R E V I E W S & A N A LY S E S Addressing the Rise in Neonatal Abstinence Syndrome: A Multifaceted Approach Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Pennsylvania Patient Safety Authority The number of neonatal abstinence syndrome (NAS) cases involving newborns who experience withdrawal symptoms after birth from prenatal exposure to drugs such as opioids is dramatically increasing, causing hospitals to rethink their approaches to diag- ABSTRACT nosis and treatment.1-3 With the rising incidence of neonatal Opioid prescribing increased in the United States from around 76 million in 1991 abstinence syndrome (NAS) over the to nearly 207 million in 2013, crossing all populations, including pregnant women.4-6 last decade, healthcare professionals Addiction may occur after opioids are prescribed for chronic pain caused by an acci- are recognizing that close collabora- dent, fibromyalgia, or other causes.2 tion and standardized protocols aid in Maternal use of prescription or illicit drugs during pregnancy can result in the new- effectively diagnosing and treating new- born experiencing NAS.4,7 Tolia et al. reported that the frequency of neonatal intensive borns with drug withdrawal symptoms. care unit (NICU) admissions for newborns with NAS increased from 7 to 27 cases per Maternal use of prescription or illicit 1,000 admissions in the United States from 2004 through 2013.8 Patrick et al. calcu- drugs during pregnancy can result in the lated an increase in the rate of NAS from 3.4 to 5.8 per 1,000 hospital births per year newborn experiencing NAS, with symp- in the United States from 2009 to 2012.9 toms of excessive or high-pitched crying, irritability, poor feeding, sleep prob- Newborn symptoms of withdrawal measured using a scoring system such as the lems, slow weight gain, and seizures. Modified Finnegan Neonatal Abstinence Scoring tool include neurologic signs such as Pennsylvania Patient Safety Authority irritability; inconsolable crying and seizures; gastrointestinal disturbances of vomiting, analysts identified 797 events involv- diarrhea, and poor feeding; and autonomic concerns of fever and mottling.10 ing newborns diagnosed with NAS that Treatment for the infant depends on the type of drugs taken by the mother, the new- occurred from January 2005 through born’s overall health, and whether the newborn was born at full term or prematurely. December 2014, with an increasing Depending on the type of opioid exposure, withdrawal can occur during the first day number of events reported each year. to three days after birth, and sometimes even up to five to seven days after birth, with Healthcare professionals use a stan- an average onset of 48 hours.10 dardized scoring process, combinations Pennsylvania Patient Safety Authority analysts performed a query of the Pennsylvania of pharmacologic and nonpharmaco- Patient Safety Reporting System (PA-PSRS) to identify event reports involving NAS and logic interventions, and close care team found an increasing number of events from January 2005 through December 2014. collaboration to aid in the diagnosis Healthcare professionals report using a standardized scoring process, combinations of and treatment of newborns with NAS. pharmacologic and nonpharmacologic interventions, and close care team collaboration With the help of healthcare profession- to aid in the diagnosis and treatment of newborns with NAS. als, mothers and families can provide the supportive love and care needed METHODS to help their newborn through the with- drawal process. (Pa Patient Saf Advis Analysts queried the PA-PSRS database for reports of events that occurred from 2015 Dec;12[4]:125-31.) January 2005 through December 2014 using keywords including but not limited to “neonatal abstinence,” “NAS,” “Finnegan,” “drug dependent,” “withdrawal,” “opioid,” and “oxycodone.” Analysts manually reviewed the resulting set of event reports to iden- tify those reports with event narratives that described NAS events. Additionally, during review of event narratives, analysts determined whether licit or illicit drug use was reported by the mother. Analysts then sorted the resulting data set into the categories of (1) methadone, (2) buprenorphine, (3) other prescription opi- oids, (4) benzodiazepines, and (5) illicit substances. RESULTS Analysts identified 797 NAS events (Figure 1). All of the identified events were submitted in the event type category of “complication of procedure/treatment/test” and the subcat- egory of “neonatal complication.” The majority of the NAS events (n = 602, 75.5%) Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 125 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 