WAPC Webinar Series: Improving Care for Women and Infants Affected by Opioids What’s New in NAS ? July 13, 2015 Janice Ancona, MSN, RN Wheaton Franciscan - St Joseph Campus
Disclosures • Successful completion: Registrants must attend the full session and complete the evaluation to receive continuing education credit. • Janice Ancona has no disclosures and no conflicts of interest. • All medications used in the treatment of NAS are used off label.
Before we begin… • Listen-only mode • Questions – please ask, please answer! – Raise your hand – Type into the Question Pane – Out of time? Email wapc@perinatalweb.org • Technical problems: Email Barb Wienholtz at wienholtz@perinatalweb.org or call at 608-285-5858, ext. 201
Objectives At the conclusion of this presentation, participants will be able to: • Articulate criteria for weaning morphine at 24-hour intervals. • Identify two non-pharmacologic strategies for care of infants experiencing NAS that would apply to their practice setting.
Introduction • More maternal opiate use means---- • More neonates with neonatal abstinence syndromes downstream which means--- • More nurseries filled with withdrawing kids and thus---- • Until the river of moms exposed to opiates is stopped at the source (i.e. before they get pregnant) we will be faced with a continued flow on withdrawing neonates.
AAP guidelines of 2012 state: … each nursery should develop and adhere to a standardized plan for the evaluation and comprehensive treatment of infants at risk for or showing signs of withdrawal Hudak ML et al, Pediatrics, 2012
Clinical Guidelines for Pharmacologic Treatment of Neonatal Abstinence Syndrome (NAS) • Developed by: – Toby Cohen, Aurora Bay Care – Miles Tsuji, NCP – Carey Ehlert, MCW – Jan Ancona, Wheaton – Sue Kannenberg, Wheaton – Jeffery Garland, Wheaton, NCP, Aurora Sinai
Length of Stay Reduction: Quality Improvement Project for Neonatal Abstinence Syndrome National Children’s Hospital, Columbus, Ohio Richard E. McClead Jr., MD Medical Director, Quality Improvement Services
Measures to Reduce LO S 1. Develop Oral Morphine Protocol 2. Train Mother-Infant Staff in Finnegan scoring system 3. Established relationships with Maternal Providers 4. Obtained March of Dimes grant to educate pregnant women attending a local methadone clinic re NAS 5. Establish an NAS Developmental Follow-up clinic 6. Developed NAS Clinical Guideline
A Multicenter Cohort Study of Treatments and Hospital Outcomes in Neonatal Abstinence Syndrome (Hall ES, et al. Pediatrics, August 2014) 547 treated NAS kids in 20 hospitals in Ohio (2012-2013) 417- managed with established NAS weaning protocol 130 -without protocol driven weaning LOS ---------- 32.1 vs 22.7 days, P=0.004 Opiate Rx --- 32.1 vs 17.7 days, P<0.0001
Agreed on NAS Treatment Guidelines Yes, Guidelines (not policy, not protocol)
Guidelines 1. Send urine and meconium for toxicology screening for suspected drugs as soon as possible post -delivery for infants at risk for NAS. – (Hudak ML et al. Pediatrics 2012) 2. Begin NAS scoring every 3-4 hours with feedings for infants at risk for NAS. – (Finnegan’s Neonatal abstinence scoring tool -Finnegan LP. In: Nelson NM, ed. Current Therapy in Neonatal – Perinatal Medicine, 1990) 3. Social service consult/Breast Feed – (Social service consult a given) – PBP 6 for VON Initiative - develop clear eligibility criteria for breastfeeding and actively promote and support breastfeeding by eligible mothers. 4. Begin nursing care protocol for NAS infant.
Guidelines 5. If withdrawal symptoms do not require drug treatment, may discharge from nursery after 5-7 days. (AAP guidelines: 4-7 days in one section and 3-7 days elsewhere in the guideline) • a. Some newborn nurseries may require transfer to NICU when mother is discharged. Some units may chose to admit directly to NICU (PBP 4 for VON Initiative-Provide care for infants and families in sites that promote parental engagement in care and avoid separation of mothers and infants ) • b. Discharge requires satisfactory social service evaluation.
