Lenora Marcellus

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

Many practices related to care of infants exposed to drugs and alcohol during the prenatal period have been developed on an anecdotal basis. There are few available research studies to validate these interventions. This study describes current practices used in daily care, discharge planning, and community support for drug- and alcohol-exposed infants, their families, and alternate caregivers in one country. A survey of Canadian hospitals with annual birth rates of greater than 500 was conducted with a 51% return rate. Variations were noted in the perception of the importance of the issue of perinatal substance use, nursery care, discharge planning, and community support. Nurses are encouraged to consider these results within the context of their own communities to evaluate and develop standards of practice for substance-exposed infants and their families and caregivers.

Tobacco and alcohol use in the context of adolescent pregnancy and postpartum: a scoping review of the literature

Adolescent girls are more likely than women of other ages to smoke tobacco or drink alcohol during pregnancy. The health impacts of smoking and drinking for girls and the interconnections between alcohol and tobacco use with adolescent pregnancy underscore the urgent need for integrated approaches to prevent and reduce alcohol and tobacco use among pregnant girls/young women. This article reports on the results of a scoping review of the literature focused on adolescents’ use of tobacco and alcohol during pregnancy and postpartum. A search of CINAHL, Medline, Social Science Index and Web of Science identified 40 articles published in the two decades between 1990 and 2012 that met our inclusion criteria related to this age group, pregnancy/motherhood status, and use of both alcohol and tobacco. The review points to compelling gaps in our knowledge and our responsiveness to adolescents aged 19 and under who use alcohol and tobacco during pregnancy and the postpartum period. Research has been primarily descriptive, with separate, parallel streams of investigation to identify trends and predictors of alcohol and tobacco use, prior to, during and following pregnancy. There is a marked lack of effective interventions described in the literature that are designed to prevent or reduce alcohol and tobacco use during pregnancy among adolescent girls; and there are few examples of gender-informed prevention or treatment programmes for this population. Research is needed on interventions that attend to the context of adolescent girls’ substance use as well as their preferences and developmental needs for support that encourage sustained behaviour change throughout pregnancy and the postpartum period and that effectively address the influence of partners and friends on use.

Determination of positional skin-surface pressures in premature infants.

Purpose: To describe the skin-surface pressure distributions and points of maximal pressure that are generated by healthy premature infants in the supine, prone, and right side–lying positions. Design: A descriptive, repeated-measures design. Sample: Four medically stable premature infants of 34 weeks postconceptional age. The mean weight was 2,180 gm, and the mean age was 24.5 days. Results: Similar regions of increased skin-surface pressures were identified for the four infants. Within areas of peak pressure, some sensor cells reached 28–32 millimeters of mercury, which is considered to be the critical compressive pressure for obstruction of nutritive flow to the underlying body tissues. These descriptive results may be a starting point for development of research studies to determine positioning strategies to optimize the skin integrity of premature infants while minimizing unnecessary handling.

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.

Reenvisioning Success for Programs Supporting Pregnant Women With Problematic Substance Use

Community-based, integrated, primary care maternity programs for pregnant women affected by problematic substance use are emerging as effective models for engaging women affected by multiple health and social issues. Although addictions services have historically been evaluated by individual achievement of abstinence, new definitions of program success are required as addiction comes to be viewed as a chronic illness. We conducted a mixed-methods study to follow the formative development stages of a community-based program, identifying key evaluation indicators and processes related to this program, program team members, and women and families served. As this program model develops, it is critical that providers, community partners, and health system leaders collaborate to frame definitions of success in ways helpful for guiding program development.

Supporting Women with Substance Use Issues: Trauma-Informed Care as a Foundation for Practice in the NICU

ABSTRACT Infants with neonatal abstinence syndrome and their mothers require extended support through health and social service systems. Practitioners are interested in exploring innovative approaches to caring for infants and mothers. There is now compelling evidence linking women’s substance use to experiences of trauma and violence. A significant shift in the fields of addiction and mental health has been awareness of the impact of trauma and violence on infants and children, women, their families, and communities. In this article, the current state of knowledge of trauma-informed care is reviewed, in particular for application to practice within the NICU. Trauma survivors are at risk of being retraumatized because of health care providers’ limited understanding of how to work effectively with them. Recognizing the impact of trauma and implementing evidence-based trauma-informed practices in the NICU holds promise for improving outcomes for women and their infants.

(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.

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.

Complicating the dominant morality discourse: mothers and fathers’ constructions of substance use during pregnancy and early parenthood

IntroductionConsumption of substances is a highly controversial behaviour, with those who do so commonly viewed as deviants, even criminals, or else as out of control addicts. In other work we showed that the use of substances by women who are pregnant or have recently become parents was mainly viewed by health and social care providers as morally wrong. Problematic substance use was framed through the narrow lens of gendered responsibilisation, resulting in women being seen primarily as foetal incubators and primary caregivers of infants.MethodsIn this follow-up paper we examine descriptive and qualitative data from a convenience sample of biological mothers and fathers (N = 34) recruited as part of a larger mixed methods study of the development and early implementation of an integrated primary maternity care program. We present a description of the participants’ backgrounds, family circumstances, health status, and perception of drug-related stigma. This is succeeded by a thematic analysis of their personal views on substance use during both pregnancy and the transition to parenthood.ResultsOur results show that while many mothers and fathers hold abstinence as the ideal during pregnancy and early parenting, they simultaneously recognize the autonomy of women to judge substance use risk for themselves. Participants also call attention to social structural factors that increase/decrease harms associated with such substance use, and present an embodied knowledge of substance use based on their tacit knowledge of wellness and what causes harm.ConclusionsWhile these two main discourses brought forward by parents concerning the ideal of abstinence and the autonomy of women are not always reconcilable and are partially a reflection of the dissonance between dominant moral codes regarding motherhood and the lived experiences of people who use substances, service providers who are attuned to these competing discourses are likely to be more effective in their delivery of health and social services for vulnerable families. More holistic and nuanced perspectives of health, substance use, and parenting may generate ethical decision-making practice frameworks that guide providers in meeting and supporting the efforts of mothers and fathers to achieve well-being within their own definitions of problematic substance use.

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.