feeding and nutrition concerns of infants withdrawing from maternal substance use jeffery
TRANSCRIPT
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Feeding and Nutrition Concerns of Infants Withdrawing from Maternal Substance Use
Jeffery
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Jeffery Garland, MD, MPH; Neonatologist, Aurora Healthcare and Wheaton Franciscan Healthcare
Janice Ancona, RN, MSN; Clinical Nurse Specialist – NICU, Wheaton Franciscan – St. Joseph
Erin LeSage, MS, CCC-SLP and Julie Ditscheit, OTRL; Aurora West Allis Hospital
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39% year-to-year rise in heroin – related deaths nationally
6 overdose deaths in Milwaukee area in one 24 hour period
75% of heroin addicts began with use of prescription opioids
53% received free from friend or relative
H.I.V. and hepatitis outbreaks
90% of first-time heroin users are white
Global poppy cultivation highest level since the 1930’s
Escalating national impact of substance use
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The number of babies diagnosed with Neonatal Abstinence Syndrome (NAS) has tripled.
Increasing national cost: Hosp. charges $191M to $750M; 78% Medicaid funded
Milwaukee average cost for 1 drug-affected baby in an NICU is $180,000
National Drug Control Strategy: prescription drug abuse and heroin epidemic
President Obama, October 2015, $133 million
Prescriber training
Improving access to treatment – reimburse/facilitate access, identify/address barriers
More maternal opiate use means:
More neonates with neonatal abstinence syndrome, which means:
More community programs serving withdrawing kids, and thus----
Collaboration with partners such as WIC to improve long term outcomes!
Escalating national impact of substance use
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Neonatal Abstinence syndrome (NAS) describes behavioral and physiological symptoms of withdrawal in newborns and infants.
Not “addicted”; are drug or substance exposed; physically dependent.
Describe and quantify symptoms → NAS Score
Background
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NAS Scoring System
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Prolonged hospital stays to manage complications with feeding, sleeping, and central nervous system instability.
Creates complex issues for infants and families.
Results in unique needs and demands impacting resources, services, processes and individual providers across the continuum.
The Problem
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OperationalEnvironmentalClinical InterventionsFamily InvolvementData ManagementStaff and Physician relations
Themes to Consider Throughout the Continuum of
Care
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Finding and Using Non-Pharmacologic, Supportive
Interventions First
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Partnership with family regarding approach to care◦Prenatal preparation, engagement and holding◦Begin low stimulation in Family Care area –
keep baby with parents when possibleAccess to care areas restrictedAll conversations in whispersIndirect and dimmed lightingStrict grouping of caresDiscerning use of seats, swings, music,
strollers
Non-Pharmacologic Methods
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Automatic referrals for Speech Therapist, Occupational Therapist and Registered Dietician
Intentional use of aromatherapy.
Adapt stimulation to moderation of symptoms and advancing gestational age
Non-Pharmacologic Methods
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Medication management protocols to provide nimble response to increasing severity of symptoms and appropriate weaning in dose and frequency parameters
Medications used – Morphine, phenobarbitol, clonidine, methadone
Fewer infants home on meds!
Pharmacologic Methods
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Aurora Initiative to Reduce LOS for Infants Treated for Neonatal Abstinence Syndrome
LOS Mean -2 STDev=0 +2 STDev -3 STDev=0 +3 STDev
NAS Protocol Communicated Begin to Consider
24 Hour Option
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Wisconsin Centers: 7
Affinity NICU at St. Elizabeth HospitalAspirus Wausau HospitalAurora Baycare Medical CenterAurora Sinai Medical CenterAurora Women's PavilionGundersen Lutheran Medical CenterWheaton Franciscan Healthcare at St. Joseph
VON Quality Audit #6 – NAS Unit Data
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7 Wisconsin Centers, 58 Infants Audit 5 (N=26) Audit 6 (N=32) Median Median Birth Weight 2,918 2,943
Total duration of pharmacologic 16 11 treatment for NAS (days)
Interval between last dose of a med 32 3 for NAS and discharge Infants' total LOS in NICU (days) 20 19
Infants' total LOS in hospital (days) 22 20
VON Quality Audits 5 and 6 NAS Patient Data
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2015 Initiative 18 WINpqc NICUs participate in the VON iNICQ 2015: NAS*
GOAL Decrease need for pharmacologic treatment.
