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

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

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

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

5. 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

6. 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.

7. 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.

8. 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.

9. 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 Nov 20;

10. Assessment of Symptoms
Finnegan
Lipsitz
WAT-1

11. Finnegan Scoring Tool

12. Lipsitz Scoring Tool

14. 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.

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

16. Pharmacological strategies
Opioids
Morphine sulfate
Methadone
Buprenorphine
Other medications
Clonidine
Phenobarbital

17. 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

18. 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.

19. 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.

20. 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.)

21. 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.

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

23. 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

24. Questions now: Questions later:
Ask
Questions later:

25. Thank you. For additional information,
contact Sue Kannenberg at or
ext. 205