1. ©2013 Children's Mercy. All Rights Reserved. 09/13 The Drug Exposed Neonate; Now What? Neonatal Abstinence Syndrome (NAS) Betsy Knappen APRN, BSN, Jodi Jackson MD

2. ©2013 Children's Mercy. All Rights Reserved. 09/13 NAS Protocol Nursing Education Competencies to Monitor Education Parent Education Pharmacological Interventions Ongoing Community Support Breast Feeding Policy

3. ©2013 Children's Mercy. All Rights Reserved. 09/13 3 Is NAS a Real Problem?   Over the last decade, there has been increasing public health, medical, and political attention paid to the parallel rise in two trends – –Increase in the prevalence of prescription opioid abuse – –Increase in the incidence of neonatal abstinence syndrome (NAS)   Increase in the prevalence of NAS – –1.20 per 1,000 U.S. hospital births in 2000 – –3.39 per 1,000 U.S. hospital births in 2009

4. ©2013 Children's Mercy. All Rights Reserved. 09/13 Finnegan Scale Are you familiar with the scale? A.Yes B.No

5. ©2013 Children's Mercy. All Rights Reserved. 09/13 Finnegan Scale What is your comfort level with using the scale? 1.Not at all 2.Somewhat 3.Neutral 4.Comfortable 5.Very Comfortable

6. ©2013 Children's Mercy. All Rights Reserved. 09/13 Percentage of Mother-Baby Nurses Reporting Discomfort with Elements of NAS Scoring Before and After Education

7. ©2013 Children's Mercy. All Rights Reserved. 09/13 7 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

8. ©2013 Children's Mercy. All Rights Reserved. 09/13 8 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

9. ©2013 Children's Mercy. All Rights Reserved. 09/13 9 Finnegan Metabolic/Vasomotor/Resp   No Disturbance 0   Sweating 1   Fever less than 101° F (99-100.8, 37.2-38.2 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

10. ©2013 Children's Mercy. All Rights Reserved. 09/13 10 ©2013 Children's Mercy. All Rights Reserved. 09/13 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)

11. ©2013 Children's Mercy. All Rights Reserved. 09/13 Which is the First Line Treatment for NAS? A.Morphine B.Phenobarb C.Fentanyl D.Low Lights E.Skin to Skin Holding F.Swaddling

12. ©2013 Children's Mercy. All Rights Reserved. 09/13 12 ©2013 Children's Mercy. All Rights Reserved. 09/13 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)

13. ©2013 Children's Mercy. All Rights Reserved. 09/13 13 ©2013 Children's Mercy. All Rights Reserved. 09/13 When to use Pharmacologic Treatment   The Rule of 24: – –When 2-3 consecutive scores = 24   3 Consecutive scores of 8-11   2 Consecutive scores 12 or higher

14. ©2013 Children's Mercy. All Rights Reserved. 09/13

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16. ©2013 Children's Mercy. All Rights Reserved. 09/13 16 ©2013 Children's Mercy. All Rights Reserved. 09/13 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). 16

17. ©2013 Children's Mercy. All Rights Reserved. 09/13 If patient requires more than 1 mg/kg/day of morphine, add second line medication After starting second line medication, allow infant to stabilize for 24 hours. If Score of 24 Rule is met, continue to gradually increase morphine dose as outlined in titration schedule. Second Line Medication

18. ©2013 Children's Mercy. All Rights Reserved. 09/13 18 ©2013 Children's Mercy. All Rights Reserved. 09/13 Weaning Pharmacologic Treatment   “Stable NAS score” is defined as all NAS scores < 8 in the preceding 24 hours   Allow 24-48 hours between medication weans   After discontinuing tx continue NAS scoring   Discharge infant when scores < 8 for at least 48 hours 18

19. ©2013 Children's Mercy. All Rights Reserved. 09/13 19 ©2013 Children's Mercy. All Rights Reserved. 09/13 This part of the wean has been most difficult, it is still being revised

20. ©2013 Children's Mercy. All Rights Reserved. 09/13 Betsy Knappen APRN, BSN, Kim Mason RN, BSN, Andrea Vance RN, BSN, Jodi Jackson MD Improving Care of the Infant at Risk for Neonatal Abstinence Syndrome through a Standardized Family Centered Protocol and Nursing Education

