1. Antenatal Opioid Exposures and Associated Outcomes Through Early Childhood
July 19, 2016
Sharon McAllister, OTR/L
Debra McSweeney, PT, MSPT
Edmund N. Ervin Pediatric Center, MGMC

2. Objectives
Understand the effects of maternal substance use on the brain of a neonate.
Learn about the short and long-term developmental outcomes for infants exposed to substance in-utero.
Discuss the components of care needed to address the current and future needs for infants/children and their families

3. Disclosures
We have no relevant financial or nonfinancial relationships within the products or services described, reviewed, evaluated or compared in this presentation.

4. Level II Nursery Services at Maine General Medical Center
Orders for OT and PT are received on all babies with a diagnosis of substance exposure/NAS; babies are seen within hours of order received (except on weekends).
Our program focuses on:
Direct services to address needs – state regulation, feeding, handling, development, attachment
Parent education
Discharge planning and coordination with our community resources, such as…
CDS
Home nursing
Maine Families
Direct PT or OT services - outpatient

5. Modified Finnegan Scoring for NAS

6. Eat, Sleep, Console (ESC)

7. FRAMEWORK: Developmental Care
The creation of an environment for the infant and young child that minimizes stress and increases regulation while providing developmentally appropriate experiences for the child and family
Facilitate child-parent bonding and attachment
Established through coaching and modeling and establishing a safe community across all caregivers

8. Interventions in Developmental Care
Support the physiological organization of the individual infant and young child
Enhance the physiological stability
Protect sleep rhythms
Develop healthy and efficient feeding patterns
Promote growth, maturation and development

9. Goals of Developmental Care
INFANT
Reduce stress
Conserve energy and enhance recovery
Promote growth and well being
Support emerging behaviors at each stage of neurodevelopmental maturation

10. Goals of Developmental Care
FAMILY
Encouragement and support of parents as primary caregiver role
Enhance family emotional and social well-being and attachment
Provide knowledge related to the care of a high risk infant and the awareness of developmental concerns related to their birth history and the potential challenges they may experience
Resources available to the infant and family

11. Impact of improved regulation
Improved attention
Improved eye contact
Improved learning
Improved sleep
Improved eating
Improved social skills
Improved motor
Improved direction following
Improved speech

12. Assessment of the Infant
Characteristics of the Infant, Caregiver and the Environment as well as the Task being asked of the infant Intervention and Treatment on Individualized needs
Individual
Environment
Task

13. Factors Impacting Developmental Care and Early Development
Environment
Noise
Lighting
Visual stimulation
Positioning
Tempurature
Olfactory
Tactile
Caregivers
coordination
Infant
Condition of infant
Infant’s level of maturity and gestational age
Behavioral responses to care

14. Interventions Incorporated in Early Developmental Care
Handling and positioning
Including support for procedures
Engaging in cue-based care
Clustering nursing/infant care to provide longer periods of sleep
Reduction of noxious environmental stimulation
Encouraging parent visitation, involvement in care and kangaroo care

15. The goal is to identify an infant or child’s cues and respond appropriately.
Identification alone does not help.

16. Infants do remember!

17. INFANT CUES : COMMUNICATION

18. INFANT STATE : COMMUNICATION/CUES

19. STATE categorizing level of central nervous system arousal awake/alert
Quiet/Alert
Hyperalert
Hypoalert

20. INFANT STATE : COMMUNICATION / CUES

21. Self-regulatory strategies for infants

22. Calming input for infants
Deep pressure: rhythmic patting, holding, swaddle, baby sling, massage
Vestibular input/movement: gentle rocking, gentle swinging
Low lights, warm lighting
Predictability/structure
Soft voices
Decreased background noise
Calming music
Therapeutic use of self

23. Guidelines for Developmental Intervention
Introduce sensory stimuli gradually and methodically
Key in on the infant/child’s response to stimuli and adapt accordingly
Infant/child’s age as well as medical conditions are critical
Include parents/caregivers
Each infant/child responds differently to sensory input and therefore the ability to individualize is key to supporting an infant/child’s progression

24. High Risk Infants and Potential Developmental Outcomes
Visual
Auditory
Cognitive impairments
Motor impairments
Speech and Language Delays/ Disorders
Learning Difficulties
Attention
Behavioral Concerns
Impaired social skills

26. Readiness to Feed

27. Feeding-related Psychosocial Milestones Birth to 3 month “Homeostasis”

28. Feeding-related Psychosocial Milestones 4 to 6 months “Attachment”

29. Developmental Milestones and Feeding Skills Birth to 5 months

30. “Red Flags” Hypotonia (decreased muscle tone)
Hypertonia (increased muscle tone)
Poor tolerance to handling and daily care
Altered quality of movement
Poor postural control
Poor eye contact with caregivers
Poor state regulation
Social risk factors
Arching or stiffening of body during feedings
Irritability or lack of alertness during feedings
Prolonged feeding times (longer than 30 minutes)
Frequent spitting up
Less than normal weight gains
Less than optimal intake
Add feeding red flags

32. The identification of infants and children at risk is critical to our ability to ensure appropriate early intervention services to ensure optimal outcomes and to provide timely management.

33. The Effects of parental opioid use of the parent-child relationship and children’s developmental and behavioral outcomes”
A systematic review of published reports (2019 Jan 12 Child Adolescent Psychiatry Mental Health) found that children of parents with opioid use disorders showed greater disorganized attachment; they were less likely to seek contact and more avoidant than children in the control group. The children also had increased risk of emotional and behavioral issues, poor academic performance, and poor social skills. Younger children had increased risk of abuse or neglect, or both, that later in life may lead to such difficulties as unemployment, legal issues, and substance abuse.

34. In Australia in 2017 researchers compared the academic progress of 2234 students who had a history of prenatal drug exposure with a group of students with similar demographics but not born with NAS. The mean test scores of the children born drug exposed were lower than those of their counterparts. The results worsened as the students aged into high school.

35. Researchers in Tennessee in Sept of 2018 analyzed close to 7,200 children aged 3 to 8 years enrolled in the state’s Medicaid program. The study found 1 in 7 children with a history of opioid exposure in the womb required services for developmental delays.

36. Why is regulation important?
When children are able to regulate,
Less vulnerable to impact of stress
Improve academic success
Readiness to learn in all 5 domains of development
Social/emotional
Motor
Language
Cognition
Adaptive

37. Please keep the lines of COMMUNICATION open with
We know that most of these children will have developmental and educational CONCERNS,
Please keep the lines of COMMUNICATION open with
with a primary care provider, medical specialist, clinic, case managers or therapist and maintain a
CONNECTION
to ensure continuity of monitoring and care with ongoing assessments.

38. `
THANK YOU !