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Early Identification and Treatment of Prenatally Exposed Infants

Linda Carpenter:  Thank you. Welcome, everyone.
Good afternoon, still good morning to those of you on the West Coast.
I’m Linda Carpenter. I want to welcome you to this next webinar of the series that we’ve
been doing every month for the last 10 months. This one is, “The Impact of Maternal Opioid
Use in Pregnancy, Infant Withdrawal, and Developmental Outcomes.” In just a minute, I’m going to
introduce you to Dr. Sharon Burke. I wanted to take a couple of minutes to go
back and remind everyone that the purpose of this particular webinar was to really look
at identifying and responding to infants who are prenatally exposed during pregnancy, and
with the greatest concern being exposure to opioid use at this time.
We sent you some information. We know that the protocols that the hospitals use vary
drastically within states, across states, and we’ve had a lot of requests for protocols,
clinical pathways for how to identify and manage infants who are prenatally exposed.
In preparation for this webinar, we sent you an example of one from Children’s Hospital
in Philadelphia. We’re also going to ask Dr. Burke. In her presentation, she’s going to
walk through their clinical pathways. These are both examples. They’re not intended
for us to say, “This is the exact way that you need to do this,” but it certainly is
to give you some good examples of what other hospitals have done.
We’re going to focus this webinar on the identification and treatment of neonatal abstinence in infants
in a hospital setting. In prior webinars, we’ve…
Linda:  …pregnancy, the best way to do
that, engagement of obstetricians, and we’ve talked about the importance of medicationassisted
treatment and appropriate treatment for women who were using during pregnancy.
We received over 120 questions in preparation for this webinar, and many of them were very
similar. We’ve gone through and organized them.
We’re not going to have an open mic. You do have a chat log. You’ll see on the righthand
side of your screen there’s a chat log, so if during Dr. Burke’s presentation you hear
something that you want to know something more about, please feel free to enter that
there. I’m not going to promise you that we’ll get
to your questions during the course of the webinar, but we certainly will work with her
afterwards to respond to questions that come up.
Many of the questions that were sent during the registration process had to do more with
mother’s use, appropriate treatments, why medication assisted treatment, and a number
of things that were covered in previous webinars. I realize that there a lot of you new to this,
that are joining and may not have had the benefit of those webinars previously, might
not have had that information. We’ll work to make certain that we get that out to you.
We’ll look at the questions that come in, and talk about how to respond to them. Whether
that’s sending you prior information, research that we have, or prior webinars, so that you
have answers to those questions as well. I want to say one more thing about the questions.
There are also several questions that came in I’m fairly certain these came from our
Minnesota function, so thank you for doing that questions that were specific to work
in the tribal communities. We will talk afterward about how, and where,
and with whom to best address those questions. I think they’re very critical for your work,
so we want to be responsive to that as well. Let me take this opportunity to introduce
you to Dr. Sharon Burke. We met Dr. Burke when we were on our site visit in New Jersey.
We were very pleased with the presentation that she did at that time, and very interested
in the work that Children’s Specialized Hospital is doing around this issue. We asked her to
put together a presentation for today. I have to tell you, she spends an immense
amount time really thinking through the questions that you’ve asked, and trying to incorporate
that into her presentation, and provide you with enough information about the work that
they’re doing at their hospital, and some of the research that they’re doing.
Dr. Burke is the clinical director of the Infant Toddler Rehabilitation Program at Children’s
Specialized Hospital in New Brunswick. She joined in 1993. She’s also a clinical instructor
in pediatrics and neonatal oncology at Rutgers University and Robert Wood Johnson.
