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Neonatal Abstinence Syndrome Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome - PowerPoint Presentation

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Neonatal Abstinence Syndrome - PPT Presentation

Erin L Keels RN MS NNPBC NAS Taskforce Chair NNP Program Manager Nationwide Childrens Hospital Columbus Ohio Disclosures No conflicts of interest Off label use of medications for treatment of NAS ID: 587603

nas drug withdrawal neonatal drug nas neonatal withdrawal treatment dose care staff maternal methadone newborn substance morphine poor abstinence

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Slide1

Neonatal Abstinence Syndrome

Erin L. Keels RN MS NNP-BC

NAS Taskforce Chair

NNP Program

Manager

Nationwide Children’s Hospital

Columbus, Ohio Slide2

Disclosures

No conflicts of interest

Off label use of medications for treatment of NASSlide3

Objectives

Describe the contributing factors and symptoms of patients with NAS

.

Outline the treatment methods available for patients with

NAS.

List stressors of staff caring for patients and families with NAS.Slide4

Substance Use in Pregnancy

2011 National Survey on Drug Use and Health

http://www.samhsa.gov/

Illicit drug use among pregnant teens= 16.2%

Illicit drug use among pregnant women (18-25 yrs)= 7.4%

Pregnant women under-report drug use by 25%

High correlation between substance use/abuse and mental health issues

Approx 55-99% of women in substance abuse treatment have experienced trauma (sexual abuse, domestic violence, etc) (

TIP 51, Addressing Specific Needs of Women, 2009)Slide5

Maternal Treatment

Pregnancy can be motivating factor

Risks of treatment outweigh risk of non-treatment or withdrawal during pregnancy

Benefits of maternal treatment:

Decreased risk of relapse

Improved prenatal care

Higher likelihood of abstinence from concomitant drug use

Improved fetal well being; improved birth weight and gestational ageSlide6

Maternal Treatment

Methadone vs. Buprenorphine

MOTHER Study- infants of buprenorphine treated mothers

:

Required less morphine to treat NAS (89%)

Spent 43% less time in the hospital

Spent 58% less time in the hospital being medicated for NASSlide7

Maternal Drug Testing

ACOG and AAP:

All women should be

screened

for alcohol, tobacco and drug use

at least occasionally

Motivational interviewing

(ex. SBIRT)

Include complete

history

Consistent questions

Nonjudgemental

May occur over

time

Urine Drug Testing Benefits

Confirms

presence of a drug

Determines the use of multiple drugs

Determines if a newborn is at risk for

withdrawal

Used for Legal and CPS documentationSlide8

Maternal Drug Testing Limitations:

Negative results do not rule out substance

use

A positive test does not tell how

much/how often a

drug is

used

Alcohol (most

widely abused

substance, greatest

impact

on fetus) is

the hardest to detect due to its short half-life

.

A woman who knows she will be tested may delay access to prenatal care

False

positive results can be devastating for a drug-free

client

UNIVERSAL drug testing is not recommended

Establish a consistent protocol and use it every time a woman meets criteriaSlide9

Drug Effects on the Fetus

Direct:

Teratogenic to embryo

Subtle effects after organogenesis:

Abnormal growth, maturation

Altered neurotransmitters, synapses, brain organization

Indirect:

Mimic naturally occurring neurotransmitters

Altered delivery of nutrition related to placental insufficiency due to mother’s health, wellness and safteySlide10

Drug Effects on Fetus and Newborn

Opioids:

Readily cross placenta, decrease brain growth and development

Neonatal Abstinence Syndrome (NAS) irritability of GI, CNS, ANS:

irritability, tremors, seizures, poor sleep

high pitched crying

diarrhea, overeating, emesis

hypertonic, poor suck

restlessness

sweating

Slide11

Drug Effects on Fetus and Newborn

Opioids

Poor

fetal growth

Prematurity and/or low

birth weight

Neurobehavioral abnormalities

Urogenital abnormalities

Cerebral vascular anomalies, accidents

Necrotizing

Enterocolitis

in term newborns

STD-

Hep

B and/or C

; HIV

Prolonged

QTc

with methadoneSlide12

Drug Effects on Fetus and Newborn

Cocaine:

