Whats New in NAS ? July 13, 2015 Janice Ancona, MSN, RN Wheaton - - PowerPoint PPT Presentation

WAPC Webinar Series: Improving Care for Women and Infants Affected by Opioids

What’s New in NAS?

July 13, 2015

Janice Ancona, MSN, RN

Wheaton Franciscan - St Joseph Campus

Disclosures

• Successful completion: Registrants must

attend the full session and complete the evaluation to receive continuing education credit.

• Janice Ancona has no disclosures and no

conflicts of interest.

• All medications used in the treatment of

NAS are used off label.

Before we begin…

• Listen-only mode
• Questions – please ask, please answer!

– Raise your hand – Type into the Question Pane – Out of time? Email wapc@perinatalweb.org

• Technical problems: Email Barb Wienholtz

at wienholtz@perinatalweb.org or call at 608-285-5858, ext. 201

Objectives

At the conclusion of this presentation, participants will be able to:

• Articulate criteria for weaning morphine at

24-hour intervals.

• Identify two non-pharmacologic strategies

for care of infants experiencing NAS that would apply to their practice setting.

Introduction

• More maternal opiate use means----
• More neonates with neonatal abstinence

syndromes downstream which means---

• More nurseries filled with withdrawing kids and

thus----

• Until the river of moms exposed to opiates is

stopped at the source (i.e. before they get pregnant) we will be faced with a continued flow

• n withdrawing neonates.

AAP guidelines of 2012 state:

… each nursery should develop and adhere

to a standardized plan for the evaluation and comprehensive treatment of infants at risk for

• r showing signs of withdrawal

Hudak ML et al, Pediatrics, 2012

Clinical Guidelines for Pharmacologic Treatment of Neonatal Abstinence Syndrome (NAS)

• Developed by:

– Toby Cohen, Aurora Bay Care – Miles Tsuji, NCP – Carey Ehlert, MCW – Jan Ancona, Wheaton – Sue Kannenberg, Wheaton – Jeffery Garland, Wheaton, NCP, Aurora Sinai

Length of Stay Reduction: Quality Improvement Project for Neonatal Abstinence Syndrome

National Children’s Hospital, Columbus, Ohio Richard E. McClead Jr., MD Medical Director, Quality Improvement Services

Measures to Reduce LOS

• 1. Develop Oral Morphine Protocol
• 2. Train Mother-Infant Staff in Finnegan scoring system
• 3. Established relationships with Maternal Providers
• 4. Obtained March of Dimes grant to educate pregnant

women attending a local methadone clinic re NAS

• 5. Establish an NAS Developmental Follow-up clinic
• 6. Developed NAS Clinical Guideline

A Multicenter Cohort Study of Treatments and Hospital Outcomes in Neonatal Abstinence Syndrome (Hall ES, et al. Pediatrics, August 2014)

547 treated NAS kids in 20 hospitals in Ohio (2012-2013) 417- managed with established NAS weaning protocol 130 -without protocol driven weaning LOS ---------- 32.1 vs 22.7 days, P=0.004 Opiate Rx --- 32.1 vs 17.7 days, P<0.0001

Agreed on NAS Treatment Guidelines Yes, Guidelines (not policy, not protocol)

• 1. Send urine and meconium for toxicology screening for suspected drugs as soon as

possible post -delivery for infants at risk for NAS. – (Hudak ML et al. Pediatrics 2012)

• 2. Begin NAS scoring every 3-4 hours with feedings for infants at risk for NAS.

– (Finnegan’s Neonatal abstinence scoring tool-Finnegan LP. In: Nelson NM, ed. Current Therapy in Neonatal– Perinatal Medicine, 1990)

• 3. Social service consult/Breast Feed

– (Social service consult a given) – PBP 6 for VON Initiative- develop clear eligibility criteria for breastfeeding and actively promote and support breastfeeding by eligible mothers.

• 4. Begin nursing care protocol for NAS infant.

