Hot Topics in Newborn Care: - PowerPoint Presentation

Slide1

Hot Topics in Newborn Care:Neonatal Abstinence Syndrome & Breastfeeding Special Populations

Caitlin Vanini C-PNP, C-NNP & Stephanie Solpietro C-PNP Slide2

NEONATAL ABSTINENCE SYNDROMESlide3

OBJECTIVES

UNDERSTAND THE CURRENT STATUS OF MATERNAL OPIOD USE AND NEONATAL ABSTINENCE SYNDROME (NAS) AND ITS’ AFFECT ON COST AND LENGTH OF STAY

DESCRIBE NAS AND ITS’ CLINICAL MANIFESTATIONS

DESCRIBE MONITORING, EVALUATION OF AND TREATMENT OF NAS

DESCRIBE THE PRIMARY CARE PROVIDERS ROLE IN FOLLOW UP FOR PATIENTS WHO HAVE EXPERIENCED NASSlide4

What is Neonatal Abstinence Syndrome

The clinical findings in the neonate associated with opioid exposure and withdrawal

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide5

INCIDENCE

Opioid Prescriptions Dispensed by Retail Pharmacies—United States, 1991–2011

Prescription Pain Medication Use on the Rise

Balancing Pain Management and Prescription Opioid Abuse. (2012). Retrieved January 11, 2016, from http://www.cdc.gov/primarycare/materials/opoidabuse/index.html Slide6

One Study with a national sample found that Antepartum maternal opiate use increased from 1.19 per 1,000 hospital births in 2000 to 5.63 in 2009

Patrick, S., Schumacher, R., Benneyworth, B., Krans, E., Mcallister, J., & Davis, M. (2013). Neonatal Abstinence Syndrome and Associated Health Care Expenditures.

Obstetric Anesthesia Digest,

33

(2), 86. Slide7

U.S. Heroin Epidemic

Heroin use more than doubled among young adults ages 18–25 in the past decade.

More than 9 in 10 people who used heroin also used at least one other drug.

45% of people who used heroin were also addicted to prescription opioid painkillers.

Today’s Heroin Epidemic. (2015). Retrieved January 11, 2016, from http://www.cdc.gov/vitalsigns/heroin/ Slide8

Today’s Heroin Epidemic. (2015). Retrieved January 11, 2016, from http://www.cdc.gov/vitalsigns/heroin/ Slide9

Commonly Used Opioids

Methadone –

Commonly used in treatment program

Buprenorphine –

Commonly used in treatment program

Morphine

Oxycodone

Hydromorphone

Hydrocodone

FentanylHeroin

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal. Pediatrics,

129(2). Slide10

Data Analyzed from infants with neonatal abstinence syndrome from 2004 through 2013 in 299 neonatal intensive care units (NICUs) across the United States.

The rate of NICU admissions for the neonatal abstinence syndrome increased from 7 cases per 1000 admissions to 27 cases per 1000 admissions

The total percentage of NICU days nationwide that were attributed to the neonatal abstinence syndrome increased from 0.6% to 4.0%

Tolia, V. N., Patrick, S. W., Bennett, M. M., Murthy, K., Sousa, J., Smith, P. B. (2015). Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs. New England Journal of Medicine N Engl J Med, 372(22), 2118-2126.Slide11

Increased Risk of Readmission

A study in NYS from 2006 to 2009 showed when compared with uncomplicated term infants, infants diagnosed with NAS were more than

2x

as likely to be readmitted to the hospital 30 days of birth hospitalizations.

Patrick, S. W., Burke, J. F., Biel, T. J., Auger, K. A., Goyal, N. K., & Cooper, W. O. (2015). Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome.

