Tuesday, December 20, 2011

Major Case Study. Check!

By Sasha B. Bard, MSN

The major case study assignment is the final project of each intern’s main clinical rotation. It is an opportunity to explore an area of clinical interest by researching a chosen patient’s medical condition or disease, the nutritional implications, and appropriate medical nutrition therapy.

I have completed both the main ten-week clinical rotation as well as an elective two-week clinical rotation focused in neonatal intensive care. Because of my strong interest in working with infants, I selected a preterm neonate for my major case study. Specifically, my research explored neonatal abstinence syndrome in preterm infants. Here is the executive summary which encapsulates what I learned:

“Neonatal abstinence syndrome (NAS) refers to a collection of withdrawal symptoms observed in a newborn child including, central nervous system excitability, vasomotor dysfunction, and gastrointestinal distress. NAS is caused by fetal drug exposure secondary to maternal drug use. Since women who abuse drugs often use more than one drug, NAS may result from the combined impact of multiple exposures. Opioids are the most common drugs to give rise to NAS and include illegal drugs, such as heroin, as well as prescription medications including, oxycodone, hydrocodone, and OxyContin.

Maternal drug abuse impacts the fetus directly through drug exposure in utero as well as indirectly through compromised maternal health. For this reason, NAS is not the only health concern for drug-exposed infants. Poor maternal health habits, such as lack of prenatal care, poor nutritional status, exposure to violence, and exposure to infectious disease related to unprotected sex or intravenous drug use, increase the risk of prematurity, low-birth-weight, and fetal demise.

Medical management of a premature, low-birth-weight infant with NAS involves primary and secondary treatment and should always be individualized. Primary treatment is supportive and non-pharmacologic. Pharmacotherapy, with a drug from the same class as that causing the withdrawal, is considered secondary treatment of NAS.

Medical nutrition therapy (MNT) plays an important role in neonatal care for both prematurity and NAS, helping to ensure adequate growth and nutritional status. Nutritional considerations include elevated caloric needs and ability to feed. Preterm infants are prone to feeding difficulties due to developmental delay and fatigue. NAS further compromises feeding ability and therefore nutrition status of an already high-risk patient. NAS symptoms may also increase energy expenditure as well as caloric loss through vomiting and diarrhea.

Close monitoring of feeding and growth are essential components of MNT for the preterm infant with NAS. Human milk is the preferred energy source for all infants. Breastfeeding with regard to maternal drug use is controversial, however it must be considered due to the numerous known benefits human milk provides to the preterm baby. Infant formulas designed to meet the nutritional needs of prematurity are available when breastfeeding is not an option. “

References and full report available upon request, please email sasha.bard@gmail.com .

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