Neonatal Abstinence Syndrome

Transcription

1 Neonatal Abstinence Syndrome Jodi Jackson, MD* Betsy Knappen, MSN, APRN** *Chair Kansas Perinatal Quality Collaborative (KPQC) Medical Director NICU, Shawnee Mission Medical Center (SMMC) Neonatologist, Children's Mercy Hospital and Clinics (CMH) Associate Professor of Pediatrics University of Missouri-Kansas City School of Medicine **Education and QI Coordinator KPQC Neonatal Abstinence Program Coordinator SMMC Neonatal Nurse Practitioner SMMC and CMH

2 Disclosure We have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3 DEFINING NAS

4 What is NAS? Infants born to mothers taking some medications during pregnancy may develop symptoms after delivery upon cessation of exposure These symptoms (neurological, gastrointestinal, respiratory) are a complex known as Neonatal Abstinence Syndrome (NAS) Neonatal withdrawal symptoms have been noted to occur following prenatal exposure to several drug classes: Opioids Benzodiazepines Mood-stabilizing medications Selective serotonin reuptake inhibitors Nicotine Kraft, W. Van Den Anker, J. (2012). Pharmacologic Management of the Opioid Neonatal Abstinence Syndrome, Pediatr Clni N Am 59,

5 A schematic illustration of the mechanism of opioid withdrawal in neonates. Prabhakar Kocherlakota Pediatrics 2014;134:e547-e by American Academy of Pediatrics

6 Commentary on Reporting Babies should not be stigmatized as addicts Behavioral and compulsivity components do not apply They should be considered to be drugexposed The phenomena of tolerance and withdrawal are normal physiologic responses to drug exposure and drug discontinuation Slide adapted from Mark L. Hudak, MD Improving Outcomes for Substance-Exposed Infants and Families A Kansas Plan for Prevention and intervention

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8 Is NAS a Real Problem? Increase in the prevalence of NAS; varies by state and study per 1000 hospital births; Patick, SW et al.j Perinatol 2015; 35: per 1000 NICU admissions; Tolia VN et al. N Engl J Med 2015;372: addresses a study of 299 clinical sites (making up 33 states) Local; 16 /1000 NICU admits, 2/1000 births; 80% increase over 5 years National Average LOS for NAS requiring tx ~ 19 days

9 A. Annualized Neonatal Intensive Care Unit (NICU) Admission Rates for Neonatal Abstinence Syndrome B. Median Length of Stay, According to Year. I bars in represent interquartile ranges Tolia VN et al. N Engl J Med 2015;372:

10 Increased Prevalence of Opioid Abuse Parallels Increased Incidence of NAS Illegal drugs Prescription drugs Drastic increase in the number of prescriptions written Greater social acceptability for using medications Aggressive marketing by pharmaceutical companies Populations merge People can illegally acquire prescription drugs Start with prescription drugs and devolve to illegal drugs Start with illegal drugs, and evolve to programs Methadone Subutex/Suboxone (Buprenorphine)

11 Number of ER visit/year Gregory L. Kirk, MD Psychiatrist addiction news, addiction opinion, and public health RMPC

12 Opioid Prescription Dispensed by US Retail Pharmacies

13 America s Addiction to Opioids: Heroin and Prescription Drug Abuse

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15 KANSAS NAS

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17 With efforts to quantify (confounded by charting) it seems that in Kansas some rural areas have a greater incidence than some urban; incidence per 1000 births, rural , urban

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22 Kansas Perinatal Quality Collaborative

23 KPQC Vision and Mission Kansas is the best place to be born and to be a mother To improve Kansas maternal and infant health outcomes by assuring quality perinatal care using data-driven, evidencebased practice, and quality improvement processes.

24 NAS the first QI initiative We hope that a successful first initiative will build our capacity to do future initiatives 2 5

25 Vermont Oxford Network

26 Building Our NICU Community 950 NICUs Worldwide 265 International NICUs in 28 Countries

27 Vision To build a worldwide community of practice dedicated to providing every newborn infant and family with the best possible and ever improving medical care.

