The Innocent Vic,ms: Neonatal Abs,nence Syndrome Michael Hokenson, MD Assistant Professor of Pediatrics; Division of Neonatology Carla Saunders, NNP-‐BC Advanced Prac@ce Coordinator, East Tennessee Children’s Hospital
Learning Objec,ves • Iden@fy the scope of babies aﬀected by NAS with sta@s@cs and research. • Evaluate treatment programs around the country that work to care for babies with NAS. • Build solu@ons for clinicians to treat babies with NAS.
Disclosure Statement • Michael Hokenson has no ﬁnancial rela@onships with proprietary en@@es that produce health care goods and services. • Carla Saunders has no ﬁnancial rela@onships with proprietary en@@es that produce health care goods and services. An oﬀ-‐label discussion will take place.
Background • Despite growing knowledge, NAS con@nues to challenge us – Es@mated 4.5% of mothers 14 to 45 yrs/old use illicit drugs – ORen overlap with medica@ons for chronic pain and mental illness – 50-‐90% of neonates exposed to heroin in utero may develop signs of withdrawal 1 • Signs/Symptoms may be non-‐speciﬁc 1. Schuckit Marc A. Opioid drug abuse and dependence. Harrisons Principles of Internal Medicine. 17th edn, McGraw-‐Hill: New York, 2008
Challenges • The number of infants coded as (NAS) at d/c are on the rise – Na@onally • 1995-‐ 7,654 infants • 2008-‐ 11,937 infants – In Florida; • 1995-‐ 0.4/1000 live births • 2008-‐ 4.4/1000 live births – Possibly increased awareness, but also prescrip@on pain relief 2 2. Kellogg A, Rose CH, Harms RH, Watson WJ . Current trends in narco@c use in pregnancy and neonatal outcomes. Am J Obstet Gynecol. 2011;204:259
Clinical Presenta,on • A wide variety of drugs in utero may have an eﬀect on infant • Overlap between acute eﬀect and withdrawal of substance • The classic ﬁndings associated with opioid withdrawal are coined (NAS)
Clinical Presenta,on • Infants exposed to opioids in utero – Anywhere from 55-‐94% may exhibit signs of withdrawal 3 • Infants may also display signs of withdrawal if exposed to: – Benzodiazepines – Barbiturates – Alcohol 3. Fricker HS, Segal S . Narco@c addic@on, pregnancy, and the newborn. Am J Dis Child. 1978;132(4):360–366
Clinical Presenta,on • Signs and symptoms • Narco@cs are s@ll the vary in each infant most frequent cause – Will depend on speciﬁc and include: maternal drug(s) – Heroin – Severity of withdrawal may – Methadone not correlate with dose or – Morphine dura@on of exposure – Oxycodone – Codeine – Buprenorphine
Clinical Presenta,on • Narco@cs and Barbiturates – The @me frame for signs of withdrawal from narco@cs may vary greatly • May be present at birth and peak at 3 to 4 days • May not appear for up to two weeks • Subacute withdrawal may occur for 4 to 6 months • Neurologic irritability with abnormal Moro has been reported at 7 and 8 months of age
Clinical Presenta,on • Many systems can be • Common signs include: aﬀected – Hypertonia • The most common are: – Tremors – CNS – Hyperreﬂexia – Gastrointes@nal – High-‐pitched cry – Autonomic nervous – Sleep disturbances system – Occasionally seizures
Clinical Presenta,on • Autonomic dysfunc@on • GI symptoms may may include: include: – Swea@ng – Diarrhea – Low grade fever – Vomi@ng – Nasal conges@on – Poor feeding – Sneezing – Poor swallowing – Yawning – Failure to thrive – Skin mokling • Respiratory signs may also be present – Tachypnea – Apnea
S,mulants • Methamphetamine and cocaine are less common causes – Withdrawal signs have been observed in as few as 4% of infants – Tend to be much less severe than seen in opioid exposed infants – Generally, only 6% of infants exposed to cocaine will require pharmacologic therapy 4 4. Fulroth R, Phillips B, Durand DJ. Perinatal outcome of infants exposed to cocaine and/or heroin in utero. Am J Dis Child. 1989;143 :905 –910
