The innocent victims_nas_final

The Innocent Vic,ms: Neonatal Abs,nence Syndrome

Michael Hokenson, MD Assistant Professor of Pediatrics;

Division of Neonatology

Carla Saunders, NNP-‐BC Advanced Prac@ce Coordinator, East

Tennessee Children’s Hospital

Learning Objec,ves

•  Iden@fy the scope of babies affected by NAS with sta@s@cs and research.

•  Evaluate treatment programs around the country that work to care for babies with NAS.

•  Build solu@ons for clinicians to treat babies with NAS.

Disclosure Statement

•  Michael Hokenson has no financial rela@onships with proprietary en@@es that produce health care goods and services.

•  Carla Saunders has no financial rela@onships with proprietary en@@es that produce health care goods and services. An off-‐label discussion will take place.

Background

•  Despite growing knowledge, NAS con@nues to challenge us – Es@mated 4.5% of mothers 14 to 45 yrs/old use illicit drugs

– ORen overlap with medica@ons for chronic pain and mental illness

– 50-‐90% of neonates exposed to heroin in utero may develop signs of withdrawal 1 •  Signs/Symptoms may be non-‐specific

1. Schuckit Marc A. Opioid drug abuse and dependence. Harrison's Principles of Internal Medicine. 17th edn, McGraw-‐Hill: New York, 2008

Challenges

•  The number of infants coded as (NAS) at d/c are on the rise – Na@onally •  1995-‐ 7,654 infants •  2008-‐ 11,937 infants

–  In Florida; •  1995-‐ 0.4/1000 live births •  2008-‐ 4.4/1000 live births

– Possibly increased awareness, but also prescrip@on pain relief 2

2. Kellogg A, Rose CH, Harms RH, Watson WJ . Current trends in narco@c use in pregnancy and neonatal outcomes. Am J Obstet Gynecol. 2011;204:259

Clinical Presenta,on

•  A wide variety of drugs in utero may have an effect on infant

•  Overlap between acute effect and withdrawal of substance

•  The classic findings associated with opioid withdrawal are coined (NAS)


•  Infants exposed to opioids in utero – Anywhere from 55-‐94% may exhibit signs of withdrawal 3

•  Infants may also display signs of withdrawal if exposed to: – Benzodiazepines – Barbiturates – Alcohol

3. Fricker HS, Segal S . Narco@c addic@on, pregnancy, and the newborn. Am J Dis Child. 1978;132(4):360–366


•  Signs and symptoms vary in each infant –  Will depend on specific

maternal drug(s) –  Severity of withdrawal may

not correlate with dose or dura@on of exposure

•  Narco@cs are s@ll the most frequent cause and include: –  Heroin –  Methadone

–  Morphine

–  Oxycodone –  Codeine –  Buprenorphine


•  Narco@cs and Barbiturates –  The @me frame for signs of withdrawal from narco@cs may vary greatly •  May be present at birth and peak at 3 to 4 days

•  May not appear for up to two weeks •  Subacute withdrawal may occur for 4 to 6 months

•  Neurologic irritability with abnormal Moro has been reported at 7 and 8 months of age


•  Many systems can be affected

•  The most common are: –  CNS –  Gastrointes@nal –  Autonomic nervous system

•  Common signs include: –  Hypertonia –  Tremors

–  Hyperreflexia –  High-‐pitched cry –  Sleep disturbances –  Occasionally seizures


•  Autonomic dysfunc@on may include: –  Swea@ng –  Low grade fever –  Nasal conges@on –  Sneezing –  Yawning –  Skin mokling

•  GI symptoms may include: –  Diarrhea –  Vomi@ng –  Poor feeding –  Poor swallowing –  Failure to thrive

•  Respiratory signs may also be present –  Tachypnea –  Apnea

S,mulants

•  Methamphetamine and cocaine are less common causes – Withdrawal signs have been observed in as few as 4% of infants

–  Tend to be much less severe than seen in opioid exposed infants

–  Generally, only 6% of infants exposed to cocaine will require pharmacologic therapy 4

