2/20/2014. The Jillian Vignette. Jillian Vignette. Jillian Vignette

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Opiate Exposed Newborns: Development, Assessment and Treatment

The Jillian Vignette

Thank you to all of our speakers for making the time to be with us today. Before we begin our

presentation, I am going to start us off with a case vignette about a woman named Jillian and her son Jose Jr. The vignette will illustrate an example of a parent who is on methadone and gives birth to opiate exposed newborn. I will read a portion of the vignette before and after the first speaker to expand and highlight a number of issues common for opiate exposed newborns and their families.

Jillian Vignette

• Jillian is a 22 year old single white female with a 6 month old son, Jose Jr. Jillian is the oldest of four children. When she was 8, her mother was arrested and sent to prison for drug related charges. Jillian’s father, also a substance user, was left in charge to raise Jillian and her three siblings. Progressively, due to her father’s drug use, Jillian began to take on more and more of the family’s responsibility. Despite her best efforts, their home was often unpredictable, chaotic and unsafe.

•

Jillian Vignette

Jillian on more than one occasion was molested by various drug associates of her father. When Jillian was 12, DCF opened a case on her family and both Jillian and her siblings were removed from the home. Each of them was placed in separate foster homes. Although Jillian worried and missed her siblings, following a period of adjustment, she grew to feel comfortable living with her foster family and occasionally would get to visit with her father and her other siblings.

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Jillian Vignette

In addition, she received brief counseling around the trauma she had been through while living at her home. Yet, it was during this period that Jillian began her own drug use. She started to smoke pot and drink with her friends. Throughout her adolescence, Jillian continued to smoke and drink; however it wasn’t until she was 18, when she met Jose, Jose Jr. father, that she began to use heroin. Jose Sr., a drug dealer and heroin user, introduced Jillian first to percocets and then onto heroin. They frequently would shoot each other up to get high.

Jillian Vignette

Jillian learned she was pregnant at age 21. Almost immediately, being pregnant was a life changing experience for her. She was determined to both keep her baby, and to give her baby a different life than her own. At 8 weeks pregnant, she decided to go to the local methadone clinic.

Jillian Vignette

Jillian enjoyed being pregnant and overall had an easy pregnancy with few complications. Gradually

throughout her pregnancy, her methadone was increased, which she was told was normal, to accommodate the additional fluids in her body due to being pregnant and for the small dose that was going to the baby.

Jillian Vignette

Jose Jr. arrived 3 weeks early and he weighed 4 lbs and 15 oz. Following his birth, for the first two days, Jillian was able to have Jose Jr. with her and/or visit him in the regular nursery. Jillian was told by the nurses that Jose Jr. was being rated on a scoring scale, the neonatal

abstinence scoring scale (a.k.a. NAS), to rate his level of withdrawal. The NAS scoring tool is set of signs and symptoms that are observed in the infant at regular intervals.

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Jillian Vignette

The normal interval for scoring is every 3 hours. When scores are high and are not lowered by using therapeutic measures, medication will likely be started for the infant. The nurses explained to Jillian that if Jose Jr. received two consecutive scores of 8 points or higher on the NAS he would need to be moved into the level II nursery.

Jillian Vignette

On day 2, because Jose Jr. was showing distress and signs of withdrawal in three areas (raised temperature, his mottling skin and had a respiratory rate higher than 60 per minute), the nurses placed Jose Jr. in the level II nursery.

Jillian Vignette

Jillian shared that she had a very hard time when Jose Jr. was placed in the nursery. She shared how guilty she felt about him being in pain and knowing it was because of her substance use that he was in withdrawal. However, despite, feeling incredibly guilty, Jillian found the information she received while Jose Jr. was in the level II nursery very helpful.

Jillian Vignette

• She was taught a variety of therapeutic techniques to support Jose Jr., including how to reduce his hypersensitivity to stimuli by covering his eyes in between feedings and not rocking him in a way that too jarring or over stimulating. She learned how to swaddle Jose Jr. and how babies in withdrawal from opiates may suck differently than other babies.

