Welcome to the OPQC NAS

September 2017 Sustain Period Call

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Neonatal Abstinence

Syndrome Project

Quarterly Sustain Period Call

Ohio Perinatal Quality Collaborative

September 19, 2017

Welcome!

The OPQC NAS Project is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The

views expressed in this presentation are solely those of the authors and do not represent the views of the state of Ohio or federal Medicaid programs.

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Time Topic Presenter

3:00 pm Welcome & Agenda Review Susan Ford, MSN, RN

3:05pm Data

• Aggregate Data Overview

• Data Entry Updates

• No babies edits

• Transfer vs Discharge

Moira Crowley, MD

Susan Ford

3:25 pm NAS Care at & After Discharge

• Infant disposition/safety plan at discharge

• f/u clinic at CCHMC

Susan Ford

Jenny McAllister, MD

3:45 pm Questions/Team Discussion Susan Ford

3:55 pm Upcoming Conferences/Next Steps Susan Ford

Agenda

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Key Driver DiagramProject Name: OPQC Neonatal NAS Leader: Walsh

SMART AIM

KEY DRIVERS INTERVENTIONS

By increasing identification of and

compassionate withdrawal treatment for full-term infants born with

Neonatal Abstinence Syndrome (NAS), we will

reduce length of stay by 1 day across participating sites by June 30, 2016.

Improve recognition and non-judgmental support for Narcotic

addicted women and infants

Connect with outpatient support and treatment program prior to

discharge

Standardize NAS Treatment Protocol

Optimize Non-Pharmacologic Rx Bundle

Initiate Rx If NAS score > 8 twice. Stabilization/ Escalation Phase Wean when stable for 48 hrs by 10%

daily.

Swaddling, low stimulation. Encourage kangaroo care Feed on demand- MBM if appropriate

or lactose free, 22 cal formula

All MD and RN staff to view “Nurture the Mother- Nurture the Child”

Monthly education on addiction care

Attain high reliability in NAS scoring by nursing staff

Partner with Families to Establish Safety Plan for Infant

• Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.

Establish agreement with outpatient program and/or Mental Health

Utilize Early Intervention Services

Collaborate with DHS/ CPS to ensure infant safety.

Prenatal Identification of MomImplement Optimal Med Rx Program

Engage families in Safety Planning. Partner with other stakeholders to influence policy and primary

prevention. Provide primary prevention materials to sites.

To reduce the number of moms and babies with narcotic exposure, and

reduce the need for treatment of NAS.

GLOBAL AIM

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Same chart; different y axis

(ability to see greater detail)

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Data Updates

• No Babies

– Please open a New Form each month

– Do NOT edit a previous month’s submission

of “no babies” for a new month

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Data Updates

• Transfer vs Discharge

– Do NOT enter data on NAS infant if he/she is

being transferred to another site for NAS

treatment. That will result in duplicate

submissions for one infant. The treating site will

enter data on that infant after discharge.

Response if “other” is chosen for infant disposition

Level 3

transferred to XXX hospital

Transferred to XXX Hospital

Transferred to XXX per parent request for medication treatment

transfer to XXX for treatment

Transfer to XXX for pharmacologic treatment

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Aggregate Safety Plan/Social Work

replies from OQPC database

Answer to Safety Plan/Social Work

Questionn (%)

Yes 637 (64.0%)

No 313 (31.4%)

Can't Determine 46 (4.6%)

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Answer to Disposition Question on NAS Sustain Form

n (%)

Discharged with mother743

(74.6%)

Discharged with other family member (other than mother)

98(9.8%)

Discharged with foster/adoptive care135

(13.6%)

Other20

(2.0%)

Aggregate Infant Disposition

from OQPC database

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From the American Academy of Pediatrics

During follow-up, infants with NAS particularly require

(1) neurodevelopmental assessments to identify motor deficits, cognitive delays, or

relative microcephaly

(2) psycho-behavioral assessments to identify hyperactivity, impulsivity, and

attention-deficit in preschool-aged children, as well as school absence, school failure,

and other behavioral problems in school-aged children

(3) ophthalmologic assessment to identify nystagmus, strabismus, refractive errors,

and other visual defects

(4) growth and nutritional assessment to identify failure to thrive and short stature

(5) family support assessments to exclude continuous maternal substance abuse and

child abuse.