4. Fulroth R, Phillips B, Durand DJ. Perinatal outcome of infants exposed to cocaine and/or heroin in utero. Am J Dis Child. 1989;143 :905 –910

S,mulants

•  Signs may include: –  Tremors – High-‐pitched cry –  Irritability – Hyper-‐alertness – Apnea –  Tachycardia

•  Most commonly seen around 72 hours of age

S,mulants

•  Infants exposed to methamphetamine or cocaine also may exhibit: 5 –  Higher rates of prematurity

–  IUGR –  Asphyxia secondary to placental abrup@on

•  Mul@ple drug use is common in this group – Which will oRen complicate the clinical picture

5. Eyler FD, Behnke M, Garvan CW, Woods NS, Wobie K, Conlon M . Newborn evalua@ons of toxicity and withdrawal related to prenatal cocaine exposure. Neurotoxicol Teratol. 2001;23(5):399–411

Depressants and Seda,ves

•  Ethanol withdrawal may be seen as early as 3 to 12 hours of life –  Physical findings of FAS may be superimposed

•  Classic signs of NAS (irritability, poor feeding, crying) may be seen –  Although the severity is much less compared to infants exposed

to opioids

SSRI’s

•  Selec@ve Serotonin Reuptake Inhibitors: – Most commonly prescribed medica@on for depression 6

•  Poten@al effects seen in infants exposed are: 7 –  Con@nuous crying –  Irritability –  Fever –  Tachypnea –  Tremors

–  Hypoglycemia

–  Seizures 6. Alwan S, Friedman JM . Safety of selec@ve serotonin reuptake inhibitors in pregnancy. CNS Drugs. 2009;23(6):493–509

7. Haddad PM, Pal BR, Clarke P, Wieck A, Sridhiran S . Neonatal symptoms following maternal paroxe@ne treatment: serotonin toxicity or paroxe@ne discon@nua@on syndrome? J Psychopharmacol. 2005;19(5):554–557

SSRI’s

•  Debate over source of signs and symptoms – Excess serotonin (drug itself) – Low serotonin (withdrawal of drug)

•  SSRI’s seem to be safe in pregnancy – Many reviews have not shown long term neurodevelopmental impairment 8

8. Mark L. Hudak, MD, Rosemarie C. Tan, MD, PhD, THE COMMITTEE ON DRUGS, and THE COMMITTEE ON FETUS AND NEWBORN. Neonatal Drug Withdrawal. Pediatrics Vol. 129 No. 2 February 1, 2012

Abs,nence scoring systems

•  Many scoring systems exist –  No par@cular one has been adopted as “the standard”

•  The most comprehensive and widely used is the Finnegan scoring system 9

•  The Finnegan scoring system takes 20 of the most common signs and groups them into: –  CNS disturbances –  Metabolic/Vasomotor/Respiratory disturbances –  GI disturbances

9. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abs@nence syndrome: assessment and management. Addict Dis. 1975;2 :141 –158

Finnegan Scores

•  The signs were ranked according to pathologic significance –  Those with the least poten@al for adverse affects were given a

“1” –  Those with the most poten@al for adverse affects were given a

“5” –  A score of 7 or less is considered mild and babies do well with

nonpharmacologic comfort measures –  A score of 8 or greater generally indicates that infants may need

pharmacologic therapy

Opioid Withdrawal Recap

•  Mostly affects: –  CNS – Autonomic nervous system – Gastrointes@nal system

•  Other things to keep in mind: –  Presenta@on will vary depending upon:

•  Maternal dose •  Placental metabolism •  Maternal drug history •  Polysubstance abuse

Prematurity

•  Some studies suggest a lower risk for withdrawal 10

•  However, the classic signs may not be present – Scoring systems developed around Term infants – Decreased maturity of CNS system – Less adipose @ssue

•  Good maternal history and general assessment of infants status is key

10. Liu AJ, Jones MP, Murray H, Cook CM, Nanan R . Perinatal risk factors for the neonatal abs@nence syndrome in infants born to women on methadone maintenance therapy. Aust N Z J Obstet Gynaecol. 2010;50(3):253–258.