S,mulants • Signs may include: – Tremors – High-‐pitched cry – Irritability – Hyper-‐alertness – Apnea – Tachycardia • Most commonly seen around 72 hours of age
S,mulants • Infants exposed to methamphetamine or cocaine also may exhibit: 5 – Higher rates of prematurity – IUGR – Asphyxia secondary to placental abrup@on • Mul@ple drug use is common in this group – Which will oRen complicate the clinical picture 5. Eyler FD, Behnke M, Garvan CW, Woods NS, Wobie K, Conlon M . Newborn evalua@ons of toxicity and withdrawal related to prenatal cocaine exposure. Neurotoxicol Teratol. 2001;23(5):399–411
Depressants and Seda,ves • Ethanol withdrawal may be seen as early as 3 to 12 hours of life – Physical ﬁndings of FAS may be superimposed • Classic signs of NAS (irritability, poor feeding, crying) may be seen – Although the severity is much less compared to infants exposed to opioids
SSRI’s • Selec@ve Serotonin • Poten@al eﬀects seen in Reuptake Inhibitors: infants exposed are: 7 – Most commonly – Con@nuous crying prescribed medica@on – Irritability for depression 6 – Fever – Tachypnea – Tremors – Hypoglycemia – Seizures 6. Alwan S, Friedman JM . Safety of selec@ve serotonin reuptake inhibitors in pregnancy. CNS Drugs. 2009;23(6):493–509 7. Haddad PM, Pal BR, Clarke P, Wieck A, Sridhiran S . Neonatal symptoms following maternal paroxe@ne treatment: serotonin toxicity or paroxe@ne discon@nua@on syndrome? J Psychopharmacol. 2005;19(5):554–557
SSRI’s • Debate over source of signs and symptoms – Excess serotonin (drug itself) – Low serotonin (withdrawal of drug) • SSRI’s seem to be safe in pregnancy – Many reviews have not shown long term neurodevelopmental impairment 8 8. Mark L. Hudak, MD, Rosemarie C. Tan, MD, PhD, THE COMMITTEE ON DRUGS, and THE COMMITTEE ON FETUS AND NEWBORN. Neonatal Drug Withdrawal. Pediatrics Vol. 129 No. 2 February 1, 2012
Abs,nence scoring systems • Many scoring systems exist – No par@cular one has been adopted as “the standard” • The most comprehensive and widely used is the Finnegan scoring system 9 • The Finnegan scoring system takes 20 of the most common signs and groups them into: – CNS disturbances – Metabolic/Vasomotor/Respiratory disturbances – GI disturbances 9. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abs@nence syndrome: assessment and management. Addict Dis. 1975;2 :141 –158
Finnegan Scores • The signs were ranked according to pathologic signiﬁcance – Those with the least poten@al for adverse aﬀects were given a “1” – Those with the most poten@al for adverse aﬀects were given a “5” – A score of 7 or less is considered mild and babies do well with nonpharmacologic comfort measures – A score of 8 or greater generally indicates that infants may need pharmacologic therapy
Opioid Withdrawal Recap • Mostly aﬀects: – CNS – Autonomic nervous system – Gastrointes@nal system • Other things to keep in mind: – Presenta@on will vary depending upon: • Maternal dose • Placental metabolism • Maternal drug history • Polysubstance abuse
Prematurity • Some studies suggest a lower risk for withdrawal 10 • However, the classic signs may not be present – Scoring systems developed around Term infants – Decreased maturity of CNS system – Less adipose @ssue • Good maternal history and general assessment of infants status is key 10. Liu AJ, Jones MP, Murray H, Cook CM, Nanan R . Perinatal risk factors for the neonatal abs@nence syndrome in infants born to women on methadone maintenance therapy. Aust N Z J Obstet Gynaecol. 2010;50(3):253–258.