1. Number of Neonatal Abstinence Syndrome Events Reported to the NAS scoring was done on the night Pennsylvania Patient Safety Authority, 2005 through 2014 shift with [resulting scores of] 9 and 12; in the morning also 12. Symp- NO. OF toms included excoriation, excessive EVENT REPORTS yawning, sneezing, and sucking with 250 increased tone. A neonatologist was 221 notified, and the patient was trans- 197 ferred to NICU. 200 DISCUSSION 150 126 Helping newborns through the difficult time of withdrawal requires a series of observations over a period of time for 100 76 correct diagnosis and collaboration of all 70 healthcare professionals who contribute 50 33 to treatment, including pharmacologic 28 29 16 and nonpharmacologic interventions.1-3 MS15594 1 Families also play a key role in learning 0 how to interact with their newborn, 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 whose symptoms may include irritability, YEAR inconsolable crying, vomiting, and poor feeding.2,3,10,11 involved newborns who had an withdrawal with Finnegan scores of Dramatic increases in US addiction rates unplanned transfer to the NICU. The 10 and 14. Transferred to NICU spurred the recent passage of a bill calling remainder of the events (n = 195, 24.5%) for further evaluation and possible for information about NAS and opioid were listed under “other.” treatment. dependency in women. See “Addiction Baby girl was being scored for with- Surges in the United States” and Types of Drugs drawal from methadone and benzodi- “Protecting Our Infants Act” for more Specific drugs were mentioned in 289 azepines. She had increased Finnegan information. reports, with 68% describing drugs used scores multiple times in a row. Physi- to treat opioid dependence (i.e., metha- cian from the NICU was called and Multidisciplinary Approach done and buprenorphine) (Figure 2). came to evaluate her. Infant was The healthcare team. Treating the new- transferred to NICU to be started on born with NAS requires a team approach Types of NAS Events morphine. Physician spoke with par- using family-centered care, according to The following are examples of events ents, and infant was taken to NICU. John Chuo, MD, MS, neonatal quality reported to the Authority involving NAS:* Infant delivered by a mother with a officer and medical director of tele- history of marijuana, cocaine, and medicine at the Children’s Hospital of Infant delivered by C-section. Infant Percocet use during the pregnancy. Philadelphia.3 “The care team has the showed signs of possible drug with- Initial NAS score was low; how- opportunity to set the attitude and tone drawal. Finnegan score observed ever, as time progressed, NAS score towards the mom, being empathetic and over initial period and was noted to increased to 16. The infant was very non-accusatory,” he said.3 Management be increasing. Infant was observed fussy and jittery. Decision was made can include pharmacologic treatments, by physician and was transferred to to transfer to a higher level of care. such as using a morphine wean, and NICU. Mother denied any drug use. nonpharmacologic treatments, such as Mother positive for oxycodone and Change in infant status. High-pitched encouraging breastfeeding, swaddling, and other drugs. Infant showed signs of cry and severe tremors. Providers skin-to-skin contact, Chuo said.3 assessed infant. Infant NAS scored at * The details of the PA-PSRS event narratives 16. Parents deny all drug use. Infant The neonatologist relies on information in this article have been modified to preserve transferred to NICU. assessed by the nursing staff to determine confidentiality. the type and dose of pharmacologic Page 126 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority Figure 2. Maternal Use of Prescription and Illicit Drugs* as Described in Neonatal home a healthy and strong family unit, Abstinence Syndrome Events Reported to the Pennsylvania Patient Safety Authority, according to Bawn Maguire, MSN, RN, 2005 through 2014 outreach coordinator and programmatic nurse specialist, Magee-Womens Hospital NO. OF EVENTS of the University of Pittsburgh Medical 175 167 Center. “Nursing’s role is more than tak- ing a vital sign and changing a diaper,” 150 she said.11 “They are helping these families to become stronger, and become a family. 