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Neonatal Abstinence Syndrome: Development of a New Service
Introduction
This Study was undertaken in the Grampian Health Board Area, based at the Aberdeen Maternity Hospital and Royal Aberdeen Children's Hospital. The lead investigators were Dr D.J. Lloyd, Consultant in Perinatal Medicine and Dr E.J. Myerscough, Consultant Paediatrician (Designated Doctor for Child Protection). Both consultants have a long-standing clinical interest in the children of substance misusing mothers and have provided collaborative services for many years. For this project, they were joined by two Study Nurses (Ms N. Sim and Ms N. Black) whose terms of office ran consecutively.
Neonatal Abstinence Syndrome ( NAS) occurs at birth, because, with the separation of the foetal and maternal circulations, the baby's supply of misused substances stops abruptly. In the case of opiates such as heroin this is then followed by symptoms of withdrawal in the infant. The progress of this withdrawal suggests that it is not a simple pharmacological process, and in addition there may be further future effects on the growing brain. NAS resolves slowly and some infants will still need medication when discharged home - these are described as having "continuing NAS." Others have no signs initially and then go on to develop NAS. When this occurs after eight days of age, this is defined as "delayed onset NAS."
The Aberdeen Maternity Hospital is the regional referral centre for the Grampian Area and Orkney and Shetland Islands. Approximately 10% of Scotland's births are delivered in the Grampian Area. The regional protocol for substance misusing mothers recommends that all their infants should be delivered in Aberdeen where specialist obstetric and neonatal care is available. The clinical services in Aberdeen Maternity Hospital have developed gradually since 1985, when the first two infants with NAS were identified in Grampian.
Development of the current NAS service
- In 1996, a dedicated multidisciplinary service for substance misusing mothers began to develop. The team included obstetricians, midwives, social workers, drug misuse agencies, a neonatologist and a paediatrician.
- In 1997 a 'drop-in' antenatal clinic was started in a city centre women's health centre.
- Additional clinics are now held at the Aberdeen Maternity Hospital and in a peripheral GP maternity hospital.
Pregnant mothers can be referred to the specialist antenatal service by their general practitioner, midwife, health visitor or substance misuse counsellor, but an important alternative route is self-referral.
The multidisciplinary team holds regular discussions to share information regarding general issues of maternal drug use, management of individual pregnancies and issues of child protection. All the consultants who look after newborn infants share the clinical care of the infants, but one consultant (Dr Lloyd) attends most pre-delivery case discussions and overviews the service.
The infants are referred for out-patient follow-up to one Consultant Paediatrician who is also the designated Doctor for Child Protection (Dr Myerscough), thereby providing consistency in management. The existence of this team was a prerequisite for the introduction of the new interventions described in this report.
Frequent non-attendance at out-patient appointments means that there is a failure of service delivery to a number of children and their parents. At that time this service could not always identify those with delayed onset/continuing NAS, and therefore the extent of this problem was not known.
The establishment of early health and social support in pregnancy and the postnatal period with working between agencies may prevent some of these difficulties. These recommendations are supported by the Scottish Executive Response to Hidden Harm (2004: p7) while guidance on planning services is to be found in Good Practice Guidance for working with Children and Families affected by Substance Misuse "Getting Our Priorities Right'' (Scottish Executive, 2003).
Aims and objectives of the study
We therefore decided to improve the service for NAS to provide a comprehensive, structured, community-delivered programme of care for infants up to six months of age, using existing health professionals and skills. The NAS service was already well developed in the Grampian Health Board area, and we were able to use our knowledge of the local epidemiology of NAS as a basis for undertaking a study with the following objectives:
- to develop and deliver a community-based health visitor intervention that could be used to:
- determine the prevalence of continuing and delayed onset NAS in infants of substance misusing mothers;
- produce recommendations for service developments;
- to measure the prevalence of delayed visual maturation in this group of infants;
- to evaluate the community-based structured health visitor assessment by comparing it to data from the existing service, and by canvassing the views of the professionals involved.
The structure of the report
The next chapter outlines current relevant evidence on parental substance misuse and its effect on infants, with Chapter 2 focusing on the study and new community-based health visitor assessment. Chapter 3 investigates the prevalence of delayed visual maturation and Chapter 4 looks at the health visitors' views of the new community-based service. The final chapter, Chapter 5, concludes the report by providing a brief summary of the main points from each chapter.
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