1. Feeding and Nutrition Concerns of Infants Withdrawing from Maternal Substance Use
Jeffery

2. 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

3. Escalating national impact of substance use
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

4. Escalating national impact of substance use
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!

5. Background
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

6. NAS Scoring System

7. The Problem
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.

8. Themes to Consider Throughout the Continuum of Care
Operational
Environmental
Clinical Interventions
Family Involvement
Data Management
Staff and Physician relations

9. Finding and Using Non-Pharmacologic, Supportive Interventions First

10. Non-Pharmacologic Methods
Partnership with family regarding approach to care
Prenatal preparation, engagement and holding
Begin low stimulation in Family Care area – keep baby with parents when possible
Access to care areas restricted
All conversations in whispers
Indirect and dimmed lighting
Strict grouping of cares
Discerning use of seats, swings, music, strollers

11. Non-Pharmacologic Methods
Automatic referrals for Speech Therapist, Occupational Therapist and Registered Dietician
Intentional use of aromatherapy.
Adapt stimulation to moderation of symptoms and advancing gestational age

12. Pharmacologic Methods
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!

13. Begin to Consider
24 Hour Option

14. VON Quality Audit #6 – NAS Unit Data
Wisconsin Centers: 7
Affinity NICU at St. Elizabeth Hospital
Aspirus Wausau Hospital
Aurora Baycare Medical Center
Aurora Sinai Medical Center
Aurora Women's Pavilion
Gundersen Lutheran Medical Center
Wheaton Franciscan Healthcare at St. Joseph

15. 7 Wisconsin Centers, 58 Infants
VON Quality Audits 5 and 6
NAS Patient Data
7 Wisconsin Centers, 58 Infants
Audit 5 (N=26) Audit 6 (N=32)
Median Median
Birth Weight , ,943
Total duration of pharmacologic
treatment for NAS (days)
Interval between last dose of a med
for NAS and discharge
Infants' total LOS in NICU (days)
Infants' total LOS in hospital (days)

16. 2015 Initiative 1 8 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 n = % meds
Initiative Jan. – Aug n = % meds
TOP PERFORMERS
mostly Subutex, very few methadone n = % meds
initiated intentional use of aromatherapy n = % meds
All Level III NICUs include their Level II referral centers in NAS initiatives

17. 2015 Initiative 2 - WINpqc NAS - 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 Survey
100% “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”.

18. Improvement Methods – Breastfeeding
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

19. 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:
Consent for discussion with SA provider
Counselor agrees with plan for breast milk
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 days prior to delivery
Relapse or evidence of active drug use in the 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

20. Improvement Methods – Nutrition
Specialty Formulas
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

21. Specialty Formulas
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)

22. Specialty Formulas 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

23. Nestle Gerber Good Start Soothe
Specialty Formulas
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

24. 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 minutes
Note:
CNS disturbance may impair suck-swallow- breathe coordination
Atypical, disorganized suck, seal, latch or swallow
Regurgitation common
Consider indwelling NG tube with pump feedings

25. Effects on Oral Feeding:
Physiologic stability
State regulation
Organization
Oral-motor/ sensory skill
Coordination of suck-swallow-breathe
Active engagement
Pleasurable Experience

26. Physiologic Stability
Questions to ask:
Appropriate breathing rate?
Tolerating feedings?

27. 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

28. 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

29. 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”

30. Coordination of SSB
Excessive / continuous sucking and impact during oral feeding
Safety of swallowing
STRESS CUES

31. Active Participation
Should 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

32. 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:
Poor coordination of airway protection
Defensive feeding behaviors
Association between feeding and aversive experience

33. Positive Experience For baby AND caregivers Watch for Stress Cues
Neuropathways are forming for feeding/ swallowing
Need to eat multiple times per day, FOREVER

34. Stress Cues: Facial grimace Gagging/ vomiting Coughing/choking
Eyebrow raise
Furrowed eye brows/ “Worried look”
High pitched “crowing sound” / Stridor
Nasal flaring/blanching
Head bobbing (increased breathing rate)
Retracting
Color change
Oxygen desaturation
Drop in heart rate
Gulping
Multiple swallows
Drooling

35. 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

38. 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

39. 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.

40. 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)

41. 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.

42. 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.

43. 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

44. Current Initiatives
Increase parental engagement
Partner with community agencies to improve transitions and continuity of care.
Local, state, and national sharing of protocols and pooling of data
Gather long-term outcomes
Non-NICU setting for NAS service.

45. Improvement in care practices Influence policy at all levels National
Current Initiatives
Improvement in care practices
Influence policy at all levels
Standards, funding, ? legislation
National
Vermont-Oxford Neonatal Network
State
Wisconsin Neonatal Perinatal Quality Collaborative
WIC !!

46. Thank You!