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Jillian Vignette

Jillian was able to bring Jose Jr. to the residential treatment program where she was from the hospital when he was 14 days old. When she left the hospital, Jose had been weaned completely off morphine and would continue to stay on a low dose of phenobarbital, for a few weeks that would be checked and monitored by a visiting nurse.

Caring for Substance Exposed

Newborns

Rachana Singh, MD MS

Assistant Professor of Pediatrics, Tufts University School of Medicine Attending Neonatologist , Baystate Children’s Hospital

Springfield, MA

Background

_{NAS Incidence (infants/1000 births)}

0 10 20 30 40 50 60 70 80 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Massachusetts average 17.2/1000 2009 National average 3.4/1000 NAS i n fa nt s/ 1 000 li v e bi rt hs

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Management of SEN

• Prenatal • Postnatal • Post- discharge

Prenatal Management

• Rehabilitation through Medically Assisted Treatment Programs (Methadone, Buprenorphine)

• Provision of safe living environment • Consistent Prenatal care institution

• Counselling about smoking cessation (tobacco as well as marijuana)

• Prenatal consultation with the Pediatric/Neonatal team make families aware of potential for NAS and its management • Familial awareness of their responsibilities and role in caring

of their baby

Jones et al. Methadone and Buprenorphine for Management of opioid dependence in pregnancy. Drugs. 2012 Jones et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine exposure. NEJM 2010 ACOG: Committee Opinion 2012. Opioid Abuse, Dependence and Addiction in Pregnancy

Postnatal Management

• Guidelines for monitoring • Non-Pharmacological • Pharmacological

Guidelines for Monitoring

Time to Withdrawal

Drug Mean time to

withdrawal

Range of

withdrawal onset Opioids 48‐72 hours 2 days‐4 weeks

Alcohol 3‐12 hours 3‐24 hours

Sedative‐

hypnotics

12‐21 days 3‐4 weeks

Barbiturate 4‐7 days 1‐14 days

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AAP monitoring recommendations

• Based on the variability of time to withdrawal and half life of maternal medications the current recommendation is in patient monitoring for 5- 7 days prior to discharge • Goal is prevent early discharge and re-admission with

NAS and its complications

Modified Finnegan’s Neonatal Abstinence Scoring Tool.

Hudak M L et al. Pediatrics 2012;129:e540-e560

Non-Pharmacological Management

• Initial management for all infants with NAS should

be supportive care

– Providing non-nutritive sucking - pacifiers – Swaddling

– Reduction in stimuli - light, noise – Maintaining calm, quiet environment

– Small, frequent feedings with hypercaloric breast milk and/or formula to meet the calorie requirement – Breastfeeding strongly recommended if mother is in

stable MAT programs

Pharmacological Management

• If supportive care fails then the next level of care is pharmacotherapy

• The goal of pharmacotherapy is to

- Ameliorate the discomfort from withdrawal - Promote growth

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Pharmacological Management

• The choice of therapy should be tailored to the maternal medications in pregnancy

• Opioids are the main stay for treatment

• Adjunctive medications help shorten the overall treatment time with smaller doses of opioids needed to treat

• Most of these require in hospital treatment

Hudak M L et al. Pediatrics 2012;129:e540-e560

Pharmamacological Management

• Opioids - Neonatal Morphine Sulfate - Methadone - Buprenorphine • Alpha agonists - Clonidine • Barbiturates - Phenobarbital • Benzodiazepenes - Diazepam - Lorazepam • Others - Chlorpromazine

Coyle et al, J Peds 2002 Kraft et al, Pediatrics 2008 Agthe et al, Pediatrics 2009 Surran et al, J Perinatology 2013

Post -Discharge

• Referral to Early Intervention as high risk for neurocognitive and behavioral impairment • Frequent follow-up

- to optimize growth an nutrition

- to wean off medications if discharged home on them ( Methadone, Phenobarbital)

- to provide support to families as they transition from hospital to home environment

Bandstra et al, J Addict Ds 2010 McMurray et al , Front Psychol 2013

Jillian Vignette

Jillian and Jose Jr’s transition from the hospital to the residential program was difficult and scary for Jillian and Jose Jr. Jillian was extremely anxious about how the other residents would react to Jose Jr.’s needs and if the residential home would be able to accommodate her frequent transports to see the doctor and provide transportation. After getting back to the program, Jillian immediately decided to set up an appointment with the program’s case manager.

