10/15/2018. The Tiniest Victims of the Opioid Crisis Tara Sundem, RN, NNP-BC, MS

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1 The Tiniest Victims of the Opioid Crisis Tara Sundem, RN, NNP-BC, MS What is Neonatal Abstinence Syndrome (NAS)? What causes NAS? Signs and Symptoms of NAS? Treatment of NAS? Follow up for babies with NAS? Medication assisted treatment- What is it? What is Hushabye Nursery s care model? Why Hushabye? 1

2 HushabyeNursery l hushabyenursery.org l As the number of opioid overdoses and deaths increase at an alarming rate, we must take action. It s time to call this what it is an. Governor Ducey June 15, 2017 HushabyeNursery l hushabyenursery.org l More than are born passively dependent in AZ every day. 2

3 estimated NAS babies were born in 2017 in AZ, which is a 466% increase from 2008 (145 cases). 1 kids in foster care as of March 2017; AZ was 5th in the nation in 2015 for number of children in foster care. 2 of all NAS cases in AZ have been paid for by AHCCCS in 2014, costing an average of $31,000/ NAS baby in the NICU. 3 1 AZ Taskforce Guidelines, 2008 and AZ Department of Child Safety, AZ Department of Child Safety, 2017 Note: full citations and articles available upon request. 3

4 Condition experienced by an infant after birth due to sudden discontinuation of exposure to certain drugs such as opioids that were used by their mother during pregnancy. PrabhakarKocherlakota PediatricsAug 2014, 134 (2) e547e561; DOI: /peds How could a mother put her baby through that? Why doesn t she just stop? Methadone is trading one drug for another. This is her third NAS baby. Frustrating. We shouldn t send these babies home with these families. We should lock these moms up. During pregnancy almost every medication, drug, and substance can pass through the placenta to the baby. Prescription medications Over the counter medications Street drugs Herbal remedies Alcohol Cigarettes Caffeine PrabhakarKocherlakota PediatricsAug 2014,134(2)e547e561;DOI: /peds

5 Prescription Drugs Morphine Methadone Subutex OxyContin Oxycodone (Percocet) Vicodin Hydromorphone (Dilaudid) Fentanyl Hydrocodone Buprenorphine Tramadol Codeine Street Drugs Heroin Oxys Fentanyl Non-Opiates SSRI s (antidepressants) Benzodiazepines Prabhakar Kocherlakota PediatricsAug 2014, 134 (2) e547e561; DOI: /peds Cocaine Crack Methamphetamines Speed Ectasy PrabhakarKocherlakota PediatricsAug 2014,134(2) e547e561;doi: /peds PrabhakarKocherlakota Pediatrics Aug 2014,134(2) e547e561;doi: /peds

6 Increase: Gestational age >37 weeks Appropriate birth weight for gestational age Polysubstance abuse Smoking Concomitant benzodiazepines use Concomitant SSRI use Dose of Methadone or Subutex Genetic Polymorphisms (OPRM1 118AA, COMT 158AA) Decrease: Breastfeeding Detweiler, A., & Ward, C. (2015). Neonatal Abstinence Syndrome and Breastfeeding: A Review of Literature. Low birth weight Small head circumference Abnormal tone may persist for months Seizures & abnormal EEG pattern Signs of withdrawal (drug dependency) Prabhakar Kocherlakota Pediatrics Aug 2014, 134 (2) e547e561; DOI: /peds Neonatal Abstinence Syndrome Prabhakar Kocherlakota Pediatrics Aug 2014, 134 (2) e547- e561; DOI: /peds

7 Vomiting Diarrhea Mottling of skin Skin breakdown Tremors, jittery Sweating Inconsolable high-pitched cry Poor feeding or excessive sucking Inability to sleep Stuffy nose and sneezing Increased breathingrate Seizures Mottling of Skin Excoriation to Face and Limbs 7

8 Neonatal Abstinence Scoring System- usually completed every 2-4 hours for 5-7 days minimum Modified Finnegan scoring system Eat Sleep Console Addiction Science & Clinical Practice20149:19 8

9 How to treat the scores? Scores of > 8 are concerning Three scores totaling 24 or more require pharmacologic therapy Finnegan LP,Connaughton JF Jr, KronRE, Emich JP Addictive Diseases[01 Jan 1975, 2(1-2): ] -New way to assess NAS -Easy to use -Has decreased Length of Stay A Novel Approach to Assessing Infants With Neonatal Abstinence SyndromeMatthew R.Grossman,Matthew J. Lipshaw, Rachel R. Osborn, Adam K. Berkwitt Hospital PediatricsDec 2017, hpeds ; DOI: /hpeds HushabyeNursery l hushabyenursery.org l FOSTER CARE 9

10 HushabyeNursery l hushabyenursery.org l Current NICU Environment Congratulations!!! Connect with Obstetrician/ Perinatology Consult Birthing classes (OUD/SUD specific) No THC DCS plan SENSE program Identify Safety Monitors Withdrawal Symptoms and Interventions Breastfeeding HIV/Hepatitis C status and Counseling Minimize symptomatology (supportive & pharmacologic) Avoiding seizures is ultimate goal! Promote growth and weight gain Promote caretaker-child interaction Strategies directed to social issues Improve short-term and long-term outcomes Identify and possibly improve long-term behavioral problems 10

