5/10/2018

An Introduction to Substance Exposed Mothers and Maridee Shogren DNP, CNM Region 8: Mountain Plains ATTC

 ATTC serves the United States through 10 regional offices and the Ukraine, Southeast Asia, Africa and Vietnam The  Funded by U.S. Department of Health and Human Service (DHHS) and Service Administration Technology (SAMHSA)  Region 8: Transfer Center  Housed at UND‐NPCBR‐suite 220  Partners with University of Nevada‐Reno’s Center for the Network: Application of Substance Abuse Technologies (CASAT) Region 8:  Serves six states: CO, ND, MT, SD, WY, UT  Especially responsive to rural needs Mountain Plains  People in MT (53%) ND (40%) SD (35%) and WY (57%) live at least 60 minutes from a city with at least 50,000 ATTC people (US Census data)

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 Utilizes an array of technology strategies to accelerate diffusion of innovations regarding substance abuse treatment and recovery.  Prepares addiction treatment providers and pre‐professionals to use evidence based practices in their current and future practice.  Accelerate the adoption and implementation of promising addiction treatment and recovery‐oriented practices and services—offers training and technical assistance for providers using technology.  Heighten the awareness, knowledge, and skills of the workforce to Goals of the address the needs of people with substance use or other behavioral ATTC health disorders.  Fosters regional and national alliances among culturally diverse practitioners, researchers, policy makers, funders, and the recovery community.  Improve treatment and recovery services in the region for people with addictive behaviors.  Advances culturally and linguistically competent services.

 At the end of the presentation  Participants will identify at least three potential consequences of maternal substance use disorder.  Participants will identify at least five common symptoms of Objectives Neonatal Syndrome  Participants will identify at least three non‐pharmacological interventions for Neonatal Abstinence Syndrome  Participants will recognize the need for a multidisciplinary approach to caring for substance exposed mothers and infants.

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is a relatively short, but important, period of time in a woman’s life:  40 weeks…10 lunar months…9 calendar months  ~50% of in US are unintended  Rate is 2‐3 times higher among women with substance problems Pregnancy and (Terplan, 2015)  Women are at highest risk for developing a Substance Use Substance Use Disorder (SUD) during reproductive years  Fair to say that polysubstance use is common  Still much stigma attached to substance use in pregnancy  May be less likely to seek care OR may be more willing to seek/complete treatment  Pregnancy may interrupt the pattern of substance use

 Substance use does still occur during pregnancy  Tobacco: most common: 15.9% continue to smoke  Alcohol: 8.5‐12% continue to drink  Illicit drugs: 8.5% continue to use Pregnancy and  1‐2% use opiates, may be as high as 21% (Ettlinger, 2016)  Nationally estimated that Substance Use  225,000‐380,000 babies born each year with prenatal drug exposure  550,000 are exposed to alcohol  Over 1 million are exposed to tobacco in utero (Forray, 2015, Ettlinger, 2016)

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 HOWEVER…. Many women with preconception risky or problem use ARE able to abstain temporarily during pregnancy and will quit or reduce after pregnancy is confirmed  Percent of women who abstain: Pregnancy and  96% abstain from Alcohol Substance Use  78% abstain from Cannabis  73% abstain from Cocaine  32% abstain from Tobacco  If they continue in pregnancy, they typically don’t understand the potential harm or CANNOT stop using on own (Klie, 2017)

As a Result… postpartum relapse is another issue!

Pregnancy and Substance Use

Slide courtesy of Dr. Larry Burd, SMHS

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 ALL women should be UNIVERSALLY screened for licit and illicit substance use in pregnancy  Selective screening misses most with problematic use Prenatal  Early identification is a must  Common co‐occurring conditions with substance use: mental health, Screening DV, legal issues, social services  Remember that the increase in co‐occurring conditions = increased risk for negative outcomes

 Patient history/self‐report (universal)  Preferred for initial screening  Maternal specimen testing (may be biased, not universal)  Urine most common for ease but is not gold standard ; a negative test does not rule out sporadic use (ACOG, 2017) Prenatal  Only detects recent use (past several days)  May not detect synthetic opioids, some benzodiazepines Screening  THC‐ excreted and testable for up to 10 days in maternal urine if mom is regular user, up to 30 days if chronic, heavy user  Alcohol, nicotine, opiates, cocaine and amphetamines (Behnke, 2013)  Hair  Drugs trap in hair, may reflect longer period of time  Nicotine, opiates, cocaine, amphetamines