Hospital Pediatrics,

5

(10), 513-519.Slide12

Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. (2015). Retrieved January 11, 2016, from http://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome Slide13

HIGH RATES IN WESTERN NY

Newborn drug-related diagnosis rate per 10,000 newborn discharges

2007 2011-2013

New York City: 45.5 66.6

Ontario County 86.5 165.3

Monroe County (Rochester): 85.6 180.2

Erie County (Buffalo): 123.7 228.7

Onondaga County: 221 248.8

New York state: 58.4 95

REGIONS WITH THE HIGHEST RATES:

WESTERN NY REGION TOTAL 219.4

FINGER LAKES REGION TOTAL 159.4

Newborn drug-related (2014, December.). Retrieved January 11, 2016, from https://www.health.ny.gov/statistics/chac/hospital/h46.htm Slide14

MONROE COUNTY Newborn drug-related diagnosis rate per 10,000 newborn discharges

Newborn drug-related (2014, December.). Retrieved January 11, 2016, from https://www.health.ny.gov/statistics/chac/hospital/h46.htm Slide15

State Medicaid Programs Paying the Majority of the Cost

Cost is 15 to 16 times higher than healthy infants

Cost is rising –Mean hospital charges for discharges with NAS increased from $39,400 in 2000 to $53,400 in 2009

Patrick, S., Schumacher, R., Benneyworth, B., Krans, E., Mcallister, J., & Davis, M. (2013). Neonatal Abstinence Syndrome and Associated Health Care Expenditures.

Obstetric Anesthesia Digest,

33

(2), 86.

Roussos-Ross, K., Reisfield, G., Elliot, I., Dalton, S., & Gold, M. (2015). Opioid Use in Pregnant Women and the Increase in Neonatal Abstinence Syndrome. Journal of Addiction Medicine, 9(3), 222-225.Slide16

Hospital in Florida studies cost and length of stay related to NAS from 2008 -2011

NAS not requiring pharmacologic intervention

Treated with Morphine

Normal Newborns

Length of Stay

5

23

1-2

Hospital Charges

4215

43000

873-1746

Roussos-Ross, K., Reisfield, G., Elliot, I., Dalton, S., & Gold, M. (2015). Opioid Use in Pregnant Women and the Increase in Neonatal Abstinence Syndrome. Journal of Addiction Medicine, 9(3), 222-225.Slide17

Screening

Maternal History

Maternal Urine Drug Screen

Infant Drug Screen - can have false negative as it requires recent exposure to be accurate

Meconium testing - often not available at hospitals and not practical as it delays diagnosis

Bio, L. L., Siu, A., & Poon, C. Y. (2011). Update on the pharmacologic management of neonatal abstinence syndrome. J Perinatol Journal of Perinatology, 31(11), 692-701.

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129(2). Slide18

SIGNS OF WITHDRAWAL IN NEWBORNS

Onset, severity, presentation and signs of withdrawal vary greatly among each infant

Increased Temperature

Skin Mottling

Yawning Sneezing

Nasal Stuffiness

Tachypnea

Increased Metabolic Rate with High Calorie RequirementsSlide19

SIGNS OF WITHDRAWAL IN NEWBORNS

Excessive sucking/uncoordinated suck

Poor feeding

Weight loss/Poor Gain

Reflux

Loose watery stools —> diaper rashSlide20

SIGNS OF WITHDRAWAL IN NEWBORNS

High pitched Cry/Excessive Crying

Irritability

Excoriation

Poor Sleep

Hypertonia

Tremors disturbed or undisturbed

SeizuresSlide21

Onset of Withdrawal

Methadone

Heroin

Buprenorphine

24-72 hours

Within 24 hours from birth

~ 40 hours

Infants are typically monitored for a minimum of 72-96 hours for signs of Withdrawal

Withdrawal onset can be delayed for up to 5-7 days

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide22

FINNEGAN SCORING SYSTEM

Most widely used tool in the US

Scores are used to help quantify the severity of the withdrawal and they are used as a guide to start, wean and discontinue treatment

A normal newborn can have scores as high as 8

At SMH treatment is typically initiated with consistent scores > 8

Training of staff completing scoring very important

Examination of infant just as important as evaluation of scores as scores can be somewhat subjective

Scores are a reflection of a period of time and not one moment in time

Trending scores over time is important in determining management Slide23

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide24

Goal of Therapy

To alleviate the symptoms of NAS and to prevent complications including fevers, seizures, discomfort, weight loss etc.