Parents need to be educated about sudden infant deaths as well as complications

due to perinatal infections. The complexity and challenging nature of the home

atmosphere should never be underestimated in these situations. The importance of

an optimal home environment for the global development of these children should be

emphasized to all parents.

http://pediatrics.aappublications.org/content/134/2/e54723

Follow Up Care of NAS Infants

Neonatal Abstinence Follow Up ClinicCincinnati Children’s Hospital Medical Center

Jennifer McAllister, MD

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NAS Clinic

• Since 2012 we have been following babies

with NAS who were discharged home on

phenobarbital in NICU follow up clinic at

CCHMC

– This arose from a need to have expertise in

weaning these babies from phenobarbital as

well as understanding the NAS patient

– Infants were scheduled among other NICU

follow up babies including former preemies,

surgical babies, and other infants with complex

medical needs

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NAS Clinic

• In 2015, we opened a specialized clinic under our current NICU follow-up clinic dedicated specifically to babies treated for NAS

• Mission Statement:– It is our goal that NAS Clinic is a unique,

comprehensive, collaborative clinic in which we provide care for those infants exposed to opioids prenatally and infants treated for NAS after discharge. We will provide support for parents and caregivers, and we will establish a foundation for long term research on the effects of in utero opioid exposure.

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Referrals

• Our referral base consists of 14 level II and III hospitals in the Greater Cincinnati, Northern Kentucky, Dayton area

• All infants treated for NAS are referred to our clinic

– If they are >32 weeks without other complex medical issues they are seen in NAS clinic

– Otherwise we follow them in regular NICU follow up clinic

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NAS cases FY14-FY16

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Clinic Patients

• We receive 20-25 referrals for new visits

each month

• We see approximately 500 new visits per

year

• We follow from birth until age 2-3 years

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Discharge Disposition

• In a study of NAS follow-up patients, 25% went home with mother, 30% went home with kinship care, 45% went to foster/adoptive families

• At 2 year follow up, 20% with mothers, 35% with kinship care, 45% foster/adoptive families

• Currently, in JFS, 70% of all babies in care are due to substance use

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Services Provided

• Educational information and NAS Clinic Brochure for parents prior to discharge from the hospital

• Appointment scheduled prior to discharge

• Monitoring of ongoing NAS symptoms after hospital discharge

• Weaning instructions for infants on home NAS medications including phenobarbital, clonidine, and gabapentin

• Nutrition counseling and assessment of growth

• Standardized developmental testing and evaluation

• Social services and referrals to community programs

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Our Team

• Clinic visits

– MD/NNP

– OT

– SW

– RD via phone/sometimes in person

• Office Staffing

– M-F, 9-5 RNs field phone calls, referrals, and perform pre-clinic planning

– MD on call 24/7

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Scheduling

• NAS clinic is 1-2 half-days/week at both

Main Campus and Liberty Campus

• First clinic visit within 2 weeks of hospital

discharge

• Subsequent visits every 4-6 months

depending on severity of issues

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NAS Follow Up Clinic

First clinic visit scheduled within 2 weeks of d/c OT and SW evaluation at each new visit

Evaluate home formula and caloric concentration

Next visit in 1 mos

Next visit at 4-6 mos with ASQ-SE• Refer to Ophthalmology if strabismus

present or reported• Vision screening if >6 months• Refer to PT if torticollis present

Next visit at 9-12 mos with ASQ-SE • Refer for Audiology evaluation at 1 year• Vision screening if not previously performed

Next visit at 15-18 mos with ASQ-SE• Schedule Bayley• Hep C testing if recommended• Vision screen if >1 year since last screen