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 Continued observation/screening during pregnancy a must…  Screen in first trimester and at least every trimester for women who screen positive OR  Screen at first and every prenatal visit Prenatal  DON’T forget postpartum! (ACOG, 2017; Forray et al, 2015; WHO, 2014) Screening  ALSO…Concurrent infectious disease screening, psychosocial assessment, contraception needs post‐pregnancy (NIDA, 2012)

 No single best screening tool for self‐report or as part of patient interview. Many options!  Alcohol:  NIAAA Single Question  AUDIT  AUDIT‐C Screening  T‐ACE  TWEAK Tools in  MAST Pregnancy  Both Alcohol and other substances  DAST  4Ps Plus  CRAFFT/CRAFFT 2.0 (pregnant adolescents)  CAGE‐AID  SBIRT model encouraged: Screening, Brief Intervention, Referral to Treatment

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 Substance use in pregnancy connected to many complications/negative health outcomes for mom/baby dyad Consequences  Indirectly linked to of Substance  Lack of nutrition (mom and fetus/)  Domestic violence (mom and fetus/infant) Use in  Increased risk of mental illness/infection Pregnancy  Any substance has potential to cross over to the fetus

Maternal / fetal transfer of licit/illicit drugs BBB

Google images, 2017

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 Generally, substances can be teratogenic in: Maternal /  Embryonic Stage and/or Fetal Transfer  Fetal Period  Impact abnormal growth, alteration in of Licit and neurotransmitters/receptors, brain organization Illicit Drugs placental insufficiency

National Organization on Fetal Alcohol Syndrome (NOFAS). (Coles, 1994) (2004; adapted from Moore, 1993).

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 Absorption  Alcohol enters stomach where absorption and metabolism occur rapidly  Blood ethanol concentrations peak in ~1hour  **Women attain consistently greater blood ethanol levels than men with equal consumption  Distribution and Placental effects Alcohol  Alcohol readily passes into fetal blood  Once in fetal blood, alcohol reaches concentrations similar to mom  Embryo has limited ability to metabolize alcohol, mostly because liver is immature and lacks enzymes to do so, alcohol passed back to mom for metabolism  This takes time! Alcohol levels may remain higher in embryo for longer periods of time which increases risk of exposure (Behnke, 2013, Brimacombe et al, 2009)

 No area of the brain is resistant to the effects of fetal alcohol exposure  Alcohol can cause thinning or absence of the corpus callosum leading to deficits in attention, intellectual function, reading, learning, verbal memory, and executive and psychosocial Neuromorphol functioning. ogical Birth  Preterm delivery  Craniofacial abnormalities Defects  Impaired motor development  Growth deficiencies (Behnke, 2013; Brimacombe, 2009; Brown, 2016)

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Mattson, S.N. et al. 1994; Brimacombe, 2009

Non-alcohol effected vs. Profoundly Alcohol-effected Brain

Brimacombe, 2009 (Clarren , 1994)

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Cigarette Smoking: Tobacco / Nicotine

Retrieved from: http://sites.psu.edu/krfaustnutr/2015/10/28/smoking‐pregnancy‐psa/

 Fetus exposed to over 4000 compounds through cigarette smoking  ~ 30 compounds linked to adverse outcomes  Nicotine  Concentration higher in placenta, amniotic fluid, fetal blood than in maternal serum Cigarette  May cause alterations in brain metabolism and abnormal brain development Smoking:  Believed to cause hypoxia Tobacco /  LBW, IUGR, prematurity  Increased risk of SIDS Nicotine  Potential for placental abruption  Weakly associated with oral clefts  1.8‐2.8x greater risk of stillbirth  Passive exposure‐2.1x greater risk of stillbirth  No particular syndrome noted (Behnke, 2013, NIDA, 2016)

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 Interesting fact: Among women using BOTH Alcohol and Nicotine in the pregnancy  20.4% also used Marijuana  9.5% also used Cocaine  Women NOT using Alcohol or Nicotine FYI  0.2% used Marijuana  0.1% used Cocaine

