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Neonatal Abstinence: Neonatal Abstinence: Neonatal Abstinence: Neonatal Abstinence: What’s In, What’s Out, & WhyWhat’s In, What’s Out, & WhyWhat’s In, What’s Out, & WhyWhat’s In, What’s Out, & Why

September 19, 2019

Jeanne Mrozek MD

Minnesota Neonatal Physicians

mnneo.org

ObjectivesObjectivesObjectivesObjectives

• Identify two new therapies for treatment of NAS

•Describe what you will no longer do for babies with NAS

• Identify three non-pharmacologic treatment measures

Ask your self:

Why do we do what we do?

Answer: Because we did it yesterday…..

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Call to Action!! Call to Action!! Call to Action!! Call to Action!!

• Opioid crisis now a national epidemic

• Implications for mothers, babies, & families

• Can ONE person actually make a difference?

• Can that ONE person be you?

Opioid CrisisOpioid CrisisOpioid CrisisOpioid Crisis---- Current StateCurrent StateCurrent StateCurrent State

• 91 people die EACH DAY from opioids

• Increased NICU admissions for NAS

• NICU average length of stay is higher than for any other diagnosis other than prematurity

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Current State: Public Health EmergencyCurrent State: Public Health EmergencyCurrent State: Public Health EmergencyCurrent State: Public Health Emergency

• 2017 death toll: 70237 drug overdose deaths in U.S.- 2/3rds involve opioids

• 2014 v 1999: 4 times as many mom’s with opioid use disorder

• 2014• 1 neonate with NAS diagnosed every 15 minutes

• 32000 infants

• $563 million in estimated costs

Increased newborns treated pharmacologically

Present in all ethnicities and communities

Again, What can 1 person do?Again, What can 1 person do?Again, What can 1 person do?Again, What can 1 person do?

For Good

• Nelson Mandela

• Mother Theresa

• Ghandi

• Thomas Edison

• Semmelweis

• Steve Jobs

• Bill Gates

For Bad

• Hitler

• Stalin

• Mass shooters

What is NASWhat is NASWhat is NASWhat is NAS

•Neonatal Abstinence Syndrome (NAS) is a CLINICAL DIAGNOSIS that is the consequence of the sudden discontinuation at birth of fetal exposure to substances that were used/abused during pregnancy

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AgeAgeAgeAge----old approachold approachold approachold approach

• NICU admission

• Finnegan Scoring

• Medications

• Staff care for babies

• Maternal/infant separation

• No breast milk or breast feeding

Limitations of current modelLimitations of current modelLimitations of current modelLimitations of current model

• An NICU is an NICU

• Nurses assigned to multiple patients

• High acuity patient needs can trump demand feedings

• Can’t maximize non-pharmacologic therapy

• Feed on demand

• Low stimulation environment

• Minimal holding

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Opioid Use DisorderOpioid Use DisorderOpioid Use DisorderOpioid Use Disorder---- The MOMThe MOMThe MOMThe MOM

• Reframe OUD as a medical condition that requires diagnosis and treatment…. Just like pre-gestational diabetes…. Or pneumonia

• It is a chronic, relapsing disease… lupus, arthritis, etc etc

• Stigma leads to obstacles in care

• Current recommendations: avoid withdrawal during pregnancy and get appropriate opioid agonist treatment

Maternal Opioid Use Disorder: The BABYMaternal Opioid Use Disorder: The BABYMaternal Opioid Use Disorder: The BABYMaternal Opioid Use Disorder: The BABY

• Impact on developing fetus and brain unknown

• Duration of impact unknown and likely goes beyond first few weeks of life

• Association with structural birth defects: gastroschisis

• Possible need for special education and school services

NASNASNASNAS---- The SyndromeThe SyndromeThe SyndromeThe Syndrome

• Neurological: tremors, high pitched excessive crying, seizures

• Gastrointestinal: diarrhea vomiting, excessive sucking

• Autonomic: fever, sweating, tachypnea

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SeveritySeveritySeveritySeverity

• Depends on amount and purity of drug used

• Depends on length of maternal use

• Depends on drug metabolism of both the mom and the newborn• Single nucleotide polymorphisms (SNPs)

• SNPs in 2 opioid receptor genes associated with worse NAS severity and longer length of stay. Can be in mom OR baby

• Genomic variation relates to drug metabolism

How do we assess NAS?How do we assess NAS?How do we assess NAS?How do we assess NAS?

• Finnegan Neonatal Abstinence Scale (1975)• Loretta Finnegan• Founded landmark program, MATER

(Maternal Addiction Treatment Education & Research), in Philadelphia in 1972. It is still running!

• Poverty and childhood trauma are precipitating factor for almost all women in MATER program

• Used by 95% of institutions

• Requires initial and repetitive training

• Never meant to separate the mom and the baby

Does the tool do what we want?Does the tool do what we want?Does the tool do what we want?Does the tool do what we want?

• What is a baby supposed to do?

• What do we REALLY care about in babies? • Eat, sleep, pee/poop

• That’s what happens in the newborn nursery

• And at home

• Finnegan is a frustrating tool to use… requires training, variation in caregivers

• Finnegan scoring creates the need to give meds to meet a score

• Purpose gets distorted to treat the score, NOT the baby

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Eat, Sleep, ConsoleEat, Sleep, ConsoleEat, Sleep, ConsoleEat, Sleep, Console

• Developed 2017

• Manage NAS based on the baby’s ability to FUNCTION• Interruption of function means inability to perform “activities of daily living”

• Decreases use of postnatal opioids

Huh?Huh?Huh?Huh?