Next visit at 22-26 mos after Bayley performed

• Consider Child Behavior Checklist• Refer to DDBP if needed

• Visits can be scheduled more frequently if necessary

• OT should evaluate any baby with tone issues, developmental concerns, or any child with abnormal ASQ- SE

• Use .NASNOTE template

• Common diagnoses:• Neonatal abstinence syndrome P96.1 (0-28 days only)• Other long term drug therapy (list drug) - if still on medication Z79.899 • Personal history of other drug therapy (list drugs) - if off of meds Z92.29• Perinatal Hepatitis C exposure Z20.5• Screening for developmental handicaps in early childhood Z13.4• Vision screen with abnormal findings Z01.01, without abnormal findings

Z01.00• Abnormal posture, hypertonia• Torticollis, positional plagiocephaly• Diaper rash, thrush

NoHome on adjunct therapy?

Suggested Wean:• No/mild symptoms: cut dose by

50% x1 week, then d/c• Moderate symptoms, cut dose by

25% each week until d/c• Severe symptoms: continue current

dose and re-evaluate at next visit

Yes

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Short and Long Term Issues in the

NAS Patient

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Continued Symptoms of NAS

• Most commonly noted symptoms at follow-

up:

– Periodic fast breathing

– Nasal stuffiness/congestion

– Reflux, spitting up

– Tremors

– Crying spells, irritability

– Mottling

– Hypertonia

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Continued Symptoms of NAS

• Recommendations:

– non-pharmacologic treatment (swaddling, skin to skin, low stimulus environment)

– Calming strategies• 5 S’s

– Overall assessment of functioning: eat, sleep, console

– Stretches, range of motion

– Positions for play

– Tummy time

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Diaper Rash

• Have had babies evaluated in the ED after

hospital discharge due to diaper rash

• Diaper rash recommendations:

– Criticaid and Cavilon if severe and broken

down

– Assess for yeast

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Feeding and Growth• Transition from hospital formula to WIC formula

– Have seen good results with Gerber Soothe

– WIC will allow Enfamil Gentlease with a diagnosis of NAS

– If continued GI distress, we have had success with Alimentum

• We advise 20kcal formula– In clinic, volumes reported are quite high and if

remains on higher calorie, have seen increase weight gain

• Many NAS babies with reflux– Consider treatment if having difficulties with feeding

secondary to reflux

– Consider smaller, frequent feedings

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Breastfeeding• Breastfeeding should be encouraged if

mother’s are in a stable treatment program

• Babies are not at risk for withdrawal as mother’s wean from breastfeeding, little methadone or buprenorphine excreted in breastmilk

• May increase compliance with medication assisted treatment

• Mothers need help after discharge– As many as 60% of those who initiate

breastfeeding stop after 6 days

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Hepatitis C

• Risk of transmission from mother to baby is about 5%

• Transmission depends on concentration of HCV RNA in the mother’s blood– If mother’s have undetectable viral load, risk of transmission very low

– 15-20% of people will spontaneously clear infection and will only have positive antibody

– Up to 10-20% transmission with co-infection with HIV

• HCV RNA testing can be performed as early at 2 months, but is not accurate and would need to be repeated (false negatives)

• Recommendation is HCV antibody testing at 18 months

• Breastfeeding is safe with HCV, mothers should consider pumping if nipples are cracked/bleeding until healed

• Important to receive Hepatitis A and B vaccines for this population

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Torticollis• Incidence of positional/postural torticollis on the rise

since “back to sleep” with associated plagiocephaly

• In the NAS population, we have seen a 6x higher incidence of torticollis than in the general population (11% of infants seen in clinic)

• 2/3 of these infants also have plagiocephaly

• About 1/3 received services through HMG or KY First Steps

• Over 50% required additional Physical Therapy

• Prevention is key, early diagnosis helpful in resolution– Refer to PT if present

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Social Emotional Problems

• At each visit, we are performing Ages and

Stages Social Emotional Questionnaire

• If concerned, consider referral for family

counseling, psychiatry, behavioral pediatrics

– At CCHMC we have Baby TIP (Therapeutic

Interagency Program)