Prenatal Screening • Consider prenatal screening if certain risk factors present – Absent/Late prenatal care – Unexplained fetal demise – Placental abrup@on – Large swings in cardiovascular status – Prior history of drug abuse • Can be a delicate issue
Is it NAS? • Be aware of other systemic disorders that may have similar symptoms – Hypoglycemia – Inborn errors metabolism – Calcium dysregula@on – Intracranial process (HIE, hemorrhage) – Uncommon neuromuscular disorders
What to Expect? 11,12 Heroin Methadone Buprenorphine Onset of Usually by 24 Usually 1-‐3 Usually 2-‐3 Symptoms hours days days • However, some infants may not display signs un@l 5-‐7 days 11. Zelson C, Rubio E, Wasserman E . Neonatal narco@c addic@on: 10 year observa@on. Pediatrics. 1971;48(2): 12. Kandall SR, Gartner LM . Late presenta@on of drug withdrawal symptoms in newborns. Am J Dis Child. 1974;127(1):58–61
Treatment • The treatment should begin with non-‐ pharmacologic measures – Gentle handling – Ambient noise control – Swaddling – On demand feeding • Be mindful of infants needs – Caloric requirement, sleep..etc
Pharmacologic Treatment • Pharmacotherapy may be helpful if… – Seizures are present – Weight loss/Dehydra@on • Secondary to vomi@ng and diarrhea – Poor feeding skills • Opioids (morphine/methadone) – Reduce excessive bowel mo@lity – Reduc@on of seizures
Pharmacologic Treatment • What is a concerning score? (Finnegan) – Usually 8 or higher • Goal of therapy? – Allow gradual withdrawal – Absence of excessive excita@on • The length of the weaning process may vary
Morphine vs. Methadone • Morphine – Shorter half life (4-‐16 hours) – Poten@al to “capture” quicker • Methadone – Longer half life (16-‐25 hours) – Less frequent dosing
Na,onwide Children’s Protocol • Enteral morphine based • Ini@ate protocol if – 2 consecu@ve scores above 8 – 1 score above 12 • Both within a 24 hour period • Star@ng dose – Morphine 0.05 mg/kg/dose PO q 3 hours • IV would be 0.02 mg/kg/dose
NCH Protocol Cont. • Escala@on – Increase Morphine by 0.025-‐0.04 mg/kg/dose every 3 hours un@l scores < 8 – If IV, increase by 0.01 mg/kg/dose • Rescue dose – If scores are s@ll above 12 • Double the previous dose x 1 • If s@ll above 12, increase dose by 50% – Un@l captured • Rescue dose only in ini@al phase
NCH Protocol Cont. • Stabiliza@on – Once captured (scores <8) con@nue maintenance dose for 72-‐96 hours • Weaning – Following the above, wean by 10% every 24 to 48 hours – Do not rou@nely weight adjust meds – Drug may be d/c’ed when a single dose is < 0.02 mg/kg/dose q 3 hours
NCH Protocol Cont. • Problems with weaning – If scores following a wean are above 8 • Ensure comfort measures – Maximize swaddling – Holding – Decreased s@muli – Go back to dose where infant was stable – Do not use rescue dose – Consider weaning at longer intervals • 48 hours vs 24 hours – Monitor for 48-‐72 hours prior to d/c
Adjunct Therapy • Consider a second agent if: – Infant has 2 consecu@ve weaning failures – No progress in weaning oﬀ morphine by day 14 – May be added earlier • Based on infants symptoms • Maternal history
Adjunct Therapy • Phenobarbital – Binds to GABA receptors – Helps with CNS issues such as • Irritability, sleeplessness and tone – Has been shown to reduce LOS, and severity of withdrawal 13 13. Coyle MG, Ferguson A, Lagasse L, Oh W, Lester B. Diluted @ncture of opium (DTO) and phenobarbital versus DTO alone for neonatal opiate withdrawal in term infants. J Pediatr 2002; 140(5): 561–564
Adjunct Therapy • Phenobarbital may be beneﬁcial if – CNS symptoms predominate • (Hyperac@ve reﬂexes, tremors, increased tone) – History of polysubstance abuse
Adjunct Therapy • Cau@ons with phenobarbital – Poten@al to oversedate – Impaired feeding – Drug interac@ons – Longer half life (45-‐100hr) – Alcohol content (15%)
Adjunct Therapy • Clonidine – Alpha 2 adrenergic receptor agonist • Ac@vates inhibitory neurons • Reduced sympathe@c tone – Has been shown to help with • Faster stabiliza@on • Decreased dosing requirements of opioid therapy 14 14. Agthe AG, Kim GR, Mathias KB, Hendrix CW, Chavez-‐Valdez R, Jansson L et al. Clonidine as an adjunct therapy to opioids for neonatal abs@nence syndrome: a randomized, controlled trial. Pediatrics 2009; 123(5): e849–e856