Guidelines

Guidelines

• 5. If withdrawal symptoms do not require drug

treatment, may discharge from nursery after 5-7 days. (AAP guidelines: 4-7 days in one section and 3-7 days elsewhere in the guideline)

• a. Some newborn nurseries may require transfer to NICU when

mother is discharged. Some units may chose to admit directly to NICU (PBP 4 for VON Initiative-Provide care for infants and families in sites that promote parental engagement in care and avoid separation of mothers and infants )

• b. Discharge requires satisfactory social service evaluation.

Guidelines

• 6. Consider beginning pharmacologic

treatment if three consecutive NAS scores ≥8

• r if two NAS scores are > 12.
• 7. Start oral morphine solution with feedings,

usually Q 3-4 hours with a total of 6-8 doses per day.

• 8. Initial dosing:

– A. 0.04-0.1 mg/kg/dose – B. Suggested dosing of NAS based on Finnegan scores:

Finnegan Scores Morphine total daily dose (administer q 3-4 hours with feedings) Morphine Single Dose (if given on a q 3 hour schedule)

9-10 0.32 mg/kg/day .04 mg/kg 11-13 0.48 mg/kg/day .06 mg/kg 14-16 0.64 mg/kg/day .08 mg/kg 17 + 0.8 mg/kg/day 0.1 mg/kg

• C. If NAS scores remain elevated despite

initial dosing, increase morphine by:

– 1. 0.02 mg/kg/dose if NAS scores 9-10 – 2. 0.04 mg/kg/dose if NAS scores > 10

• D. Goal “capture” within 24-48 hours of

initiating treatment

• E. Maximum dose 0.2 mg/kg/dose

• 8. Methadone is an acceptable treatment

alternative for morphine; however, it is used less frequently and not acceptable for outpatient usage unless clinics are developed

• 9. Consider adding clonidine early if morphine

dose >0.1 mg/kg/dose or if significant insomnia or diarrhea symptoms exist. (Agthe AG et al. Pediatrics 2009)

• 10. Consider adding phenobarbital for

infants exposed to a poly-drug using mother.

• 11. Dosing for secondary line of drugs:

–a. Clonidine: 0.5-2.0 mcg/kg q 6 hrs. –b. Phenobarbital: 5 mg/kg/day

Weaning

• 1. After the infant is “captured” for at least 48

hours wean morphine by 10 % of the maximum dose in mg/dose every 48 hours.

• 2. Weaning can be done every day if NAS scores

are stable and <9; however, consider weaning by 5% of the maximum.

• 3. More rapid weaning or even holding a dose

may be necessary if the initial dosing is too high for the infant.

Weaning

• 4. If three scores in a 24-hour period are > 8-10 or two

scores > 12, consider increasing the dose back to the last stable dose and holding at that dose for 24-48 hours before restarting weaning process.

• 5. When the total dose is < 0.2 mg/kg/day (0.025

mg/kg/dose based on q 3 hour dosing) consider weaning every 24 hours.

• 6. When neonates reach 3 weeks of age, Finnegan scoring

may not be as reliable as it had been in the immediate newborn period. Tolerating Finnegan scores <11 and basing weaning on this score range may be appropriate.

Weaning

• 7. Morphine dosing usually can be spaced out or

discontinued in most infants when the dose has been weaned to 0.03- 0.06 mg/doses. Some infants may be weaned off at a higher dosing schedule.

• 8. Clonidine if used, can be weaned after morphine

is discontinued, over a 2-3 day period.

• 9. Phenobarbital if used, can be discontinued after
• ther medications have been weaned off. Get off

Phenobarbital in a timely fashion

Guidelines

Occupational therapy – Consults should be considered for all NAS neonates treated in NICU Discharge

• 1. Infants may be discharged home 48 hours after successful

discontinuation of oral morphine as long as Finnegan scores remain stable.

• 2. Completely weaning off opiate therapy is the usual goal prior to

discharge.

