5/10/2018
An Introduction to Substance Exposed Mothers and Infants 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 Addiction Funded by U.S. Department of Health and Human Service (DHHS) Substance Abuse and Mental Health 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 Abstinence 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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Pregnancy is a relatively short, but important, period of time in a woman’s life: 40 weeks…10 lunar months…9 calendar months ~50% of pregnancies 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/infant) 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 facial clefts 1.8‐2.8x greater risk of stillbirth Passive exposure‐2.1x greater risk of stillbirth No particular neonatal withdrawal 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) Depression/Stress/Anxiety General discomforts of pregnancy Fun Cannabis Insomnia 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, impulsivity, cognition No clear physical teratogenic effects BUT Lower birth weight 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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Methamphetamines: 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 hypersomnia 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 Paranoia, hallucinations, delusions
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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 methamphetamine‐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 Breastfeeding 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 swaddling 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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