Transcript Effect of substance abuse on the mother and the newborn

Effect of substance abuse on the mother and the
newborn: Experience of WVU Healthcare
Collaboration on Substance Abuse in Pregnancy.
Panitan (Pete) Yossuck M.D. Associate Professor SOM. Pediatrics: Neonatology.
Patrick Marshalek M.D. Assistant Professor SOM. Behavioral Medicine & Psychiatry.
Laura Lander MSW, LICSW. Assistant Professor SOM. Behavioral Medicine & Psychiatry.
Courtney Sweet PharmD, BCPS. Pharmacy Clinical Specialist, Pharmaceutical Services WVUH
Disclosure.
• Nothing to disclose.
• All drugs (in neonate) discussed are off label.
Objectives
• To be aware of the WVU Healthcare Collaboration for
Substance Abuse in Pregnancy.
• To understand the current situation of substance abuse in
pregnancy; prevalence, societal cost, drugs of abuse and
treatment.
• To be familiar with substance abuse and addiction program
at WVU Healthcare at Chestnut Ridge Center.
• To understand the WVUCH Neonatal Abstinence Syndrome
(NAS) QI project and describe the postnatal management of
newborn infants with NAS.
Effects of Substance Abuse in
pregnancy on mother and newborn
Patrick Marshalek, MD
Laura Lander, MSW, LICSW
Prevalence
• NSDUH 2009-2010 illicit drug use
– Pregnant women age 12-17 – 16.2%
– Pregnant women age 18-25 – 7.4%
– Pregnant women 26-44 – 1.9%
• Stitely, 2010
– 759 samples or chord blood taken
– 142 + for drugs or alcohol (19.2%)
• Most common THC and opioids
• Montgomery, 2008
– Among patients at high risk for substance abuse, 32% of infant cord
tissue tested positive for drugs
• Over 1 million babies are born every year to mothers who abuse
substances
• 4,000 in WV
• Treatment improves birth outcomes
Delivery/Infant Complications
• Higher incidence of premature labor
– Breathing problems
– Feeding problems
• Withdrawal
–
–
–
–
–
NAS - opioids
Nicotine
Cocaine
Sedative/Hypnotic
Amphetamine
Post Delivery issues
•
•
•
•
•
•
•
•
NAS/NOWS
Breast feeding
Increase risk of relapse
Increased risk of dropping out of treatment
Post partum depression
Pain management
Negative family interactions
Guilt and Shame
The Disease of Addiction
• Biological
• Dependence, Tolerance, Withdrawal
• Psychological
• Obsession and Compulsion
• Social
• Consequences
Drugs of Abuse
• Classification
– Opioids, sedatives, stimulants…
• Intoxication/Withdrawal/Tolerance
– Use to feel normal
• Routes of Administration
– Like in medicine
• Detection
– BAL/UDS
Pregnant Women with substance use
disorders
•
•
•
•
•
•
•
•
Higher rates of domestic violence
High levels of shame and guilt
Fear CPS intervention
Women with addiction often do not have regular
menses so may not realize they are pregnant
right away
Childcare issues
Transportation issues
Employment issue/financial limitations
At risk for medial complications
Treatment
• Biological
– Medication Assisted Treatment (MAT)
•
•
•
•
Methadone
Buprenorphine
Naltrexone
Vivitrol
– Detoxification
Medication Assisted Treatment
• Why MAT (Volkow, NEJM, 2014)
– Safe
– Cost effective
– Reduced overdoes rates
– Improved retention in treatment
– Improved social functioning
– Reduced risk of infectious disease transmission
– Reduced criminal activity
Treatment
• Psychological
– Individual therapy
– Group therapy
– Approaches
•
•
•
•
Supportive
Motivational
Cognitive Behavioral Therapy
Contingency management
Treatment
• Social
– 12 Steps
• NA, AA, Al-Anon, others
– Self help meetings for patient and family members
• Treatment improves outcomes for whole family
• Abstinence versus Recovery
Levels of Care
• Outpatient (COAT)
– MAT
• COAT/OTP
• Intensive Outpatient (AIOP)
– Dual diagnosis
• Partial Hospitalization (PHP)
• Acute Inpatient
– Detox needs or safety concerns
• Residential
Chestnut Ridge Center Model
Comprehensive Opioid Addiction Treatment (COAT)
Participants must:
•
•
•
•
understand and sign a written contract
attend at least 4 AA or NA meetings per week
Attend group therapy
participate in random drug screens
(occasionally observed)
• Patient must actively work the 12 steps
WVUCH NICU: Neonatal Opioid
Withdrawal Syndrome (NOWS)
Panitan (Pete) Yossuck. M.D.