Attain sufficient sleep and nutrition

Establish pattern of weight gain

The goal is NOT to eliminate every single symptom

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide25

NON-PHARMACOLOGIC MANAGEMENT

Decrease Environmental Stimuli

Dim lighting

Quiet environment

Swaddling

Decreased Handling

Pacifier

Firm prolonged touch vs frequent stroking etc.Slide26

Multidisciplinary Approach

Medical Providers

Nurses

Parents

Social workSlide27

CAN THESE INFANTS BREASTFEED?

YES! As long as the mother is in a supervised treatment program

There may be other medications or diseases that may be contraindicated, however most of the infant’s treated at SMH can breastfeed if desired!

If mother is unable to breastfeed or desires to use formula then often Gentlease or it’s equivalent is used given the GI symptoms that occur with NAS

Mother’s need to be reassured that despite being on prescribed opioids there is still overall benefit!

Methadone and Buprenorphine transfer to breast milk is very small

BF has been associated with less severe NAS with later onset of withdrawal and less need for pharmacologic treatment

If mother hepatitis C positive – this is not a contraindication unless mother has bleeding or cracked nipples

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide28

PHARMACOLOGIC MANAGEMENT - MORPHINE

Short half life allows for weaning, shorter half life than Methadone

Dosed every 4 hours

Infant needs to be monitored during initial therapy for signs of respiratory depression Due to decreased responsiveness to carbon dioxide tension

Opioids decrease pain perception and cause euphoria and sedation.

They also decrease GI motility resulting in constipation and anorexia.

At SMH - Once infant “captured” on dose with stable scores for ~ 48 hours then the dose is weaned 10-20% every 1-3 days until discontinued

At SMH - Once discontinued infant is monitored in the hospital for an additional 24-48 hours to ensure there is no rebound withdrawal

Bio, L. L., Siu, A., & Poon, C. Y. (2011). Update on the pharmacologic management of neonatal abstinence syndrome. J Perinatol Journal of Perinatology, 31(11), 692-701.

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal. Pediatrics, 129(2). Slide29

PHARMACOLOGIC MANAGEMENT – PHENOBARBITAL 2nd line agent

Most commonly used when there is history of poly -substance use

May be used with severe NAS or when morphine is very difficult to wean

suppresses hyperactivity, decreases CNS activity, helps to control insomnia and irritability . Does not have any affect on opioid specific withdrawal symptoms such as diarrhea and poor feeding

Long half life - drug may not need to be given every day

Infant may be discharged on Phenobarbital with pre-planned taper and close follow up by PCP

Bio, L. L., Siu, A., & Poon, C. Y. (2011). Update on the pharmacologic management of neonatal abstinence syndrome. J Perinatol Journal of Perinatology, 31(11), 692-701.

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal. Pediatrics, 129(2). Slide30

PHARMACOLOGIC MANAGEMENT - Other Therapies That Have Been Used

Tincture of opium

Methadone

Clonidine - for poly-substance

diazepam - for poly-substance

Buprenorphine has recently been under investigation as an option to consider in the management of NAS

Bio, L. L., Siu, A., & Poon, C. Y. (2011). Update on the pharmacologic management of neonatal abstinence syndrome. J Perinatol Journal of Perinatology, 31(11), 692-701.

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal. Pediatrics, 129(2). Slide31

Protocol Used At SMH

Approaches at each hospital may be slightly different. It is important to have a standardized approach to assessment with a scoring system and a protocol for management.

NAS Flowsheet. (2014, July.) Retrieved January 11, 2016 from https://connect.urmc.rochester.edu/ CSCOE /portal.htmSlide32

Decreased Risk Of Withdrawal After Opioid Exposure In Preterm Infants

Immature central nervous system

Decreased fat deposition of drug

Decreased length of drug exposure in utero

Inability to express motor dysfunction as compared to term infants i.e. tremors

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2).

Dysart, K., Hsieh, H., Kaltenbach, K., & Greenspan, J. S. (2007). Sequela of preterm versus term infants born to mothers on a methadone maintenance program: Differential course of neonatal abstinence syndrome.

