KOSAIR CHILDREN'S

NICU

Norton Suburban Hospital

Bring for a Baby with

Neonatal Abstinence Syndrome

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KOSAIR CHILDREN'S
NICU
Norton Suburban Hospital

4001 Dutchmans Lane

Louisville, KY 40207
(502) 893-1000

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Norton Heatthcare 6/11 KCH-4600

What to expect during your baby's

hospital stay
Your baby is being admitted to the neonatal intensive care unit (NICU)
because he or she is withdrawing from drugs. This withdrawal is called
neonatal abstinence syndrome (NAS). Babies can become addicted to drugs
that the mother took while she was pregnant. Babies must be weaned slowly
from those drugs.
We understand that drug withdrawal is a sensitive issue. Our staff is not
here to judge you. We are here to help your baby go through a safe and
medically supported drug withdrawal, which would not be safe to do at
home. Your baby may need medication to help him or her have an easier
time slowly withdrawing from the drugs.
To determine what medications are needed, your baby will get a score every
four hours based on his or her withdrawal symptoms. There is a list of 21
symptoms that nurses look for when scoring your infant. We will explain
these symptoms throughout this booklet.

Dear parents:
Thank you for entrusting us with your baby's
care. Your baby will receive very good care
at Norton Suburban Hospital. This booklet
will address some of the questions you may
have about your baby and provide tips to
help you care for your baby while he or she is
recovering.

Your baby will stay in the hospital until he or she does not need the
medication anymore and is well enough to be discharged.
All babies are different. No one, not even the doctor or nurse practitioner,
knows exactly when your baby will be ready to go home with you. Drug
withdrawal can take as long as six to nine months. Your baby typically will
require medical treatmentin the hospital for one to two months. Please talk
with your baby's nurse or caregiver if you have any questions.
Hospital chaplains and social workers can help you during this stressful
time. We also encourage you to ask family members or friends to help you
while your baby is in the hospital. We can help you best if you let us know:
Who you would like to receive information about your babys condition
when you are not at your baby's bedside
Who is it OK to talk in front of when you are spending time with your
baby

You are the most important person in your baby's life. We want you to
spend as much time with your baby as you can. It will help you get to know
your baby and help with bonding. Spending time with your baby also will
help you learn how to care for him or her.
We want you to understand that it is important for your baby to rest. Please
sit quietly by your baby's bed if he or she is asleep. One of your baby's
challenges will be getting restful sleep. It is important for you to participate
in your baby's withdrawal support by sitting quietly rather than waking him
or her up.

Babies and drug withdrawal

Babies who are withdrawing from drugs may act particularly different than
most newborn infants. These symptoms often begin within the first three
days after birth. Sometimes withdrawal symptoms do not show up until
seven to 10 days after birth. Symptoms include:
Often crying for a long time
Being hard to calm
Having trouble sleeping
Tremors or being jittery
Problems taking a bottle

Ways you can help your baby

Babies going through drug withdrawal need special care to keep them safe
and comfortable. It is important that you learn how to calm and comfort
your baby. This involves knowing how your baby is handled. You can help
your baby by using the tips in this booklet and talking with your baby's
nurse about ways to calm and care for your baby.

Swaddling
Babies with NAS have a hard time doing different things at the same time.
They cannot focus on taking a bottle or sleeping if they are uncomfortable.
We can help your baby be calm by swaddling or wrapping your baby
snugly. This will help your baby control movements and provide comfort.

The 'C' position

Holding your baby in the "C" position will help him or her have more
control and be able to relax. Hold your baby securely and tuck the baby's
head and legs into a "C" shape. Your baby's chin should be resting near his
or her chest with arms near the center of the chest. Your baby's back should
be rounded with the legs tucked toward his or her belly. Wrap your baby
snugly in the blanket to help him or her stay in this position. You also can
help your baby stay in the "C" position when laying him or her down. Just
place your swaddled baby on his or her side and use positioning devices
around your baby. Begin placing your baby on his or her back for sleeping
as he or she slowly gets better. The American Academy of Pediatrics
recommends this position when babies are sleeping to reduce the risk of
sudden infant death syndrome (SIDS).

