Transcript Specialty Formulas - Wisconsin WIC Association

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
Escalating national impact of
substance use
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!
Background

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
NAS Scoring System
The Problem

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.
Themes to Consider Throughout the
Continuum of Care
Operational
Environmental
Clinical Interventions
Family Involvement
Data Management
Staff and Physician relations
Finding and Using Non-Pharmacologic,
Supportive Interventions First
Non-Pharmacologic
Methods

Partnership with family regarding approach
to care
◦ Prenatal preparation, engagement and holding
◦ Begin low stimulation in Family Care area –
keep baby with parents when possible





Access to care areas restricted
All conversations in whispers
Indirect and dimmed lighting
Strict grouping of cares
Discerning 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
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!
Aurora Initiative to Reduce LOS for Infants
Treated for Neonatal Abstinence Syndrome
LOS
Mean
-2 STDev=0
+2 STDev
-3 STDev=0
+3 STDev
100
NAS Protocol
Communicated
90
Begin to Consider
24 Hour Option
82
80
79
76
70
60
62
58
50 52
50
50
42
40
36 35
25
20
1515
29 29
22
23
10
31
2424
26
21
16
11
24
21 21
16
22
14
25
2322
15
12
11
9 10
10
242225
20
18
16
25
18
27
22
21
17
15
13 12
6
44
2
0
38
36
3232
17 18
15
11
17
13
38
36
22
18
10
38
32
30
48
43
77
75
73
71
69
67
65
63
61
59
57
55
53
51
49
47
45
43
41
39
37
35
33
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
1
VON Quality Audit #6 – NAS Unit
Data
Wisconsin Centers: 7
Affinity NICU at St. Elizabeth Hospital
 Aspirus Wausau Hospital
 Aurora Baycare Medical Center
 Aurora Sinai Medical Center
 Aurora Women's Pavilion
 Gundersen Lutheran Medical Center
 Wheaton Franciscan Healthcare at St. Joseph

VON Quality Audits 5 and 6
NAS Patient Data
7 Wisconsin Centers, 58 Infants
Audit 5 (N=26)
Audit 6
Median
Median
2,918
2,943
Total duration of pharmacologic
treatment for NAS (days)
16
11
Interval between last dose of a med
for NAS and discharge
32
3
Infants' total LOS in NICU (days)
20
19
Infants' total LOS in hospital (days)
22
20
(N=32)
Birth Weight
2015 Initiative 1
8 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
Initiative Jan. – Aug. 2015
TOP PERFORMERS
 mostly Subutex, very few methadone
n = 81
n = 179
43% meds
35% meds
n = 29
31% meds
n = 44
18% meds
2

initiated intentional use of aromatherapy
All Level III NICUs include their Level II referral centers in NAS initiatives
2015 Initiative 2 - WINpqc
NAS - 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.
100%
100%
88%
76%
75%
50%
Discharge Survey
“right amount” of information; feel ready
for discharge.
Held infant as much as they wanted
Quiet environment helped parents feel
calm and capable
LOS shorter than or about as expected.
Felt they were not treated differently
Describe their experience in the quiet
room as “great”.
Improvement Methods – Breastfeeding

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
YES


All conditions must be met.
Maternal functioning indicating that
lactation SHOULD be supported.
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.

NO

If any ONE of these conditions is met.


Maternal functioning indicating that
lactation should NOT be supported.



Prenatal care begun by 4th month and > 7
visits at term.
Substance Abuse (SA) treatment
program:
o
Consent for discussion with SA
provider
o
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
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
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
Improvement Methods – Nutrition
Specialty Formulas

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
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)
Gentlease
Lactose: 20%
Corn Syrup solids: 80%
Nonfat Milk and Whey
(partially hydrolyzed)
(Whey:Casein 60/40)
Nestle′
Good Start Soothe
Low
(195 mOsm/kg water)
Lactose: 30%
Maltodextrin: 70%
100% Whey
(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
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-swallowbreathe coordination
 Atypical, disorganized
suck, seal, latch or
swallow
 Regurgitation common
 Consider indwelling NG
tube with pump feedings
Effects on Oral Feeding:
Physiologic stability
 State regulation
 Organization
 Oral-motor/ sensory skill
 Coordination of suck-swallow-breathe
 Active engagement
 Pleasurable Experience

Physiologic Stability

Questions 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 swallowing
 STRESS CUES
•
Active Participation
Should 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, wellregulated 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 protection
o Defensive feeding behaviors
o 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 grimace
 Gagging/ vomiting
 Coughing/choking
 Eyebrow raise
 Furrowed eye brows/
“Worried look”
 High pitched “crowing
sound” / Stridor
 Nasal flaring/blanching

Head bobbing (increased
breathing rate)
 Retracting
 Color change
 Oxygen desaturation
 Drop in heart rate
 Gulping
 Multiple swallows
 Drooling

Strategies/ Interventions

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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:

COMPLIMENTARY MEDICINE:
◦ Swaddling
◦ Massage
◦ Quiet, gentle awakening
◦ Aromatherapy
◦ Decreased stimulation
◦ Light Therapy
◦ Increased non-nutritive suck
◦ Chiropractic Treatments
◦ Positioning with containment
◦ Music Therapy
◦ Vertical rocking
◦ Swings: head-to-toe movement
◦ Sleep protection
◦ Breastfeeding
◦ Build parental confidence and motherinfant dyad
Casper&Arbour 2014
MacMullen, Dulski, & Blobaum 2014
Velez &Jansson 2008
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

Current Initiatives
Increase parental engagement
 Partner with community agencies to
improve transitions and continuity of care.
 Local, state, and national sharing of
protocols and pooling of data
 Gather long-term outcomes
 Non-NICU setting for NAS service.

Current Initiatives
Improvement in care practices
 Influence policy at all levels

◦ Standards, funding, ? legislation

National
◦ Vermont-Oxford Neonatal Network

State
◦ Wisconsin Neonatal Perinatal Quality
Collaborative

WIC !!
Thank You!