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
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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 Slide40Slide41
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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