Placental abruption

Prematurity

Respiratory distress, TTNB

Low birth weight

Microcephaly, neural tube defects

Vascular accidents

Defects: limb, heart, genitourinary, seizures, cerebral bleeding

Long term: poor growth, delayed neurobehavioral milestonesSlide13

Drug Effects on Fetus and Newborn

Heroine:

Low birth weight

SSRI

:

Readily crosses placenta

CNS irritability

Feeding problems

Sleep disturbances

Amphetamine

:

Readily crosses placenta and blood-brain barrier

Poor

fetal

growth

C

ardiac anomaliesSlide14

Drug Effects on Fetus and Newborn

Alcohol

Significant concentrations in fetal and maternal compartments

Congenital anomalies

FAS: abnormal facies

poor tone and suck

restlessness

excessive cry

poor sleep, poor growth

neurodevelopmental delay

hearing and visual disturbances,

Slide15

Drug Effects on Fetus and Newborn

Nicotine:

Concentrations higher in fetal compartment than maternal serum levels

Preterm labor, PROM, previa, abruption

Poor growth, esp head

Tremors

Eye and ear malformations

Heart and brain abnormalities

Risk of SIDS

Childhood asthma

ADHDSlide16

Drug Effects on Fetus and Newborn

Marijuana:

THC easily crosses placenta; 11-nor-9carboxyTCH does not

Remains in body up to 30 days, increases fetal and neonatal exposure

Infant neurobehavioral effects:

Decreased self-quieting ability

increased fine tremors and startles, hand to mouth activity

sleep pattern changes

Longer term:

Disturbed nocturnal sleep

Behavior problems:

inattention, impulsivity and hyperactivity,

delinquency and externalizing problems

self-reported depressive and anxiety symptoms

Slide17

Long Term Neurodevelopmental Outcomes

Negligible difference between opioid exposed infants and non-opioid exposed infants at age 2, 3 and 5 (school age)

Documented adverse neurodevelopmental outcomes from nicotine, alcohol, possibly THC exposure

Possible epigenetic changes?

Direct impact on outcomes- environment and social factorsSlide18

Incidence of NAS

2000-2009:

Rate of NAS per 1000 hospital births increased from 1.2 to 3.39

Rate of antepartum maternal opiate user per 1000 hospital births increased from 1.19 to 5.63

Hospital charges per patient related to NAS increased from $39,400 to $53,400

77.6% attributed to Medicaid

LOS 16 days

(Patrick et al., 2012)Slide19

Neonatal Drug Withdrawal

20-90% of drug exposed infants will exhibit withdrawal symptoms, depending on:

Type of drug/s- singular or multiple, half life; concomitant SSRI and tobacco use

Maternal: weight, drug dosage and timing

Infant weight, gestation

Infant’s intrinsic metabolismSlide20

Neonatal Drug Withdrawal

Drug toxicity- symptoms resolve as drug clears

Drug withdrawal- symptoms worsen as drug clears

NAS= opioid withdrawal

Neonatal Drug Withdrawal= everything else

Onset: 24 hours to days

Duration: 16 days to months, self limitingSlide21

Neonatal Observation

Minimum 2-3 days for any maternal history of drug use

5-7 days if mom on multiple and/or long acting drugsSlide22

NAS Assessment Tools

Finnegan Neonatal Abstinence Scoring Tool

Neonatal Withdrawal Inventory (NWI)

The

Neonatal Narcotic Withdrawal

Index

The Neonatal Drug Withdrawal Scoring System (

Lipsitz

)

Ostrea

Tool

Neonatal Drug Withdrawal Scoring System (NDWSS) Slide23

NAS Assessment

2005 study: 81% centers surveyed use assessment tool, 52% have guidelines

Allows for “common language”, decrease variability

Based on opiate withdrawal

One tool for all substance withdrawal?