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Jillian Vignette

The case manager was courteous, but did not appear to understand the need for Jillian to set up all of Baby Jose’s Dr. Appointments. Jillian reminded herself to stay calm and to communicate clearly, the importance of the Dr. check-ups for Jose Jr. She felt relieved when the case manager agreed to assist her with the medical transport part of her and baby Jose’s needs.

Jillian Vignette

• Jillian’s next quest was to ensure that the infant daycare located in the program was ready to care for Jose Jr. while she focused on her treatment. She wanted to make sure that the program nursery had a place for baby Jose, which had low lighting, soothing music and an overall quiet environment. She was faced with the difficulty of the nursery being at capacity with caring for four other babies, none of which were born substance exposed.

Jillian Vignette

Jillian once again felt the pang of guilt for having caused her baby to have all the added needs. She wished that, she could have known what to tell the nursery before they arrived, so that the program and staff would have been more prepared to help her with Baby Jose.

Jillian Vignette

Jillian remembered what the discharge nurse at the hospital had told her and she tried very hard to remain calm and regulated in order to make sure the nursery was prepared for Baby Jose’s first day at daycare. Jillian also had to think about her busy day of therapy groups and then she would have a chance to spend time with Jose Jr. As she thought it through she realized that she could see him during morning break, lunch and again at afternoon break.

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Jillian Vignette

She was exhausted thinking through all of these details, but was looking forward to working with the parenting counselor that the program had set up for her. She wanted to continue practicing swaddling her baby, learning how to give her baby soothing massages and overall, just learning about what Jose Jr’s cues were and to watch him progress.

Jillian Vignette

• Later, Jillian thought, I will worry about how I will tell all the other residents about Jose Jr.’s needs and how they can help me. She thought about printing out some information on the needs of babies born exposed to substances and how this might help the other women understand why her baby behaves the way he does.

Jillian Vignette

She also wanted to share with the other residents what the nurses and doctors in the hospital had shared with about the importance of staying calm and regulating her own feelings in order to help baby Jose. Jillian felt this information would be useful to all mothers, not just babies that are born substance exposed.

Jillian Vignette

Jillian knew she had a very hard road ahead of her, full of uncertainty and worry, but she was grateful she did have Jose Jr. with her and she was determined to work hard and make sure he had everything he needed in order to thrive and overcome the obstacles he was born into. She could sense, and almost feel, the light at the end of the tunnel.

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Next Speaker

Supporting Parents & Infants

From Hospital to Home:

Amy R. Sommer, LICSW

Clinical Coordinator

Project BRIGHT II & Project NESST

Review: Symptoms of Opiate Exposure

• Less time between feedings – because difficult to settle after feedings and eats more frequently

• Difficulty breathing, cold-like symptoms, “asthma”

• Increased startle responses and “hypervigilance” – harder to put to sleep or soothe

• High-pitched, increased frequency cry

• “Bad eater” – uncoordinated suck, increased reflux, vomiting • Overwhelmed in new or loud or crowded environments – hard to

go out!

Remember – these symptoms occur in up to 90% of exposed newborns, NOT just those diagnosed or treated in a hospital setting with ‘withdrawal’.

What we can do:

Supporting Parents

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Supporting Parents

• Support, empathy, and non-judgment

– All new parents feel afraid, anxious, judged, or isolated at some point

– Winicott: Is my baby OK? Can I care for this baby? – Research across cultures suggests that women in MAT

experience great judgment from others, including other addicts, and great self-doubt and self-blame (Zweben 1991).

– Bottom line: Guilt and anxiety are common. Reducing guilt and anxiety helps parent and baby connect.

Guilt + parent = _______

• Angry – turn anger at self onto others – argumentative, “don’t give me advice”

• Turn anger at baby – irritable, misattributions

• Turn anger on self- self-destructive; relapse? triggered by shame

• Anxious – withdrawn, hypervigilant, ‘paranoid’, trigged by w/d sx

Tips for Reducing Guilt & Shame

• At the hospital: Always empower parent unless there is an urgent and clear medical risk. (Example: Feeding her baby – let her try unless the baby is at risk of immediate harm.)

