1. Neonatal Abstinence Syndrome EAT SLEEP AND CONSOLE METHOD Changing the way we look at the withdrawal process

2. The “Why”: Addiction Affects Us All
Addiction crosses all social, cultural, and economic barriers
440,000 babies are born in the United States every year with a dependency to at least one substance
Some states report as high as 1 out of every 13 babies being born addicted
As many as 15% of caregivers have addiction problems

3. WHY ARE WE CHANGING THE WAY WE SCORE OUR BABIES
● Looking at the research and processes being done by other institutions
● Using an evidence based approach to how we treat our patients with NAS
● Come up with a new protocol for NAS in the NICU
● Educate staff on how to use the Eat Sleep and Console tool correctly and consistently
● Use video example when education occurs
● Using a more family centered approach
● More involvement from the Cuddler Program

4. PROBLEMS WITH THE FINNEGAN NAS TOOL:
It wasn’t evidence based practice
Became a standard of care for 40+ years
Very subjective
Difficult to differentiate between normal newborn behavior and withdrawal symptoms
Quick to start morphine
Long treatment time/extended hospital stay
Does not encourage a family focus

5. EAT SLEEP CONSOLE FOCUS
Encourage parents to “room in” with baby so they can take an active part in comforting baby (meals will be provided even if not breastfeeding
Skin-to-skin contact by parents as much as possible.
Feed on Demand- don’t watch the clock. Encourage small frequent feedings
Calming Techniques-swaddle, pacifiers, shooshing and slow, rhythmic up and down movements
Quiet Room
Dimming light
Cluster care-use of the giraffe signage on door
Medication-changing our 2nd line drug to clonidine

6. EAT SLEEP CONSOLE FOCUS
Encouraging parents to be more involved with the infant’s care
Handbooks for parents using non-judgmental language
Extensive periods of kangaroo care
Breastfeeding (if mom in recovery) and accountability
Developing ways to improve our attitudes and perceptions
Goal is to help mothers feel less judged and in turn increase willingness in care participation

7. TOOLS FOR COMFORTING NAS INFANTS
● Toys-from child life
Mobiles-from Child life
Sound Machines-NAS cabinets-time limit is 30min. Turn off when baby sleeping
Swings-Mamaroo on the lowest speed that is effective
Swaddlers-In orange pod cabinets
Large gauze blankets- NAS cabinets
Soothing devices- vibrating pad or vibrating ring-NAS cabinets
Oral sucrose 24% on a nipple (>32 weeks and tolerating feeds), with prescriber order
The Tools located in the NAS cabinets are only for NAS babies. The cabinets are locked so you will need to ask CN/supervisor for key

8. EAT SLEEP CONSOLE SCORING TOOL
Neonatal Abstinence Syndrome - Eat Sleep Console Score Mode
EAT SLEEP CONSOLE SCORING TOOL

9. EAT SLEEP CONSOLE SCORING TOOL-PAGE 2

10. WHEN DO WE SCORE PER UNIT PROTOCOL
ASSESS
FREQUENCY
DOCUMENT
Eat Sleep Console Scores (ESC)
Start with every 3-4 hours or as ordered
If score is ≥ 3 for consoling support needed or a “YES” for any ESC item notify provider and a Parent/Caregiver Huddle is recommended. Continue to score in ordered intervals 
Effectiveness of pain management Interventions (non-pharmacologic and pharmacologic)
30 minutes after feeding or as ordered
We are in the final stage of getting updates put in powerchart

11. We will now evaluate the baby
EXAMPLE
Baby is admitted to the NICU from Maternal Newborn at 1420 for showing signs of NAS. Baby is 2 days old and is having difficulty feeding, tremors and is extremely fussy after being held, placed in swing and offered pacifier. Baby has a hyperactive root and takes about 5 min to get coordinated before sucking effectively. Baby is sleeping about 1 ½ hour spurts. Mom has a significant drug history in the last 7 years but started a treatment program once she found out she was pregnant and was prescribed Subutex. See is a smoker and has refused to quit at this time. Mom has spent the last 4 hours trying to comfort baby.
We will now evaluate the baby