11 Non-pharmacologic care -Parents, Parents, Parents!!! -Decreasing stimulation Turning the lights down Quiet environment -Skin-to-skin -Rooming-in or Nesting -Nutrition- small frequent feedings, warm the bottle -Breastfeeding, if not contraindicated -Infant Massage -Warm compresses to tummy Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower CostAlisonVolpeHolmes,Emily C. Atwood,BonnyWhalen,JohannaBeliveau,J. DeanJarvis,John C.Matulis,Shawn L.Ralston PediatricsJun 2016, 137(6)e ;DOI: /peds Non-pharmacologic care: teach parents! Your baby will be sensitive to light, sound and touch. Keep the surroundings calm and quiet. Limit visitors. Mute your cell phone. Only wake babies for feedings if necessary. Let your baby sleep. It is very important for them to rest well. Avoid rubbing and stroking, gently pat to provide extra comfort. Smoking can be an irritant. Calms Baby & Calms Caregivers 3 Deep Yoga Breaths Breathe in Hold Breathe out Repeat x 3 11

12 Swaddle in light blanket and onesie- they sweat! Hands to face Knees to chest Swaddle tightly Swaddle tightly Hands to face Knees to chest Pacifier Start squating while shushing (mimics mom s heart beat) Sometimes turn babies away from you to decrease all stimulation 5 S s, 6 and now 7 -Swaddle baby -Side or stomach carrying -Suckle -Swing -Shush him/her -Stay Calm -Squat The Happiest Baby on the Block- Harvey Karp 12

13 Small Frequent Feedings- On Demand Don t make them wait Pacifier May need to feed before changing the diaper Breastfeeding if not contraindicated Simethicone Similac Sensitive, Gentle Ease or elemental formula Increasing calories might be necessary Warming formula What to start? Morphine opiate replacement Methadone- opiate replacement Clonidine- adjunct therapy. Helps to stabilize the autonomic nervous system Temp instability Watch B/P! Phenobarbital- adjunct therapy. Weaning is prolonged. PediatricsJuly 2014 From the American Academy of Pediatrics State-of-the-Art Review Article Music Therapy 13

14 Aromatherapy Therapy No significant association with immediate newborn complications Effects are subtle initially, but adverse effects noted later in childhood or adolescence Behavior problems Proctor-Williams, Louw, Ratliff, 2017 Babies with NAS are at high risk. Close follow-up can identify needs! Early intervention improves outcomes. 14

15 Recommended Follow-up Neurodevelopmental assessments Motor deficits Cognitive delays Sensory Processing Disorder Obsessive Compulsive Disorder Attention Deficit Hyperactivity Disorder Proctor-Williams, Louw, Ratliff, 2017 Hyperactivity Impulsivity Recommended Follow-up Psycho-behavioral assessments Attention-deficit in preschool-aged children Behavioral problems in school-aged children Proctor-Williams, Louw, Ratliff, 2017 Recommended Follow-up Growth and nutritional assessment Failure to thrive Short stature Feeding issues Reflux Oral aversion Proctor-Williams, Louw, Ratliff,

16 Reduced acuity Nystagmus Delayed visual maturation Strabismus Refractive errors Cerebral visual impairment PrabhakarKocherlakotaPediatricsAug 2014, 134 (2) e547e561; DOI: /peds Less efficient feeders Poor sucking Rejection of nipple, spillage Increased hiccupping Coughing, reflux Fussing, crying Increased risk for failure to thrive The goal is a quiet, alert state -When stress is detected, modify the interaction and stimulation level. Proctor-Williams, Louw, Ratliff, 2017 Pediatrician Newborn follow-up clinic with Developmental Pediatrician or Neonatologist Ophthalmologist appointment if indicated OT, PT (Torticollis) and Speech Hearing Screens NAS parent support groups NICP, SENSE & AZEIP- encourage participation Torticollis in Infants with a History of Neonatal Abstinence Syndrome McAllister, Jennifer M. et al. The Journal of Pediatrics, Volume 196,

17 There are adverse long-term neurodevelopmental consequences of NAS We must: Help decrease stigma associated with substance abuse so that information may be provided to the benefit of the child. Educate other team members on NAS. Develop assessment and treatment protocols for babies and children post-nas. Further research is required! Proctor-Williams, Louw, Ratliff, 2017 A Brain Disease, not a moral failure! How we talk impacts the way we think. Improved understanding that opioid use disorder is a complex interplay of biology and environment will decrease stigma and increase access to healthcare. Olsen Y, SharfsteinJM. Confronting the Stigma of Opioid Use Disorder and Its Treatment. JAMA. 2014;311(14): doi: /jama Why not??? Increases the risk of miscarriage High incidence of relapse Not recommended by ACOG currently 17