Head-to-toe movement
Avoid movements with your baby that are fast or jerky, such as:
Back and forth rocking
Swings or bouncy seats (later on, in the middle to late stages of drug
withdrawal, the use of side-to-side swings at a slow speed can be
helpful in calming and comforting your baby)
These movements can be too stimulating to your baby's nervous system
during the early stages of drug withdrawal. Slow and rhythmic swaying
that follows a line from head to toe is calming. Be sure to keep your baby
swaddled and held securely in the "C" position. Keeping your movements
slow and rhythmic may help to relax and comfort your baby. It also can be
calming if you go slowly when changing your baby's position.

Patting
Another way to help your baby relax is to pat his or her diapered and
blanketed bottom. You may feel your baby's muscles relax when you cup
your hand and pat in a slow and rhythmic way. It can be very soothing for
some babies. However, it is sometimes too much for very sensitive babies.

Feeding
IInhies going through drug withdrawal often suck frantically on a pacifier.
They also may have a mixed-up or disorganized suck because they are very
~;(rcssed, This can make it hard for them to take a bottle without help. Hold
YUIll' baby securely so he or she can relax enough to suck. Always feed your
baby in a calm and quiet place. This means no bright lights, music, noise or
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Be sure your baby is swaddled and held in a "C" position.
Ytl\U baby may cry, along with wanting to suck on his or her pacifier,
very often. It does not always mean your baby is hungry. Overfeeding
Y(IlU' baby to try and calm him or her can lead to even more discomfort.

1\:11 ii('n with NAS tend to have trouble feeding and have colic (bellyache).
bahy will be given a lactose-free or soy formula to help prevent this. If
l'l Iltll!"!' brcastfccdtng, we will use one of these formulas to supplement your
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breastfeedings as needed. We recommend feeding your baby every three

to four hours. We also can give your baby some liquid drops as needed for
gas relief and place a warm blanket around his/her tummy to help with the
discomfort.

Bath time/massage
A tub bath may be very relaxing for your baby when he or she is starting to
feel better. You can give your baby a tub bath after his or her umbilical cord
falls off. At first you may want to keep your baby swaddled during the bath.
After a bath, a gentle massage with warm lotion also may help your baby
relax. Your babys nurse can contact someone to teach you how to massage
your baby.

Controlling the environment

One of the most important things you can do for your baby is to give him
or her a calm environment:
Turn down or turn off music near his or her bed.
Limit the number of people and loud voices around your baby. This is
especially important in the beginning.
Ceiling lights or bright lights may be overwhelming during the first
weeks of drug withdrawal.
Your baby may be comforted by your soothing and calm presence.
Your baby will benefit from you speaking quietly and moving slowly.
A daily routine is important for your baby.
Rest also is very important for your baby. Please allow your baby
to sleep until he or she wakes up for a feeding.
Try to pay attention to your own energy level. Are you nervous, tense,
feeling anxious? Are you moving constantly? It may help your baby if
you do not hold him or her close to your body when you are having these
feelings. It is OK to take a break to give your body a chance to relax before
you pick up your baby again.

NAS scoring
We must be able to correctly assess you babys symptoms due to drug
withdrawal. It will help us know how to take care of your baby. The NAS
scoring tool was created to make this possible. The NAS scoring tool is a
set of 21 signs and symptoms that your baby may have. We look at these
symptoms every four hours. Each symptom has a score, and the total of
these scores helps us plan the best treatment for your baby. This score is a
very important number. If the score is less than eight, your baby is having
an easier time with the drug withdrawal. Low scores tell us that your baby
may be weaned from the medications sooner. High scores tell us that your
baby is having a harder time with the drug withdrawal. It means your baby
will be weaned slower from the medications and may stay in the hospital
longer. The score can change quickly from high to low. It also can change
from day to day.

Assessing your baby's symptoms

Excessive high-pitched (or other) cry
Continuous or irregular crying for up to five minutes, even with attempts to
calm your baby. This symptom will be scored if it is observed in your baby.
Your baby will not be scored for excessive crying if it happens right before a
feeding and he or she calms with the feeding.

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Continuous crying for more than five minutes, even with attempts to
calm your baby. This symptom will be scored if it is noted with your baby.
Newborn infants typically do not need to be held constantly to stay
calm or soothe themselves. We encourage you to hold your baby if it
helps to comfort him or her. We want you to understand
that your
baby will be scored if he or she needs excessive help from you or
others to stay calm.