 Alcohol and Nicotine CO‐USE is a marker for other drug use. (Burd, 2017)

Cannabis

https://www.google.com/search?q=photo+image+marijuana&tbm=isch&tbo=u&source=univ&sa=X&ved=0ahUKEwiLmffIjf3VAhUp5IMKHV_bAyMQsAQILg&biw=1920&bih=924#i mgdii=SS0oE8TPbBHI4M:&imgrc=8qcNmFE4OuWV4M:

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Cannabis

7.5% of pregnant women 18‐25y use cannabis, 4% in all pregnant women (Forray, 2015; Grant et al, 2017; Klie, 2017)

 Expectant mothers might use for  N/V of pregnancy  Weight gain (increase appetite)  //Anxiety  General discomforts of pregnancy  Fun Cannabis   Marijuana use in pregnancy associated with  Increased risk of dysfunctional labor  Precipitous labor  Meconium stained amniotic fluid (Grant, 2017; Klie,2017)  Legalization continually opening up new issues  Many think of cannabis use in pregnancy as “medical marijuana”

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 THC is main chemical compound  Readily crosses placenta / BBB rapidly  May alter fetal oxygenation: Produces 5x amount of carbon monoxide (when smoked)  Fetal exposure may vary via oral consumption, smoking Cannabis or IV  May be up to 3x increase in fetal concentration when inhaled and IV (Foeller, 2017)  Chronic exposure vs episodic may be different as well as potency of the product

 Can stay in system up to 30 days and cause prolonged fetal exposure/altered brain biochemistry  Long term exposure may be linked to inattention, , cognition  No clear physical teratogenic effects BUT  Lower  2.3x greater risk of stillbirth Cannabis  Not specific to Neonatal Abstinence Syndrome BUT  Increased startles and tremors have been noted in newborns  Poor feeding  Weight loss  Hypotonia  Possible sleep disturbances

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 Cocaine:  Easily crosses placenta and BBB  Decreases placental blood flow  Affects areas of brain that regulate attention and executive functioning:  Arousal  Subtle attentional deficits  Memory Cocaine  Impulsivity  May damage nervous system and cause altered response to environmental or pharmacologic challenges later in life  Preterm delivery  IUGR  Placental abruption  No physical abnormalities to date (Brown, 2017; Forray, 2015)

 MA only illegal drug that can be easily made from legally obtained ingredients  Smoked, snorted, injected, oral or anal Methampheta  Smoking/injecting=few minute rush  Snorting (in 3‐5 mins) or oral (15‐20 mins)=euphoria mines (MA)  All methods lead to increased wakefulness and energy, decreased appetite  MA seems to have been overshadowed by Opioid Epidemic, but…

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Primary Stimulant Rates, by State/Jurisdiction 2004 ‐2014

METH/AMPH

19 SOURCE: SAMHSA, Treatment Episode Data Set, 2014 results.

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:  Stimulate CNS  Increases pleasure experience by blocking reuptake of dopamine  Potential maternal complications: Methampheta  Heart arrhythmias  HTN (includes higher risk of preeclampsia) mines  Seizures  Hyperthermia

 Chronic use can lead to:  Anxiety  Insomnia  Women more likely to experience related to withdrawal  Confusion / Memory loss  Weight loss  Dental problems “Meth mouth” Methampheta  Higher rate of problems in women mines  Depression  Violent behavior  Hepatitis  STI risk higher in women using amphetamine type stimulants  Hypersexuality physiological effect occurs  Psychotic symptoms may persist months or years after stopping and may recur  , hallucinations,

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 Readily passes through placenta and BBB  May increase fetal blood pressure and decrease oxygenation  *In addition to typical poor maternal nutrition, increased BP leads to vasoconstriction and restriction of nutrients/oxygen to fetus  IUGR, LBW, SGA, decreased head circumference and length  Possible structural abnormalities but likely multifactorial  Preterm delivery (3.5 x increased risk) Methampheta  PTL mine use in  Placental abruption  IUFD Pregnancy  Limited knowledge/studies  *Amphetamines used for ADHD treatment: no known effects to date (Behnke, 2013)  Stopping MA at any time during pregnancy improves birth outcomes