How Are We Doing

15 15 25 18 36 13 35 10 22 50 42 17 32 58 38 2 15 17 11 18 29 22 29 36 23 32 32 24 24 62 76 11 21 16 4 4 50 26 52 21 82 21 16 43 79 10 24 14 22 38 15 25 23 22 12 9 10 11 25 18 16 24 22 25 20 48 36 18 31 22 27 15 17 13 38 12 21 6 10 20 30 40 50 60 70 80 90 100 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77

LOS for Infants Treated at Aurora Sinai Medical Center for Neonatal Abstinence Syndrome

LOS Mean

• 2 STDev=0

+2 STDev

• 3 STDev=0

+3 STDev

NAS Guideline Communicated Begin 24 hour weaning initiative

Criteria for Weaning Morphine at 24-Hour Intervals

Weaning dose is 10% of maximum “capture dose” Symptoms have been controlled for at least 48 hours after “captured”.

Criteria for Weaning Morphine at 24-hour Intervals

No consecutive scores In 2nd 12 hours ≥ 9 for previous 24 hours if one score ≥ 9 or last three scores are rising Wean dose q 24 hours Wait another 24 hours (24-hour interval wean) to assess weaning readiness (48-hour interval wean) Morphine dose q 3 hrs Scores q 3 hrs

Criteria for Weaning Morphine at a 24-hour Intervals Among Neonates >21 days of Age

No consecutive scores In 2nd 12 hours >11 for previous 24 hours if one score >11 or last three scores are rising Wean dose at a 24 hour interval Wait another 24 hours (24-hour interval wean) to assess weaning readiness (48-hour interval wean) Morphine dose q 3 hrs Scores q 3 hrs

Criteria for Weaning Morphine at 24-hour Intervals

May wean meds at 24 interval since last reduction if:

During the past 24 hours there are no consecutive 9s if <21 days of age or 12s if >21 days of age. During the last 12 hours there are no 9s. The most recent 3 scores were not increasing.

Where To in 2015?

iNICQ 2015-VON Partnerships with Statewide Collaboratives

• n NAS (7 State Initiative)

Three Level III Aurora NICUs and Wheaton Franciscan Healthcare-St Joseph Hospital will all: Concentrate on non-pharmacologic interventions – Family involvement – Volunteer involvement – Breastfeeding – Environment

References AAP Clinical Report: Neonatal Drug Withdrawal. Pediatrics 129 No. 2 (February 1, 2012) e540-e560. Grim K, Harrison TE, Wilde RT. Management of Neonatal Abstinence Syndrome from

• Opioids. Clin Perinatol. 40 (2013) 509–524.

Zimmermann-Baer U, Ursula Nötzli, U, Rentsch, K, Bucher, H. Finnegan neonatal abstinence scoring system: normal values for first 3 days and weeks 5–6 in non-addicted

• infants. Addiction, 105 (2010) 524–528.dd_2802 524..52

Environment - Low Stimulation

• Begin in Family Care area – keep baby with

parents when possible

• Adapt to moderation of symptoms and

advancing gestational age

• Staffing to support swift response to infant

needs

Feeding

• Specialty formulas

– Easily digested proteins, carbs, and lactose proportions, probiotics. – Begin in Family Care area

• Similac Sensitive – ready to feed
• Good Start Soothe

– WIC – Powder form only – Needs warming – Transition when morphine dose is 0.04 mg/kg/dose

• Speech Therapy for state instability and oral motor control

Feeding the Baby with NAS

• Supportive handling and

swaddling

• Decrease stimulation while

feeding baby

• Cue based –allow for breaks as

needed

• CNS disturbance leads to

inability to coordinate suck- swallow-breathe

• Consider indwelling NG tube

with pump feedings

• Atypical, disorganized suck,

seal, latch or swallow

• Encourage optimal nutrition:

Increased caloric needs (hyper metabolic); increase calories/ounce

• Encourage and engage mother

in understanding baby’s feeding needs

• Feedings may take 30-45

minutes

• Regurgitation common
• Use of non-nutritive sucking -

hunger vs NAS symptomatology

Debra Kirkpatrick-Wojcik, BSN, RNC Wheaton Franciscan - St Joseph Campus

Breast Feeding Use criteria-based guidelines for supporting use of breast milk L.C. and breast pump for the “ineligible”?

YES

All conditions must be met. Maternal functioning indicating that lactation SHOULD be supported.