Section of Neonatology
Pediatrics. School of Medicine
The incidence of infants with history of maternal drug exposure
admitted to WVUH NICU was significantly increased in 2011.
(Nanda S. WVU Medical Journal ; in press 2014)
The number of infants with history of in-utero buprenorphine exposure increased
from 1 case in 2009 (0.18%), 2 cases in 2010 (0.37%) to 25 cases in 2011(4.5%), while
the number of infants exposed to maternal methadone showed no drastic changed
(1.5, 1.7 and 2.1% accordingly).
(Nanda S. WVU Medical Journal ; in press 2014)
The incidence of infants who developed NAS and required
pharmacological therapy decreased significantly in 2011 ; only
one third of infants had NAS that required pharmacological
treatment.
(Nanda S. WVU Medical Journal ; in press 2014)
(Nanda S. WVU Medical Journal ; in press 2014)
Background
• Modified Finnegan NAS scoring system has
been used without standardization.
• No specific guidelines for scoring, diagnosis,
treatment for NAS.
• Care for infants with NAS was directed
discretely based on neonatologist attending
on service
Clinical Aims
• Develop the guideline for management of infants
with NAS.
• Clinical Parameter after two years of
implementation:
– Adherence to the guideline
– LOS: shorten by 15% while maintain the mean LOS of
untreated infant at 3 days
– Reduce outliner by 25%( LOS more than 21 days)
– Length of Treatment (LOT)
VONS DATA: Soll R. 2014
100%
95%
92%
90%
88%
90%
84%
83%
80%
80%
78%
76%
76%
84%
81%
76%
72%
70%
67%
59%
60%
69%
66%
59%
68%
57%
55%
49%
50%
45%
Audit 1
Audit 2
Audit 3
40%
Audit 4
30%
20%
10%
0%
Maternal
Screening
Evaluation and
Treatment
Standardization
Non
Pharmacological Feeding Breast
of source
pharmacological
Treatment
Milk
Treatment
Centers: 181, 170,125, and 119 Audited.
22% Level A, 60% Level B, and 18% Level C.
Department of Pediatrics
Section of Neonatology
VONS DATA: Soll R. 2014
100%
89%
90%
82% 82% 82%
80%
70%
Audit 1
60%
Audit 2
50%
Audit 3
40%
Audit 4
30%
27%
24% 24%
20%
22%
16% 15% 16%
11%
10%
7%
10% 9% 9%
4% 3% 4%
0%
0%
Morphine
Methadone
Clonidine
Phenobarb
DTO
Infants: 1050, 991,797, and 620 Audited.
Department of Pediatrics
Section of Neonatology
WVUCH NAS Quality Improvement Project
Maternal Exposure
Newborn Infants from
Maternal Drug Use
OB service
•Identification
•Screening
(Antenatal visit,
at labor
admission)
(universal vs risk
based screening)
•Prenatal
education and
expectation of
neonatal outcome
Infant diagnosed with NAS
NAS infants required Drug
Rx and NICU admission
NICU
•None PharmRx
•NAS Scoring system
•Initiation of drug Rx
based on NAS score.
•Wean and discontinue
drug Rx based on NAS
score.
•Discharge disposition
Postpartum
nursery team
•Identification
•Screening:
universal vs risk
based, methods of
screening
•Diagnosis: NAS
scoring system
•Management:
NonePharmRx
•Identified NAS
infant require
DrugRx based on
NAS score
FLOW CHART
OB ANC
Pregnant Mother
Labor
●Universal UDS:
research project
●Education
●Referring to BMP
Postpartum
Service
OB
Exposed NB infant
●Universal
UDS
●Univeresal
CTDS
●NAS score
(standardized)
●Diagnosis of NAS
●Provided
●NonePharmRx
●Identify PharmRx
Candidate based on
clinical and NAS score
NICU admission
NICU
●NAS score
(standardized)
Continue
●NonePharmRx
●Initiate PharmRx
and follow the NAS
guideline
Department of Pediatrics
Section of Neonatology
Our RoadNAS
Map Quality Improvement Project
WVUCH
Distribution of work process to
committee members.
