1. Many Disciplines: One Goal. Care of the Drug Exposed Newborn Kelly Burch, PharmD NICU Conference October 26, 2010 St. John’s Mercy Children’s Hospital

2. Questions

3. Many Disciplines: One Goal. Testing Testing Clinical Criteria Clinical Criteria Methodology Methodology Interpretation Interpretation Therapy Therapy Supportive care Supportive care Symptom monitoring Symptom monitoring Opiate replacement therapy Opiate replacement therapy Support Support Family Family Staff Staff

4. Mother/Baby Identification: Who are we looking for? Who are we looking for? Infant of drug abusing mother Infant of drug abusing mother Infant of mother on methadone maintenance Infant of mother on methadone maintenance Short term (recent transition to methadone) Short term (recent transition to methadone) Long term Long term Infant of mother with chronic pain syndrome Infant of mother with chronic pain syndrome Objective vs subjective screening criteria Objective vs subjective screening criteria legal repercussions of discriminatory testing legal repercussions of discriminatory testing Consent requirements Consent requirements Policy development implications Policy development implications

5. Body Fluid sampling Urine Time frames for finding drug or metabolite Mom: First urine after admission Baby: First void after birth SAMHSA Five (Amphetamines, Cocaine, Opiates, PCP and THC) More complete screening (Amphetamine, Barbituate, Benzodiazepine, Cannabinoid, Cocaine metabolite, Opiate, and PCP) Strategies for masking positive results DeferralSubstitutionDilution Substance ingestion Meconium Advantages of complete collection Analytical techniques Saliva Infant limitations Forensic use implications Cord

6. Symptom Monitoring in the Newborn Opiate withdrawal symptoms BehavioralPhysiologic/autonomic Symptom scoring: Finnegan (22 elements, Rx if 8+) Lipsitz (11 elements, Rx if 6+) NWI (11 elements, Rx if 8+) Premature vs. term monitoring Pain scores vs. withdrawal scores

7. Neonatal Withdrawal Inventory Assessment procedure for NWI Assessment procedure for NWI Observe infant (1 min) Observe infant (1 min) Unswaddle and gentle wakening Unswaddle and gentle wakening Count RR Count RR Measure axillary temp Measure axillary temp Inspect for excoriation Inspect for excoriation Assess tone and Moro Assess tone and Moro Diaper change Diaper change Reswaddle and position Reswaddle and position Observe infant (1 min) Observe infant (1 min) Score of 8 or greater indicates need for therapy adjustment begin increase

8. Treatment Guidelines for Opiate Exposed Newborns Environment of care Quiet, dark, warm Positioning (developmental, Back to Sleep) Inpatient monitoring and symptom suppression NWI score assessment per policy or as ordered 2-3/day Small frequent feedings Drug therapy Opiate replacement therapy Morphine/methadone/DTO/paregoric Adrenergic blocking agent Clonidine Non-specific symptom suppression Phenobarbital/pentobarbital

9. Treatment Guidelines for Opiate Exposed Newborns (more) Breastfeeding decision Indications for safe home care with parent(s), which leads to Controlled substance management Rx writing Parent education

10. Evolution at SJMMC Implemented NWI in NICU Implemented NWI in NICU 1:1 teaching 1:1 teaching Pocket cards Pocket cards Neonatologist/NNP education re/ initiation and interpretation Neonatologist/NNP education re/ initiation and interpretation Implemented NWI in FTN Implemented NWI in FTN Nurse educator teaching, pocket cards Nurse educator teaching, pocket cards Monitor until treatment threshold, then transfer Monitor until treatment threshold, then transfer Accessed new methods of outpatient therapy Accessed new methods of outpatient therapy Low income clinic Low income clinic Outpatient pharmacies Outpatient pharmacies Sign off by DEA re/ use of methadone Sign off by DEA re/ use of methadone Communicated with obstetricians/pediatricians Communicated with obstetricians/pediatricians Once achieved “predictable” clinical course Once achieved “predictable” clinical course Environment of care Environment of care Volunteer role Volunteer role

11. Nursing implications of caring for NAS infants Struggle to minimize caregiver judgment of families Struggle to minimize caregiver judgment of families Caregiver empathy varies depending on family situation Caregiver empathy varies depending on family situation Families present varying insight into infant risk Families present varying insight into infant risk Delicate communication with extended families taxes privacy policies Delicate communication with extended families taxes privacy policies Caregivers all want to protect the babies Caregivers all want to protect the babies All acknowledge that the babies are innocent of their predicament All want to protect infants from possible consequences of untreated withdrawal Most willing to meet family needs to protect baby.

