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Scoring tools for NOWS/NAS Finnegan Neonatal Abstinence Scoring System 31 items Symptoms are weighted Guidelines for pharmacologic treatment at score of 8 or greater MOTHER score (modified Finnegan score) 19 items (which contribute to total score) Items weighted differently Some Finnegan items eliminated and others added Guidelines for treatment based on score rather than weight Lipsitz Neonatal Drug-Withdrawal Scoring System 11 items Items scored for severity and gives guidelines for treatment The Neonatal Withdrawal Inventory – 8 point checklist The Neonatal Narcotic Withdrawal Index – 6 signs plus others Credit: Anne Johnston, MD Jones, Fielder. Preventive Medicine 2015 NAS score is not the sole determining factor in the decision to start pharmacotherapy for NAS Score can be affected by State of infant Painful stimuli Order of score “Motive” of scorer All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs. All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs. NOW evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization. Scores above a threshold trigger medication initiation to reduce NOW severity – no or delayed treatment can result in morbidity or mortality. Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers. Medication amount is increased then gradually decreased until the neonate is stable without medication. Sarkar, Donn. J Perinatol 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev 2011 NOW: Measurement and Response Short-acting opioids (morphine sulfate, dilute tincture of opium) Short-acting opioids (morphine sulfate, dilute tincture of opium) Methadone Inpatient treatment and inpatient to outpatient treatment Symptom versus weight based Allows for shorter length of stay (with outpatient treatment) Endorsed by the AAP (2012) (Several studies including MS Brown et al (2015) which revealed shortened duration of treatment with methadone) Dilute tincture of opium and phenobarbital (Coyle et al, 2002) Decreased severity of withdrawal, decreased length of stay Buprenorphine (Kraft et al, 2011) Shorter length of stay in buprenorphine treated infants Well tolerated Clonidine (Agthe et al, 2009) Oral clonidine as adjunct to short-acting opioids Shortens the duration of therapy, no short-term cardiovascular side effects observed NOWS: Pharmacologic Treatment NOWS: Non-pharmacologic Treatment Breastfeeding is associated with reduced severity of withdrawal, delayed onset, decreased need for Rx (Abdel-Latif et. al., 2006) Rooming-in decreased the need for Rx, length of Rx, and LOS (Abrahams et. al., 2007) Waterbeds decreased amount of medication needed (Oro et. al., 1988) Acupuncture (Filippelli et. al., 2012) Kangaroo therapy or skin to skin Decreased environmental stimuli Frequent small demand feeds Pacifiers Swaddling, containment, holding, vertical rocking Provider, nursing attitudes Image credits: www.susquehannahealth.org; www.simplymotherhood.com NOW occurs in the majority of all prenatally opioid-exposed neonates. NOW occurs in the majority of all prenatally opioid-exposed neonates. Medication to treat NOW is required in approximately 50% of the cases. NOW following prenatal exposure to an opioid agonist is best assessed with a standard scoring tool and best treated with an opioid medication. Patients and the providers who treat them will be best served through having a range of medication options from which to tailor treatment. As treatment for maternal opioid dependence advances, so must neonatal treatment (i.e., buprenorphine in the infant may be an important medication for treatment of buprenorphine exposure in utero) Osborn et al. Cochrane Database Syst Rev 2010 All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs. All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs. NAS evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization. Scores above a threshold trigger medication initiation to reduce NAS severity – no or delayed treatment can result in morbidity or mortality. Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers. Medication amount is increased then gradually decreased until the neonate is stable without medication. NAS: Measurement and Response Sarkar, Donn. J Perinatol. 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev, 2011 Later Outcomes
Cognition in opioid and non-opioid-exposed infants
Psychomotor in opioid and non-opioid-exposed infants
Cognition in opioid and non-opioid-exposed infants
Psychomotor in opioid and non-opioid-exposed infants