METHODS Family engagement (prenatal education, holding)
RESULTS Baseline Oct.-Dec. 2014 n = 81 43% meds
Initiative Jan. – Aug. 2015 n = 179 35% meds
2 TOP PERFORMERS mostly Subutex, very few methadone n = 29 31%
meds initiated intentional use of aromatherapy n = 44 18%
meds
All Level III NICUs include their Level II referral centers in NAS initiatives
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2015 Initiative 2 - WINpqcNAS - Family Preparation and Engagement GOAL: To decrease incidence and severity of symptoms by increasing family preparation and engagement.
METHODS: Flip chart for prenatal education of parents Hold by family and volunteers (↑# and
hrs.) Admission/ discharge surveys to identify
sources of information for parents, effectiveness of pre-delivery and in-hospital strategies, readiness for discharge, and satisfaction with services
BOTTOM LINE: Moms are getting prenatal education,babies are being held, and parents are less angry
Admission Survey 92 % Know s/s, scoring, comfort techniques, and POC. 62% prenatal educ; most from OB provider. 55% Plan to breastfeed. 54% Worried about how they and baby might be treated.
Discharge Survey100% “right amount” of information; feel ready for discharge.100% Held infant as much as they wanted 88% Quiet environment helped parents feel calm and capable 76% LOS shorter than or about as expected. 75% Felt they were not treated differently 50% Describe their experience in the quiet room as “great”.
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Breastfeeding practice changes◦ Criteria-based protocol for support of breastfeeding◦ Volume-based /proportional use of EBM
◦ Transition to breast: Mom “clean” and breast milk supply established Can transition while weaning meds
Speech Therapy and Occupational Therapy to address:◦ State Instability
Use of non-nutritive sucking -hunger vs NAS symptomatology
Watch for subtle/early hunger cues See feeding “hints”.
◦ Oral Motor Control Nipple Biting/Munching
Improvement Methods – Breastfeeding
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YES
All conditions must be met. Maternal functioning indicating that lactation SHOULD be supported.
Prenatal care begun by 4th month and > 7 visits at term.
Substance Abuse (SA) treatment program:o Consent for discussion with
SA providero Counselor agrees with plan
for breast milk o Drug abstinent for 90 days
prior to delivery Sober in an outpatient
setting Negative urine drug test
at delivery
MAYBE Interdisciplinary assessment and decision for lactation support May feed colostrum until final determination made or up to 48 hours. Decision will be made to breastfeed, to pump and dump, or to avoid breast milk feeding.
Prenatal care begun in the 3rd trimester (> 28 weeks)
Inadequate or no prenatal care Sobriety only in an inpatient setting Use of other prescribed medications
along with the substance(s) in question – e.g. pain clinic
Woman in SA treatment not relapsing within 30-90 days prior to delivery
Relapse or evidence of active drug use in the 30-90 days prior to delivery.
Agrees to urine drug test
NO If any ONE of these conditions is met. Maternal functioning indicating that lactation should NOT be supported.
Relapse or evidence of active drug use in the 30 days prior to delivery
No SA treatment In SA treatment but unwilling to
provide consent for discussion with SA provider/counselor
No plans for postpartum SA treatment
Relapse to drug use after the establishment of lactation
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With RD collaboration
Begin with first feedings in Family Birth Centers
Use for supplementation of breast milk
Designed to decrease fussiness, gas, and excessive crying.◦ Easily digested carbs, differ in milk proteins
Optimize nutrition for increased caloric needs 20 hyper metabolic state if unable to achieve ample volumes◦ Short-term fortify with 40 cal/oz to total 22calorie/ounce
Improvement Methods – Nutrition
Specialty Formulas
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Formula Osmolality Carbohydrate Source Protein Source
Similac Low Lactose: None Milk Protein Isolate
Sensitive (200 mOsm/kg water) Maltodextrin: 77.2% (Whey:Casein 18/82)
Sugar: 19.3
Galacto-oligosaccharides 3.5%
Enfamil (220mOsm/kg water) Lactose: 20% Nonfat Milk and Whey
Gentlease Corn Syrup solids: 80% (partially hydrolyzed)
(Whey:Casein 60/40)
Nestle′
Good Start Soothe Low Lactose: 30% 100% Whey
(195 mOsm/kg water) Maltodextrin: 70% (partially hydrolyzed)
Specialty Formulas
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Abbott Nutrition Similac Sensitive ◦ Good tolerance◦ No lactose◦ Ready to feed, sterile◦ 1st choice of NICUs around the country◦ 19 calories per ounce – changing?