Adjunct Therapy • Clonidine – May be useful if majority of symptoms are in the autonomic category • (swea@ng, fever, yawning, mokling..etc) – Monitor for hypotension and bradycardia – Avoid rapid discon@nua@on – Observe for 48 hours oﬀ prior to d/c • Do not recommend treatment as outpa@ent
Prenatal Counseling • Many mothers feel anxiety and guilt – Clinicians should be prepared to be empathe@c and nonjudgmental • Essen@al components to prenatal counseling include: – Poten@al for teratogenicity – Expected clinical course – Breasueeding and Lacta@on – Social considera@ons
Social Considera,ons • Be empathe@c and nonjudgmental • Be aware of maternal psychosocial status – Is there signs of postpartum depression? – Is counseling a reasonable resource? • Always be honest – Not every baby follows the rules – Updates frequently regarding status
The Innocent Vic@ms: Neonatal Abs@nence Syndrome Carla Saunders, NNP-‐BC
Epidemiology NIDA es@mates $600 billion is spent annually on costs associated with substance abuse in U.S. American Diabetes Associa@on es@mates annual costs associated with diabetes is $174 billion in 2007. Na@onal Cancer Ins@tute es@mates $125 billion in annual costs for cancer care in 2010. • 2009 Na@onal Survey on Drug Use and Health: • 4.5 percent of pregnant women aged 15 to 44 have used illicit drugs in the past month. • In 2008 there were 9430 babies born in Knox County according to Knox County hospitals birth records: Es@mated 424 babies born annually in Knox County whose mother used illicit drugs in the past month. • 2009 Key Birth Stats from CDC report 4,131,019 births in U.S. • Approximately 186,000 babies born to mothers who used illicit drugs in past month 1. NIDA InfoFacts: Understanding Drug Abuse and Addic@on. Na@onal Ins@tute on Drug Abuse. hkp://www.drugabuse.gov/infofacts/understand.html. Accessed May 28, 2011 2. Diabetes Cost Calculator. American Diabetes Associa@on. hkp://www.diabetesarchive.net/advocacy-‐and-‐legalresources/cost-‐of-‐diabetes.jsp. Accessed May 28, 2011. 3. The Cost of Cancer. Na@onal Cancer Ins@tute. hkp://www.cancer.gov/aboutnci/servingpeople/cancer-‐sta@s@cs/costofcancer. Accessed May 28, 2011. 4. Substance Abuse and Mental Health Services Administra@on. (2010). Results from the 2009 NaMonal Survey on Drug Use and Health: Volume I. Summary of NaMonal Findings (Oﬃce of Applied Studies, NSDUH Series H-‐38A, HHS Publica@on No. SMA 10-‐4856Findings). Rockville, MD. 5. Number of Babies Born. Kids Count Data Center. hkp://datacenter.kidscount.org/data/bystate/Rankings.aspx?state=TN&ind=2996. Accessed May 27, 2011.
1999 Veterans Health Admin. Ini,a,ve: “Pain as the 5th Vital Sign” JCAHO ins,tute pain standards in 2001 Cocaine Heroin
Tolerance – Dependence – Addic@on • Tolerance – Our body develops tolerance to a drug’s eﬀect so that an increased amount of drug is required to produce eﬀect. • Dependence – If the supply of the drug is removed then the person will exhibit “withdrawal symptoms”. • Addic@on – The con@nuing, compulsive nature of the drug use despite physical and/or psychological harm to the user and society
Unique Concerns for the Substance Abusing woman US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
Substance Use Treatment among Women of Childbearing Age Substance Abuse and Mental Health Services Administration, Office of Applied Studies.(October 4, 2007). The NSDUH Report: Substance Use Treatment among Women ofChildrearing Age. Rockville, MD.
Return on Investment • For every $1 spent on addic@on treatment programs – $4 to $7 saved in reduced drug-‐related crime, criminal jus@ce, and theR – Up to $12 saved when including health-‐care costs – Other considera@ons • Neonatal abs@nence syndrome might be reduced NIDA. Principles of Drug Addiction Treatment, A research-based Guide. NIH Publication No. 09-4180. April 2009 • Greater workplace produc@vity
Incidence of Maternal Opiate Use and NAS Maternal Opiate Use increased x 5 NAS Incidence tripled Patrick, S. W. et al. JAMA 2012;307:1934-1940
Why do expectant mothers use drugs? Prior injury / chronic pain Medical need for pain management Appropriately managed Inappropriately managed In a substance abuse treatment program Confusion between symptoms of withdrawal and pregnancy.