Journal of Perinatal Medicine, 35(4). Slide33

FOLLOW UP

A visiting nurse often sent to infant’s home in the first few days after discharge to

assess weight, feeding and vital signs.

Close follow up in the first few days after discharge is indicated to evaluate for continued withdrawal.

At SMH all infants are seen in the Kirch Pediatric Developmental Clinic at 3 months of age

CPS involvement often ongoing after discharge. Note: If mother in a treatment program at time of delivery then CPS will not be notified

Mother may be given referral for outpatient social workerSlide34

THE PRIMARY CARE PROVIDERS ROLE

Monitor weight gain closely given high metabolic demands

Determine if infant requires increased caloric density or if infant has stable or excessive weight gain they can be transitioned off higher calorie formula or BM

Advocate for child if parental substance use is suspected to be continuing by reporting to CPS

Work with in-patient clinician on weaning phenobarbital if infant is to go home on medication

Understand the clinical manifestations of NAS and determine if infant experiencing clinically significant withdrawal that would require initial admission or readmission

Understand that withdrawal can occur after hospital discharge and still may require hospitalization

Many times mothers also have a diagnosis of hepatitis C at time of delivery. Be sure to screen at risk infant’s for disease according to Red Book guidelines

Continue to follow infant’s development and refer for evaluation as indicatedSlide35

OUTCOMES

More research needs to be done! Very limited data on long term outcomes of in utero exposed infants.

Dysfunctional caregivers and other environmental variables make interpretation of outcomes difficult

Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics,

129

(2). Slide36

The Breastfeeding Newborn

:

Special PopulationsSlide37

Objectives

State AAP recommendations for breastfeeding newborns

Identify Healthy People 2020 goals for breastfeeding

Identify important interview points for the breastfeeding mother

Identify special considerations necessary when caring for late preterm infant

Create a feeding plan to optimize growth in the late preterm infant, infant with significant weight loss, and infant with tongue tie

Recognize newborn with tongue tie and make necessary referral and feeding plan to optimize growth

Identify resources for mothers to obtain breast pumps and lactation supportSlide38

Breast Feeding Recommendations

AAP recommends exclusive breast feeding for the first 6 months of life, then continued breast feeding with the introduction of complimentary foods

According to the CDC 2014 Breast Feeding Report Card:

“In 2011, 79% of newborn infants started to breastfeed. Yet breastfeeding did not continue for as long as recommended. Of infants born in 2011, 49% were breastfeeding at 6 months and 27% at 12 months.”Slide39

What makes breast milk optimal nutrition?

Breast milk is a “complex and dynamic fluid that supports ideal infant growth and immune function development.

The composition of human milk changes over time, and contains live cells along with macronutrients and micronutrients and bioactive factors.”

(Denne 2015)

Colostrum is the first milk, it begins to produced during the second trimester of pregnancy and is available in relatively low volumes during the first days following delivery. I

t is rich in secretory IgA, lactoferrin, leukocytes, and epidermal growth factor

Breast milk transitions to mature milk during over the next 2-4 weeks. I

t is rich in lactose, fat, immunoglobulins and total proteins

(Denne 2015)Slide40

Important questions for breast feeding mothers

Complete history:

Medical and obstetric history

Daily medications and supplements

Did she experience breast changes during the first trimester of pregnancy

Maternal breast feeding goals

How long does mother want to breast feed for?

Does she wish to feed at the breast or pump breast milk for bottle feeding

What is her previous breast feeding experience and does she have support at home

Maternal access to breast pumps

thanks to the Affordable Care Act, most new mothers will be able to attain an electric breast pump through insurance, these are generally available through a durable medical equipment supplyMothers with WIC may be able to obtain a breast pump through the WIC peer counselorSlide41

Special populations

Late Preterm or Small Infants

Tongue Tie

Significant Weight LossSlide42

Breastfeedingthe late preterm infant

Infants born between 34 0/7 weeks and 36 6/7 weeks gestation are:

75% of preterm births and they:

“lag behind in terms of their cardiorespiratory, metabolic, immunologic, neurologic, and motor development”

“4 times more likely than term infants to be diagnosed with jaundice, respiratory distress, poor feeding, temperature instability, or hypoglycemia during the birth hospitalization”

