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Neonatal Abstinence Syndrome Project

Action Period Call

Ohio Perinatal Quality Collaborative March 2015

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Time Topic Presenter

3:00 pm Welcome & Agenda Review Andrea Hoberman, MPH

3:05 pm Data Overview – February Results

Scott Wexelblatt, MD

3:15 pm NAS: Breastfeeding Benefits and Challenges

Presenter 1 Presenter 2

3:45 pm Sharing Seamlessly - Team Discussion All teams

3:55 pm Next Steps •Data Submission Reminder •MPR/PDSA Reminder •Unit Comparison Tool

Andrea Hoberman, MPH

Agenda

Roll Call: Please sign in with your hospital affiliation and the

names of your team members on the call in the Question box

Promedica Toledo Children’s

Miami Valley

Mercy Anderson

Aultman

Mt. Carmel East OSU

UH Rainbow Babies & Children’s

Bethesda North Hospital

Nationwide Dublin Methodist

Akron Children’s Summa

Cincinnati Children’s

Hillcrest Hospital Fairview Hospital

Cleveland Clinic

Dayton Children’s

Nationwide Riverside Methodist

Nationwide Grant

Nationwide Mt. Carmel St. Ann’s

UH Cincinnati

Good Samaritan Hospital

MetroHealth

Mt. Carmel West Nationwide Doctor’s

Akron Children’s

Nationwide Children’s

Mercy Children’s Hospital

Atrium Medical Center

Fort Hamilton

Mercy Hospital Fairfield

Mercy Medical Center Canton

The Christ Hospital

St. Rita’s Medical Center

Southview Medical Center

Good Samaritan Hospital Dayton

Kettering

Mercy Health West

Southern Ohio Medical Center

Genesis Healthcare System

OhioHealth MedCentral Mansfield

Marion General

Elyria Medical Center -UH

Mercy Regional Medical Center Lorain ProMedica

Bay Park

Lima Memorial Health System

Springfield Regional Medical Center

Adena Regional

Medical Center

Soin Medical Center

Upper Valley Medical Center

Licking Memorial Health System

NAS Participating Sites 2014

1/2014 start Level 3 and Level 2 teams

Akron Children’s

St. Elizabeth Health

Center/Mahoning Valley

Trumbull Memorial

4/2014 start Level 2 teams

Key Driver Diagram Project 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 20% across participating sites by June 30, 2015.

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 Mom Implement 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

OPQC Neonatal BSI/HM Project

Data (Blood Stream

Infection/Human Milk)

Breastfeeding for the NAS Infant Key Driver: Optimize Non-Pharmacologic Rx Bundle Intervention: Feed on demand- MBM if appropriate

Teams Breastfeeding Protocol as reported on February MPR (n=36)

Breastfeeding in the Opiate- Dependent Mother

Presenter 1

Breastfeeding and Human Milk in the General Population

• Well-documented Infant Benefits – bacteremia – diarrhea – respiratory tract infection – necrotizing enterocolitis – otitis media – urinary tract infection – late-onset sepsis in preterm infants – type 1 and type 2 diabetes – lymphoma, leukemia, and Hodgkin's disease – childhood overweight and obesity – SIDS: especially in the exclusively breastfed population Pediatrics Vol. 129 No. 3 March 1, 2012

pp. e827 -e841

Breastfeeding and Human Milk in the General Population

• Well-documented Maternal Benefits – decreased postpartum bleeding and more

rapid uterine involution – decreased menstrual blood loss and

increased child spacing (lactational amenorrhea)

– earlier return to pre-pregnancy weight – decreased risk of breast and ovarian cancers

Pediatrics Vol. 129 No. 3 March 1, 2012 pp. e827 -e841

Breastfeeding and Human Milk in the General Population

• In 2012 the AAP updated its guidelines:

– “The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”

Pediatrics Vol. 129 No. 3 March 1, 2012 pp. e827 -e841

Breastfeeding and Human Milk in the General Population

• In spite of this clear recommendation: – The rate of initiation of breastfeeding for the total US population based

on the latest National Immunization Survey data are 75%. – Hispanic or Latino population = 80.6%, non-Hispanic black or African

