

National Institute of Drug Abuse (2020c). Sex and Gender Differences in Substance Use Disorder Treatment. Accessed from: https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use-disorder-treatment

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References

The Royal Women’s Hospital (n.d.a). Breastfeeding and cigarette smoking. Victoria Australia. Accessed from: https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/breastfeeding-and-cigarette-smoke/

The Royal Women’s Hospital (n.d.,b). Safe breastfeeding for drug users. The. Accessed from: https://www.thewomens.org.au/health-information/breastfeeding/medicines-drugs-and-breastfeeding/safe-breastfeeding-for-drug-users/

Contact info: info@nursesinternational.org

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References

Queensland Government (2017). Breastfeeding and drugs. Accessed from: http://conditions.health.qld.gov.au/HealthCondition/condition/8/31/217/breastfeeding-and-drugs

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