Behaviour in opioid and non-opioid-exposed infants Favors non-opioid-exposed Later Outcomes (continued) Baldacchino et al. BMC Psychiatry 2014 A Model of Integrated Pharmacotherapy and Behavioral Treatment Designed and Implemented to Help Women and Children Trauma and Addiction Treatment Early Intervention Services Maternal-Child Psychotherapy Outcomes without Horizons UNC Horizons saves North Carolina an estimated $3,366,815 every year Prenatal Care Postnatal Care Substance Abuse Treatment Staff trained on trauma-informed care: Staff realizes the widespread impact of trauma and understands potential paths for healing Staff recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system Staff responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings Team includes: OB, Nurse practitioner (NP), peer-support specialist, and therapist NP provides primary obstetrical care and manages women taking Suboxone prescribed by the OB Peer-support provides assistance and access to community resources and services Therapists provides counseling Psychiatrist is available as-needed for evaluation and medication management Fielder, Johnson, Jones, Australian nursing & midwifery, 2015 Team educates women on recovery and SUD and supports autonomy Team collaborates with nursery staff to educate women about NAS Incentives to participate in services include: Assistance with parking Gas vouchers Mommy Bucks Transportation Referral and Long-Term Follow-up for Exposed Infants DSS involvement This can and should be seen as supportive, not punitive Often past history with DSS precludes acceptance CDSA referral from the nursery Can be difficult depending on county and resources Ongoing treatment for mother and family Learn your local resources Preschool when available PCP, OB/GYN, Pediatrician Engage all players before delivery for planning Early testing in mother during gestation in addition to mother and baby at delivery is key Evidence-based protocols exist for Labor & Delivery and Newborn Anesthesiologist Newborn Nursery Team Infant assessment, Finnegan Scales, non-pharmacologic treatments, encourage breastfeeding Neonatal Critical Care Team Symptomatic Infants, Acute Withdrawal DSS involvement This can and should be seen as supportive, not punitive Often past history with DSS precludes acceptance Visit from child therapist within first week of delivery, even if in NICU Focus on infant strengths, learning infant cues (Hug Your Baby) Continue on going parent education (twice per week) At 6 weeks: Referrals for developmental assessments (Early Intervention) including Speech/Language, Occupational Therapy, Physical Therapy, and Social-Emotional Assessment Support Dyad: Weekly Child Parent Psychotherapy (CPP) Further support via Parent Education during Substance Use Treatment Attachment-based parenting program: Circle of Security-Parenting© http://circleofsecurity.net Nurturing Parenting Program for Substance Abuse http://www.nurturingparenting.com/ Hug Your Baby http://www.hugyourbaby.org/ Child Parent Psychotherapy http://www.nctsn.org/sites/default/files/assets/pdfs/cpp_general.pdf Postnatal Evidence-Based Tools Parents need continued education and support at home In the first few months, these infants can be difficult to sooth/irritable, have difficulties transitioning and maintaining sleep, and have feeding issues This can put infants at risk for insecure attachment Parents frequently have other stressors Researchers have found that mothers with substance abuse histories: Have repeated relationship disruptions Report more irritable babies Are less sensitive in interactions Are less emotionally engaged Are less attentive Have less positive affect Children from families with substance abuse issues have higher rates of insecure and disorganized attachment. Treatment for NAS occurs during the pregnancy, post-delivery, and in the home Treatment for mother, infant, and the dyad Focus on strengthening attachment relationship Focus on helping parents learn to read and respond to their infants’ cues Referrals to early intervention paramount Summary 1. Different behavioral interventions and medication assisted treatments can help to increase treatment engagement and reduce drug use among pregnant and/or parenting women 2. Neonatal abstinence signs and symptoms can be increased or minimized in response to the care provided as well as other factors. Providers play a key role in helping to support resilience among mothers and their children who have been prenatally opioid-exposed 3. The SAMHSA Block Grant provides elements of effective care for pregnant and parenting women. First page credits: “side view of pregnant woman” by imagerymajestic; “mother-child-family-happy-love-1039765/” by the danw; “family eating at the table” by skeeze Contact: Hendrée E Jones, PhD Executive Director, UNC Horizons Professor, Department of Obstetrics and Gynecology School of Medicine University of North Carolina at Chapel Hill 127 Kingston Drive Chapel Hill, NC 27514 USA Hendree_Jones@med.unc.edu Direct Line: 1-919-445-0501 Main Office: 1-919-966-9803 Fax: 1-919-966-9169
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