WisPQC Standardized Protocol Webinar for NAS/NOWS Initiative November 7, 2018 12:00-1:00 p.m. GoToWebinar®

Available Resources Neonatal Care Support Developmental Support Including Nutrition Developmental Support Pharmacological Support

Identification of Infants at Risk Maternal history Maternal screening Maternal biological testing Prescription Drug Monitoring Program (PDMP)

Identification of infants at risk Neonatal history Surgical procedure? Need for long-term sedation?

Non-pharmacological Management Strategies (begins with risk factors or symptoms) Unpacking the Non-Pharmacologic Bundle Rooming-in Optimal feeding at early hunger cues (breastfeeding & nutrition) Parent/caregiver presence Holding by caregiver/cuddlers Safe swaddling Quiet, low-light environment Non-nutritive sucking/pacifier Limiting visitors Clustering care Safe sleep/fall prevention

Importance of Non-Pharmacologic Bundle Recent literature supports that initial treatment options for NAS should primarily be supportive non-pharmacological measures. Edwards, L & Brown, L. (2016). Nonpharmacological management of NAS: An integrative review. Neonatal Network, 35(5), 305‐313. Grossman, M., Seashore, C. & Holmes, A. (2017). Neonatal opioid withdrawal management: A review of recent evidence. Review of Recent Clinical Trials, 12(4), 226‐232 AAP states: “Non-pharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after non-pharmacological measures or if the infant develops severe withdrawal.” Non-pharmacologic supportive measures that include minimizing environmental stimuli, promoting adequate rest and sleep, and providing sufficient caloric intake to establish weight gain should constitute the initial approach to therapy” ALL INFANTS can and should be comforted with dim lights, a quiet room, minimal stimulation, and other techniques such as swaddling and skin-to-skin that provide a comfortable environment. Create a culture of compassion, understanding, and healing for the mother infant dyad affected by the problem of NAS.

Eat, Sleep, Console (ESC) Developed by Boston University School of Medicine and used first at Children’s Hospital at Dartmouth-Hitchcock (CHaD) and Yale. 1st edition of manual published in 2017.

Breastfeeding / Breast Milk Breastfeeding and the provision of expressed human milk should be encouraged if not contraindicated for other reasons. Currently, there are no universally accepted policies addressing breastfeeding/use of breast milk for women who test positive for illicit substances.

Rooming-in Advantageous and encouraged, especially with single-patient rooms More difficult to accommodate for NICUs without single-patient rooms, but could get creative to encourage rooming-in (i.e., one single-patient room for use near to patient discharge) Encourages bonding of infant and family; is comforting to infant McKnight S. Coo H, Davies G, Holmes B, Newman A, Newton L, et al. Rooming-in for Infants at Risk of Neonatal Abstinence Syndrome. Am J Perinatol. 2015 Nov 20;

Assessment of Symptoms Finnegan Lipsitz WAT-1

Finnegan Scoring Tool

Lipsitz Scoring Tool

Withdrawal Assessment Tool – Version 1 (WAT-1) An assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Looks for presence of 19 withdrawal symptoms. Rates the patient’s overall withdrawal intensity using a numeric rating scale where 0 indicates no withdrawal and 10 indicates the worst possible withdrawal.

Pharmacological Strategies What is a standardized medication protocol? Indication for initiating medication Guidelines for adjusting dose Guidelines for weaning and discontinuing medication Examples

Pharmacological strategies Opioids Morphine sulfate Methadone Buprenorphine Other medications Clonidine Phenobarbital

Infant Discharge from the Hospital Feedings Medications Resource Information Parent Survey of care rendered Follow-up Pediatric care Home Care Social Services Therapy(ies) Developmental follow-up

Feedings Breast milk or formula Keep in mind dose of MAT and effect on infant; encourage slow tapering from breast milk to formula if mom desires to discontinue providing breast milk. If formula, consider what formula will be used at home and begin to transition to home formula if different from hospital formula.

Medications Will the infant be discharged on morphine, methadone, clonidine and/or phenobarbital? Consider family situation prior to discharge on medication. If medications are ordered, Assist in making sure prescriptions are filled prior to discharge or can be obtained without delay; Assure family is comfortable measuring and administering medications.

Information (NAS and Resources) Have a folder of written materials for families. Consider making available prior to discharge to allow for review and asking questions prior to discharge. Include name and phone number for connection to hospital unit discharged from, pediatrician, community hotline numbers, community support groups (i.e. public health, church groups, etc.)

Parent Survey of Care Rendered Learning from families about the care experienced is important. Take time to learn from the families you serve. Use a written or electronic survey. Ask families to complete the survey near the time of infant discharge.

Follow-up Pediatric Care Developmental Follow-up Therapy(ies) Hospital follow-through clinics School/early childhood intervention Therapy(ies) Occupational Physical Speech

Upcoming Webinar Meetings Invite your team of opioid project champions to gather together Weekday Date Time Topic Tuesday Nov 13 12:00– 1:00 pm Data Collection & Reports Nov 27 Change Package Thursday Dec 6 Eat, Sleep, Console Wednesday Dec 12 Learning Collaborative Sessions: Schedule & Format Nursing

Questions now: Questions later: Ask Questions later: kannenberg@perinatalweb.org

Thank you. For additional information, contact Sue Kannenberg at kannenberg@perinatalweb.org or 608-285-5858 ext. 205