 Prenatal care begun by 4th month and > 7 visits at term.  Substance Abuse (SA) treatment program:

• Consent for discussion with SA

provider

• Counselor agrees with plan for breast

milk

• Drug abstinent for 90 days prior to

delivery

• Sober in an outpatient setting
• Negative urine drug test at

delivery

MAYBE

Interdisciplinary assessment and decision for lactation support May feed colostrum until final determination made or up to 48 hours. Decision will be made to breastfeed, to pump and dump, or to avoid breast milk feeding.  Prenatal care begun in the 3rd trimester (> 28 weeks)  Inadequate or no prenatal care  Sobriety only in an inpatient setting  Use of other prescribed medications along with the substance(s) in question – e.g. pain clinic  Woman in SA treatment not relapsing within 30- 90 days prior to delivery  Relapse or evidence of active drug use in the 30- 90 days prior to delivery.  Agrees to urine drug test

NO

If any ONE of these conditions is met. Maternal functioning indicating that lactation should NOT be supported.  Relapse or evidence of active drug use in the 30 days prior to delivery  No SA treatment  In SA treatment but unwilling to provide consent for discussion with SA provider/counselor  No plans for postpartum SA treatment  Relapse to drug use after the establishment of lactation

Resources for Breastfeeding and Marijuana

ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use

• r Substance Use Disorder, Revised 2015

Reece-Stremtan Sarah, Marinelli Kathleen A., and The Academy of Breastfeeding

• Medicine. Breastfeeding Medicine. April 2015, 10(3): 135-141.

doi:10.1089/bfm.2015.9992 Marijuana Use During Pregnancy and Lactation ACOG Committee Opinion. Committee on Obstetric Practice Number 637 • July 2015 Maine brochure http://www.maine.gov/dhhs/samhs/osa/help/fasddab/pubs/MJ-

BF%20rack%20card.pdf

Breast Feeding

• Consider volume-based/proportional use of

EBM

• Transition to breast

– Mom “clean” – Breast milk supply established – Can transition while weaning meds

Family Engagement

• Prenatal information and preparation

– S/S; scoring; interventions; skin-to-skin; criteria for d/c; feeding; social service/CPS

• Written materials using positive words

and phrases.

<Picture removed>

Family Engagement

WINpqc Withdrawal Care Improvement Project - Admission

You are being asked to fill this out because you have a baby who may have symptoms of

• withdrawal. We want to improve our care for moms and babies exposed to medicines or

drugs during pregnancy. Answering these questions is your choice, and will not change anything about the care for you or your baby.

• During this pregnancy did someone talk to you about newborn withdrawal? Yes No
• Circle all the ways that you got information about newborn withdrawal

The doctor who took care of my pregnancy/The doctor who takes care of my other children

Prenatal meeting with nurse or doctor/Internet /Friends/Pregnancy and childbirth classes Methadone clinic/Pain clinic/I’ve had other children with NAS/I did not get any information

• I know the signs and symptoms of withdrawal in a newborn:

Yes No

• I know that babies will be watched for symptoms in the hospital for up to 7 days: Yes No
• Are you worried about how you and the baby will be treated in the hospital? Yes

No

• If you are not breastfeeding, please circle all the reasons why you are not:

I just don’t want to/I am worried I won’t have time/I’m worried I won’t make enough milk/I am worried

about the medicines or drugs I am taking going into the milk/I was told that I shouldn’t Were you told a reason? Yes No Reason__________________ The staff of the quiet room at ___thanks you for your honesty, your time and your help.

Family Engagement

WINpqc Withdrawal Care Improvement Project - Discharge

• Did you hear about withdrawal in newborns (NAS), before you came to ____to deliver?
• Did you meet with someone from ____about newborn withdrawal, before you delivered?
• Looking back, how much information do you feel you had about withdrawal in newborns at the

time you delivered?

I didn’t get any information/ I got a little bit of information but not enough/ I got the right amount of information/ I got a lot of information but I would have liked more/ I got too much information

• A better place, or way, for me to get information during pregnancy about withdrawal in newborns

would have been________________________________________________________.

• How do you feel about the information that you have received about withdrawal in infants during

the baby’s stay in the hospital?