125 The nurse holds the power in her hands 100 to help these families care for the baby, 77 see the baby, and understand the baby. 75 The true treatment is the time the mom 51 starts to care for her baby. The stronger 50 45 nursing can make the unit, the healthier the family. That’s what this is all about.”11 25 19 MS15596 Finnegan Scoring System 0 Tools available for quantifying the severity e† † ) m on s ro s ine of neonatal withdrawal include the Lipsitz ph id he nce on la e) or io ph in) Zo ad a, sta m op tool, the Neonatal Withdrawal Inventory, or RA eth an b en RO tion iju su the Neonatal Narcotic Withdrawal Index, LP M pr ,A ar it YD rip Bu lic and the Finnegan Neonatal Abstinence g. , H esc , m Il e. Scoring System.10 The Finnegan scoring NE r s( rp ne DO he system is the most commonly used NAS pi ine O Ot ze assessment tool in the United States.1,10 ca ia co od A version of the Modified Finnegan nz ., yC .g Be Neonatal Abstinence Scoring tool can ox (e ., be accessed at http://www.lkpz.nl/docs/ .g (e lkpz_pdf_1310485469.pdf. DRUGS * Two hundred and eighty-nine events described specific drugs. More than one drug The Finnegan scoring system is used to was identified in 50 events. score symptoms over time and can be † Used in the treatment of opioid dependence. used to initiate, wean, or escalate pharma- cologic treatment. The nurse scores the intervention. “Adjusting medication dos- higher risk for weight loss, so we also work newborn throughout the course of the ages often requires a discussion amongst with the nutrition department. We often hospital stay, assigning a predetermined the care providers, including physicians, need to involve social services because the number of points for specific symptoms nurses, and pharmacologists, especially moms have extra needs. We also use vol- of gastrointestinal, metabolic, vasomotor, when the baby’s Finnegan scores are bor- unteers who swaddle and hold the babies. respiratory, and central nervous system derline,” he said.3 And then we need to have follow-up with disturbances.10 Assessing and treating newborns with these babies. We send them to the high- The first abstinence score is recorded NAS is “definitely a multidisciplinary risk [follow-up] clinic, and we need to approximately two hours after birth or approach,” according to Scott Wexelblatt, hand them off to their pediatrician for upon admission to the nursery for a MD, regional medical director for new- monitoring.”2 baseline score. Following the baseline born services, Cincinnati Children’s Nursing’s role. The healthcare team score, newborns are scored at four-hour Hospital Medical Center, who has con- of physicians, nurses, social workers, intervals. Depending on the results, the ducted studies on NAS.2 and dietitians coordinate the care of frequency of scoring can be increased to the newborn with NAS. Nursing’s role every two hours.12 If the combined score “Nurses are key in this process,” is greater than or equal to 8 on any three Wexelblatt said. “These babies are at is particularly vital in helping to send Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 127 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Neonatal Services reduced its length of ADDICTION SURGES IN THE UNITED STATES stay for newborns with NAS from 36 days to 18 days by training in the assessment Addiction has surged over the past decade and is closely related to the nation’s ongoing prescription drug epidemic.1-3 Following are findings that illustrate the of NAS symptoms using the Finnegan increases in opioid and heroin usage and addiction: scoring system along with a standardized pharmacologic protocol.13 ——  The number of prescriptions for opioids such as hydrocodone and oxycodone increased from about 76 million in 1991 to nearly 207 million in 2013.2 Pharmacologic Approaches ——  In 2013, an estimated 517,000 people reported past-year heroin abuse or dependence, a nearly 150% increase since 2007.1 Drug therapy is indicated for moderate to severe NAS to ease the withdrawal process ——  About 75% of new heroin users first became addicted to prescription opioids. 1 and prevent complications such as weight ——  Heroin use is reaching new populations, including women and middle-class users.1 loss and seizures; however, unnecessary ——  Heroin overdose death rates nearly quadrupled in the United States from 2002 use of drugs could prolong withdrawal to 2013.1 and the duration of hospitalization.1 ——  Factors that may have contributed to the rise include the following:1,4 There are currently no uniformly accepted * Dramatic increases in the number of pain management prescriptions written pharmacologic interventions or standard- and dispensed (usually for chronic pain) ized treatments for NAS management.1 * Greater social acceptance for using medications for pain management Most treatment strategies include gradual * Aggressive marketing campaigns by pharmaceutical companies weaning of a single opioid.14 Typically, Notes clinicians use morphine or methadone as the first drug of choice.14 A sedative, such 1 Jones CM, Logan J, Gladden RM, et al. Vital signs: demographic and substance use trends among heroin users, United States, 2002–2013. MMWR Morb Mortal Wkly Rep 2015 Jul as phenobarbital or clonidine, may be 10;64(26):719-25. added as an additional medication when 2 Volkow ND. America’s addiction to opioids: heroin and prescription drug abuse [online]. opioid treatment alone is ineffective.14 Senate Caucus on International Narcotics Control. 