Screening process
Scoring process
Diagnostic criteria based on the NAS
score
None pharmacological management
Drug of choice
Criteria to initiate pharmacological
treatment
Weaning and discontinue
pharmacological treatment based on the
NAS score
Discharge criteria (both with and
without pharmacological treatment
WVU Children
Hospital Neonatal
Abstinence
Syndrome Quality
Improvement
Committee was
established. Chaired
and leaded by
Stephanie Greyson
(second year Neofellow), and
Courtney B. Sweet
(NICU PharmD).
July 2012 Aug-Oct
2012
WVUCH NAS
guideline were
launched and in
effect.
all the NICU nursing staff have
gone to mandatory trained to use
standardized NAS scoring
system. General pediatric
nursing preceptors and PICU
nursing preceptor were also
trained and become the trainer
for their unit. The WVUCH
guideline was distributed to all
NICU attending, fellow,
pediatric house staff, Pediatric
and NICU PharmD, hospitalists
and PICU attending.
Nov –Dec
2012
Jan 2013
All NICU admitted infants had universal
MDS. Concern for missing MDS for
postpartum normal newborn infants and
unable to detect Buprenorphine from MDS
were discussed. The option of obtaining
universal cord tissue drug screen was
discussed with the clinical laboratory
department. The OB service agreed with
universal cord tissue drug screening.
universal MDS for
every NICU
admission was
discussed. Meeting
with clinical
laboratory
department resulted
in the universal
MDS.
Feb 2013
Standardize the NAS
scoring process for OB
postpartum nursing staffs
Collecting and analysis
the data over the past
year
Breast feeding and use of
MBM for NAS infant
guideline
Parent Brochure and
education for NAS
Non-pharmacological
management re-education
Universal cord tissue
screening was started;
Buprenorphine is part of
the drug screened but not
THC. OB department
started “Maternal addiction
screening” in antenatal
care service and
antepartum maternal
education.
March 2013
April
2013
VONs QI meeting
in Chicago: Data
Presentation
Sep 2013
Oct 2013
July 2014
Department of Pediatrics
Section of Neonatology
Department of Pediatrics
Section of Neonatology
Modified Finnegan Score: 1986, CNS, GI, Metabolic. VONS audit: 61% used
High Risk
Neonate for NAS
Obtain Modified Finnegan Scale every
2-4 hr before feed after birth.
NAS if score ≥ 8 on two
successive evaluations.
Non-pharmacological
Management
NAS score ≥12 on three
consecutive occasions, or combine
consecutive NAS score of ≥28
OMS at 0.05 mg/kg/dose q 3 hr
Dose escalation: If S&S of NAS persist or two
consecutive NAS score >10, increase the dose
to 0.075, 0.10 and 0.125 mg/kg/dose q 3 hr.
Add phenobarb if need OMS more than 0.125
mg/kg/dose q 3 hr
Two consecutive NAS score still
≥12, rescue dose of 0.025
mg/kg/dose and increase the
dose to 0.075 mg/kg/dose q 3 hr
Three days of stabilization and improvement of NAS
Weaning: all NAS score <10 for the past 24 hr. Reduce the
total dose by 10% of stabilized dose every day. Wean the
interval to q 4, q 6 and then q 8 hr every other day as
tolerated (but keep the 10% total reduction).
Discharge: Total dose must be ≤30% of
stabilized dose and the interval must be at
least q 8 hr for 24 hr. Primary care provider
must be notified and provided with weaning
scale.
Dose adjustment: Switching from
OMS to morphine injection must be
discussed with PedsPharmD as
necessary
Cessation of treatment: Total dose must be
≤10% of stabilized dose. If the cessation occurs in
the hospital, the infant must be observed for at
least 24 hr after the OMS was discontinued.