• Ask more than once how things are going. Guilt and shame may prevent parents from answering honestly the 1st_{time, and asking} more than once normalizes the fact that a parent’s answer may change over time.

• Inform, inform, inform. Parents need to know that they are not crazy, that behaviors will become manageable, that this has happened to other parents, and that their child has a good prognosis for health and development.

Other ideas for Parent Support

• Our qualitative data suggests that the post-partum period is a time of increased risk for relapse. Providers should use brief screening, direct questions and observations to monitor possible relapse and be prepared to assess readiness for treatment and offer treatment options to parents.

• Help parents identify a care-giving system so that they can take breaks and/or baby can be cared for by family members when parent is not available

• If applicable and possible in your state, talk with parents about the possibilities for protective services involvement beforebirth and/or before a report is made to protective services. • Don’t forget about post-partum mood!

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Supporting the Parenting

Relationship

Attachment is one of the biggest challenges for mothers (and fathers) and babies in MAT – and one of the biggest

opportunities for intervention

Attachment: What we know

• Attachment: We mean a pattern of interactions over time that creates a sense of trust and security in an infant.

• What does it require on the parent’s part? – Regulation, attunement, good self-concept, flexibility • What does it require on the infant’s part?

– Emerging regulation, cues, flexibility

• Attachment is interactional and bi-directional, meaning it takes a PARTNERSHIP. Small differences in baby’s functioning – even those that disappear after a few months of life – may cause significant impairments in attachment relationship that are much longer-lasting and more likely to impact long-term development.

Attachment Difficulties in MAT

The Mother:

• Anxious about the infant’s prognosis • Anxious about legal/DCF involvement • Sense of guilt • Intoxification • Withdrawal symptoms/dosing • Difficulties in relationships • Low self-esteem • Depression

• Ambivalence about parenting • Problems with paternity • Little support/social network • Separation from the infant in the

hospital

The Newborn • Premature • Low birth weight • Sensory/regulatory difficulties • Infections

• Withdrawal symptoms • Medications/reactions • Separated from the mother in NICU • Other neonatal problems

Adapted from Finnegan et al. (2009). New Approaches in the Treatment of Opioid Dependency During the Pregnancy. Heroin Addict Relat Clin Probl 2009; 11(2): 47-58

“The substance-exposed mother and child are difficult regulatory partners for each other, as the exposed infant often has an impaired ability to regulate his states of

wakefulness, sleep, or distress, and needs more parental help. At the same time, the mother usually has a reduced capacity to read the child’s communicative signals. This combination easily leads to a viciously negative cycle that culminates in withdrawal from interaction and increased risk for child neglect and abuse.”

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Supporting Newborns and Infants

3 Key Thoughts

• A small change in a baby’s behavior, like less crying or more healthy nursing, may make it MUCH easier for parents to connect with babies.

• A small step in a parent feeling successful makes it MUCH easier for parents and babies to connect. • When possible, teach interventions to parents rather than

doing them ourselves!

Supporting Infants

• Current recommendations support hospital discharge only when behavioral symptoms begin to reduce (i.e. able to soothe), however increased billing pressures on hospitals may mean that once a baby is medically stable (feeds, blood pressure, temperature, etc) the baby may be discharged.

• Non-medical interventions for the detoxing baby: Soothing, Support & Self-Regulation

Soothing

• Swaddling

– Benefits: reduces startle, helps regulate and soothe babies – Needs to be taught over and over in multiple ways (just like

everything else!)