Confounding factors

Term vs preterm vs beyond neonatal period

Staff training and competency maintenance

Subjectivity

Parent involvementSlide24

NAS Withdrawal ScalesSlide25

Neonatal Drug Testing

Urine

●Detects recent use of nicotine, opiates, cocaine, amphetamine, TCH

●High rate of false negatives

●Bagged specimen can be difficult to obtain

●Parent, staff stress related to trying to collect sample

●Turnaround time

●Relatively inexpensive

Meconium

●Detects more long-term use of nicotine, alcohol, opiate, cocaine, amphetamine, THC

●? Effect of urine, transitional

stoll

on sample

●Can be difficult to collect

●May pass in utero/during birth.

●May not be timely -obstruction, short stay, delayed stooling

●Parent, staff stress related to trying to collect sample

●Turnaround timeSlide26

Neonatal Drug Testing

Hair

●Highly reliable

●Detects long term exposure to nicotine, alcohol, cocaine, amphetamine

●Valid

●Specimen collection difficult for newborns

Umbilical Cord

●Highly reliable and valid

●Expanded panel of drugs

●Chain of custody

●Turnaround time

●Expense

●Ease of collection

●StorageSlide27

NAS Nonpharmacologic care

Dyad care when possible

D

ecrease in LOS and NICU admissions

Decrease stimuli

Cluster

care

Quiet environment

Containment- then transition to back to sleep

Pacifier

?kangaroo

care

Slow, smooth rhythmic rocking/swaying

Small

, frequent

feeds

Skin

careSlide28

Breastfeeding

Benefits:

Attachment

Nutritional benefits

Other health benefits

Financial benefits, convenience

Decreased NAS severity

Could improve mom’s abstinence or treatment adherence

Risks:

-Medical

Drug transfer

Type of drug/s

Maternal infections

Legal

State Law

Organizational Policies

Slide29

Breastfeeding

AAP Recommendation:

No clear

reason to

discourage breastfeeding

in mothers

who adhere to

methadone or

buprenorphine maintenance

treatment”

What is your Hospital’s policy? Slide30

Pharmacologic Treatment

Used to relieve symptoms not controlled with non-pharm (seizures, weight loss)

Prolongs hospital stay and exposure to drugs

No evidence for improved long term outcomes with drug therapy

No evidence for short or long duration drug therapySlide31

Pharmacologic Management

Paragoric

toxic ingredients: camphor (a CNS stimulant), benzoic acid (acidosis, CNS depression, seizures and death in premature infants) high concentration of alcohol (~45%)

Tincture of Opium

25 fold concentration of morphine solution- increases possibility of medication errors

contains alcohol

Morphine

short half life; allows for quicker weans

given Q3 hours with feeds- interrupts ad lib/breastfeeding

Methadone

longer half life; given frequently- easier with ad lib/breastfeedingSlide32

Pharmacologic management

Buprenorphine-

study shows promise

Phenobarbital-

treatment of seizures, sedation

Clonidine-

used to help decrease ANS output (tachycardia, hypertension, diaphoresis, diarrhea); effective as primary or adjunct treatment

Benzodiazepine-impaired excretion, late onset seizuresSlide33

NCH Medical Treatment (2012)

Protocol should be initiated if an infant has 2 consecutive scores

>

8 or 1 score

>

12 within a 24 hour period (just as was done previously with the methadone taper).

Concentration of Enteral Morphine to be used for ALL doses: 0.2 mg/ml

 

Starting Dose:

Enteral:

0.05 mg/kg/dose

po

q3h

IV:

0.02mg/kg/dose (IV morphine and enteral morphine doses are not equivalent)

Titration:

Enteral:

Increase by

0.025-0.04 mg/kg

every 3

hrs

until controlled (NAS <8)

IV:

increase by

0.01 mg/kg

every 3

hrs

until controlled (NAS <8)

*Rescue Dose*:

If infant has 1 score of

>

12. double the previous dose given (enteral or IV) x 1 and then adjust accordingly:

-

If NAS score now < 12: make the scheduled maintenance dose (MD) the same as the rescue dose that was just administered. The first higher MD should be given at the next scheduled care/feed.