 MA exposed newborns do not exhibit NAS requiring Newborn pharmacological intervention  Disorganized state, poor movement, increased CNS stress have Effects been observed  Typically resolved in 1 month of birth

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 Abnormal behavioral and cognitive function in children up to 7.5 years Childhood  Increased anxiety, emotional problems, aggressive behaviors, Effects inhibitory control / ADHD symptoms  The postnatal environment is a critical factor for attenuating ‐induced changes in neural function (SMITH, 2015)

Opioids

Image Retrieved from http://www.healthline.com/health‐news/opioids‐problems‐for‐chronic‐pain‐patients

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 In 2013‐2014:  98,000 women (up 5.4% from 2011‐2012) reported past month non‐medical use of psychotherapeutics (oxycodone type)  109,000 women (up 31% form 2011‐2012) reported past month heroin use (Klaman et al, 2017)  75% of opioid dependent women also smoked tobacco (Krans, 2015) Opioid Use  Basic definition of OUD: Pattern of opioid use characterized by tolerance, craving, inability to control use and continued use Disorder despite adverse consequences (ACOG, 2017) (DSM‐5 replaced opioid abuse and opioid  Opioids include: dependence with OUD)  Morphine  Hydrocodone  Oxycodone  Heroin  Fentanyl  Codeine

 Diminish intensity of pain signals  Cause a sense of euphoria  Can cause respiratory depression, overdose, death, cellulitis/infection at injection site, Hepatitis B/C, HIV and dependence  Heroin withdrawal symptoms:  Occur within 4‐6 hours, peak at 1‐3 days  Long‐acting opioid withdrawal symptoms:  Occur within 24‐36 hours and may last several weeks (ACOG, 2017) Maternal  Use in pregnancy:  6x more risk for OB complications Effects  3rd trimester bleeding, placental abruption, PTL, intrauterine passage of meconium  Related to lack of prenatal care, engagement in high‐risk activities, exposure to STDs, violence, legal consequences  Co‐Occurring conditions:  Depression (30%)/Post Partum Depression(40%)  History of trauma  Stress disorder/anxiety  Other substance use/abuse

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 Opiates  Rapidly cross placenta  Drug equilibration between mom and fetus  Decrease brain growth and cell development in animals  Linked to cognitive impairment and academic underachievement (verbal, arithmetic, reading abilities) Fetal Effects  May be connected to overall growth defects  LBW, IUGR  Fetal distress  No clear physical anomalies (Brown, 2017; Ettlinger, 2016)  Complications primarily related to withdrawal  *Neonatal Abstinence Syndrome

SUD/OUD  Several Barriers to Treatment exist:  Stigma Treatment  Lack of access to gender‐specific care  Limited child‐care availability at treatment facilities During  Few providers with OB AND addiction treatment expertise Pregnancy  Fear of criminal or child welfare consequences

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 MAT linked to prevention of opioid withdrawal symptoms, may reduce relapse risk, improve adherence to prenatal care and reduce risk of OB complications  MAT is the standard of care for OUD: This should NOT be altered Medication by pregnancy! Assisted  Goals: Treatment  Manage / prevent withdrawal  Reduce cravings During  Provide opioid blockade (prevent euphoria from illicit use)  Increase adherence to prenatal care Pregnancy  Improve maternal nutrition  Improve infant birth weight

 Methadone  Dispensed daily (may be an access barrier) through registered opioid Medication treatment programs  Buprenorphine Assisted  Approved for treatment of OUD by Rx in an office‐based setting Treatment  Linked to fewer drug interactions than methadone  POSSIBLY less severe NAS, shorter hospital stay During  89% less morphine needed to treat NAS  43% shorter hospital stay Pregnancy  58% shorter duration of NAS treatment (2010 RTC) (Saia et al, 2016)

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 Pregnant women with OUD have noted tolerance and opioid‐ induced hyperalgesia (hypersensitivity to pain) Intrapartum  A birth plan SHOULD be discussed prior to labor onset care  Those on MAT may require higher doses of opioids to achieve pain relief OR use other options:  Spinal or epidural anesthesia suggested  NSAIDs

 Mothers will still need help with pain control during recovery

 PP is CRITICAL time for follow up and observation (Ettlinger, 2016)  Increased vulnerabilities:  Loss of insurance and access to treatment Postpartum  Newborn demands  Sleep deprivation  Threat of loss of child custody  Large potential for relapse