(WVU Children Hospital Treatment Guideline for Neonate with NAS 2012)
NAS (779.5) WVUCH NICU 2012 and 2013
10.00%
9.20%
9.00%
8.10%
8.00%
7.00%
6.00%
NAS 779.5
5.00%
4.10%
4.00%
3.90%
from MICC
3.00%
2.00%
1.00%
0.00%
Total NICU admission
2012
2013
579
621
Department of Pediatrics
Section of Neonatology
2012
2013
1336
1405
87 (6.5%)
85 (6.0%)
Neonatal Opioid Withdrawal
Syndrome (NOWS)
38/87 (43.7%)
57/85 (67.0%)
NOWS and NICU admission
24/38 (63.2%)
24/57 (42.1%)
MICC admission (n)
Opioid exposure (n)
code 760.72
Department of Pediatrics
Section of Neonatology
NOWS infants ≥ 35 wk GA in NICU and treated.
2012 (n=8)
2013 (n=13)
P value
Length of Stay
(LOS) (day ± SD)
18.8 ± 4.9
15.5 ± 5.9
P=0.32
Length of
Treatment (LOT)
(day ± SD)
22.0 ± 7.5
14.4 ± 6.3
P=0.04
Department of Pediatrics
Section of Neonatology
2012
2013
Max dose (mg/kg/day)
0.16-0.80
0.40-0.60
CPS involvement
12/23 (52.3%)
17/24 (70.8%)
Discharge home with
parents
23/23 (100%)
22/23 (95.6%)
CTS
0/24
15/20 (7 bup, 4 methad)
UDS
3/24
1/1 (bup)
MDS
13/24
2/2 (1 methad)
Department of Pediatrics
Section of Neonatology
CTDS: APRIL 2013 TO MARCH 2014
TOTAL OF 1430 SPECIMENS TESTED.
CTDS (April2013 to March2014)
1600
1430
1400
1200
1000
800
CTDS (April2013 to March2014)
600
400
230
283
200
16.1%
19.8%
Positive
Drug Hit
0
Total
Department of Pediatrics
Section of Neonatology
CTDS: APRIL 2013 TO MARCH 2014
PERCENTAGE OF POSITIVE DRUGS
12
* THC data: from October 2013 to March 2014
9.8
10
8.4
8
Opioids
Bup/Metha
6
Sedative
Stimulant
THC*
4
3.3
2.6
2
1
0
Opioids
Bup/Metha
Sedative
Stimulant
THC*
Department of Pediatrics
Section of Neonatology
DRUG CLASS
# of POS
%POS
%ALL
Opiates
120
47.5%
6.5%
THC*
64
25.2%
3.4%
Sedatives/Hypnotics
47
20.9%
2.8%
Buprenorphine & Methadone
37
18.0%
2.5%
Stimulants
15
2.9%
0.4%
283
Department of Pediatrics
Section of Neonatology
WVUCH BREAST FEEDING AND USE OF
MATERNAL BREAST MILK FOR NAS
INFANTS
• Absolute Contraindications:
– Evidence of active alcohol or drug abuse
(illicit or prescriptive).
– HIV or HTLV-II positive.
– Galactosemia
– Maternal medications contraindicated in
lactation such as lithium, methotrexate,
radioactive or immunosuppressive agent,
antimetabolites and IV drugs of abuse.
Department of Pediatrics
Section of Neonatology
WVUCH BREAST FEEDING AND USE OF
MATERNAL BREAST MILK FOR NAS
INFANTS
• Absolute Contraindications:
– For mothers with a history of substance abuse or
those receiving treatment in an opioid
maintenance program and:
• Refusal of consent to speak with prescribing physician
or treatment facility.
• Relapse with illicit drugs 30 days before delivery.
• No plans to follow in substance abuse treatment
program.
• Relapse of drug use after delivery.
• Sobriety achieved and maintained only in inpatient
setting.
Department of Pediatrics
Section of Neonatology
WVUCH BREAST FEEDING AND USE OF
MATERNAL BREAST MILK FOR NAS
INFANTS
• Relative Contraindications:
– Perinatal providers, substance abuse providers, physicians, lactation
consultants, NNP’s and nurses will work collaboratively to individually assess
risks / benefits of breastfeeding in the following mothers:
• No, limited or late prenatal care.
• Women in treatment program, but relapsing 30 to 90 days prior to delivery.
• THC: Any patient with a positive screen for THC needs to receive counseling.
During discussion providers should determine if use is acute, recreational, or
chronic. Mothers should be encouraged to discontinue ALL use if she desires to
breast feed. This discussion should be documented in baby’s chart.
• All maternal medications will be reviewed for lactation compatibility delivery.
• Untreated, symptomatic psychiatric issues or non-compliance of treatment.