Why do MDs con@nue to prescribe? • ACOG Guidelines and SAMSHA Guildelines recommend to con@nue methadone (possibly buprenorphine) • “Lesser of two evils” – Risky drug-‐seeking behaviors – Goals of quelling cravings – Prevent mini-‐withdrawals – Ceiling eﬀect of being in treatment • Methadone, suboxone, subutex – Reveal danger of I.V. suboxone
“Standard of care for pregnant women with opioid dependence: referral for opioid-‐assisted therapy with methadone…emerging evidence suggests that buprenorphine also should be considered.” Abrupt d/c of opioids can result in preterm labor, fetal distress, or fetal demise During intrapartum/postpartum period, special considera@ons are needed…ensure appropriate pain management, prevent postpartum relapse, prevent risk of overdose, ensure adequate contracep@on.
Prenatal Care is Vital • “Adequate prenatal care oRen deﬁnes the diﬀerence between rou@ne and high-‐risk pregnancy and between good and bad pregnancy outcomes. Timely ini@a@on of prenatal care remains a problem na@onwide, and it is overrepresented among women with substance use disorders. In part, the threat of legal consequences for using during pregnancy and limited substance abuse treatment facili@es (only 14 percent) that oﬀer special programs for pregnant women (SAMHSA 2007) are key obstacles to care.” US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
Early Interven@on • Window of opportunity – “Brief interven@ons can provide an opening to engage women in a process that may lead toward treatment and wellness.” • Pregnancy creates a sense of urgency to – Enter treatment – Become abs@nent – Eliminate high-‐risk behaviors US Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration. SubstanceAbuse Treatment: Addressing the Specific Needs of Women; TIP 51. DHHS 2009.
NAS Incidence in the U.S. Patrick, S. W. et al. JAMA 2012;307:1934-1940
TennCare Office of Healthcare Informatics. Neonatal Abstinence Syndrome among TennCare enrollees. September,2012.
American Academy of Pediatrics (AAP) Guidelines “Reported rates of illicit drug use…underes@mate true rates…” 55 to 94% of neonates exposed to opioids in utero will develop withdrawal signs. Each nursery that cares for infants with NAS should develop protocol for screening for maternal substance abuse Screening is best accomplished by using mul@ple methods Maternal history Maternal urine tes/ng Tes@ng of newborn urine/meconium May consider umbilical cord samples Hudak ML, Tan RC, The Committee on Drugs and The Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.
AAP Guidelines -‐ Newborn Observa@on Risk Factors Recommenda,on • No prenatal care • Observe in the hospital • Limited prenatal care for 4 to 7 days • History of substance use • Early outpa@ent or abuse followup • Any posi@ve screen – Reinforce caregiver educa@on about late during pregnancy withdrawal signs • Posi@ve UDS on admission Hudak ML, Tan RC, The Commikee on Drugs and The Commikee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.
American Academy of Pediatrics (AAP) Guidelines • Pharmacologic interven@ons include: – oral morphine solu@on, or methadone as primary therapy – Increasing evidence for clonidine as primary or adjunc@ve therapy – Buprenorphine use as primary or adjunc@ve therapy is also increasing – Treatment for polysubstance exposure may include opioid, phenobarbital, and clonidine in combina@on. Hudak ML, Tan RC, The Commikee on Drugs and The Commikee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129:e540e560.