2014 May 14 [cited 2015 Aug 14]. Standardized treatment. A multicenter http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2014/ americas-addiction-to-opioids-heroin-prescription-drug-abuse cohort study of treatments and hospital outcomes in Ohio concluded that regard- 3 Warren MD, Miller AM, Traylor J, et al. Implementation of a statewide surveillance system for neonatal abstinence syndrome—Tennessee, 2013. MMWR Morb Mortal Wkly Rep 2015 less of the initial opioid used in treatment Feb 13;64(5):125-8. of newborns with NAS, use of a standard 4 Calabresi M. Why America can’t kick its painkiller problem. Time 2015 Jul 15;185(22):26-33. treatment protocol with stringent weaning guidelines significantly reduced duration of pharmacologic intervention (17.7 ver- sus 32.1 days, P < .0001) and length of consecutive ratings, the average of two trained to do the Finnegan scoring stay (22.7 versus 32.1 days, P = .004).14 scores is greater than or equal to 12, or system, and we rely on those scores to the scores for two consecutive ratings are initiate treatment, wean treatment, or Nonpharmacologic Bundle greater than or equal to 12, the newborn escalate treatment.”2 Nursing manages the nonpharmacologic is assessed for pharmacologic treatment.12 Neonatal Services initiated a “train the bundle at Cincinnati Children’s Hospital Standardizing scoring methods. Neonatal trainer” program in which a nursing Medical Center and works with mothers Services, a joint venture between Nationwide expert used an instructional video for key and other family members, Wexelblatt Children’s Hospital and five maternity nurses to ensure they received specific said. “We rely on nurses for swaddling, hospitals in central Ohio, found that training on how to best evaluate NAS decreasing stimulation, providing parental excessive variability in the scores recorded symptoms. These “super users” then education, and helping the babies with by the neonatal nurses complicated the trained the rest of the nursing staff with their feedings,” he said.2 management of newborns with NAS.13 video instruction, two practice exams, and “Learning how to feed the baby appro- The Finnegan scoring method should an instruction manual with proper scor- priately is essential since they have an be objective rather than subjective, ing definitions.13 uncoordinated suck,” he said. “Knowing Wexelblatt said. “The nurses are all how to soothe the baby is very important. Page 128 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority Maguire said. “There are a lot of moms PROTECTING OUR INFANTS ACT with substance abuse who have felt unloved for so long. Their cup is empty, In November 2015, the president signed a bill requiring the Agency for Healthcare and they don’t have a lot to give to their Research and Quality to report on prenatal opioid abuse and neonatal abstinence syndrome. The bill calls for examination of relevant literature, causes and treatment, babies. They are looking to their baby as and barriers to care for pregnant women to help develop recommendations for pre- a source of love for them,” she said. “But venting, identifying, and treating opioid dependency. their baby cannot provide this because of the physical process of going through The act can be accessed at https://www.congress.gov/bill/114th-congress/ withdrawal.” Nurses work with mothers senate-bill/799. to help them understand the transient nature of withdrawal, Maguire said.11 The nurses learn to speak frankly with a We help the family learn the soothing are not available, we have volunteers who mom who is already feeling guilty that her techniques that will help their individual hold the babies,” she said. Volunteers can newborn is going through withdrawal, baby and help the family manage the include high school or college students or Maguire said. “This is quite a fragile time stress of a baby that is going to cry more retired adults.16 with moms. If we allow the guilt to fester, than a typical baby.”2 Other methods used at Phoenixville it doesn’t do the mom any good.”11 Other nonpharmacologic interventions Hospital to soothe the newborns