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29 VON Universal Training Program Statewide Subscription 18 Micro-Lessons relevant to every care team member with CME/CNE (VON learning center, LMS microlessons) A VON NAS Quality Improvement Toolkit (VON LMS State Collaborative) A 5-chapter Virtual Video Visit and Facilitator s Guide Sample policies, procedures, guidelines and family educational tools essential for NAS care 1 5

30 Training Across the Continuum Who to include in the Hospital: Bedside Nurses, RT, LC, Pharmacists, Dieticians, CNS, Educators, PT/OT/SPL, SW, Discharge Coordinators NNP, Neonatologists, Fellows, Residents, Midwives, OB Unit Medical/Nursing Directors, Quality & Safety Leaders, Senior Leaders, Hospital administrators Parents/Consumer Advisors 1 6 Who to include outside the Hospital: Department of Children and Family Services Caseworkers Rapid Responders Judges Insurance companies Support networks (MOD other) Government organization representatives

31 Centers of Excellence Individual centers will receive Center of Excellence in Universal NAS Training and Education designation if 85% of identified learners complete training Kansas will receive State of Excellence designation in Universal NAS Training and Education if 85% of all birthing centers enrolled receive Centers of Excellence 19

32 KPQC Support Help centers to enroll in VON Help centers access VON State collaborative site, micro lesson and learning system (LMS) Help centers with first VON Day Audit (Spring, Summer or Fall) KPQC bimonthly webinars assisting on data collection and standard practice protocols (QI methods and projects) KPQC regional workshops Monthly VON Universal Education Center Participation data review by Quality Improvement Coordinator Spring 2020: Second VON Day Audit (Post)

33 Best Practices Recommendations

34 ACOG Committee Statement on Opioid Use/Abuse in Pregnancy Early universal screening: using interview tools and lab Referral for tx of women with opioid use improve outomes A coordinated/multidisciplinary approach without criminal sanctions best chance of helping infants and families For pregnant women with an opioid use disorder: Opioid agonist Tx is the recommended therapy Is preferable to medically supervised withdrawal because withdrawal is associated with high relapse rates, which lead to worse outcomes. More research is needed to assess the safety (particularly regarding maternal relapse), efficacy, and long-term outcomes of medically supervised withdrawal ACOG, Aug 2017

35 Highlights From the AAP Clinical Report 1. Consensus protocol for maternal screening for substance abuse and evaluation/management of infants at risk for or with signs of withdrawal. 2. Emphasis on non-pharmacologic support. 3. Standardization of assessment of clinical signs. 4. Caution about initiating pharmacologic treatment. 5. Optimal threshold score for initiating treatment is unknown. 6. Encouragement of breastfeeding when indicated. 7. Pharmacologic treatment, when needed, with opioids. Absolute indications include seizures, feeding intolerance, dehydration/poor weight gain. 8. Duration of in-hospital observation; outpatient follow-up. Hudak ML, Tan RC, Committee on Drugs, Committee on Fetus and Newborn. Pediatrics 2012; 129:e540-60

36 Vermont Oxford Network (VON) Potentially Better Practices in NAS Care Develop and implement a standard process for identification, evaluation, treatment and discharge of infants with NAS Care sites that promote parental engagement in care/avoid separation of mothers Engage mothers and family members in providing nonpharmacologic interventions first-line therapy at risk infants Create a culture of compassion and healing for mother/infant dyad Develop breastfeeding criteria/support Standardized process for safe discharge Universal education and training Develop/Implement a standard process for measuring and reporting rates of NAS and drug exposure

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38 KEY TO SUCCESS: FAMILY SUPPORT

39 Supporting the Families Supports the Baby Family education during the pregnancy Collaboration between hospital care team and prenatal outpatient OB team prior to delivery Family and provider education regarding non-narcotic treatment of pain before, during and after birth Support of mothers during pregnancy regarding drug rehab, or just a stable environment has been shown to be beneficial to both mom and baby, and results in the best outcome for both

40 This Amazing Program via VON

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42 Site of Care Ideally mother/infant remain together Increased comfort care Decreased pharmacologic TX/LOS Methadone studies- 30% response to comfort measures VON Centers- 50% reduction in TX with low lights/noise Increased bonding Facilitates breastfeeding (if eligible)

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45 Maternal Treatment Programs 45