Prenatal Screening

•  Consider prenatal screening if certain risk factors present – Absent/Late prenatal care – Unexplained fetal demise – Placental abrup@on – Large swings in cardiovascular status – Prior history of drug abuse

•  Can be a delicate issue

Is it NAS?

•  Be aware of other systemic disorders that may have similar symptoms – Hypoglycemia –  Inborn errors metabolism – Calcium dysregula@on

–  Intracranial process (HIE, hemorrhage) – Uncommon neuromuscular disorders

What to Expect?

•  However, some infants may not display signs un@l 5-‐7 days

Heroin Methadone Buprenorphine

Onset of Symptoms

Usually by 24 hours

Usually 1-‐3 days

Usually 2-‐3 days

11,12

11. Zelson C, Rubio E, Wasserman E . Neonatal narco@c addic@on: 10 year observa@on. Pediatrics. 1971;48(2):

12. Kandall SR, Gartner LM . Late presenta@on of drug withdrawal symptoms in newborns. Am J Dis Child. 1974;127(1):58–61

Treatment

•  The treatment should begin with non-‐pharmacologic measures – Gentle handling – Ambient noise control – Swaddling – On demand feeding

•  Be mindful of infants needs – Caloric requirement, sleep..etc

Pharmacologic Treatment

•  Pharmacotherapy may be helpful if… – Seizures are present – Weight loss/Dehydra@on •  Secondary to vomi@ng and diarrhea

– Poor feeding skills •  Opioids (morphine/methadone) – Reduce excessive bowel mo@lity – Reduc@on of seizures

Pharmacologic Treatment

•  What is a concerning score? (Finnegan) –  Usually 8 or higher

•  Goal of therapy? – Allow gradual withdrawal – Absence of excessive excita@on

•  The length of the weaning process may vary

Morphine vs. Methadone

•  Morphine – Shorter half life (4-‐16 hours) – Poten@al to “capture” quicker

•  Methadone – Longer half life (16-‐25 hours) – Less frequent dosing

Na,onwide Children’s Protocol

•  Enteral morphine based •  Ini@ate protocol if – 2 consecu@ve scores above 8 – 1 score above 12 •  Both within a 24 hour period

•  Star@ng dose – Morphine 0.05 mg/kg/dose PO q 3 hours •  IV would be 0.02 mg/kg/dose

NCH Protocol Cont. •  Escala@on –  Increase Morphine by 0.025-‐0.04 mg/kg/dose every 3 hours un@l scores < 8

–  If IV, increase by 0.01 mg/kg/dose

•  Rescue dose –  If scores are s@ll above 12

•  Double the previous dose x 1 •  If s@ll above 12, increase dose by 50%

–  Un@l captured

•  Rescue dose only in ini@al phase

NCH Protocol Cont.

•  Stabiliza@on – Once captured (scores <8) con@nue maintenance dose for 72-‐96 hours

•  Weaning –  Following the above, wean by 10% every 24 to 48 hours

– Do not rou@nely weight adjust meds

– Drug may be d/c’ed when a single dose is < 0.02 mg/kg/dose q 3 hours

NCH Protocol Cont. •  Problems with weaning –  If scores following a wean are above 8 •  Ensure comfort measures

– Maximize swaddling

–  Holding –  Decreased s@muli

– Go back to dose where infant was stable – Do not use rescue dose –  Consider weaning at longer intervals •  48 hours vs 24 hours

– Monitor for 48-‐72 hours prior to d/c

Adjunct Therapy

•  Consider a second agent if: –  Infant has 2 consecu@ve weaning failures – No progress in weaning off morphine by day 14 – May be added earlier •  Based on infants symptoms

•  Maternal history

Adjunct Therapy

•  Phenobarbital – Binds to GABA receptors – Helps with CNS issues such as •  Irritability, sleeplessness and tone

– Has been shown to reduce LOS, and severity of withdrawal 13

13. Coyle MG, Ferguson A, Lagasse L, Oh W, Lester B. Diluted @ncture of opium (DTO) and phenobarbital versus DTO alone for neonatal opiate withdrawal in term infants. J Pediatr 2002; 140(5): 561–564

