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

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

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

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!

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

NAS Scoring System

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.

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

Finding and Using Non-Pharmacologic, Supportive Interventions First

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

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

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!

Begin to Consider 24 Hour Option

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

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 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

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. 2014 n = 81 43% meds Initiative Jan. – Aug. 2015 n = 179 35% meds 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

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”.

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

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 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

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

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)

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

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

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 common Consider indwelling NG tube with pump feedings

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

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

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

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

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”

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

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

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

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

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

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

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

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.

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)

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.

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.

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

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.

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 !!

Thank You!