46 The Perinatal Outcome of Children Born to Women With Substance Dependence Detoxified in Residential Treatment During Pregnancy Journal of Addictive Disesase: Haabrekke, KJ PhD Candidate et al Published online: 09 Apr 2014 Slide adapted from Mark L. Hudak, MD Improving Outcomes for Substance-Exposed Infants and Families A Kansas Plan for Prevention and intervention

47 Incarnated Inpt Detox/ Intense F/U Inpt Detox/ Nonintense F/U Outpt Wean/ Behavioral F/U Slide adapted from Mark L. Hudak, MD Improving Outcomes for Substance-Exposed Infants and Families 47 A Kansas Plan for Prevention and intervention

48 Challenges in Maternal Treatment Limitations to Substance Abuse Treatment Programs Most Inpatient program require detox vs mediated rehab Limited programs accept Medicaid Many women are only Medicaid eligible 60 days post delivery Private pay seen often with Subutex Our current progress Treatment referrals are generally limited for methadone clinic and Subutex provider for Medicaid patients This is part of the state effort

49 Consistent Scoring

50 NAS Scoring Indicated Morphine Codeine Hydrocodone (Lortab, Vicodin) Oxycodone (Percocet, Oxycontin) Methadone Suboxone Heroin Tramadol Benzodiazepines: Ativan, Xanax, Valium, Clonaxepam (Klonopin) Polysubstance use- combination of medications (ie: mood stabilizer with an antidepressant or antipsychotic)

51 Scoring Principles Consistent Timing of Scoring Scoring Competencies for Reliability Second Scorer Validation

52 Elements of the Finnegan Scale Opioid receptors are concentrated in the CNS and the gastrointestinal tract, the predominant signs and symptoms of pure opioid withdrawal reflect: CNS irritability Autonomic over-reactivity Gastrointestinal tract dysfunction

53 Finnegan CNS No CNS disturbance 0 Excessive high pitched cry 2 Continuous high pitched cry 3 Sleeps less than 1 hr after feeding 3 Sleeps less than 2 hr after feeding 2 Sleeps less than 3 hours after feeding 1 Hyperactive moro reflex 2 Markedly hyperactive moro reflex 3 Mild tremors disturbed 1 Moderate-severe tremors disturbed 2 Mild tremors undisturbed 3 Moderate-severe tremors undisturbed 4 Increased muscle tone 2 Excoriation 1 Myoclonic jerks 3 Generalized convulsions 5

54 Finnegan Metabolic/Vasomotor/Resp No Disturbance 0 Sweating 1 Fever less than 101 F ( , C) 1 Fever greater than 101 F (38.4C) 2 Frequent yawning (3-4x/exam period) 1 Mottling 1 Nasal stuffiness 1 Sneezing (3-4x/exam period) 1 Nasal flaring 2 RR > 60/min 1 RR > 60/min with retractions 2

55 Finnegan GI No GI disturbance 0 Excessive sucking 1 Poor feeding 2 Regurgitation 2 Projectile vomiting 3 Loose stools 2 Watery stools 3 Adapted from L.P. Finnegan (1986)

56 Comfort Measures Initial treatment Minimizing environmental stimulation Light Sound Decreasing Auto-stimulation Swaddling Positioning responding to infant s cues frequent feedings non-nutritive suck clustering of cares (Hudak & Tan, 2012; Jansson & Velez, 2012)

57 When to use Pharmacologic Treatment The Rule of 24: When 2-3 consecutive scores = 24 3 Consecutive scores of Consecutive scores 12 or higher

58 Eat, Sleep, Console Assess infant after feedings, preferably while skin-to-skin or held swaddled by mother/caregiver. Review baby s ESC behaviors since last assessment 3-4 hours ago using Newborn Care Diary with parents. If infant with Yes for any ESC item or receiving 3s for Soothing Support Used to Console Infant, perform team huddle with mother/parent & RN to determine non-pharm interventions that can be optimized further. If infant continues with Yes for any ESC item or 3s for Soothing Support despite optimal non-pharm care and symptoms felt likely due to NAS, perform full team huddle with mother/parent, RN, and Infant Provider to determine if medication treatment is needed.