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 Screening for PPD should be routine!  Edinburgh Postnatal Depression Scale (EPDS)  The 10‐question EPDS is a valuable and efficient way of identifying Postpartum patients at risk for “perinatal” depression.  EPDS is easy to administer and has proven to be an effective Depression screening tool.  https://pesnc.org/wp‐content/uploads/EPDS.pdf

Symptoms of PPD Symptoms of Substance Use

 Depressed mood or severe mood swings.  Problems at school or work — frequently missing school or work,  Excessive crying. a sudden disinterest  Difficulty bonding with your baby.  Physical health issues —lack of energy and motivation PPD vs SUD  Withdrawing from family and friends.  Neglected appearance —lack of interest in clothing, grooming or …or is she just  Loss of appetite or eating much looks more than usual.  Changes in behavior TIRED?  Insomnia or sleeping too much.  Red eyes  Overwhelming fatigue or loss of energy  Increased appetite or weight loss  Slowed thinking  Decreased mental sharpness/ drowsiness  Neglected appearance  Insomnia  Physical aches/pains

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 All substances have potential to pass into breastmilk  is NOT contraindicated with moderate alcohol use or with smoking  Breastfeeding while using cannabis, cocaine, methamphetamines, opioids IS contraindicated  HOWEVER…Breastfeeding on MAT can be encouraged IF Breastfeeding  Mom is stable on MAT  Methadone / buprenorphine found in low concentrations in breastmilk  Is not using illicit drugs (also need to discuss current alcohol use)  Has no other contraindications  Is NOT HIV+

 Breastfeeding on MAT may  Decrease severity of NAS  Lessen need for pharmacotherapy for infant  Shorten hospital stay for infant  Contribute to maternal/infant attachment  Enhances maternal confidence and encourages active maternal participation in the management of the infant  Facilitate skin‐to‐skin contact Breastfeeding  Reinforces sobriety  Breastfeeding DOES provide immunity to infant (Forray, 2016)  One last word about skin to skin….not just for breastfeeding moms  Skin to skin contact with any feeding and snuggling WILL promote bonding AND is great for newborn development!

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 Need to discuss contraception (ACOG, 2017; Ettlinger, 2016)!  Unintended pregnancy rate among women with SUD is ~80% Postpartum  No evidence of medication interactions between Contraception contraceptives and methadone or buprenorphine  Consider Long Acting Reversible Contraception …just a little  IMMEDIATLEY PP soapbox

 Please remember……  SUD impacts the mother/infant DYAD  Healthcare professionals are humans too and need to ask ourselves:  How do I feel toward a baby in withdrawal?  How do I feel toward the substance dependent mother of that baby?  Is it easier to feel empathy for the baby than the mother? The Neonatal  Is the substance dependent mother a key component of infant treatment and recovery? Impact  If I also consider and address the emotional needs of the mother, can I help her better attend to her infant’s emotional needs?  “The way a mother experiencing Perinatal Substance Use Disorder is treated and her view of herself as being a capable (or incapable) mom will impact how her relationship and attachment with her baby develops.” (MAIMH, 2017)  One last thing……SUD impact on neonates is NOT new!

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FIGURE 1(Kocherlakota, 2014) Time line of NAS. FDA, Food and Drug Administration.

 Neonatal Abstinence Syndrome (NAS) (Klaman et al, 2017)  Broad non‐specific term assigned to withdrawal presentation in NB  One NAS affected infant born every 25 minutes in US in 2012! (Ko, 2016)  Increased 383% nationally during 2000‐2012  120 babies born in ND, 2013 with NAS (ND Task Force on Substance Exposed Newborns, 2016)  Infants are typically exposed to multiple substances (Klaman, 2017) Neonatal  NAS may be secondary to morphine, heroin, methadone, buprenorphine, prescription opioids, antidepressants, Abstinence anxiolytics…(Kocherlakota, 2014) Syndrome  Not clearly related to “dose”  Affects about 45‐94% of infants exposed in utero(ACOG, 2017;Forray, 2016)  Rarely fatal (Kocherlakota, 2014)  This is an EXPECTED and TREATABLE condition due to prenatal opioid exposure