Adjunct Therapy

•  Phenobarbital may be beneficial if – CNS symptoms predominate •  (Hyperac@ve reflexes, tremors, increased tone)

– History of polysubstance abuse

Adjunct Therapy

•  Cau@ons with phenobarbital – Poten@al to oversedate –  Impaired feeding – Drug interac@ons – Longer half life (45-‐100hr) – Alcohol content (15%)

Adjunct Therapy

•  Clonidine – Alpha 2 adrenergic receptor agonist •  Ac@vates inhibitory neurons •  Reduced sympathe@c tone

– Has been shown to help with •  Faster stabiliza@on •  Decreased dosing requirements of opioid therapy 14

14. Agthe AG, Kim GR, Mathias KB, Hendrix CW, Chavez-‐Valdez R, Jansson L et al. Clonidine as an adjunct therapy to opioids for neonatal abs@nence syndrome: a randomized, controlled trial. Pediatrics 2009; 123(5): e849–e856

Adjunct Therapy

•  Clonidine – May be useful if majority of symptoms are in the autonomic category •  (swea@ng, fever, yawning, mokling..etc)

– Monitor for hypotension and bradycardia – Avoid rapid discon@nua@on – Observe for 48 hours off prior to d/c •  Do not recommend treatment as outpa@ent

Prenatal Counseling

•  Many mothers feel anxiety and guilt –  Clinicians should be prepared to be empathe@c and nonjudgmental

•  Essen@al components to prenatal counseling include: –  Poten@al for teratogenicity –  Expected clinical course –  Breasueeding and Lacta@on –  Social considera@ons

Social Considera,ons

•  Be empathe@c and nonjudgmental

•  Be aware of maternal psychosocial status –  Is there signs of postpartum depression? –  Is counseling a reasonable resource?

•  Always be honest –  Not every baby follows the rules –  Updates frequently regarding status

The Innocent Vic@ms: Neonatal Abs@nence Syndrome

Carla Saunders, NNP-‐BC

Epidemiology   NIDA es@mates $600 billion is spent annually on costs associated with

substance abuse in U.S.  American Diabetes Associa@on es@mates

annual costs associated with diabetes is $174 billion in 2007.  Na@onal Cancer Ins@tute es@mates

$125 billion in annual costs for cancer care in 2010. •  2009 Na@onal Survey on Drug Use and Health: •  4.5 percent of pregnant women aged 15 to 44 have used illicit drugs in the past

month. •  In 2008 there were 9430 babies born in Knox County according to Knox County hospitals birth

records: Es@mated 424 babies born annually in Knox County whose mother used illicit drugs in the past month.

•  2009 Key Birth Stats from CDC report 4,131,019 births in U.S. •  Approximately 186,000 babies born to mothers who used illicit drugs in past month

1.  NIDA InfoFacts: Understanding Drug Abuse and Addic@on. Na@onal Ins@tute on Drug Abuse. hkp://www.drugabuse.gov/infofacts/understand.html. Accessed May 28, 2011

2.  Diabetes Cost Calculator. American Diabetes Associa@on. hkp://www.diabetesarchive.net/advocacy-‐and-‐legalresources/cost-‐of-‐diabetes.jsp. Accessed May 28, 2011.

3.  The Cost of Cancer. Na@onal Cancer Ins@tute. hkp://www.cancer.gov/aboutnci/servingpeople/cancer-‐sta@s@cs/costofcancer. Accessed May 28, 2011. 4.  Substance Abuse and Mental Health Services Administra@on. (2010). Results from the 2009 NaMonal Survey on Drug Use and Health: Volume I. Summary of

NaMonal Findings (Office of Applied Studies, NSDUH Series H-‐38A, HHS Publica@on No. SMA 10-‐4856Findings). Rockville, MD. 5.  Number of Babies Born. Kids Count Data Center. hkp://datacenter.kidscount.org/data/bystate/Rankings.aspx?state=TN&ind=2996. Accessed May 27, 2011.