I got a little bit of information but not enough/ I don’t believe I know enough/ I believe I got the right amount

• f information/ I feel ready for discharge/ I got so much information it was overwhelming/

I got a lot of information but I would have liked more about____________

• Were you encouraged to hold the baby as much as possible? Yes No
• If you wanted to breastfeed, did you feel encouraged to do that? Yes No
• Do you believe that you were treated differently because your baby was at risk for withdrawal?

Can you say how you felt it was different?

Your time, honesty, and thoughtful answers in completing this will help us improve the care provided to future families. It has been our privilege to care for your baby, for you, and your family.

Family Engagement

• Family as primary therapeutic caregiver
• Teach family therapeutic touch, calming

techniques and appropriate interventions

• Support positive interactions with the baby – focus
• n bonding and attachment
• Assess interactions to prevent/de-escalate

symptoms

• Expand use of trained nurturers.

Debra Kirkpatrick-Wojcik, BSN, RNC, Wheaton Franciscan - St Joseph Campus

Barriers to Family Engagement

• Denial –most people

struggling with addiction lie to their families, friends, CPS, but mostly to themselves

• Embarrassment
• Stigma
• Anger
• Unrealistic expectations
• Safety / care of other

children

• Anxiety, depression,

psychiatric issues

• Continued substance use
• Domestic violence
• Economic limitations
• Transportation issues
• Legal issues
• Relapse is part of recovery

Debra Kirkpatrick-Wojcik, BSN, RNC Wheaton Franciscan - St Joseph Campus

Into the Community

• Methadone clinics - 16 in Wisconsin
• Pain clinics
• Recovery Treatment Facilities - Meta House
• BHD – Well Baby Initiative and Community Access to Recovery
• Community-based options for infants post-

acute withdrawal.

– West Virginia, Washington

– Milwaukee Center for Independence, Pediatric Community Care

• Pilot at Aurora Sinai
• Birth to 3; OT/PT; Drug-exposed infant Task

Force of CPS

• Parenting support – Black Health Coalition;

Mental Health America Strong Families Healthy Homes (Parent Peer Specialists)

• Safe Babies Court Teams

Home-based supports and interventions

State-wide initiatives

• Hennepin County, MN, Project Child

Keep pregnant women sober through early intervention, group therapy, and peer support. 301 women since 2010, 90% drug-free babies

• Vermont, Children and Recovering Mothers

(CHARM): Time efficient coordination of array of services; ID of

needs and tx earlier in pregnancy; everyone is healthier

• Maine, The Snuggle ME Project: Embracing Drug Affected

Babies and their Families in the First Year of Life To Improve Medical Care and Outcomes Maine

• WI - SBIRT
• Require buy-in, engagement, and effort

Outcomes

• Maternal – Childbearing continuum
• LOS
• Measures of medication management
• Measures of family engagement

– # of visits, length of visits, interactions, satisfaction

• Staff – attitudes and satisfaction
• Post-discharge development and health
• $

Things to Watch

• Inter-rater reliability among staff and units
• Connect with community partners
• U. S. GAO report to Congress

– PRENATAL DRUG USE AND NEWBORN HEALTH Federal Efforts Need Better Planning and Coordination (February 2015) (61 pages)

• Bill submitted to House of Representatives.

– Protecting Our Infants Act of 2015. Representative Clark. – To “combat the rise of opioid abuse and neonatal abstinence syndrome”, calls for addressing gaps in research. – Requires one-year turnaround strategies.

A wise colleague* said It Takes a Village…

No single entity or person can address the multitude of needs of babies and families affected by substance abuse

*Debra Kirkpatrick-Wojcik, BSN, RNC, Wheaton Franciscan - St Joseph Campus

THANK YOU

Janice.Ancona@wfhc.org

Future Webinars

• August 11, 12:00-1:00 p.m.

– “Screening and Managing Women with Opioid Substance Use Disorders”

• October 27, 12:00-1:00 p.m.

– “You Reap What You Sow: The Relationship Between Adverse Childhood Experiences and Substance Use Disorders”

• December 9, 12:00-1:00 p.m.

– “Let’s Work Together: Coalitions for Improving Care of Women and Infants Affected by Opioids”