She did a pediatric internship and residency at Newark Beth Israel Medical Center. From
1989 to 1993, Dr. Burke was the clinical director of the NICU at University Hospital in Newark,
New Jersey. She graduated from Ross University School of Medicine in 1983, and she’s won
several awards and honors for her work. Dr. Burke, I want to thank you for all the
time that you’ve put into this, and your gracious offer to present today. I’m going to turn
it over to you. Dr. Sharon Burke:  Thank you, Linda, and
to CFF for graciously inviting me to host this webinar. I find it very exciting. I’d
like to say a big welcome to all my colleagues and participants today. Welcome to my home
state of New Jersey. This is a topic that is near and dear to my
heart, and to many of you. What I hope to do today will be to present an overview of
the mother/child dyad, and the complexity of this problem.
I have tried to update the presentation with as much research and evidencebased protocols
as I could find in those that are as current as possible. I tried not to go back beyond
2012. I actually just updated it with information from 2014 and ’15.
I’m just trying to advance the slide. The objectives for today would be to, hopefully,
be able to define and distinguish the difference between neonatal abstinence syndrome and infant
withdrawal. Understand the changing demographics of maternal substance use. Describe benefits
of an inpatient program, including detoxification and rehabilitation. To discuss instant developmental
outcome measures, and future areas of research. Certainly, when we talk about the motherchild
interaction during pregnancy, it is a complicated one.
There are many, many factors that we take into consideration when talking about the
health and wellbeing of both mother and fetus. Things such as infections, diabetes, IVF,
pregnancyinduced hypertension, maternal age, uterine and placental indicators, alcohol,
cigarettes, marijuana, illicit drugs, and prescription medication.
There is probably not one of those items that impacts the mother that it does not, in some
way, also impact the developing fetus, and we want to talk about that in a little more
detail in a few minutes. There are three very big overriding thoughts
that we should consider when talking about public health issues that pertain to the mother
and the child. First of all, setting the stage, there has been an increase of over 300 percent
in overall sales of prescription pain killers in the United States, of which there was a
33 percent increase in the use of prescription analgesics in pregnant women.
I suspect that this number is somewhat underrepresented. Opioid exposure in highrisk pregnancies does
call for guidelines among national agencies that protect both the pregnant mother, the
fetus, and subsequent newborn with NAS. This was a policy statement by the National
Center for Substance Abuse and Child Welfare. There was further discussion that medication
assisted treatment with methadone or buprenorphine is safe and necessary to prevent maternal
relapse during her pregnancy, infant demise, or severe IUGR Intra Uterine Growth Restriction.
This policy statement came from the committee’s opinions of the American Academy of obgyns,
the American Society for Addiction Medicine, and the American Academy of Pediatrics.
These are several very large, wellreputed organizations that absolutely recommend treatment
of moms who are going through their own struggle with opioid or drug polysubstance use to be
treated with medicationassisted treatment during pregnancy.
To not treat a mother during pregnancy would be to cause not only fetal demise or severe
prematurity, but also consequences to the mother that would make it an unsafe pregnancy.
Then lastly, there are overarching principles developed for the identification and treatment
of pregnant women with substance use and their newborns, as well as protection against the
discrimination, stigmatization and criminalization of this use, and that was by the World Health
Organization in 2014. It is really my firm belief that we treat
these moms with respect, with dignity, and integrity, and that we provide them the very
best care that medicine has to offer. In doing so, we will also then protect the fetus.
In terms of identification of maternal substance use, we know from, again, the committee of
The American College of Obstetrics and Gynecology that screening tools are entertained for the
purposes of identifying atrisk pregnancies. Here I really have to say that that relationship
between the obstetrician and the pregnant mom really should be built on trust and respect.
This is the part of medicine that is an arch, not just to science. It takes a wellexperienced
obstetrician to engage a young mother who may feel embarrassed, who may feel ashamed
in admitting that she is taking or is using either illicit drugs or abusing drugs of prescription.