– Most common response: “My baby doesn’t like it.” Most common reason: Not done properly

• Alternatives to swaddling: upper/lower extremity containment, firm pressure, “tuck” position

• Low stimulation: low noise, low light, skin-to-skin time can be helpful but not frequent touching/position changes

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Signs of Disregulation

• Recognizing signs of over-stimulation/disregulation – Looking away

– Spitting up or sudden bowel sound – Coughing or hiccupping – Glassy eyes

– Jerky movements or almost no movements at all – High-pitched cries

– Color change: red or “bluish” – Splayed limbs (even fingers or toes)

Supporting Regulation

• Smooth transitions in position, light, sound • Routine in care-giving hospital and home • Modified feeding and sleeping environments • Respecting any signs of disregulation and reducing

stimuli accordingly

• Opportunities for non-nutrative sucking (pacifier, hands if skin is healthy)

• Signs of re-engagement: eye contact, soft vocalizations, smooth movements, head turning.

Supporting Feeding

• AAP: Breastfeeding where possible, desired, and not contra-indicated

• Feeding education (small, frequent feedings; feeding positioning)

• Concrete support for things like counting oz. in a bottle, how to hold a baby with reflux (v. different from traditional holds)

• High-calorie feeds to compensate for low birth weight and increased post-natal weight loss.

Additional Resources

• Nelson, C., Bhagat, R., Browning, K., and Mills, L. (2011). Baby Steps: Caring for babies with prenatal substance exposure. (3rd_{ed.) Ministry of Children}

and Family Development. Available at

http://www.mcf.gov.bc.ca/foster/pdf/BabySteps_S ept2011.pdf

• Velez, M & Jansson, L. (2008). The Opioid dependent mother and newborn dyad: nonpharmacologic care. Journal of Addiction Medicine, 2(3), 113-120.

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Next Speaker

Cheryl Pratt Ph.D. Children’s Research Triangle

The Impact of

Prenatal Opiate

Exposure on an

Infant’s Long Term

Development

Identifying the Pieces of a Complex Puzzle

• Multiple risk factors which impact research outcome findings: – Prenatal polysubstance

exposures

– Familial mental health histories – Attachment concerns

– History of abuse, neglect, witness to domestic violence

– Maternal Characteristics: SES, level of education, and other environmental factors

– Foster care and placement disruptions

At risk for neurodevelopmental impairments

• 7% of children born to opiate addicted parents develop neurological deficits

• Microcephaly • Cerebral Palsy • Mental Retardation

• Associated with more severe NAS and seizure disorders • Neuroimaging study with small N (10) showing smaller brain

volume, decreased thickness in the cortical mantle-especially left hemisphere-more changes in the anterior cingulate and left lateral orbitofrontal cortex, smaller amygdala, putamen, and pallidum

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Primary Difficulties of Prenatally Opiate

Exposed Young Children

• Self-Regulation Abilities • Sensory Processing Problems • Motor Skill Development • Attachment Problems/Concerns

• Feeding Difficulties and Communication Development • Cognitive Development

• Behavioral and Emotional Functioning

Self-Regulation

The capacity to modulate

mood, self-calm, delay

gratification and tolerate

transitions in activity

Self-Regulation

• Self-Regulation determines:

– state regulation, habituation, and reflex development* (impact of withdrawal)

– Sleeping *

– ability to self-sooth and self-calm* – modulation of affect

– ability to delay gratification – tolerance of transitions – attention

– mood modulation

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.

Sensory Processing Difficulties in the

Opiate PSE Young Child

• An inability to process information received through the senses which includes touch, movement, body positions, sights, sounds, smells and tastes

• The brain cannot analyze, organize, connect or interpret sensory messages which is reflected in the child’s sensory reactivity, motor, and behavioral patterns

• The infant/child cannot respond to sensory information to behave in a meaningful, consistent way

.

Postural Tone and Motor Skills Difficulties

• Hypotonia (oral motor, decreased core postural tone, or generalized hypotonia in extremities)

• PDI scores more impacted in the first two years of life. Ongoing psychomotor difficulties after the age of 2 correlated with more severe NAS and at age 3 more severe NAS and stronger opiates

• Cerebral Palsy-occurs more in preterms

• Fine Motor/Visual Motor/Perceptual performance abilities –see more in late toddler/preschoolers

.