include “We tell the moms that the bottom line is can include a quiet environment, with placing the newborn in a quiet and you can’t change the past,” she said. “You dim lighting and soft music, according dark room that has the least amount of can learn from the past but cannot dwell on to Maguire.11 “We do a lot of comfort stimulation, Clemens said. “For some this. You have got to keep moving forward. measures,” she said. “We like the baby to newborns, soothing music is helpful, but Your baby only knows the future, and you be held a lot. These babies enjoy being it depends on the baby,” she said.16 will continue to grow with your baby.”11 rocked and enjoy low humming. They also do not like a lot of eye contact.” Compassionate Treatment CONCLUSION Breastfeeding support. The literature Mothers may feel guilty that their baby is NAS is a growing problem in Pennsylvania recommends breastfeeding for mothers requiring treatment, and they may also and throughout the United States as use who are part of a drug treatment pro- feel that they are being judged by the staff of prescribed and illicit drugs by pregnant gram.1 Breastfeeding is contraindicated if doctors, nurses, therapists, and social women continues to escalate.1,17 Effective the mother is taking illicit drugs, abusing workers. “We have been working on try- use of a standardized method of NAS multiple drugs, or infected with HIV.1 ing to improve the nonjudgmental care assessment (such as the Finnegan scoring Multiple studies have confirmed that for these moms,” Wexelblatt said.2 system), medications, and a combination breast milk contains only minimal quanti- Substance abuse is a medical condition, of nonpharmacologic interventions tai- ties of drugs used in the maintenance Maguire said.11 “We don’t judge people lored to the newborn’s individual needs programs for drug-dependent women.1 with chronic diseases such as diabetes and are suggested to help newborns through Breastfeeding increases bonding between hypertension,” she said. “This is another the difficult time of drug withdrawal.2,3 the mother and newborn, enhances medical condition. We remind the nurse Nonjudgmental and compassionate care maternal confidence, and helps mothers that these women love these babies as any by all healthcare workers versed in the feel involved in treating the newborn for woman would love her baby.” management of maternal substance abuse withdrawal.15 and NAS is recommended.11 Role models. Through role modeling “About half of our moms breastfeed,” and training, Maguire helps nurses look Acknowledgments Maguire said. “And many of our moms beyond judging the addicted mom.11 Lea Anne Gardner, PhD, RN, senior patient safety are successful.” Magee Womens Hospital has been treat- analyst, Pennsylvania Patient Safety Authority, and Monica Williams, BSN, RN, psychiatric nurse, Other methods. A “cuddler” program in ing mothers with substance abuse for Mercy Philadelphia Hospital, contributed to data Phoenixville Hospital helps families who about 13 years and has seen a 10-fold acquisition for this article. Matthew Grissinger, cannot always be with their newborns in increase in NAS over the last 12 years.11 RPh, FISMP FASCP manager, medication safety , , analysis, Pennsylvania Patient Safety Authority, the NICU,16 according to Jayne Clemens, “In the ideal world, a mom’s heart is provided pharmacologic expertise. RN-C, NICU staff nurse. “If the parents so overflowing with love for her baby,” Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 129 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S NOTES 1. Kocherlakota P. Neonatal abstinence syn- 7. Orlando S. An overview of clinical 13. Asti L, Magers JS, Keels E, et al. A quality drome. Pediatrics 2014 Aug;134(2):e547-61. tools used to assess neonatal abstinence improvement project to reduce length of 2. Wexelblatt, Scott (Regional Medical syndrome. J Perinat Neonatal Nurs 2014 stay for neonatal abstinence syndrome. Director for Newborn Services, Cincin- Jul-Sep;28(3):212-9. Pediatrics 2015 Jun;135(6):e1494-500. Also nati Children’s Hospital Medical Center). 8. Tolia VN, Patrick SW, Bennett MM, et al. available at http://pediatrics.aappublica- Conversation with: Pennsylvania Patient Increasing incidence of the neonatal absti- tions.org/content/early/2015/04/28/ Safety Authority. 2015 Jul 8. nence syndrome in U.S. neonatal ICUs. peds.2014-1269.full.pdf 3. Chuo, John (Neonatal Quality Officer N Engl J Med 2015 May 28;372(22): 14. Hall ES, Wexelblatt SL, Crowley M, et and Medical Director of Telemedicine, 2118-26. al. A multicenter cohort study of treat- Children’s Hospital of Philadelphia). 