Heroin

Cocaine

1999 Veterans Health Admin. Ini,a,ve: “Pain as the 5th Vital Sign” JCAHO ins,tute pain standards in 2001

Neonatal Abs@nence Syndrome (NAS)

  Constella@on of withdrawal symptoms   CNS

  Inconsolability, high-‐pitched crying, skin excoria@on, hyperac@ve reflexes, tremors, seizures

  GI   Poor feeding, excessive sucking, feeding intolerance, loose or watery stools

  Autonomic/metabolic   Swea@ng, nasal stuffiness, sneezing, fever, tachypnea, mokling

Tolerance – Dependence – Addic@on

•  Tolerance – Our body develops tolerance to a drug’s effect so that an increased amount of drug is required to produce effect.

•  Dependence –  If the supply of the drug is removed then the person will exhibit “withdrawal symptoms”.

•  Addic@on –  The con@nuing, compulsive nature of the drug use despite physical and/or psychological harm to the user and society

Unique Concerns for the Substance Abusing woman

US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. Substance Abuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.

Substance Use Treatment among Women of Childbearing Age

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (October 4, 2007). The NSDUH Report: Substance Use Treatment among Women of Childrearing Age. Rockville, MD.

Return on Investment

•  For every $1 spent on addic@on treatment programs – $4 to $7 saved in reduced drug-‐related crime, criminal jus@ce, and theR

– Up to $12 saved when including health-‐care costs – Other considera@ons •  Neonatal abs@nence syndrome might be reduced

•  Greater workplace produc@vity NIDA. Principles of Drug Addiction Treatment, A research-based Guide. NIH Publication No. 09-4180. April 2009

Incidence of Maternal Opiate Use and NAS

Patrick, S. W. et al. JAMA 2012;307:1934-1940

Maternal Opiate Use increased x 5 NAS Incidence tripled

Why do expectant mothers use drugs?

 Prior injury / chronic pain

 Medical need for pain management  Appropriately managed  Inappropriately managed

 In a substance abuse treatment program

 Confusion between symptoms of withdrawal and pregnancy.

•  ACOG Guidelines and SAMSHA Guildelines recommend to con@nue methadone (possibly buprenorphine)

•  “Lesser of two evils” – Risky drug-‐seeking behaviors – Goals of quelling cravings – Prevent mini-‐withdrawals – Ceiling effect of being in treatment •  Methadone, suboxone, subutex

–  Reveal danger of I.V. suboxone

Why do MDs con@nue to prescribe?

 “Standard of care for pregnant women with opioid dependence: referral for opioid-‐assisted therapy with methadone…emerging evidence suggests that buprenorphine also should be considered.”

 Abrupt d/c of opioids can result in preterm labor, fetal distress, or fetal demise

 During intrapartum/postpartum period, special considera@ons are needed…ensure appropriate pain management, prevent postpartum relapse, prevent risk of overdose, ensure adequate contracep@on.

Prenatal Care is Vital

•  “Adequate prenatal care oRen defines the difference between rou@ne and high-‐risk pregnancy and between good and bad pregnancy outcomes. Timely ini@a@on of prenatal care remains a problem na@onwide, and it is overrepresented among women with substance use disorders. In part, the threat of legal consequences for using during pregnancy and limited substance abuse treatment facili@es (only 14 percent) that offer special programs for pregnant women (SAMHSA 2007) are key obstacles to care.”


Early Interven@on

•  Window of opportunity – “Brief interven@ons can provide an opening to engage women in a process that may lead toward treatment and wellness.”

•  Pregnancy creates a sense of urgency to – Enter treatment – Become abs@nent

– Eliminate high-‐risk behaviors


Patrick, S. W. et al. JAMA 2012;307:1934-1940

NAS Incidence in the U.S.

TennCare Office of Healthcare Informatics. Neonatal Abstinence Syndrome among TennCare enrollees. September, 2012.

American Academy of Pediatrics (AAP) Guidelines

  “Reported rates of illicit drug use…underes@mate true rates…”   55 to 94% of neonates exposed to opioids in utero will develop withdrawal signs.