Department of Pediatrics
Section of Neonatology
Department of Pediatrics
Section of Neonatology
Department of Pediatrics
Section of Neonatology
NON-PHARMACOLOGICAL TREATMENT GUIDELINES FOR NAS
WVU CHILDREN HOSPITAL
– Swaddle, Cuddle, Kangaroo care
– High caloric content formula (24 cal/oz) and frequent feeding.
– Feeding on demand: q 2-4 hr.
– Consider reduce the caloric content back to regular formula (20 cal/oz)
when infant consumes volume more than 160 ml/kg/day.
– Place in a quiet, reduce stimulus environment etc.
– Consider using Infant Motion Soothing Machine.
– Consider early application of cream/paste to prevent perianal skin
breakdown.
Department of Pediatrics
Section of Neonatology
NAS NON-PHARMACOLOGICAL
NURSING TOOL KIT
Department of Pediatrics
Section of Neonatology
THE 5 S’S OF SOOTHING:
HOW TO RAPIDLY CALM YOUR FRANTIC BABY
• Swaddling
• Side/stomach position
• Shushing sounds
• Swinging
• Sucking
Department of Pediatrics
Section of Neonatology
OTHER NURSING INTERVENTIONS FOR NON-PHARMACOLOGIC
TREATMENT OF NAS INFANTS
• Encourage Family to stay & Participate in cares;
holding/cuddling, feeding, settling/console,
changing diaper (promote bonding)
– The parent is the best constant care giver: The more
the parent is here the better he/she will do
– Teach them the 6 basic principles and 5 S’s
• Cluster Care
• Gently Rocking
• Swaddling tight & proper
– Swaddle with hands up or hands at side
Department of Pediatrics
Section of Neonatology
OTHER NURSING INTERVENTIONS FOR NONPHARMACOLOGIC TREATMENT OF NAS INFANTS
• Hold close to body
• Decrease noise and lights
• Speak softly & remind those
visiting and around to use quiet
voices
• Protect from scratching/rubbing- use mittens or socks
• Patting buttocks/back gently & rhythmically
Department of Pediatrics
Section of Neonatology
OTHER NURSING INTERVENTIONS FOR NONPHARMACOLOGIC TREATMENT OF NAS INFANTS
• Frequent Diaper changes
• Discuss with physician/NNP possibility of ordering
aquaphor prior to breakdown
• Feed as ordered
• Support/Encourage Breast feeding
• Encourage kangaroo care
• Infant Massage
Department of Pediatrics
Section of Neonatology
OTHER NURSING INTERVENTIONS FOR NONPHARMACOLOGIC TREATMENT OF NAS INFANTS
• Use of relaxation techniques
• Use of Boppy, infant chair or Mamaroo
• Pacifier/ Wubbanub
• Soft linens to help reduce with excoriation
• Soft gentle touch
• Utilize ancillary staff
(CA's, PT, OT, cuddlers)
Department of Pediatrics
Section of Neonatology
Standardized Pharmacologic
Treatment of NAS: A Year in Review
Courtney Sweet, PharmD, BCPS
Baseline Data
• Timeframe: January 2009- December 2011
• All infants admitted to WVU Children’s Hospital with an ICD-9
of 760.7x (Noxious influences affecting fetus or newborn via
placenta or breast milk) or 779.5 (Drug withdrawal syndrome
in newborns)
358 infants in total
• 129 patient born at less than 37 weeks gestation
• 155 patients born at 37 weeks or more and did not receive
morphine or methadone
• 61 patients born at 37 weeks or more and received morphine
or methadone
• 13 term infants excluded due to congenital heart of GI anomaly
Baseline Data- Treated
• 39% (61/ 216) of term infants received pharmacologic therapy
• 60 infants received morphine (98%)
• 2 infants received methadone (3.3%)
• Mean length of stay= 22 days (SD 10.7)
• Median length of stay= 20 days (Range 5-61 days)
• 46 % of treated infants required a LOS greater than 21 days
• 5% of treated infants received any breast milk 24 hours prior
to discharge
Timeline
• July 2012 NAS Committee’s 1st Meeting
• December 2012 NICU Nurses completed training on
Finnegans scoring tool
• January 1st 2013 Treatment algorithm Go-Live January 1st
2013
• February 2013 MICC Nurses completed training on
Finnegans scoring tool