American population = 58.1%. – Among low-income mothers (participants in the Special Supplemental

Nutrition Program for Women, Infants, and Children [WIC]), the breastfeeding initiation rate was 67.5%,

– Ineligible for WIC, initiation was 84.6%. – Breastfeeding initiation rate was 37% for low-income non-Hispanic black

mothers. – Similar disparities are age-related; mothers younger than 20 years

initiated breastfeeding at a rate of 59.7% compared with the rate of 79.3% in mothers older than 30 years

– The lowest rates of initiation were seen among non-Hispanic black mothers younger than 20 years, in whom the breastfeeding initiation rate was 30%.7

Pediatrics Vol. 129 No. 3 March 1, 2012 pp. e827 -e841

Breastfeeding and Human Milk in the General Population

• Although over the past decade, there has been a modest increase in the rate of “any breastfeeding” at 3 and 6 months, in none of the subgroups have the Healthy People 2010 targets been reached.

• The 6-month “any breastfeeding” rate for the total US population was 43%, the rate for the Hispanic or Latino subgroup was 46%, and the rate for the non-Hispanic black or African American subgroup was only 27.5%.

• • Rates of exclusive breastfeeding are further from Healthy

People 2010 targets, with only 13% of the US population meeting the recommendation to breastfeed exclusively for 6 months. Pediatrics Vol. 129 No. 3 March 1, 2012

pp. e827 -e841

Breastfeeding in the Opiate-Dependent Population

• Overall rates of breastfeeding are low

• >50% of those who initiate breastfeeding discontinue within 1 week

• Cautions to consider: lethargy, respiratory difficulty, and poor weight gain in infants of opiate-dependent mothers

Methadone Levels and Breastfeeding

• Studies have shown that infant serum levels of methadone are typically low, <3% of maternal levels or undetectable

Wojnar-Horton RE, Kristensen JH, Yapp P, et al. Methadone distribution and excretion into breast milk of clients in a methadone maintenance programme. Br J Clin Pharmacol 1997; 44:543.

Buprenorphine Levels in Breast milk

• Studies have found that the amount of buprenorphine and its metabolite (norbuprenorphine) that accumulates in breast milk is small and thus unlikely to negatively affect infants.

Oxycodone Levels and Breast milk

• In a study of 50 mothers taking oxycodone post-cesarean section, 45 blood samples were taken from 41 breastfed infants at 24, 48 or 72 hours postpartum. Only 1 of the samples had a detectable (>2 mcg/L) oxycodone level of 7.4 mcg/L.

Seaton S, Reeves M, McLean S. Oxycodone as a component of multimodal analgesia for lactating mothers after Caesarean section: Relationships between maternal plasma, breast milk and neonatal plasma levels. Aust N Z J Obstet Gynaecol. 2007;47:181-5. PMID: 17550483 http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

Non-Nutritive Benefits of Breastfeeding

• Promotes mother-infant bonding – Breastfeeding indicative of a mothering style that

is frequently accompanied by more maternal contact

– Promotes infant attachment

• Promotes passive immunity

• May be associated with less postpartum depression

Breastfeeding and NAS

• Babies exposed to methadone in utero who were breastfed were less apt to require treatment for NAS

• Length of stay significantly less than formula fed babies

Breastfeeding and NAS

• Breastfeeding initiated at birth and continued for at least 72 hours has been shown to decrease the severity of NAS and need for pharmacologic treatment

Breastfeeding and NAS

• It is unknown if pumped breast milk has the same benefits as feeding at the breast.

Skin-to-Skin contact

• Positively affects maternal feelings toward their infant – Oxytocin effect

• Infants cry less • Mothers more likely to breastfeed in the

first 1-4 months and continue longer than those who did not initiate skin to skin at birth

How to increase rates of Breastfeeding in this Population

• Uniform in our message of safety, with

reinforcement throughout their prenatal journey

• Promote skin-to-skin • Increased availability of lactation support • Social support

Breastfeeding & NAS Legal Implications

Presenter 2

OPQC Webinar March 2015

Disclaimer

Why Would Administration Forbid Breastfeeding?

Fear that is illegal or violates rules – JCAHO, Maternity licensure, etc.