Feeding Problems and Speech and Language

Delays and Impairments

• Feeding problems due to postural tone, oral motor and oral sensory problems

• Language production /concept development • Speech articulation

• Auditory filtering and processing problems

Attachment Issues: Substance Using Mothers:

Maladaptive Parent Child Interactions

• Decreased sensitivity

• Decreased responsiveness and emotional availability • Lack of structure and adaptability

• Intrusive interactions • Decreased attunement

• Decreased involvement, parental self regulation difficulties

• Lack of self-reflective capacity

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Resources for Opiate/Substance

Exposing Mothers

• Attachment focused model programs (Inpatient, Residential, and Outpatient):

• The Mothers and Toddlers Program (Yale)

• The Haven (Denver, CO)

• Breaking the Cycle (Canada)

• Infant Parenting Child Care Program (Oklahoma)

• Families in Recovery Staying Together (FIRST) (Oakland, CA)

Mary Dozier’s Attachment and Biobehavioral Catch-up (ABC)

• Home Visiting Programs (Old’s Model)

Cognitive Difficulties

• Impact of prematurity, SGA, poor prenatal nutrition, fetal distress/HIE, severe NAS, seizure disorders, living with substance abusing parents, trauma experiences, witnessing domestic violence, foster care, SES and level of maternal education; at risk for academic problems • Most kids look normal from birth to age 2

• 2-5 years children have same IQ as peers with same SES • At age 5 ½ -more cognitive issues are identified

(ADHD)

• School age performance associated with parental factors

Behavioral Problems

• Increased activity level • Impulse control difficulties • Decreased attention • Low frustration tolerance • Increased aggressive behaviors • Poor self-esteem

The Environment

• Plain walls, muted colors

• During withdrawal-quiet, dark environment • Avoid mobiles/hanging items

• Soft lighting (no fluorescents!)

• Limit wide open spaces by providing visual or physical boundaries (furniture)

• Label therapy/home/school areas with pictures & words

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Strategies for Developing Self-Regulation

• Swaddle, hold and rock

• Look for Cues that Child is Overwhelmed

• Remain Calm

• Develop Soothing Routines

• Decrease Stimulation

• Infant Massage

• Structure the child’s environment and

their experiences

• Predictability in parenting interactions

• Provide consistent limits

• Repetition of verbal directions and

experiences

• Contingency

• Prepare child for transitions

Sensory Processing Strategies for

Self-Regulation

• Adjust the environment, decrease stimulation • Swaddle

 Allow controlled opportunities for sensory input  fidget toys, water bottles (with straws), sugar free gum  Sensory Diet

 Provide frequent breaks with motor movement  Provide a quiet, safe place for times of dysregulation

 equip with beanbags, soft lighting, soft pillows, squeeze/fidget toys, chewy toys

Transitions

 Use physical cues such as turning a light on and off or a transition song/singing directions

 Tell the child for ex. “ We are leaving in 15 minutes, then 10, then5,4,3,2,1 minutes.”

 Sing directions

 Adapt work to minimize frustration and anxiety  Break work into small amounts

 Shorten time of work

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Creating a Picture of Time

Visual/Pictorial Schedule

Strategies for Supporting Modulation of

Affect

• Calm Care-giving

• Label Emotional Experiences with

Words

• Recognize Over-stimulation--Intervene

Early

• Recognize Child’s Body Patterns

Promote Healthy Self-Esteem



Catch the child being good



Provide LOTS of praise for positive behavior



“All of our brains work differently”



Emphasize areas of strength



Destigmatize difficult areas



Model this concept for the child



Avoid punitive consequences



Emphasize natural consequences

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Resources for Opiate Exposed Infants and

Young Children

• Fussy Baby Network Programs • Infant Massage USA

• NICU Developmental Follow-up Programs • Early Intervention/CFC’s

• Early Head Start/Head Start Programs • Home Visiting Programs

• Educational Block Grant Programs-Parent Initiative and Training Components

• Wellness Centers • Child Welfare Databases • Children’s Hospitals

http:// www.childstudy.org cpratt@cr-triangle.org 312-726-4011

Next Speaker

I Am A Mother In Recovery

Erica Asselin,

Mentoring Mom, Project NESST, JF&CS Boston Recovery Coach, MAT Advocate,

MotherWoman Facilitator Co-creator of Ashley’s Moms