-

If NAS score still

>

12: increase next dose by 50%. Continue to do so until score is < 12. Once <12. then follow guideline listed aboveSlide34

NCH Medical Treatment (2012)

Wean:

Once stabilized on a dose for 72-96 hours, use this dose as the starting point of the wean

(please note this dose on infant’s card)

.

Begin weaning the dose by 10% (of the original dose when the first wean was started) every 24-48 hours. Drug may be discontinued when a single dose is < 0.02 mg/kg/dose. Please see below for example.

*Ad lib infants*:

Given the shorter duration of action of enteral morphine, it is best suited to be dosed on a q3hr schedule. Infants should be allowed to ad lib feed volumes but kept on a q3hr schedule.

*Backslide*:

If infant’s NAS scores become consistently elevated (ex: 2 consecutive

>

8) during the weaning process, assure that

nonpharmacological

measures are optimized (

ie

: swaddling, holding, decreased stimuli,

etc

) before going back to pervious dose at which patient was stable. If infant’s scores continue to be elevated (even after physical exam to ensure nothing else is wrong/bothering the infant), either weight adjust medication and/or continue to back up in a stepwise fashion until patient’s scores are <8. Once stabilized on a new dose for minimum 48 hrs. resume 10% wean but consider weaning at longer intervals.

Discharge:

Observe in-house x 48-72 hours off of medication before discharge.Slide35

NCH Medical Treatment (2012)

Phenobarbital

Adjunct

therapy: Opioid ‘CNS’ issues not controlled by morphine/methadone

Tone, irritability, sleeplessness

Added at 14 days of therapy empirically if still unable to wean

morphine

Clonidine

I

ncreased

autonomic s/

sx

of opioid withdrawal not controlled with morphine/methadone

MOA:

a

2

receptor agonist

Negative feedback

 prevents further

sympathomimeitc

release

Side effects:

Hypotension,

bradycardia

R

eflex

tachycardia/HTN can occur if stopped abruptlySlide36

Discharge Management

Safe Home Environment

:

States, counties vary re: CPS referral

Work through Social Worker

Family

Education

? Ongoing scoring

Nutrition

Well baby parenting

Follow Up

 

Developmental screening

? Risk for

Hep

, HIVSlide37

The Nationwide Children’s Hospital Experience

Nationwide Children’s Hospital (NCH) is a large, free-standing academic pediatric facility in Columbus, Ohio with 450 licensed beds.

Neonatal Services (NS)

8 Intensive care nurseries

191 Neonatal beds

2300+ admissions/year

22% < 1500 g birth weightSlide38

Length of Stay Issues

Background

:

In 2009 at NCH

7.6% of all NICU/NSCU admits

Average Length of Stay (ALOS) 35.5 days on the main campus, 78 days in an off-campus unit

Significance:

Long LOS negatively impacts psychosocial situation

Created backlog of NICU/NSCU beds

Majority Medicaid Managed Care-capitated

Caregiver stressSlide39

Staff Concerns

Poor communication and inconsistency of plans of care

Poor competency with assessment and documentation of symptoms

Stress related to neonatal care

Stressful family dynamics and interactions

Discharge planning Slide40
Slide41

Nursing Assessment and Documentation

Finnegan Training Courses ( March- April 2010)

Two half day NAS Workshops

Train the trainer format

Implement standardized training of new staff with commercially produced program

Ongoing competency for all staff

Slide42

Workshop Intra-rater Reliability

Pre- workshop Post-workshop

Paired T for Post-Workshop – Pre-Workshop

N Mean St

Dev

SE Mean

Post-Workshop 82 13.8 1.6 0.1

Pre-Workshop 82 12.1 2.6 0.2

95% CI for mean difference: (1.0, 2.3);

T-Test of mean difference = 0 (

vs

not = 0): T-Value = 5.1 P-Value = 0.000

Conclusion:

The Post-Workshop NAS Scores appear to be significantly different than the Pre-Workshop NAS Scores.Slide43

Pharmacologic Management

Initially used Methadone

Changed to Oral Morphine

Continue to refine based on outcomesSlide44

NAS Taskforce

“Clearing house” of information, resources, and potentially better practices

Monthly interdisciplinary collaborative meetings:

Developed practice guidelines

Enhanced antenatal professional communication, collaboration

Outreach education and support for providers in the Region.