ETCH Haslam Neonatal Intensive Care • Unit 152 beds / Level III NICU – 60 beds – About 30 % of our NICU admissions primarily for NAS treatment – 135 admissions for 2011 – 283 admissions for 2012 • ProjecMng 315 for 2013 – Highest daily census: 37 in September, 2012 Average Daily Census for NAS babies 1st Quarter (JAN-‐MAR) 4th Quarter (OCT-‐DEC) 2011 8 18 2012 29 27
Our rate of admissions is almost 1 baby every day…
Previous Treatment Plan Goal: Stabilize on meds and discharge to wean Drugs: Methadone and Phenobarbital No consistent approach to ini@a@on of meds, dosing, or weaning or criteria for discharge Avg LOS: 16 days to discharge on meds Confusion of staﬀ and families about treatment and expecta@ons
Discharge Support • Discharged only to DCS approved caregivers • Discharged with weaning schedule • Dedicated pediatric follow up • Physiatry follow up • DCS services in the home • Home health nursing visits with social work support
Factors for Change in Treatment Plan Realiza,on that safety plan was failing Barriers to compliance Caregiver resistance (biological/foster) Caregiver changes Drug diversion Outpa@ent management issues About 80% of discharged NAS infants do not keep follow-‐up Pediatrician refusal to manage weans Observa@ons that babies were not receiving meds Issues with retail pharmacy comfort/availability of methadone Former NAS infant, D/C on methadone, presents DOA at ETCH-‐ED
ETCH Mul@disciplinary Team Medical team (NNP lead) PT/OT and Speech Pharmacy Child Life Staﬀ nurses Volunteer Services Administra@on Security Pa@ent Care Coordinator Nutri@on Services Social Work PCAs Lacta@on Unit Secretaries Physiatry Service Excellence
Project Objec@ves Develop a treatment plan to treat NAS that will: Iden@fy neonates at risk for NAS Consistently evaluate the presence and severity of withdrawal symptoms Standardize and simplify the opioid withdrawal treatment plan Ini@ate appropriate non-‐pharmacological interven@ons and pharmacotherapy to control symptoms Safely minimize length-‐of-‐stay: Wean the opioid-‐dependent infant as quickly as possible while providing good control of withdrawal symptoms Discharge infant weaned from NAS pharmacotherapy Will not require outpaMent management of methadone
Morphine Algorithm Literature review Goals for protocol Safe EﬀecMve Quick Iden@ﬁed treatment plan symptom-‐based protocol Dr. Jansson /Johns Hopkins Adapted protocol Simple to use Standardize treatment decisions.
Typical course of treatment • 70 % of NAS babies • 30 % of NAS babies – Wean in 20 days – Wean in 60 days – No adjunc@ve meds – Require adjunc@ve meds • Phenobarbital (27%) – LOS 24 days • Phenobarbital +Clonidine (7%) – LOS 68 days • (longest LOS = 155 days)
Unique Challenges Environment Work load Nursing Pharmacy Social Work Rehabilita@on Services Volunteer Services Security
Emo@onal Challenges • A_tudes / PercepMons • Family / Caregiver Issues • Preventable nature of • Personal addic@on of condi@on parents • Personal prejudices • Mental health issues • Literacy problems • Feelings • Comprehension/ • Confusion / fear reten@on issues – HIPPA concerns – Ethical Issues • FaMgue/exhausMon/burnout Educa/onal deﬁcit regarding the science of addic/on
Public Health Issues NICU beds taken by infants whose only need is withdrawal treatment Behavioral issues in childhood Schools – teacher retraining Poten@al long-‐term public health issue Genera@onal addic@on problems 2nd and 3rd genera@onal behaviors sustained Gene@c predisposi@on? Does intrauterine exposure ac@vate gene in utero? Does NAS treatment complicate addic@ve tendencies?
Long-‐Term Consequences of NAS • At risk for: – Aken@@on deﬁcit disorder – Hyperac@vity – Diﬃculty transi@oning between tasks – Impulse-‐control – Sleep disorders – Sensory disorders – Future risk of addic@ve behavior
Lessons Learned • Withdrawal outpa@ent is unreliable even unsafe • Withdrawal is not linear • Consistency is invaluable • Data drives success • Challenges are unique to this pa@ent popula@on • Scoring tools are not designed for older neonate • Early capture may lead to decreased LOS
More lessons…. • Not all drug “screens” are created equal • Collect meconium from ﬁrst stool to transi@on • Maternal histories are not always reliable • Mother can be posi@ve and baby nega@ve • Addic@on knows no boundaries • If it “quacks”…. You will likely discover it IS a duck!
Summary • The impact of NAS does not end in the NICU. • Long-‐term beneﬁts to both the healthcare system and society are signiﬁcant. • Prenatal care in the otherwise healthy woman is widely accepted to be beneﬁcial to mothers and babies. • We must do all we can to promote prenatal care and substance abuse treatment/counseling in this high-‐risk popula@on. • Incen@ves to seek help may allow more opportuni@es for the woman to receive successful treatment with lifelong beneﬁts.
Shoot for the moon,even if you miss you’ll land among the stars.