9. Patrick SW, Davis MM, Lehman CU, et ments and hospital outcomes in neonatal Conversation with: Pennsylvania Patient al. Increasing incidence and geographic abstinence syndrome. Pediatrics 2014 Safety Authority. 2015 Jul 8. distribution of neonatal abstinence Aug;134(2):527-34. 4. Association of State and Territorial Health syndrome: United States 2009 to 2012. J 15. Maguire D. Care of the infant with neo- Officials. Neonatal abstinence syndrome: Perinatol 2015 Apr 30;35(8):650-5. natal abstinence syndrome: strength of how states can help advance the knowl- 10. Jansson LM. Neonatal abstinence syn- the evidence. J Perinat Neonatal Nurs 2014 edge base for primary prevention and best drome [online]. UpToDate 2015 Jun 12 Jul-Sep;28(3):204-11. practices of care [online]. 2014 [cited 2015 [cited 2015 Jul 7]. http://www.uptodate. 16. Clemens, Jayne (Neonatal Intensive Care Aug 8]. http://www.astho.org/prevention/ com/contents/neonatal-abstinence- Unit Staff Nurse, Phoenixville Hospital). nas-neonatal-abstinence-report syndrome Conversation with: Pennsylvania Patient 5. Warren MD, Miller AM, Traylor J, et al. 11. Maguire, Bawn (Outreach Coordinator Safety Authority. 2015 Jul 13. Implementation of a statewide surveil- and Programmatic Nurse Specialist, Magee 17. Bruce D. Erie hospitals see more babies lance system for neonatal abstinence Women’s Hospital of the University of who need drug withdrawal [online]. syndrome—Tennessee, 2013. MMWR Morb Pittsburgh Medical Center). Conversation Erie Times News 2015 Oct 26 [cited Mortal Wkly Rep 2015 Feb;64(5):125-8. with: Pennsylvania Patient Safety Author- 2015 Oct 29]. http://www.advisen. 6. Volkow ND. America’s addiction to ity. 2015 Apr 15, 2015 Jul 13. com/tools/fpnproc/fpns/articles_ opioids: heroin and prescription drug 12. Cramton RE, Gruchala NE. Babies new_2/P/247940588.html abuse [online]. Senate Caucus on Inter- breaking bad: neonatal and iatrogenic national Narcotics Control. 2014 May withdrawal syndromes. Curr Opin Pediatr 14 [cited 2015 Aug 14]. http://www. 2013 Aug;25(4):532-42. drugabuse.gov/about-nida/legislative- activities/testimony-to-congress/2014/ americas-addiction-to-opioids-heroin- prescription-drug-abuse (See the following page for self-assessment questions.) Page 130 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS —— Identify the symptoms of neonatal The following questions about this article may be useful for internal education an abstinence syndrome (NAS). assessment. You may use the following examples or come up with your own questions. —— Recall the most commonly used 1. The following are symptoms of the newborn exhibiting NAS except: NAS assessment tool. a. High-pitched crying —— Recognize pharmacologic and non- b. Increased appetite pharmacologic interventions for c. Sleep problems newborns exhibiting NAS. d.Seizures —— Assess family interventions and tech- 2. Which of the following is the most commonly used NAS assessment tool? niques to help parents care for their a. The Finnegan Neonatal Abstinence Scoring System newborn with NAS. b. The Neonatal Withdrawal Inventory c. The Neonatal Narcotic Withdrawal Index d. The Lipsitz tool 3. Which is the first drug class of choice typically used in NAS management? a.Benzodiazepines b.Barbiturates c.Anticholinergics d.Opioids 4. According to Kocherlakota, breastfeeding newborns who exhibit NAS is not recommended if the mother: a. Uses buprenorphine b. Participates in a treatment program c. Is HIV-positive d. Uses methadone 5. Which of the following nonpharmacologic interventions is helpful for newborns exhibiting NAS? a. Bright lights b. Soothing music c. Vigorous rocking d. Decreased room temperature Question 6 refers to the following scenario: Within a day of birth, a newborn exhibits high-pitched crying, severe tremors, and other signs of drug withdrawal. A scoring system is used to observe the newborn, and the score is increasing. When approached, the parents of the newborn deny maternal drug use. 6. Which of the following represents the best scenario and outcome: a. Tell the mother you believe she was taking opioids during her pregnancy and you will be notifying social services. b. Transfer the newborn to the neonatal intensive care unit before involving the parents. c. Meet with the parents, explain what is happening to their newborn, and deter- mine a treatment plan. d. Keep the newborn in the nursery and have the nursing staff administer treatment. Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 131 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 4—December 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. 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