12. Effect on nurses of caring for NAS infants NICU skills vs. infant care skills Fitting the needs of the NAS infant into the hospital model into the nursing assignment Family related challenges Collaboration with new team members

13. Teamwork: Collaborating with Community Services and Social Service Networks Who are the members of the outpatient team? DFS worker/supervisor Family Court prosecutor and Judge Court Appointed Special Advocate Family members Medical Foster Care family Supervised living staff Private pediatrician Nursing agency for skilled visits Nurses for Newborns visits

14. Discharge management of NAS infant Stable dose, weaned once successfully Stable dose, weaned once successfully Q 8 H vs. Q 6 H Q 8 H vs. Q 6 H Other discharge needs met (ears, circ, car seat, class, CPR?) Other discharge needs met (ears, circ, car seat, class, CPR?) DFS disposition DFS disposition Parent teaching Parent teaching

15. Parent teaching S/sx of infant withdrawal S/sx of infant withdrawal No need to focus on score No need to focus on score Parent may be familiar with adult symptoms, need baby filter Parent may be familiar with adult symptoms, need baby filter Medication teaching Medication teaching Home prescription is diluted to individualized infant dose in 1 mL. Home prescription is diluted to individualized infant dose in 1 mL. Wean by 10% twice weekly by giving less volume (1>>>0.9>>>0.8, until off. Wean by 10% twice weekly by giving less volume (1>>>0.9>>>0.8, until off.

16. Teaching sheet Morphine700mcg/ml. Give medicine every day at about the same time. Decrease the dose gradually, using this schedule. DayDate Number of mcg Amount to giveHow Often? Current DoseNow700 Mcg 1mLevery8 Hours Thursday10/28630mcg0.9mLevery8 Hours Monday11/1560Mcg0.8mLevery8 Hours Thursday11/4490Mcg0.7mLevery8 Hours Monday11/8420Mcg0.6mLevery8 Hours Thursday11/11350Mcg0.5mLevery8 Hours Monday11/18280Mcg0.4mLevery8 Hours Thursday11/22210Mcg0.3mLevery8 Hours Monday11/25140Mcg0.2mLevery8 Hours Thursday11/2970Mcg0.1mLevery8 Hours On12/2stop giving medication. You will have a pediatrician appointment around that time.

17. What’s next? Cord testing Cord testing Clonidine vs opiate replacement therapy Clonidine vs opiate replacement therapy Improve discharge teaching sheet safety Improve discharge teaching sheet safety Improve integration with EPIC Improve integration with EPIC Increase collaboration Increase collaboration cuddler team cuddler team methadone treatment clinics methadone treatment clinics JFK, pediatric follow up JFK, pediatric follow up

18. Why clonidine for NAS? Opiates activate receptors in the locus ceruleus which decrease norepinephrine & dopamine Over time the locus ceruleus up-regulates to increase NE output. Removal of opiate exposure at birth removes the inhibition Upregulated, now uninhibited = noradrenergic overcharge and associated symptoms Clonidine (centrally acting alpha agonist) inhibits NE has analgesic effects doesn’t complicate drug screening tests not a controlled substance neuroprotective

19. How clonidine for NAS? Clonidine 1 mcg/kg/dose q 4-6 h (depending on feedings) Hold if SBP less than 50 or HR less than 90 Increase dose by 1 mcg/kg/dose if score over treatment threshold. Wean by decreasing interval Morphine prn if GI symptoms prominent Home if stable on one drug, and dosing interval is q 8-12 hours.

20. What’s next? Cord testing Cord testing Clonidine vs opiate replacement therapy Clonidine vs opiate replacement therapy Improve discharge teaching sheet safety Improve discharge teaching sheet safety Improve integration with EPIC Improve integration with EPIC Increase collaboration Increase collaboration cuddler team cuddler team methadone treatment clinics methadone treatment clinics JFK, pediatric follow up JFK, pediatric follow up

21. Questions

22. TV tonight? Turf War Turf War DIY network (Charter 116) DIY network (Charter 116) 7 PM 7 PM