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

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!

Escalating national impact of substance use

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

Background

NAS Scoring System

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.

The Problem

OperationalEnvironmentalClinical InterventionsFamily InvolvementData ManagementStaff and Physician relations

Themes to Consider Throughout the Continuum of

Care

Finding and Using Non-Pharmacologic, Supportive

Interventions First

Partnership with family regarding approach to care◦Prenatal preparation, engagement and holding◦Begin low stimulation in Family Care area –

keep baby with parents when possibleAccess to care areas restrictedAll conversations in whispersIndirect and dimmed lightingStrict grouping of caresDiscerning 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

Non-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!

Pharmacologic Methods

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Aurora Initiative to Reduce LOS for Infants Treated for Neonatal Abstinence Syndrome

LOS Mean -2 STDev=0 +2 STDev -3 STDev=0 +3 STDev

NAS Protocol Communicated Begin to Consider

24 Hour Option

Wisconsin Centers: 7

Affinity NICU at St. Elizabeth HospitalAspirus Wausau HospitalAurora Baycare Medical CenterAurora Sinai Medical CenterAurora Women's PavilionGundersen Lutheran Medical CenterWheaton Franciscan Healthcare at St. Joseph

VON Quality Audit #6 – NAS Unit 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

VON Quality Audits 5 and 6 NAS Patient Data

2015 Initiative 18 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

2 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 - WINpqcNAS - 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 Survey100% “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”.

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

Improvement Methods – Breastfeeding

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:o Consent for discussion with

SA providero Counselor agrees with plan

for breast milk o 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

 

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

Improvement Methods – Nutrition

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◦ Ready to feed, sterile

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

Specialty Formulas

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 commonConsider indwelling

NG tube with pump feedings

Effects on Oral Feeding:Physiologic stabilityState regulationOrganization Oral-motor/ sensory skillCoordination of suck-swallow-

breatheActive engagement Pleasurable Experience

Physiologic StabilityQuestions 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 swallowingSTRESS CUES

Active ParticipationShould 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: o Poor coordination of airway protectiono Defensive feeding behaviorso 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 grimaceGagging/ vomitingCoughing/chokingEyebrow raiseFurrowed eye

brows/ “Worried look”

High pitched “crowing sound” / Stridor

Nasal flaring/blanching

Head bobbing (increased breathing rate)

RetractingColor changeOxygen

desaturation Drop in heart rate GulpingMultiple swallowsDrooling

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

Increase parental engagementPartner with community agencies

to improve transitions and continuity of care.

Local, state, and national sharing of protocols and pooling of data

Gather long-term outcomesNon-NICU setting for NAS service.

Current Initiatives

Improvement in care practices Influence policy at all levels

◦Standards, funding, ? legislationNational

◦Vermont-Oxford Neonatal NetworkState

◦Wisconsin Neonatal Perinatal Quality Collaborative

WIC !!

Current Initiatives

Thank You!