Breast fed late preterm infants are more likely to be readmitted to hospital than formula fed counterparts due to failure to thrive, jaundice and dehydration

(Radtke 2011)Slide43

Wight, Pediatric Annals 2003; 32:5

Less stamina

Less coordinated S/S/B

Less effective suckling

Less alert, awake periods

Insufficient milk transfer

Hypoglycemia

Jaundice

Poor weight gain

Readmission

Supplementation

Separation from mother

Insufficient milk supply

Insufficient breast stimulation

Incomplete emptyingSlide44

Breastfeedingthe late preterm infant

American Academy of Breastfeeding Medicine Guideline

Inpatient:

Communicate feeding plan with late preterm order set and modify daily as needed given infant status (weight loss, physiologic stability)

Encourage rooming in and ad lib breast feeding (at least every 2-3hours)

Educate parents about waking techniques, ways to facilitate effective latch and hold

Ensure daily formal breast feeding assessment

If supplementation is required: 5-10ml/feed on day 1 and 10-30ml/feed day 2 and on. Mother should pump if supplementation is required

(Academy of Breastfeeding Medicine, 2011)Slide45

Breastfeedingthe late preterm infant

Role of the Primary Care Provider

Before hospital discharge:

Ensure effective at breast feeding with daily evaluation of feeding quality by hospital lactation services

Closely monitor weight and bilirubin

Create home breast feeding plan based on weight/weight loss and bilirubin, as well as maternal factors and desires

In PcP office

First visit 24-48hrs following hospital discharge

Continued close monitoring of weight, bilirubin and hydration

Identification of lactation support (private Lactation support company, La Leche League, WIC)

Modification of home breast feeding plan

(Academy of Breastfeeding Medicine, 2011)Slide46

Breastfeeding& tongue tie

Congenital condition causing a short, thick lingual frenulum

Effects 1.7-4.7% of newborns, causes feeding difficulties in 44% of these infants

There are potential for both short and long term sequelae of anykyloglossia, including speech difficulties, orthodontic and mandibular abnormalities and psychological problems

(Academy of Breastfeeding Medicine)Slide47

Breast feeding& tongue tie

Normal Newborn Tongue

Samples of Tongue Tie

Significant tongue tie prevents the normal tongue extension, lift and peristaltic movements during breast feeding

This results in not only trauma to the nipple due to poor latch, but can also lead to ineffective milk transfer by the baby

Leading to poor weight gain or significant weight loss in severe cases, but also poor stimulation for the mother to establish her breast milk supply

(Academy of Breastfeeding Medicine)Slide48

Breastfeeding& tongue tie

What to do??

Frenotomy is the procedure during which the tongue is released by clipping the restrictive lingual frenulum

Though some evidence reports decreased maternal nipple pain and improvements in the infants ability to latch and transfer milk – there are very few randomized controlled trials that report this procedure to be effective treatment although there is a tendency toward performing this procedure to protect breastfeeding.

If concern for tongue tie exists and is thought to be affecting feeding and weight gain, referral to ENT can be made or tongue can be clipped AND a feeding plan can be created to optimize milk transfer and weight gain, this will generally include supplementation and maternal pumping

(Academy of Breastfeeding Medicine)Slide49

Breast feeding& significant weight loss

What defines significant weight loss in newborn

In late preterm infant, weight loss of > 3% in first 24hrs or >7% by day 3 of life

Factors to consider:

Gestational age at birth as well as birth weight

Immediate postpartum course – has infant been rooming in and exclusively breast fed? Was first feeding delayed for any reason?

Maternal breast feeding history as well as past medical history that could affect breastfeeding (breast surgery, polycystic ovary syndrome, etc.)

Maternal medications (many medications can delay or hinder breastmilk production)

Experienced mother vs first time breast feeding mother

Delivery modality- vaginal vs c-sectionSlide50

Breast feeding& significant weight loss

What to do??

Significant weight loss during the newborn period can easily be remedied by providing the infant feeding via supplementary or complementary feeds, but what is the difference…

Supplementary feedings:

Feedings provided in place of breastfeeding.