12. DEFINITIONS Eating Poor eating due to NAS:
Baby unable to coordinate feeding within 10 minutes of showing hunger OR
Unable to sustain feeding for at least 10 minutes at breast or with 10 ml
by alternate feeding method ( or other age-appropriate duration/volume) due
to opioid withdrawal symptoms (e.g. fussiness, tremors, uncoordinated suck,
excessive rooting)
Special note:
Do not indicated Yes if poor eating is clearly due to non-opioid related factors (e.g. prematurity, transitional sleepiness or spottiness in first 24 hours, inability to latch due to infant/ maternal anatomical factors)

13. NO LETS START WITH EAT…… WHAT DO YOU THINK? YES OR NO? TIME 1430
EATING
Poor eating due to NAS?
Yes No
WHAT DO YOU THINK?
YES OR NO? NO

14. DEFINITIONS Sleeping Sleep < 1 hour due to NAS:
Baby unable to sleep for at least one hour after feeding due to opioid withdrawal symptoms (e.g. fussiness, restlessness, increased startle, tremors)
Special note:
Do not indicate Yes if sleep <1 hour is clearly due to non-opioid related factors (e.g. symptoms in first day likely due to nicotine or SSRI withdrawal, physiologic cluster feeding in first few days of life, interruptions in sleep routine for routine newborn testing)

15. NEXT LET’S LOOK AT SLEEPING
TIME
1430
EATING
Poor eating due to NAS? Yes/NO
Yes No
SLEEPING
Sleep< 1 hour due to NAS? Yes/No
What do you think ?
Yes or No? NO

16. DEFINITIONS Consoling Unable to console within 10 minutes due to NAS:
Baby unable to console within 10 minutes (due to
opioid withdrawal symptoms) despite infant
caregiver/provider effectively providing any/all of the
consoling support Interventions
Special note:
Do not indicate YES if infan’s inconsolability is clearly due to non- opioid related factors (e.g. caregiver non-responsiveness to infants hunger cues, circumcision pain)

17. DEFINITIONS Consoling – continued
Consoling Support Interventions (CSI’s)
1. Caregiver begins softly and slowly talking to infant, using voice to calm infant.
2. Caregiver looks for hand-to-mouth movements and facilitates by gently bringing infant’s hand to mouth.
3. Caregiver continues talking to infant and places caregiver’s hand firmly but gently on infant’s abdomen.
4. Caregiver continues softly talking to infant bringing baby’s arms and legs to the center of body.
5. Caregiver picks up infant, holds skin-to-skin or swaddled in blanket, and gently rocks or sways infant

18. DEFINITIONS Consoling continued
6. Caregiver offers a finger or pacifier for infant to suck, or a
feeding if infant showing hunger cues.
Special note:
Parent/caregiver should offer CSI’s to infant in manner that the feel is best at the time (e.g. feeding if infant showing hunger cues, picking baby up if crying). Providers should consider introducing CSI’s in the order above, to assess the level of support needed to console the infant over time.

19. Consoling support needed?
AND NOW CONSOLING
TIME
1430
EATING
Poor eating due to NAS? Yes/No
Yes No
Sleeping
Sleep < 1 hour due to NAS? Yes/No
Consoling
Unable to console within 10 min due to NAS? Yes/No
Consoling Support Needed
1: Able to console on own
2: Able to console with caregiver support within 10 min
3: Unable to console with caregiver support within 10 min
What do you think?
Consoling support needed?
Yes or No 3
Yes

20. CONSOLING SUPPORT NEEDED - 3
LET’S LOOK AT THE SCORE
TIME
1430
EATING
Poor eating due to NAS? Yes/No
Yes No
SLEEPING
Sleep < 1 hour due to NAS? Yes/No
CONSOLING
Unable to console within 10 min due to NAS?
Consoling Support Needed
1. Able to console on own
2. Able to console with caregiver support within 10 min
3. Unable to console with caregiver support within 10 min 3
CONSOLING SUPPORT NEEDED - 3
YES total - 1