Medication is started when your baby's scores are high and he or she does
not respond to the traditional comfort methods (as discussed earlier in this
hooklet). Morphine, methadone and sometimes phenobarbital may be given
to your baby. The amount of medication is based on your babys scores.
Medication is started when:

It is normal for a baby at two to three months of age to cry for a short
period of time as he or she learns how to soothe himlherself. It is not
necessary to pick your baby up as soon as he or she begins to cry because it
can interfere with your baby's learning of this very important skill. However,
your baby should not be left.to cry for long periods of time without any
help. We do not score your baby for this type of cry because it is different
from the excessive cry of a baby going through drug withdrawal.

Three scores in a row are greater than or equal to 8

Two scores in a row are greater than or equal to 12
Or, one score is greater than or equal to 15
Medications are increased/added until your baby's scores remain mostly
less than 8. We begin decreasing the medications 72 hours after your baby's
average daily score is less than or equal to 8. (Your babys doctor or nurse
prncritioner will take all the scores from the past 24 hours and average
111I:nl into one score t.ohelp determine when
III wean your baby from the medication.) It
in wry important for the scores to be correct.
YUill' babys nurse has been trained to use this
f~l'l\l'lngtool, Below is the set of symptoms
yn(U' hnby:-; nurse will look for when scoring
yntll' IllIhy.

Sleeping
Sleeps less than one hour after feeding
Sleeps less than two hours after feeding
Sleeps less than three hours after feeding

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Your baby will be scored based on longest length of time that he or she slept
during the scoring period. We do not score if your baby is disturbed by the
doctors, nurse practitioners or nurses for procedures or other reasons. The
doctors and nurse practitioners won't wake your baby up for an assessment;.
they will wait until the baby wakes up on his or her own.

We want you to understand that newborns usually eat and then go

right to sleep. They wake up when they need to eat again, which is around
three to four hours later. They will gradually begin to stay awake for longer
periods of time as they get older.

Skin breakdown
Your baby's skin can break down when it is rubbed repeatedly against a
flat surface. Some areas of the skin that may break down include the chin,
knees, cheeks, elbows, toes and fingers. Your baby's bottom also can break
down because of frequent bowel movements.

Mora reflex
This is a normal reflex that all babies are born with. We evaluate it by
gently lifting your baby slightly off the mattress by the wrists. The baby will
straighten his or her arms and move them out at the elbows.
The wrists go into a "C" shape. The arms then return to the chest in a
resting position. A baby may cry during this evaluation. It is important to
check this reflex when your baby is calm.

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Hyperactive Moro - Your baby will be scored in this area if he or she

has a noticeable jitteriness of the hands during or at the end of the
Mora reflex.

Sweating

Fever

Tremors

Your baby will be scored if his or her temperature is between 99F to

lOO.SF. He or she will get a higher score if the temperature is higher
than 101F. Your babys temperature is taken under the arm.

Tremors and jitteriness are the same thing. They are involuntary movements
that are rhythmic and occur in the arms, legs, hands or feet. Some jitteriness
in sleep is normal and is not scored. Tremors are based on how severe they
are, from mild to severe. They also are scored depending on when they
occur. Your baby will get a higher score if tremors are noticed when
he or she is not being disturbed.

Tone is the ability of the muscles to resist movement. Muscle tone is

assessed when your baby is awake and calm. Your baby is scored for an
increase in tone when he or she has no head lag. It also is scored if your
baby is stiff or arching.

These are involuntary spasms of the muscle. They are quick and jerky, and
do not last long. They can occur in the face, arms or legs. They may occur
as a single jerk or many jerks. They are different from tremors because they
are quick, jerky movements of one arm or leg. This symptom is scored if
your baby has them.

This symptom is scored if there is wetness on your babys forehead, upper

lip or the back of the neck. It will not be scored if it happens because your
baby is swaddled snugly.

Markedly hyperactive Moro - Your baby will be scored in this area

if jitteriness and jerking of the hand and/or arms or feet are noticed
during or after the reflex.

Increased muscle tone

Myoclonic jerks

Generalized convulsions/seizures
Seizure activity is sometimes hard to notice. It can include:

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Quick movements of the eyes that your baby cannot control

Chewing

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Rowing motion of the upper arms, or bicycling of the legs

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Back arching
Fist clenching
Please let a nurse know if you see your baby doing any of these
things. The nurse will examine your baby to be sure he or she is OK.
Generalized convulsions/seizures are scored.