18 Harm Reduction and Evidence-Based Treatment for OUD Combines behavioral therapy and medications to treat substance use disorders Proven efficacy with Opioid Use Disorder Methadone, Buprenorphine (Subutex), Suboxone (Buprenorphine/Naloxone), Naltrexone (Vivitrol) Decrease HIV/AIDS Decrease mortality Decrease healthcare costs Decrease in drug-related crime Decrease IV drug use Improved family stability Improved pregnancy outcomes Adverse Childhood Experiences Study (1998)- 7 Domains 3 Types of Abuse Physical Sexual Emotional Mental Illness in household Substance abuse in household Evidence of Criminal Activity in household Mother abused in the household PediatricsMarch2003, VOLUME 111 / ISSUE 3Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study Shanta R. Dube,Vincent J. Felitti,MaxiaDong,Daniel P. Chapman,Wayne H. Giles,Robert F. Anda 18

19 Event + Experience + Effect LIVING WITH SOMEONE WHO IS MENTALLY ILL or SUICIDAL LIVING WITH SOMEONE WHO HAS AN ALCOHOL OR DRUG PROBLEM EXPERIENCING SOCIOECONOMIC HARDSHIP BEING TREATED OR JUDGED UNFAIRLY DUE TO RACE, ETHNICITY, OR IDENTITY HAVING A PARENT IN JAIL EXPERIENCING THE DEATH OF PARENT EXPERIENCING DIVORCE OR PARENTAL SEPARATION WITNESSING DOMESTIC VIOLENCE BEING A VICTIM OR WITNESS OF NEIGHBORHOOD VIOLENCE NAS babies have 2 or 3+ ACE s at birth.. 19

20 Recovery Center for Neonatal Abstinence Syndrome HushabyeNursery l hushabyenursery.org l Hushabye Nursery s Mission To embrace substance exposed babies and their caregivers with compassionate, evidence-based care that changes the course of their entire lives. 20

21 Congratulations!!! Connect with Obstetrician/ Perinatology Consult Birthing classes (OUD/SUD specific) No THC DCS plan SENSE program Identify Safety Monitors Withdrawal Symptoms and Interventions Breastfeeding HIV/Hepatitis C status and Counseling HushabyeNursery l hushabyenursery.org l Prenatal Services Medical Care Addiction Treatment Counseling DCS Collaboration Medication Assisted Tx Financial Guidance Nursery Services NAS Recovery Services NAS Environment Specialized Training Nonjudgmental Environment Family Care Model Discharge Services Newborn Follow-Up SENSE Pediatric specialists Developmental services Family Counseling Financial Guidance Service Coordination Access to Care 21

22 HushabyeNursery l hushabyenursery.org l Hushabye Nursery Environment Provide the very best care for babies We will care for NAS babies in a calm and nurturing environment designed specifically for their needs, using the latest therapeutic techniques combined with pharmacologic approaches. Support moms and families We collaborate with community partners to provide wraparound services prenatally and after discharge. Keeping families united is proven to decrease pregnancy, unemployment, and incarceration rates. 1 Decrease costs for the taxpayer We will spend less than the NICUon neonatal care, plus reduce costs over the babies lifetime by providing wraparound, preventative services. Lily s Place 2 has reduced costs by up to 50%. AZ will lead the nation with Hushabye Nursery s innovative care model that provides integrated, wraparound services, saving lives and money. 1 MIT Sloan School of Management & NBER, Lily s Place is the only neonatal nursery for NAS babies in the US. Located in WV, they utilize a similar neonatal care model; however, Hushabye Nursery will be the first in the nation to provide wraparound, preventative services. NICU Model Treat babies in bright, noisy, intense environment Design NICU for premature babies, not NAS babies Provide minimal education/limited resources Restrict visitation and prohibit overnight stays Ensure one caregiver to every three babies (1:3) Staff teams with limited NAS training Hushabye Model Treat babies in quiet, dark, calm environment Design nursery with one crib per room Educate families on how to care for NAS baby Encourage moms to stay in-room 24/7 Ensure one caregiver per baby (1:1) Hire specially-trained staff with passion for NAS babies Promote bonding and breastfeeding Use five Ss, rock up and down, 6th S-squat techniques Wean and treat babies with medications as necessary Validate Finnegan Neonatal Abstinence Scoring System Provide physical, speech, occupational therapy Provide behavioural health services to families on site Collaborative Care Plan 22

23 We will care for babies, support families, and save taxpayer dollars, resulting in: 1 Collective Impact By connecting community partners, we will build collaboration and connect the silos. 3 Reduced Costs By providing specialized care and wraparound services, we will save money throughout their entire lives. 4 2 Stronger Families By providing wraparound services (including DCS Safe Model), we will help families stay together. Better Outcomes By caring for NAS babies the tiniest victims of the opioid epidemic we will build brighter futures. How could a mother put her baby through that? Why doesn t she just stop? Methadone is trading one drug for another. This is her third NAS baby. Frustrating. We shouldn t send these babies home with these families. We should lock these moms up. HushabyeNursery l hushabyenursery.org l

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