Guidelines • 6. Consider beginning pharmacologic treatment if three consecutive NAS scores ≥8 or if two NAS scores are > 12. • 7. Start oral morphine solution with feedings, usually Q 3-4 hours with a total of 6-8 doses per day. • 8. Initial dosing: – A. 0.04-0.1 mg/kg/dose – B. Suggested dosing of NAS based on Finnegan scores:
Finnegan Scores Morphine total Morphine daily dose Single Dose (administer q 3-4 (if given on a q 3 hours with feedings) hour schedule) 9-10 0.32 mg/kg/day .04 mg/kg 11-13 0.48 mg/kg/day .06 mg/kg 14-16 0.64 mg/kg/day .08 mg/kg 17 + 0.8 mg/kg/day 0.1 mg/kg
• C. If NAS scores remain elevated despite initial dosing, increase morphine by: – 1. 0.02 mg/kg/dose if NAS scores 9-10 – 2. 0.04 mg/kg/dose if NAS scores > 10 • D. Goal “capture” within 24 -48 hours of initiating treatment • E. Maximum dose 0.2 mg/kg/dose
• 8. Methadone is an acceptable treatment alternative for morphine; however, it is used less frequently and not acceptable for outpatient usage unless clinics are developed • 9. Consider adding clonidine early if morphine dose >0.1 mg/kg/dose or if significant insomnia or diarrhea symptoms exist. (Agthe AG et al. Pediatrics 2009)
• 10. Consider adding phenobarbital for infants exposed to a poly-drug using mother. • 11. Dosing for secondary line of drugs: – a. Clonidine: 0.5-2.0 mcg/kg q 6 hrs. – b. Phenobarbital: 5 mg/kg/day
Weaning 1. After the infant is “captured” for at least 48 • hours wean morphine by 10 % of the maximum dose in mg/dose every 48 hours. • 2. Weaning can be done every day if NAS scores are stable and <9; however, consider weaning by 5% of the maximum. • 3. More rapid weaning or even holding a dose may be necessary if the initial dosing is too high for the infant.
Weaning • 4. If three scores in a 24-hour period are > 8-10 or two scores > 12, consider increasing the dose back to the last stable dose and holding at that dose for 24-48 hours before restarting weaning process. • 5. When the total dose is < 0.2 mg/kg/day (0.025 mg/kg/dose based on q 3 hour dosing) consider weaning every 24 hours. • 6. When neonates reach 3 weeks of age, Finnegan scoring may not be as reliable as it had been in the immediate newborn period. Tolerating Finnegan scores <11 and basing weaning on this score range may be appropriate.
Weaning • 7. Morphine dosing usually can be spaced out or discontinued in most infants when the dose has been weaned to 0.03- 0.06 mg/doses. Some infants may be weaned off at a higher dosing schedule. • 8. Clonidine if used, can be weaned after morphine is discontinued, over a 2-3 day period. • 9. Phenobarbital if used, can be discontinued after other medications have been weaned off. Get off Phenobarbital in a timely fashion
Guidelines Occupational therapy – Consults should be considered for all NAS neonates treated in NICU Discharge • 1. Infants may be discharged home 48 hours after successful discontinuation of oral morphine as long as Finnegan scores remain stable. • 2. Completely weaning off opiate therapy is the usual goal prior to discharge.
How Are We Doing LOS for Infants Treated at Aurora Sinai Medical Center for Neonatal Abstinence Syndrome LOS Mean -2 STDev=0 +2 STDev -3 STDev=0 +3 STDev Begin 24 hour 100 weaning initiative NAS Guideline 90 Communicated 82 80 79 76 70 62 60 58 52 50 50 50 48 43 42 40 38 38 38 36 36 36 35 32 32 32 31 30 29 29 27 26 25 25 25 24 25 24 24 24 23 23 22 22 22 22 22 22 21 21 21 21 20 20 18 18 17 17 18 18 17 16 16 15 15 16 15 15 15 14 13 13 12 12 11 11 11 10 9 10 10 10 6 4 4 2 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77
Criteria for Weaning Morphine at 24-Hour Intervals Weaning dose is 10% of maximum “capture dose” Symptoms have been controlled for at least 48 hours after “captured”.
Criteria for Weaning Morphine at 24-hour Intervals Morphine dose q 3 hrs Scores q 3 hrs No consecutive scores In 2 nd 12 hours ≥ 9 for previous 24 hours if one score ≥ 9 or last three scores are rising Wean dose q 24 hours Wait another 24 hours (24-hour interval wean) to assess weaning readiness (48-hour interval wean)
Criteria for Weaning Morphine at a 24-hour Intervals Among Neonates >21 days of Age Morphine dose q 3 hrs Scores q 3 hrs No consecutive scores In 2 nd 12 hours >11 for previous 24 hours if one score >11 or last three scores are rising Wean dose at a 24 hour interval Wait another 24 hours (24-hour interval wean) to assess weaning readiness (48-hour interval wean)
Criteria for Weaning Morphine at 24-hour Intervals May wean meds at 24 interval since last reduction if : During the past 24 hours there are no consecutive 9s if <21 days of age or 12s if >21 days of age. During the last 12 hours there are no 9s. The most recent 3 scores were not increasing.
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