59 Breast Feeding

60 Support Breast Feeding in Women Who: Engaged in substance abuse treatment program in coordination with outpatient counselor Plan to continue treatment in postpartum period Have been abstinent from drugs for 90 days prior to delivery Have a negative UDS at delivery except for prescribed medications Received consistent prenatal care Do not have medical contraindication to BF (Such as HIV) 60

61 Discourage Breastfeeding in Women Who: Relapse into misuse in 30-day period prior to delivery Are not willing to engage in treatment program Have positive UDS for drugs of abuse at delivery Do not have confirmed plans for postpartum drug treatment Are taking psychiatric medications contraindicated to BF Are using methamphetamines, cocaine, LSD, Heroin, PCP due to the severe risk to the baby of these drugs There is some concern with the use of marijuana Recommendations continue to be updated about drugs/medications and the safety of BF

62 Consider and Coordinate Care Among Providers for Breast Feeding in Woman Who: Did not receive prenatal care/or substance abuse tx before delivery, but are committed to after Relapsed in the 90 days prior to delivery, but abstinence within 30 days prior to delivery With poly-substance prescription medications Engaged in later prenatal care/substance abuse tx during or after the second trimester Are not presently in a program but committed to go into a treatment program and demonstrate sobriety in the hospital (social service to assist with placement)

63 Of Note: While maternal prescriptions, opioid use and methadone/buprenorphine maintenance are thought by many to be safe for infants of some lactating women, the research literature is too sparse to make absolute statements. BF may be encouraged if the mother is in a treatment program and educated on the risks and benefits involved.

64 Medical Treatment for NAS

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66 Opioid/Unknown/Poly Morphine When pharmacologic treatment begins, patient will be started on scheduled dosing, no prns will be used Start morphine if Score of 24 Rule is met. Start course based on highest score in the last 24 hours. Initial Dose Score Frequency/Route: Every 3 hours PO mg/kg/dose mg/kg/dose mg/kg/dose > mg/kg/dose Morphine Dose Escalation If Score of 24 Rule is met after initiation, increase dose by 20%. Dose may continue to be increased by 20% every 12 hours (3 4 doses) if Score of 24 Rule is met. 66

67 Pharmacologic Treatment Allow infant to stabilize 24 hours on a dose that controls symptoms prior to initiation of weaning. If symptoms are not controlled on a total daily dose > 1 mg/kg/day, consider adding a second line medication (clonidine). 67

68 Outcomes

69 Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus Marylou Behnke, Vincent C. Smith, COMMITTEE ON SUBSTANCE ABUSE, COMMITTEE ON FETUS AND NEWBORN Pediatrics Mar 2013, 131 (3) e1009-e1024; DOI: /peds Limitations: Inability to separate socio-economic factors, polydrug usage, genetic factors Difficulties of studies: Inconclusive results, lack studies, length of studies needed Adapted from Dennis Cooley, MD FAAP Presentation

70 Discharge and Follow-up for babies who have exhibited signs and symptoms of NAS Neurodevelopmental assessments to identify motor deficits, cognitive delays, or relative microcephaly Psycho-behavioral assessments to identify hyperactivity, impulsivity, and attention-deficit in preschool-aged children, as well as school absence, school failure, and other behavioral problems in school-aged children Ophthalmologic assessment to identify nystagmus, strabismus, refractive errors, and other visual defects Growth and nutritional assessment to identify failure to thrive and short stature Family support assessments to exclude continuous maternal substance abuse and child abuse. Parents need to be educated about sudden infant deaths as well as complications due to perinatal infections. The complexity and challenging nature of the home atmosphere should never be underestimated in these situations. The importance of an optimal home environment for the global development of these children should be emphasized to all parents. Prabhakar Kocherlakota Pediatrics 2014;134:e547-e by American Academy of Pediatrics

71 Big Take Home Consistency of Care Control over Subutex Distribution Education regarding non-narcotic methods of pain relief Family centered, trauma informed programming (inpatient) for women prior to giving birth, continuing in post partum..beyond Need State s Help Use this magic window of time to Protect the Unborn child and change the trajectory of the entire family unit

72 NAS Team Thank You Questions? Betsy Knappen, MSN, APRN (NAS Program Coordinator) Dr. Betsy Wickstrom (Perinatologist) Danielle Renyer, LMSW (NICU Social Worker) Kim Mason, RN, BSN (Discharge Planner) Dr. Julie Weiner (Neonatologist) Carrie Miner, MSN, RN, CCRN (Nursing Program Coordinator/Clinical Specialist)