• Pretend it’s a baby…. And treat accordingly

• Pretend its’ a mom….And treat accordingly

• Mom is the MEDICINE- the secret sauce

Does this really work?Does this really work?Does this really work?Does this really work?

Grossman et al 2018 Average LOS decreased from 22.4 to 5.9 d ays.

Morphine treatment dropped from 98% to 14%

Cost decreased $44k to $10k

287 patients

Wachman et al 2018 Opioid treatment days dropped 16.2 to 12.7 days

Decreased pharmacologic Rx from 87% to 41%

240 patients

Grossman et al 2018 Compared ESC with Finnegan scored babies:

12% treated using ESC, whereas 62% QUALIFIED for

treatment using Finnegan

50 patients

Reference: Advances in Neonatal Care Vol 19. no.2. pp 138-

144.

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How does it work?How does it work?How does it work?How does it work?

EATEATEATEAT

• Appropriate amount based on days of age

• 1-2 days ~15-30 ml/feed or ½-1 ounce/feed

• >3 days >1 ounce/feed

• Breastfeeding: quality should be “good” as defined by the mom and nursing staff

• If they are a preemie, go by what you expect based on their gestational age

• Should be voiding and stooling as per normal newborn expectations

SleepSleepSleepSleep

• Should be able to sleep undisturbed for a minimum of 1 hour

• Holding the baby to support undisturbed sleep is often necessary

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ConsoleConsoleConsoleConsole

• Should be consolable in 10 minutes by up to two people

• Maximize non-pharmacologic therapies

• Console support interventions• Speak softly and slowly with calm voice

• Look for hand to move movements and facilitate

• Talk to infant and gently place had on baby’s abdomen

• Continue talking softly and bring arms and legs to center of body

• Pick up baby, hold skin-to-skin, or swaddle; gently rock/sway

• Offer finger or pacifier if showing hunger cues

NonNonNonNon----pharmacologic therapiespharmacologic therapiespharmacologic therapiespharmacologic therapies

• EMPOWER THE PARENTS

• Try to meet family BEFORE delivery to define expectations

• “We WANT you to be involved in your child’s treatment”

• Low stimulation environment

• Good communication staff:staff, staff: family

So, how do you do “Eat, Sleep, Console”So, how do you do “Eat, Sleep, Console”So, how do you do “Eat, Sleep, Console”So, how do you do “Eat, Sleep, Console”

• Time

• Education

• Patience- This is a RADICAL change

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Start with Start with Start with Start with WHEREWHEREWHEREWHERE

• Where will these babies be cared for?

• A maternal/baby ward, NICU, pediatric ward, other?

• Local context critical

• MUST HAVES: • Privacy

• Space for families to be comfortable for several days

• Private bathroom

• Television would be nice

• Make it DESIRABLE… would YOU want to stay there?

• GOAL- families want to stay there with their infant more than any other place

What’s after WHERE?What’s after WHERE?What’s after WHERE?What’s after WHERE?

• Identify Point of Contact

• Develop core NAS work group

• Community outreach

Point of ContactPoint of ContactPoint of ContactPoint of Contact

• Help mom navigate the healthcare system

• Help moms understand how their baby may be impacted by NAS

• Teach how NAS is managed

• Empower mom to be integral part of the treatment “mom is the medicine”

• Ongoing relationship can help pre and post-natally

• Prenatal consult

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Core NAS Work GroupCore NAS Work GroupCore NAS Work GroupCore NAS Work Group

• Multidisciplinary

• Champions

• Develop local guidelines

• Gather input on BELIEFS about NAS babies and families• Can by anonymous

• Crucial to understand barriers to implementation ahead of time

• Develop education plan

Key Components of Education PlanKey Components of Education PlanKey Components of Education PlanKey Components of Education Plan

• What we used to do (previous management)

• Why we are changing (rationale for ESC)

• Program details of ESC

• Education about addiction

• Education on partnering with families in NONJUDGEMENT manner

• Nonpharmacologic interventions (5S’s of Soothing, Havey Karp)

• Criteria for discharge

• How to handle difficult situations (ongoing illicit use, foster care, etc)

Community OutreachCommunity OutreachCommunity OutreachCommunity Outreach

• Form liaisons with treatment facilities

• Form liaisons with social service programs

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Breast MilkBreast MilkBreast MilkBreast Milk

• Non-pharmacologic treatment of NAS

• Decreased withdrawal symptoms

• The act of breastfeeding protects mother against addiction relapse and stress

• ACOG recommends breastfeeding for women using methadone or buprenorphine, with exceptions for HIV- positive or illicit drug use

• Decreases duration of pharmacologic treatment

• Decreased length of stay

• Breastfeeding rates can be increased with education and support!

What happens as these babies grow up?What happens as these babies grow up?What happens as these babies grow up?What happens as these babies grow up?

• Very good question

• Scant data exist for long-term outcomes on substance-exposed infants who experienced NAS

• Confounding factors are many• Environment

• Post natal opioid administration

• Socioeconomic circumstances

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Questions?Questions?Questions?Questions?