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 Identifiable signs and symptoms typically occur 48‐72 hours post‐ birth (may be up to 96 hours)*  Present as constellation of neurologic, GI, musculoskeletal disturbances  Highly variable and severe NAS  Neonatal withdrawal is more complex than adult secondary to Symptoms immature neurological development  50‐80% of NAS infants will require pharmacologic intervention  Average length of hospital stay NAS: Risen from 13 days in 2004 to 19 days in 2013 (Raffaeli et al, 2017)  May be up to 23 days+ if pharmacologic treatment is required

Substance Specific Withdrawal

Kocherlakota, 2014

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 Autonomic and central nervous system disturbances  Yawning  Sneezing  Irritability  Excessive cry/High‐pitched cry  Poor/erratic sleep  Uncoordinated sucking reflexes>poor feeding  Fever  Rapid breathing NAS  Increased heart rate  Seizures Symptoms  Sweating/Temperature instability  Startle  Tremors / trembling  GI disturbances  Diarrhea  Poor feeding / Slow weight gain  Vomiting  Blotchy skin coloring

 Finnegan Neonatal Abstinence Scoring Tool  Used for opioid and nonopioid withdrawal assessment  Started within 24 hours of birth and performed every 3‐4 hours  Quantifies the level of neurologic excitability, GI dysfunction, autonomic/respiratory dysregulation  Toxicological confirmation needed to identify substance(s) Newborn  Urine Screen Analysis (maternal/neonatal)  Only accounts for recent consumption Assessment of  Alcohol cleared within 16 hours Withdrawal  Opiates/benzodiazepines detected up to 3rd day of life  Cocaine variable (days to weeks)  Meconium Screen Analysis may identify a chronic fetal drug exposure (from 20 weeks of gestational age)  Most common, preferred approach as more sensitive than urine  Easier to detect natural opioids than semisynthetic or synthetic opioid drugs (Kocherlakota, 2014; Raffaeli et al, 2017)

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 Non‐pharmacologic approach is INITIAL treatment option for NAS  Environmental measures  Quiet, low lights  Avoidance of waking sleeping infants Newborn  Free from external excitatory stimulus Assessment of  Gentle handling  Kangaroo care Withdrawal  Careful  Individualized developmental care  Non‐nutritive suckling  Rooming‐in if stable  Small, frequent feedings with high calorie formula  ACTIVE MATERNAL PARTICIPATION IS THE BEST NONPHARMACOLOGIC CARE!

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 Pharmacologic treatment is required if no improvement or infant develops severe withdrawal Newborn  Opioids used for opioid abuse  Morphine is most commonly preferred Assessment of  Methadone  NAS treatment algorithms are typically followed Withdrawal  Phenobarbital may be used for nonopiate NAS

 Multidisciplinary approach is a MUST  This includes parental participation!  Infants are typically discharged when  Clinically stable (feeding well, sleeping, gaining weight)  Low Finnegan score Infant  No or minimal medical support Discharge  i.e. most NICUs will not discharge infant on morphine  Prolonged clinical follow‐up needed to identify short/long‐term from NICU outcomes  Initial NAS may be short but intense and last for 1 to 2 weeks  BUT this may be followed by a long chronic and relapsing course that includes hyperirritability, sleep disturbances, hyperphagia, and other neurologic and autonomic signs that last for a few weeks to a few months (Kocherlakota, 2014)

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Typical NB Visit Schedule NAS Infant Visits

 In addition to the Typical NB Schedule, Post‐NAS infants: Infant Follow‐  Will be routinely be evaluated for hearing loss Up Care After and any seizure activity  Will have PT & OT evaluations at 6,12 & 18 Hospital months Discharge  Will be referred to Right Tracks  Will continuously be evaluated for developmental delays  Ongoing evaluation for psycho‐social concerns

Bright Futures: AAP Recommendations for Preventive Pediatric Health Care, 2017

 Post‐birth, multidisciplinary care of NAS infants and their mothers/families is EQUALLY as important as early identification in the prenatal period Reactive or  It may seem like this is REACTIVE care to a worsening endemic problem BUT it is also PROACTIVE care that will impact Proactive  Mothers  Infants  Families  Future pregnancies (INTERCONCEPTION PLANNING)

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References Available Upon Request

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