  Each nursery that cares for infants with NAS should develop protocol for screening for maternal substance abuse

  Screening is best accomplished by using mul@ple methods  Maternal history  Maternal urine tes/ng  Tes@ng of newborn urine/meconium  May consider umbilical cord samples

Hudak ML, Tan RC, The Committee on Drugs and The Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.

AAP Guidelines -‐ Newborn Observa@on

Risk Factors

•  No prenatal care •  Limited prenatal care •  History of substance use or abuse

•  Any posi@ve screen during pregnancy

•  Posi@ve UDS on admission

Recommenda,on

•  Observe in the hospital for 4 to 7 days

•  Early outpa@ent followup –  Reinforce caregiver educa@on about late withdrawal signs

Hudak ML, Tan RC, The Commikee on Drugs and The Commikee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.

American Academy of Pediatrics (AAP) Guidelines

•  Pharmacologic interven@ons include: – oral morphine solu@on, or methadone as primary therapy

–  Increasing evidence for clonidine as primary or adjunc@ve therapy

– Buprenorphine use as primary or adjunc@ve therapy is also increasing

– Treatment for polysubstance exposure may include opioid, phenobarbital, and clonidine in combina@on.

Hudak ML, Tan RC, The Commikee on Drugs and The Commikee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.

ETCH Haslam Neonatal Intensive Care Unit •  152 beds / Level III NICU – 60 beds

–  About 30 % of our NICU admissions primarily for NAS treatment

–  135 admissions for 2011

–  283 admissions for 2012

•  ProjecMng 315 for 2013 –  Highest daily census: 37 in September, 2012

Average Daily Census for NAS babies

1st Quarter (JAN-‐MAR) 4th Quarter (OCT-‐DEC)

2011 8 18

2012 29 27

Our rate of admissions is almost 1 baby every day…

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Maternal Drugs

Single-‐Substance Exposure:

122 34%

Poly-‐Substance Exposure:

234 66%

Previous Treatment Plan

 Goal: Stabilize on meds and discharge to wean

 Drugs: Methadone and Phenobarbital

 No consistent approach to ini@a@on of meds, dosing, or

weaning or criteria for discharge

 Avg LOS: 16 days to discharge on meds

 Confusion of staff and families about treatment and

expecta@ons

Discharge Support

•  Discharged only to DCS approved caregivers

•  Discharged with weaning schedule

•  Dedicated pediatric follow up

•  Physiatry follow up

•  DCS services in the home

•  Home health nursing visits with social work support

Factors for Change in Treatment Plan

Realiza,on that safety plan was failing

  Barriers to compliance   Caregiver resistance (biological/foster)   Caregiver changes   Drug diversion   Outpa@ent management issues

  About 80% of discharged NAS infants do not keep follow-‐up   Pediatrician refusal to manage weans   Observa@ons that babies were not receiving meds   Issues with retail pharmacy comfort/availability of methadone   Former NAS infant, D/C on methadone, presents DOA at ETCH-‐ED

ETCH Mul@disciplinary Team

  Medical team (NNP lead)

  Pharmacy

  Staff nurses   Administra@on

  Pa@ent Care Coordinator   Social Work

  Lacta@on   Physiatry

  PT/OT and Speech   Child Life   Volunteer Services   Security   Nutri@on Services   PCAs   Unit Secretaries   Service Excellence

Project Objec@ves

  Develop a treatment plan to treat NAS that will:   Iden@fy neonates at risk for NAS

 Consistently evaluate the presence and severity of withdrawal symptoms

 Standardize and simplify the opioid withdrawal treatment plan

  Ini@ate appropriate non-‐pharmacological interven@ons and pharmacotherapy to control symptoms

 Safely minimize length-‐of-‐stay:  Wean the opioid-‐dependent infant as quickly as possible while providing good control of withdrawal symptoms

 Discharge infant weaned from NAS pharmacotherapy

 Will not require outpaMent management of methadone

ETCH Treatment Plan

•  Holis@c mul@disciplinary approach – Non-‐Pharmacological •  Environment •  Diet •  Cuddlers

– Pharmacological •  Oral Morphine Sulfate

–  Symptom-‐based vs weight-‐based dosing

•  Non-‐narco@c –  Acetaminophen –  Simethicone

Morphine Algorithm

  Literature review   Goals for protocol

 Safe  EffecMve  Quick

  Iden@fied treatment plan   symptom-‐based protocol   Dr. Jansson /Johns Hopkins

  Adapted protocol   Simple to use   Standardize treatment decisions.