21. ©2013 Children's Mercy. All Rights Reserved. 09/13 21 ©2013 Children's Mercy. All Rights Reserved. 09/13 METHOD   Oct 1, 2013: NAS Protocol Trialed – –Mandatory NICU admit for high risk infant stopped – –Infants admitted to Mother-Baby unit – –NAS scoring per NICU RN   Dec 1, 2013: Mother-Baby education completed – –Infants scored and cared by Mother-Baby RN – –Transferred to NICU when Tx needed   Jan, 2014: Joined the iNICQ Collaborative – –PDSA QI process utilized for ongoing projects – –Begun standardized education program for NICU nurses – –NAS Scoring competency/reliability for NICU/Mother-Baby

22. ©2013 Children's Mercy. All Rights Reserved. 09/13 22 ©2013 Children's Mercy. All Rights Reserved. 09/13 MEASURES   Outcome Measure: – –Infants at risk for NAS avoiding NICU admit and Tx   Initial: month blocks pre/post protocol for NICU admission/ Tx   Ongoing: Quarterly review admission/ Tx ; run chart   Process Measures: – –Nurses attending education, impact on competency/comfort   Initial: comfort with NAS; Likert scale self report before/after   Ongoing: measure of reliably with competency evaluation   Validation of all scores > 8 by second observer

23. ©2013 Children's Mercy. All Rights Reserved. 09/13 Location of Care During Hospitalization Infants Requiring Pharmacological Treatment

24. ©2013 Children's Mercy. All Rights Reserved. 09/13 24

25. ©2013 Children's Mercy. All Rights Reserved. 09/13 25 ©2013 Children's Mercy. All Rights Reserved. 09/13 NAS scoring indicated after delivery   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)

26. ©2013 Children's Mercy. All Rights Reserved. 09/13 26 ©2013 Children's Mercy. All Rights Reserved. 09/13 NAS scoring not indicated after delivery (warrants close observation)   CNS depressant: – –Alcohol, Marijuana, K2   Hallucinogens: – –Cocaine, LSD, Methamphetamines, PCP, Phenylisopropylamines (Esctasy)   SSRI: – –Celexa, Lexapro, Prozac, Paxil, Zoloft, Luvox   SSRI/Norepiphrine Reuptake Inhibitor: – –Cymbalta   Mood Stabilizer: – –Lithium, Lamictal ?   Antipsychotics: – –Seroquel, Abilify, Latuda, Risperdal, Invega, Zyprexa, Geodon, Saphris, Fanapt, Haldol   Anxiety: – –Vistaril, Buspar

27. Kim Mason RN, BSN; Betsy Knappen, APRN, BSN; Dawn Caspers, BS Pharm, Jodi Jackson, MD Standardized Approach to Educating Families at Risk for Neonatal Abstinence Syndrome

28. ©2013 Children's Mercy. All Rights Reserved. 09/13 28 ©2013 Children's Mercy. All Rights Reserved. 09/13 Measures   Outcome Measure – – Number of families at-risk for NAS who were provided education and material prior to admission   Secondary outcome: – –Number of families at-risk for NAS who are provided education and material after admission, but prior to giving birth, or after delivery (but within 24 hours)   Process Measures – –Completion of consult checklist   Balancing Measures – – Number of “urgent” unscheduled consultations required

29. ©2013 Children's Mercy. All Rights Reserved. 09/13

30. 30 ©2013 Children's Mercy. All Rights Reserved. 09/13 Lessons Learned   A key barrier in disseminating information to families prior to delivery is identification of at-risk families. – –Need for improved identification of at-risk patients – – Communication with primary care doctors regarding institutional program – –Improved collaboration with community programs – –Need to develop a mechanism to measure and quantify – –Parent-reported satisfaction with the process

31. ©2013 Children's Mercy. All Rights Reserved. 09/13 31 ©2013 Children's Mercy. All Rights Reserved. 09/13 Breast Feeding Policy   Circumstance to encourage, discourage and equivocal   The encouragement and support of BF depends on: – –Maternal drug use – –Maternal alcohol use – –Substance abuse treatment history – –Any medical and psychiatric issues – –Any medication needs – –Infants health status, in utero or post-partum – –The presence or absence and adequacy of maternal family and community support, post-partum follow up, treatment for substance abuse as needed (Academy of Breastfeeding Medicine (ABM) Clinical Protocol #21)

32. ©2013 Children's Mercy. All Rights Reserved. 09/13 CMH SCC Our Next Initiative

33. ©2013 Children's Mercy. All Rights Reserved. 09/13 33 ©2013 Children's Mercy. All Rights Reserved. 09/13 Thank You for Your Attention Questions?