Complementary feedings:

Feedings provided in addition to breastfeeding when breastmilk alone is no longer sufficient.

What to supplement with??

Best to supplement/complement at breast feedings with either expressed breast milk, however in many cases formula is required to bridge the volume gapSlide51

Breast feeding& significant weight loss

Appropriate weight gain of a normal healthy newborn is 28-34g/day poor weight gain is defined as <20g/day

How to manage significant weight loss…

Establish clear feeding plan, generally this means giving the mother a period of time during the day (4, 6, 8 or 12 hours) during which the infant may exclusively breast feed

during the remaining hours of the day the infant may breast feed but these feedings must be supplemented with formula or expressed breast milk

Identify available lactation support

Mothers are encouraged to pump if the infant is receiving supplemented feeds or has significant weight loss to stimulate an increased supply

Follow up for this group of infants should be done frequently, at least weekly until appropriate weight gain is established. Once infant is gaining weight appropriately the feeding plan can be altered to include more hours of exclusive at breast feedingSlide52

Future breastfeeding objectivesHealthy People 2020Slide53

References

Balancing Pain Management and Prescription Opioid Abuse. (2012). Retrieved January 11, 2016, from http://www.cdc.gov/primarycare/materials/opoidabuse/index.html

Bio, L. L., Siu, A., & Poon, C. Y. (2011). Update on the pharmacologic management of neonatal abstinence syndrome. J Perinatol Journal of Perinatology, 31(11), 692-701.

Denne, S.C. (2015) Neonatal Nutrition. Pediatr Clin N Am 62 (2015) 427–438. doi.10.1016j.pcl.2014.11.006

Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. (2015). Retrieved January 11, 2016, from http://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

Dysart, K., Hsieh, H., Kaltenbach, K., & Greenspan, J. S. (2007). Sequela of preterm versus term infants born to mothers on a methadone maintenance program: Differential course of neonatal abstinence syndrome.

Journal of Perinatal Medicine,

35

(4).

Healthy People 2020 Objectives. http://www.cdc.gov/breastfeeding/policy/hp2010.htm Hudak, M. L., & Tan, R. C. (2012). Neonatal Drug Withdrawal.

Pediatrics, 129(2).

NAS Flowsheet. (2014, July.) Retrieved January 11, 2016 from https://connect.urmc.rochester.edu/ CSCOE /portal.htm

Newborn drug-related (2014, December.). Retrieved January 11, 2016, from https://www.health.ny.gov/statistics/chac/hospital/h46.htm

Patrick, S., Schumacher, R., Benneyworth, B., Krans, E., Mcallister, J., & Davis, M. (2013). Neonatal Abstinence Syndrome and Associated Health Care Expenditures.

Obstetric Anesthesia Digest,

33

(2), 86.

Radtke, J.V. (2011). The Paradox of Breastfeeding – Associated Morbidity Among Late Preterm Infants. Journal of Gynocyologic and Neonatal Nursing, 40, 9-24.

Roussos-Ross, K., Reisfield, G., Elliot, I., Dalton, S., & Gold, M. (2015). Opioid Use in Pregnant Women and the Increase in Neonatal Abstinence Syndrome. Journal of Addiction Medicine, 9(3), 222-225.

The Academy of Breastfeeding Medicine. ABM Clinical Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Breastfeeding Medicine

The Academy of Breastfeeding Medicine (2009). ABM Clinical Protocol #3. Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009. Breastfeeding Medicine, 4 (3) 175-182

The Academy of Breastfeeding Medicine (2011). ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation). Breastfeeding Medicine, 6 (3) 151-156

Today’s Heroin Epidemic. (2015). Retrieved January 11, 2016, from http://www.cdc.gov/vitalsigns/heroin/

Tolia, V. N., Patrick, S. W., Bennett, M. M., Murthy, K., Sousa, J., Smith, P. B. (2015). Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs. New England Journal of Medicine N Engl J Med, 372(22), 2118-2126.

Wight, NE (2003). Breastfeeding the borderline (near-term) preterm infant. Pediatric Annals, 32 (5): 329-336