MOD Grant: improved maternal Methadone treatment retention rate by 25% Slide45

Collaboration Outside of NICU

MIU/WBN education and training

Maternal Providers

Follow up Clinic

Perinatal Region Education and Support

State LevelSlide46

Outcomes:

Main CampusSlide47

Balance Measure:

30 day Readmission Rate

28 Readmissions 2010-2012 (N= 440)

NAS symptoms (2)

CNS symptoms unrelated to NAS Hx (3)

Feeding issues unrelated to NAS Hx (4)

BPD exacerbation (1)

Infections (13)

Surgical problems (5)Slide48

Savings to Date

$ 2.8 Million on Main CampusSlide49

Next Steps: Staff Support

Nurses struggle with issues of beneficence and

nonmaleficence

,

frustration

, burnout and

dissatisfaction

when caring for this population of patients and families.

Do our Nurses struggle with this as well??

2013 NAS Taskforce Goal:

1. Determine NCH staff level of comfort in caring for the NAS patients and families

2. Determine if additional education, training and resources are needed to help staff care for and cope with NAS patients and familiesSlide50

Nursing Staff Survey

Qualitative and quantitative data

Sent to all nursing staff of Neonatal Services (LPN, RN, APN) via email.

N= 580

Returns= 167

Response rate= 28%Slide51

Survey Results

N= 167

Type of Nurse

RNs= 130 (78%)

LPNs= 5 (3%)

APNs= 30 (18%)

MD=1 (0.6%)

Unknown=1 (0.6%)

Yrs Neonatal Nursing

0-5 years= 50 (30%)

6-10 years= 37 (22%)

11-20 years= 29 (17%)

Over 20 years= 48 (28%)

Unknown= 3 (2%)Slide52

On a scale of 1-5, rate your comfort caring for babies with NAS

Overall average= 4.2

Years of experience

Type of Nurse

0-5 yrs= 4.2 APN= 4.56

6-10 yrs= 4.1 LPN= 4.2

11-20 yrs= 4.3 RN= 4.2

Over 20 yrs= 4.3Slide53

On a scale of 1-5 rate your comfort interacting with families of NAS patients

Overall

average= 3.8

Years of experience Type of Nurse

0-5

yrs

= 4 APN= 4.0

6-10

yrs

= 3.6 LPN= 3.8

11-20

yrs

= 3.8 RN= 3.9

Over 20

yrs

= 3.9Slide54

What are some of the biggest challenges that you experience caring for babies with NASSlide55

What are some of the biggest challenges that you experience caring for babies with NAS

4. Workload

Not enough time to console

Too many babies to care for

5. “Ethics”

Patience for self and of others

“Prejudiced nurses”Slide56

2013 NAS Taskforce Action Plan

1 Staff Education:

NAS quarterly taskforce meetings

VON iNICQ Webinar series

Annual NCH conference- NAS Postconference

Ohio Opiate Summit

Podcasts by Neonatologist and Addiction Specialist

Ethics lecturesSlide57

Action Plan

2. Staff Resources

Develop website or sharepoint for

Guidelines, references, articles

Meeting minutes

iNICQ proceedings

Bedside resource packet

EPIC EMR with best practice alerts

Unit based NAS committees with SuperusersSlide58

Action Plan

3. Staff Training

FNAST ongoing competency training

Inter-rater reliability testing

4. Re-survey Slide59

Summary

Incidence of Neonatal Drug Withdrawal, including NAS, is increased

NAS has profound impact on baby, family and healthcare system

Each unit should have an NAS protocol:

Screening and testing of mom and baby

Assessment/scoring

Treatment- non pharm and pharm

Discharge management and Follow Up

LOS can shortened by decreasing variability in treatment

Staff can feel challenged /stressed when caring for NAS patients and families

Much research is needed!Slide60

Questions?

Erin.keels@nationwidechildrens.orgSlide61

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