• Early Head Start

• Weekly mental health treatment of child and

parent/guardian

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Sensory Processing Difficulties• Over responders

– Dislike textures in fabric, food, brushing hair, hugging, cuddling, poor sleepers

• Under responders– Lack of awareness to pain, people, “selective hearing,”

poor potty-trainers

• Sensory seekers– Fidgeting, climbing, jumping, “no fear,” impulsive,

making loud noises, sucking, biting

• In NAS clinic, OT will perform sensory profile– Usual recommendation is outpatient

occupational therapy

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Visual Issues

• Nystagmus

• Strabismus

• Reduced acuity

• Delayed visual maturation

• Refractive errors

• Cerebral visual impairment

• Recommend visual screen starting at 6 months– We perform vision screen with Welch Allyn Spot Vision screener

at 6 months and then annually afterwards

– Any nystagmus warrants referral at the time of diagnosis

– If strabismus still present at 4 months would refer at that time

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Behavioral Problems

• Inattention/hyperactivity ADHD

– Up to 20% greater risk, recognized in

preschool age

• Sleep disturbances

• Oppositional/defiant

• Wide range of behavioral issues

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Anesthesia Effects

• May have increased tolerance to opiate

pain medication and anesthesia

• Difficulties with pain/anesthesia control

during surgery and dental procedures

• When performing pre-surgery physicals,

make sure history of in utero opioid

exposure is documented

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Developmental Delays

• In our recent study, we looked at Bayley

exam scores on our NAS patients at 2

years

– We found lower scores for NAS patients

compared to normal infants

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Cognitive, Learning, Memory

• Many studies show poor learning and memory

– Deficits in spatial learning

• Lower scores for intelligence and school readiness

• Large national study in Australia >2000 infants with NAS matched for gestation, socioeconomic status, gender

– Mean test scores in grade 3 significantly lower

– Progressive worsening

– By grade 7, NAS children scored lower than matched children in grade 5

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Future Directions

• Expand to include some exposed but not

treated infants

• Follow patients until age 5 or longer

• Continued research projects

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Resources

• Help Me Grow

• Every Child Succeeds

• Early Head Start

• OT/PT

• Developmental and Behavioral Pediatrics

• Child Psychiatry

• Local agencies in your community

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Questions/Discussion

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Upcoming Conferences of Interest

• American Academy of Pediatrics–Ohio Chapter, October 27-28th

– AAP Ohio Annual Meeting

– Register at http://ohioaap.org/AnnualMeeting

– Panel Discussion: Opiate Crisis in Ohio

• Sean Loudin, MD, FAAP, Marshall University

• Scott Wexelblatt, MD, FAAP, CCHMC

• Sarah Adams, MD, FAAP, Akron Children’s Hospital

• Denise Strimple, NAS Newborn Foster Parent

• Cincinnati Children’s Hospital Medical Center, Friday November 7th

– Changing the Future of Children of Addicted Parents

– Register at https://cchmc.cloud-cme.com/aph.aspx?P=5&EID=20811

– NAS related Breakout Sessions include:

• Neonatal Abstinence Syndrome; Jonathon Davis, MD, Tufts Medical Center

• Medical Care for the Neonatal Abstinence Syndrome (NAS) Patient;

Jennifer McAllister, MD CCHMC

• Navigating Family Involvement with Children’s Services and the Court

System: A Panel Discussion

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Next Steps

• Please continue to submit Data for 2017 (under Sustain tab on SharePoint)

• February: 1 site has not yet submitted any monthly data

• March: 1 site has not yet submitted any monthly data

• April: 1 site has not yet submitted any monthly data

• May: 6 sites have not yet submitted any monthly data

• June: 8 sites have not yet submitted any monthly data

• July: 22 sites have not yet submitted any monthly data

• August: 31 sites have not yet submitted monthly data

• Next Quarterly Sustain Phase Call will be December 19th

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It takes a village…