• June 2014 Parent education pamphlet distribution began
• September 2014 Initiation of nursing education related to
non-pharmacologic care
January 2013-June 2014
1.5 YEARS AND COUNTING
Demographics
• Discharge Timeframe: January 2013- June 2014
• All infants coded with 760.7x or 779.5
• 74 patients were treated with a pharmacologic agent
• 63 patients born at 37 weeks or more and received morphine
or methadone
Treated Infants
• All 63 patients (100%) received morphine therapy
For 37 term, treated infants:
• Mean length of stay= 18 days (SD 5.3)
• Reduced 4 days from baseline
• Median length of stay= 18 days (Range 8-36 days)
• Reduced 2 days from baseline
• 2nd Quarter 2014 the median was 16 days
• 30% of treated infants required LOS greater than 21 days
• 14% of infants received breast milk 24 hours prior to discharge
All patients (74 patients)
ALGORITHM RESULTS
Medication Use
• 100% of infants received morphine
• 84% (62 patients) received a stabilization dose of 0.05 mg/kg
every 3 hours
• 11% (8 patients) received 0.075 mg/kg every 3 hours
• 5% (4 patients) received 0.1 mg/kg every 3 hours
• None received 0.125 mg/kg every 3 hours
• Average time stabilization dose utilized= 2.4 days
• 8 patients weaned one day after stabilization dose
Medication Use
• Average number of weaning steps required= 8.4
• (Min=2; Max= 17)
• 79% of infants discharged into the care of their parent(s)
• 35% of infants were discharged on morphine therapy
• 2 infant received phenobarbital
15 months (1st Quarter 2013-1st Quarter 2014)
49 patients
COMPLIANCE
Compliance
• Morphine initiated for 3 consecutive scores greater than 12
• 46 patients started after admission
• 78% met criteria to initiate morphine at time of initiation
• Morphine initiated at 0.05 mg/kg/dose every 3 hours
• 89% received appropriate initial dose
• 75% effectively stabilized on this dose
• Morphine increased for scores greater than 10
• 9 patients (18%) were not increased for elevated scores
• Stabilization dose utilized for 3 days- 60% of patients
• 84% utilized for 2-3 days
Compliance
Compliance with Treatment Algorithm
Percentage
90
80
70
60
Goal
50
40
30
20
10
0
1st Q 14
4th Q 13
3rd Q 13
2nd Q 13
1st Q 13
Compliance
• Addition of phenobarbital
• 2 patients – not compliant
• 100% discharged at 30% of stabilization dose
Avg. Duration Between Weans
2
p= 0.004
1.5
Compliant
Weans
1
Non-Compliant
0.5
0
Days
Outliers?
• 10 patients required LOS > 21 days
• Using Fisher’s exact and t-test comparing these patients to
patients with a LOS < 21 days
Characteristic
≤ 21 days > 21 days
(N= 27)
(N= 10)
p-value
Outborn
15
6
P= 1.0
Parental custody
24
8
p= 0.59
Use of breast milk 24 hours prior to d/c
6
0
p= 0.16
Medication at discharge
12
1
p= 0.065
Not increased with elevated scores
3
5
p= 0.02
Length of Stay
For term, treated infants (63 infants)
• 71% of infants were discharged in 21 days or less
• Of note: 78% were discharged in 22 days or less
Length of Stay
Days
35
30
25
20
15
10
5
0
2nd
Q 14
1st
Q 14
4th
Q 13
3rd
Q 13
2nd
Q 13
1st
Q 13
4th
Q 11
3rd
Q 11
2nd
Q 11
1st
Q 11
4th
Q 10
3rd
Q 10
2nd
Q 10
1st
Q 10
4th
Q 09
3rd
Q 09
2nd
Q09
1st
Q 09
What the Data Showed…
• Initiate therapy for elevated scores (> 12); soothe for fussiness
• Increase dose for elevated scores (consistently > 10)
• Utilize stabilization dose for 3 days
• If excessive sleepiness occurs, consider weaning by 20% and
document
• Wean according to guideline 10% and alternate between dose
and interval changes
What We Have Learned…
• Standardization of practice has led to a more consistent
treatment of infants with NAS
• Length of stay and duration of therapy have been reduced
• Future directions
• Formal education for all nursing staff related to nonpharmacologic care
• Focus on parent education and involvement in nonpharmacologic care