21. PLAN OF CARE
If infant with Yes for any ESC item or 3 for Consoling Support Needed: Perform a Formal Parent/Caregiver Huddle to determine Non-Pharm Care Interventions to be optimized further and continue to monitor closely.
Formal Parent/Caregiver Huddle: RN bedside huddle with parent/caregiver to determine Non-Pharm Care Interventions to optimize (“Increase”) further.
If infant continues with Yes for any ESC item or 3 for Consoling Support Needed despite maximal non-pharm care: Perform a Full Care Team Huddle to determine if medication treatment is needed. Continue to follow infant closely, maximizing all Non-Pharm Care Interventions
Full Care Team Huddle: Bedside huddle with parent/caregiver, infant RN and physician or NNP
PLAN OF CARE
Recommend Formal Parent/ Caregiver Huddle?
Yes No
Recommend Full Care Team Huddle?
Management Decision
1. Continue/Optimize Non-pharm Care
2. Initiate Medication Treatment
3. Continue Medication Treatment
4. Other (please describe) 1

22. PARENTAL/CAREGIVER PESENCES
Parental/Caregiver Presence
No Parent Present hours
< 1 hour >3 hours
2 – hours
What number would you give? 4
We recommend documentation in powerchart of the presence of a parent (biological or foster) or other caregiver (e.g. family support person, cuddler) at the bedside when assessments are performed. Documentation should reflect parental/caregiver presence with the infant since the last ESC assessment

23. NON-PHARM CARE INTERVENTIONS
Rooming-in:
Increase Reinforce
Parent/caregiver presence:
Skin-to-skin contact:
Holding by caregiver/cuddler:
Safe swaddling:
Optimal feeding at early hunger cues:
Quiet, low light environment:
Non-nutritive sucking/pacifier:
Additional help/support in room:
Limiting # of visitors:
Clustering care:
Safe sleep/fall prevention:
Parent/caregiver self-care and rest:
Optional comments:

24. WHAT NEXT?
Continue to re-evaluate ESC score every 3-4 hours with cares
Remember you are evaluating the last 3-4 hours
Document the effectiveness of pain management Interventions (non- pharmacologic and pharmacologic) 30 min after feedings or as ordered.
Document educational materials
Explain rationale for drug withdrawal interventions
Instruct parent/family about signs and symptoms of withdrawal Instruct parents/family how to provide “comfort measures”
Instruct NICU parents that are staying at the bedside and participating in cares that they may order meals from dietary service at no charge

25. WHEN TO EXPECT SYMPTOMS
ONSET OF DRUG WITHDRAWAL SYMPTOMS
Alcohol: hours
Narcotics: hours (heroin, Methadone)
Barbiturates: 4-7 days (range 1-14 days)
Cocaine: hours

26. NURSING CARE
Assignment will be NAS baby + 1 additional patient-With having a lighter assignment this gives you more time to comfort infant
Encourage parents to comfort
If parents are not available, use Cuddler volunteers-in process of getting more coverage
Dedicated primary staff for NAS babies will be assigned whenever possible
No back up alarms set on patient monitor (use of central monitors at nursing station and ASCOM phone for alarms)

27. NURSING CARE Temporal thermometer for temperature assessment
BP once daily (24 hour period) unless otherwise indicated
Pulse ox check once daily (24 hour period) unless requiring oxygen support or otherwise indicated
Encourage parents to limit visitors, limit talking on the phone (ear buds provided for TV/Music) and talk softly when on the phone or with visitors
Temperature- with cares
Blood pressure- q 24 hours
Pulse ox check- q 24 hours

28. EAT SLEEP CONSOLE MEDICATION OF CHOICE
Changing our second medication of choice from phenobarbital to clonidine
Clonidine has less developmental side effects
Phenobarbital does not relieve gastrointestinal signs and symptoms of withdrawal

29. DEVELOPING NOW:
Sleeping giraffe signs will be placed on outside doors of rooms to signal staff that the infant is withdrawing
In the bubble the nurse can write when the next set of cares/assessment is due
This will encourage staff to return to see the infant at this time and provide the infant with extended periods of uninterrupted rest
Next Feed Due:
10:30

30. FUTURE PROJECT GOALS:
Working with Child Life to educate staff on infant massage techniques

31. FUTURE PROJECT GOALS:
Making a dedicated area in the unit for NAS infants
Likely rooms of yellow pod
Have a core group of nurses who volunteer to care for NAS infants
If you are interested in being in this core group, let Liz Chronister or Amy Lade know