Fear of headlines / negative publicity Fear of liability / malpractice lawsuits

Dike v. School Board of Orange County Florida

650 F.2d 783 (1981)

“Breastfeeding is the most elemental form of parental care. It is a communion between mother and child that, like marriage, is "intimate to the degree of being sacred,”

In light of the spectrum of interests that the Supreme Court has held specially protected we conclude that the Constitution protects from excessive state interference a woman's decision respecting breastfeeding her child.

Alexis Greene

• Born September 2010 • Fourth child of Stephanie Greene – Full term, healthy, breastfed • November 13 (46 days old) Alexis is found unresponsive in bed • Mom calls 911 – “sounds groggy and unfocused,” unable to do CPR – Alexis dies • Investigators at the scene find dozens of pill bottles and painkiller patches on her nightstand where the couple’s 4 year old son could get to them • Toxicology report – Morphine level in Alexis could have been lethal for an adult

Gordon Wiltsie / National Geographic Image Collection

CBS

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Breastfeeding Legislation

46 states have laws that specifically allow women to breastfeed in public

29 states exempt breastfeeding from public indecency laws

25 states have laws protecting breastfeeding in the workplace

16 states – no jury duty while breastfeeding 5 states – breastfeeding education campaigns

Medical Practice is mainly regulated by the State

Ohio Law

3781.55 Breast-feeding in places of public accommodation.

A mother is entitled to breast-feed her baby in any location of a place of public accommodation wherein the mother otherwise is permitted.

Maternity Licensure

Ohio Administrative Code – Level I service standards – 3701-7-09(L)(5)

Each provider shall have on-staff or available for consultation, qualified staff appropriate for the services provided including a certified lactation consultant.

JCAHO Perinatal Care Core Measure Set* PC-01 Elective Delivery PC-02 Cesarean Section PC-03 Antenatal Steroids PC-04 Health Care Associated Bloodstream

Infections in Newborns PC-05 Exclusive Breast Milk Feeding PC-05a Exclusive Breast Milk Feeding

Considering Mother’s Choice *Mandatory for Hospitals with 1,100 or More Births per Year

Why Would Administration Forbid Breastfeeding?

Fear that is illegal or violates rules – JCAHO, Maternity licensure, etc.

Fear of headlines / negative publicity Fear of liability / malpractice lawsuits

Why Would Administration Forbid Breastfeeding?

Fear that is illegal or violates rules – JCAHO, Maternity licensure, etc.

Fear of headlines / negative publicity Fear of liability / malpractice lawsuits

Standard of Care is a Legal Concept!

AAP Policy Statement: Breastfeeding and the use

of human milk 2012 - Section on Breastfeeding “Maternal substance abuse is not a

categorical contraindication to breastfeeding.”

“[N]arcotic-dependent mothers can be encouraged to breastfeed

IF….”

AAP Policy Statement

Adequately nourished Enrolled in a supervised methadone

maintenance program Have negative screening for HIV Have negative screening for illicit drugs “minimize” alcohol use

– Limit 2 oz liquor or 8 oz wine or 2 beers – Wait to nurse until 2 hours after alcohol use

ABM CP #21

Academy of Breastfeeding Medicine CP #21

Academy of Breastfeeding Medicine CP #21

Conclusions While no law forbids breastfeeding w/ NAS,

some women have been prosecuted JCAHO encourages Breastfeeding when safe Work collaboratively with administration to:

– Understand their concerns – Educate them on best practices – Implement care where, as recommended by

ABM, “each mother–infant dyad” is “carefully and individually evaluated prior to the institution of breastfeeding.”

Questions and Team Discussion

• What challenges or successes have you seen at your site involving breastfeeding NAS infants?

• Questions?

Unit Protocol Comparison Survey

Unit Protocol Comparison Survey

Next Steps • Continue testing small tests of change (PDSA)

• Look for and complete the Unit Protocol Comparison

Survey by April 6th. • Please submit NAS Data by March 30th. Remember

to please submit and check “No Eligible Babies for the Month” if there were no NAS patients at your site.

• Monthly Progress Report will be sent to Key

Contacts this Friday; due March 30th

The OPQC NAS Project is funded by The Ohio

Department of Medicaid