Typical course of treatment

•  70 % of NAS babies

– Wean in 20 days

–  No adjunc@ve meds

–  LOS 24 days

•  30 % of NAS babies

– Wean in 60 days

–  Require adjunc@ve meds •  Phenobarbital (27%) •  Phenobarbital +Clonidine (7%)

–  LOS 68 days •  (longest LOS = 155 days)

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E026094565

Start date: 3/31/12 Weaned : 5/7/12 Total ,me: 37 days LOS: 40 days

Maternal Substances:

Comorbidi,es:

buprenorphine

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E025353038


Maternal Substances:

Comorbidi,es:

opiates, benzodiazepines

Dysphoric Phase Weeks to months

Sense of Excessive pain

Anguish, agi@a@on Disquiet, anxiety Restlessness malaise

Acute Phase Days to weeks

Withdrawal symptoms Flu-‐like symptoms, nausea Vomi@ng, stomach cramping

Muscle pain, spasm Fever, swea@ng,

Runny nose and eyes Insomnia, anxiety

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Maternal Substances: methadone, oxycodone, benzodiazepines

Comorbidi,es:

Polysubstance

Dysphoric Phase

Acute Phase

Unique Challenges

  Environment

  Work load   Nursing

  Pharmacy

  Social Work

  Rehabilita@on Services

  Volunteer Services

  Security

Emo@onal Challenges •  A_tudes / PercepMons

•  Preventable nature of condi@on •  Personal prejudices

•  Feelings •  Confusion / fear

–  HIPPA concerns –  Ethical Issues

•  Family / Caregiver Issues

•  Personal addic@on of parents •  Mental health issues •  Literacy problems •  Comprehension/reten@on issues

•  FaMgue/exhausMon/burnout Educa/onal deficit regarding the science of addic/on

Public Health Issues   NICU beds taken by infants whose only need is withdrawal treatment

  Behavioral issues in childhood   Schools – teacher retraining

  Poten@al long-‐term public health issue   Genera@onal addic@on problems

  2nd and 3rd genera@onal behaviors sustained

 Gene@c predisposi@on?

 Does intrauterine exposure ac@vate gene in utero?  Does NAS treatment complicate addic@ve tendencies?

Long-‐Term Consequences of NAS

•  At risk for: – Aken@@on deficit disorder – Hyperac@vity – Difficulty transi@oning between tasks –  Impulse-‐control

– Sleep disorders – Sensory disorders – Future risk of addic@ve behavior

Lessons Learned

•  Withdrawal outpa@ent is unreliable even unsafe •  Withdrawal is not linear •  Consistency is invaluable •  Data drives success •  Challenges are unique to this pa@ent popula@on •  Scoring tools are not designed for older neonate •  Early capture may lead to decreased LOS

More lessons….

•  Not all drug “screens” are created equal •  Collect meconium from first stool to transi@on

•  Maternal histories are not always reliable

•  Mother can be posi@ve and baby nega@ve

•  Addic@on knows no boundaries •  If it “quacks”…. You will likely discover it IS a duck!

Summary •  The impact of NAS does not end in the NICU.

•  Long-‐term benefits to both the healthcare system and society are significant.

•  Prenatal care in the otherwise healthy woman is widely accepted to be beneficial to mothers and babies.

•  We must do all we can to promote prenatal care and substance abuse treatment/counseling in this high-‐risk popula@on.

•  Incen@ves to seek help may allow more opportuni@es for the woman to receive successful treatment with lifelong benefits.

Shoot for the moon,

even if

you’ll land among the stars.

you miss

Health & Medicine

The innocent victims_nas_final