Enfamil Gentle Ease◦ A 1st choice for many based on contract◦ Low lactose◦ Ready to feed, sterile
Specialty Formulas
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Nestle Gerber Good Start Soothe◦ WIC◦ Powder form only and non-sterile because
of probiotics◦ Transition week of discharge
Can wean meds at same time◦ Parents react negatively to change if infant
tolerating current formula and growing◦ Warming - Difficult for rapid response to
early hunger cues
Specialty Formulas
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Feeding Hints for Infants with NAS
Encourage and engage mother in understanding baby’s feeding needs
Supportive handling and swaddling
Decrease stimulation while feeding baby
Cue based –allow for breaks as needed
Feedings may take 30-45 minutes
Note: CNS disturbance may
impair suck-swallow-breathe coordination
Atypical, disorganized suck, seal, latch or swallow
Regurgitation commonConsider indwelling
NG tube with pump feedings
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Effects on Oral Feeding:Physiologic stabilityState regulationOrganization Oral-motor/ sensory skillCoordination of suck-swallow-
breatheActive engagement Pleasurable Experience
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Physiologic StabilityQuestions to ask:Appropriate breathing rate?Tolerating feedings?
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State Regulation• Frequently demonstrate rapid state
transitions from “frantic” to “shut down”
• Watch for progression increasingly more alert/awake state AND ability to maintain this state over extended period of time.
• “Unsettled” does NOT always mean hungry
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Organization• What does body look like at rest?
Settled/Unsettled
• Ability to latch on to pacifier / nipple
• Function of oral musculature “works” off entire body
• If body is “disorganized” oral motor function will likely be disorganized
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Oral-Motor/ Sensory Skill• Watch infant with pacifier to identify
TRUE sucking skill … compression? compression and suction? Suck pattern excessive/ continuous and/or. burst /pause pattern?
• Does skill change with liquid via the nipple?
Swallowing requires higher level skill Purposeful change in skill may be to secondary
to reduced organization and/or to “protect”
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Coordination of SSB• Excessive / continuous sucking
and impact during oral feeding
• Safety of swallowingSTRESS CUES
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Active ParticipationShould demonstrate “drive” or interest with active rooting and latch
• CAUTION make sure infant not just passively/ reflexively sucking/ swallowing
Goal is to help facilitate LONG TERM oral feeding success
Eating is reflexive only until 3-4 months of age when it becomes VOLUNTARY behavior
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Active Participation
• Is necessary for learning coordinated, well-regulated feeding behaviors.
• Infants can be made to suck by stimulating the suck reflex BUT this can have detrimental consequences such as: o Poor coordination of airway protectiono Defensive feeding behaviorso Association between feeding and
aversive experience
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Positive Experience• For baby AND caregivers
• Watch for Stress Cues
• Neuropathways are forming for feeding/ swallowing
• Need to eat multiple times per day, FOREVER
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Stress Cues:
Facial grimaceGagging/ vomitingCoughing/chokingEyebrow raiseFurrowed eye
brows/ “Worried look”
High pitched “crowing sound” / Stridor
Nasal flaring/blanching
Head bobbing (increased breathing rate)
RetractingColor changeOxygen
desaturation Drop in heart rate GulpingMultiple swallowsDrooling
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Strategies/ Interventions Swaddling Positioning Nipple choice (offer appropriate control of flow rate) Follow cue –based feeding protocol Impose breaks to help with coordination, organization,
state regulation Feeding schedule Encourage and engage parent(s)/caregiver(s) in
understanding baby’s feeding needs Decrease stimulation while feeding baby Monitor length of time for feeding (30 minute
guideline)
CONSISTENCY ACROSS FEEDINGS
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When to STOP Oral Feeding
• Physiologic instability• Lack of engagement in feeding• Not observed to be a positive experience• Disorganized• Sleeping• Difficulty integrating suck-swallow-
breathe pattern despite caregiver efforts
BEST PRACTICE Offer proper nutrition via tube feeding when
necessary
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SENSORY INTEGRATION: DR. JEAN AYRES
SENSORY INTEGRATION is the nervous systems’ ability to register, organize and interpret information through a variety of senses including the visual, auditory, tactile, vestibular, and proprioceptive systems.