Yawning

Excessive sucking

This symptom is scored if your baby has frequent yawning, which is more
than three times during the scoring interval.

Excessive sucking is what happens when your baby is sucking on the

nipple so strongly that there will be a need to break the seal to release it. It
also means sucking on a pacifier frantically or almost all the time between
feedings. Your baby will he scored if this activity is noticed.

Mottling
Mottling is a change in the color of your baby's skin, making it look
"splotchy." It usually is seen on the chest, trunk, arms or legs. This symptom
will be scored if it is noticed with your baby. Mottling also can be seen if
your baby is cold. Your baby will not be scored if mottled for this reason.

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Excessive sucking does not always mean that your baby is hungry.
This can lead to overfeeding your baby. Your baby should eat
every three to four hours and use the pacifier for comfort between
feedings.

Nasal stuffiness

Loose stools

Nasal stuffiness occurs when the nostrils are partially blocked with mucus.
It usually causes noisy breathing. This symptom will be scored if your baby
has nasal stuffiness that persists after initial suctioning, even if it cannot be
seen.

This symptom will be scored if your babys stools are seedy or runny, unless
they are breast milk stools.

Watery stools
This symptom will be scored if your babys stool is liquid and/or explosive.

Sneezing
This symptom is scored if your baby sneezes more than three or four times
during the scoring interval.

Poor feeding
Your baby will be scored for poor feeding if he or she is not able to take the
amount needed within 30 minutes. Your baby will. use more calories than
he or she takes in when allowed to eat longer than 30 minutes. Using more
calories can lead to weight loss and possibly a longer hospital stay. A poor
feeding also is scored if your baby cannot take his or her bottle without a lot
of help, such as:

Nasal flaring
Nasal flaring is the outward spreading of the nostrils during breathing. This
symptom is scored when it is seen in your baby.

Respiratory rate
Babies normally breathe between 30 to 60 times every minute. A retraction
is a sign that tells us your baby is working hard to breathe. He or she will
have a sucking in of the chest wall above or around the rib cage. Your baby's
breathing rate will be counted for a full minute when he or she is content.

Chin/cheek support
Manipulating the honk
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Repositioning

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buby

Changing your postt ton

Your baby will be scored in this area if he or she is breathing more than
60 times a minute.
Your baby will get a higher score if he or she also has retractions while
breathing more than 60 times a minute.

Vomiting

Going home

This symptom will be scored if:

To make sure you have developed the skins needed to care for your
baby at home you will need to do an of the care for your baby in the
hospital for 24 hours before your baby can be discharged.

Your baby vomits two or more times during a feeding that is not
associated with burping
Your baby vomits 5 cc or more between feedings
Your baby will receive a higher score if he or she forcefully vomits during or
after a feeding.

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Introducing stimulation
Babies need stimulation for healthy development. A baby going through drug
withdrawal needs to have stimulation in small doses. It must occur when he
or she is able to handle it. It is best to go slowly and try one thing at a time,
like introducing light, sound, touch, voice, etc. You might try to see how your
baby acts when he or she is not swaddled as snugly. Then you may try gentle
rocking or talking. Stop and swaddle your baby again if he or she becomes
stressed. It will take time and patience from you. Watch for how your baby
reacts and his or her cues. Your baby will let you know what he or she can
handle. Reach out to your baby when he or she is ready and alert, not when it
is more convenient for you.

We want the transltlou 1(1 home 10 h(" it smooth one for you and your baby.
Your baby will he disl"ilOlrl'.l"l1 when hr III" she is completely weaned from
the medication. Your baby may sttll bc very irritable at limes due to drug
withdrawal. irrunbiltty [iucriucss and excessive sucking can continue for as
long as six to nine months. These symptoms can be managed with the comfort
measures that were discussed in the "ways you can help your baby" section at
the beginning of this booklet.
Your baby will be followed up in a neonatal developmental clinic at least every
three months during his or her first year of life. This is to evaluate how well
your baby is meeting his or her developmental milestones.
Your baby will he getting used to his or her new environment at home. Here
are some ways to help you cope if your baby is very fussy and difficult to
comfort:
Take slow, deep hrc.uhs and count to 10 or 20, or more.

Babies recovering from NAS will tend to not make eye contact. Your
baby may only briefly look into your eyes or gaze upon yonr face and
then turn away from you. This is normal. This does not mean your
baby is not bonding with yon. This will get better with time.

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