SENSORY PROCESSING underlies the development of all state regulation, motor and social skill development, the ability to learn and the ability to perform complex functional tasks such as feeding.
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AUTONOMIC NERVOUS SYSTEM: SIGNS OF STRESS MUSCLE TONE
◦ Non-nutritive sucking
◦ Containment, holding
◦ Swaddling
◦ Vertical Rocking PHYSIOLOGICAL ORGANIZATION
◦ Identify triggers
◦ Understand limits of tolerance
◦ Gradual (one-at-a time) presentation of stimuli
◦ Sensitive to feedback cycles
◦ Adjust environment BEHAVIORAL
◦ Assist with transition to deep sleep
◦ Appropriate stimulation = TOUCH (gentle, slow, continuous) VISUAL (dimmed, circadian light cycling)- AUDITORY (quiet voices, not abrupt) MOVEMENT (hold, contain close to body, no frequent changes)
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HANDLE WITH CARE 8 most effective principles of caregiving SWADDLING: helps to control body allowing for focused breathing, which
facilitates feeding with organized suck+swallow+breathe
C-POSITION: chin near chest, arms midline, back slightly rounded, legs bent in upright position. When lying down for diapering, place on side and keep upper body wrapped in blanket
HEAD-TO-TOE: slow, rhythmic movement relaxes while swaddled in C-position
VERTICAL ROCKING: slow and rhythmical, with baby held directly in front of you and turned away. Soothes a system that is fighting and stressed. Beware of your personal energy transferred to infant.
CLAPPING: clap/pat baby’s bottom. Clap slow and rhythmical. Relaxes through deep joint input.
FEEDING: low-stimulus environment, swaddled in c-position or sidely. Burp using deep and large circular strokes (this calms whereas clapping excites)
CONTROL ENVIRONMENT: before engaging in activity or cares. Limit number of ‘hands on’ baby. Engage your CALM presence. Minimize loud and abrupt music, noise, voice, light
MANAGEMENT OF STAGES OF WITHDRAWL IN HOME: control environment, learn infant response and EARLY cues of tolerance, regain control, gradual introduction of stimuli, introduce increasing amount of stimuli, slow unwrapping for short periods as infant maintains quiet, alert or dozing state. Infants should not be kept in darkened rooms for long periods of time; cycled lighting is very important to development.
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INTERVENTIONS
EVIDENCE-BASED:
◦ Swaddling
◦ Quiet, gentle awakening
◦ Decreased stimulation
◦ Increased non-nutritive suck
◦ Positioning with containment
◦ Vertical rocking
◦ Sleep protection
◦ Breastfeeding
◦ Build parental confidence and mother-infant dyad
Casper&Arbour 2014
MacMullen, Dulski, & Blobaum 2014
Velez &Jansson 2008
COMPLIMENTARY MEDICINE:
◦ Massage
◦ Aromatherapy
◦ Light Therapy
◦ Chiropractic Treatments
◦ Music Therapy
◦ Swings: head-to-toe movement
Approaches with these interventions
have been implemented successfully with
infants, however efficacy in the NAS
population has not been researched.
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DEVELOPMENTAL IMPLICATIONS Following inpatient stabilization, NAS infants typically are healthy
and may not require hospital-based care. Emphasis now placed on developing community-based strategies in
the care of infants through childhood. With decreases in LOS, need to build outpatient resources within comprehensive care models to improve compliance. compliance
Requires routine assessment of caregiver-infant interactions; requires knowledge of community resources to assist in developing longstanding positive relationships.
Concern re: stability of home environment and compliance with outpatient appointments for both infant and mothers (high relapse group).
Compliance improves if provided in non-threatening, non-punitive, supportive environment.
At two years of age, studies now demonstrate lower cognitive and language scores when compared to peers (may be indicative of aberrant brain development during periods of increased cortical volume, increased myelination, and rapid cerebellar development during third trimester.
The American Journal of Maternal/Child Nursing, 2013 J Perinatology, 2012
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Increase parental engagementPartner with community agencies
to improve transitions and continuity of care.
Local, state, and national sharing of protocols and pooling of data
Gather long-term outcomesNon-NICU setting for NAS service.
Current Initiatives
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Improvement in care practices Influence policy at all levels
◦Standards, funding, ? legislationNational
◦Vermont-Oxford Neonatal NetworkState
◦Wisconsin Neonatal Perinatal Quality Collaborative
WIC !!
Current Initiatives
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Thank You!