It really is up to that experienced clinician to engage her, to make her feel comfortable
to discuss that. Not only is it important that you be honest, but that we can continue
to test you during the pregnancy, do routine screenings, so that we can keep an eye on
your pregnancy and on the developing fetus. Once that level of trust and respect has been
established, it will be so much easier for the mother and obstetrician to go forward
and have a healthy pregnancy. The obstetrician and colleagues should be doing routine urine
toxicology screens, and they should also be referring these mothers to treatment centers
with an addiction specialist. Many have recommended that it be the obstetrician
who makes that very first appointment for the mother while in his or her office.
Along with this increased rise in maternal drug use we have, of course, seen an epidemic
rise in neonatal drug withdrawal. One of the most recent studies by Patrick, et al. in
2012 points to a rate of NAS of 4.4 per 1,000 live births.
The ICD9 code for this is 779.5, and my colleague David Babinski has just given me a paper to
tell me that the new ICD10 code will now be P, as in Peter, 96.1. Again, when we go forward
talking about insurance and establishing an understanding with the companies, this will
be an important ICD code to remember. 71 percent of moms report use of prescription
pain medication through the pregnancy. 151/2 percent report illicit drug use. 10 percent
of pregnant women report the use of prescription psychoactive medications. 8 percent of teenagers,
the ages of 14 to 17, report the use of prescription medication such as pain meds, antidepressants,
antianxiety, and stimulants. Hospital care expenditures are quite high.
In recent articles by Patrick in 2012 and, again, 2014, and the Healthcare Research and
Quality Commission in 2015, report national aggregates in 2012 up to $595 million.
Increased maternal hospital stays related to substance use have increased by 7.9 to
1,000. Neonatal hospital stays related to withdrawal have increased by 71 percent.
The infant mean length of treatment of methadone is 17.4 days, versus 22.2 days from morphine.
The mean infant length of stay for methadone is 21 days, versus 25 for morphine. 20 percent
of these neonate stays are also related to low birth weight, and difficulty with gaining
weight, failure to try, and 79.9 percent of the cost is covered by Medicaid.
We should talk a minute about the definition of Neonatal Abstinence Syndrome. It is the
constellation of signs and symptoms that occur in newborns involving the central, autonomic,
and gastrointestinal systems after abrupt cessation of inutero exposure to substances,
especially opioids. 55 to 94 percent of exposed infants will develop
signs of withdrawal. Not all infants will require treatment with pharmacotherapy, but
all infants should receive nonpharmacologic interventions.
The pathophysiology of opioid withdrawal has to do with its effects on receptors in the
CNS, the GI system, and the autonomic system. We are talking about opioids that are occurring
naturally in nature, derived from the poppy seed. Synthetic agonists, like heroine, methadone,
fentanyl, OxyContin. Partial agonists, like buprenorphine, and endogenous opioids, such
as endorphins. These activate the new receptors in the neuroadrenergic
nucleus of the Pons in the CNS, and it produces a state of analgesia and euphoria. There are
also significant alterations in GI motility and autonomic hyper…
Dr. Burke:  …phases can be seen in the
newborns. These opioids act to block the action of glutamate
and inhibit the release of norepinephrine. With abrupt discontinuation of maternal opioids
at birth, we see a super normal release of norepinephrine with autonomic, GI, and behavioral
disturbances such as sleep deprivation, significant selfstim patterns, alterations with feeding,
and hypermetabolic states much as you are seeing in your full term infants.
The hypothesis for this is that there are decreased receptor developments and decreased
receptor sensitivities in the preterm infant. There is decreased [inaudible 16:31] exposure
in the preterm infant, decreased transmission across the placenta during early gestation,
and decreased fatty tissue storage. We know that opioids are lipophilic molecules.
In terms of pharmacokinetics, withdrawal is the function of a halflife of the opioid,
and we take into account the newborn’s liver metabolism and renal clearance. We do know
that halflife in the newborn tends to be a little bit longer than in adults.
Morphine withdrawal may be present 24 hours after birth, but typically between 24 to 48
hours. Methadone, 24 to 72 hours after birth. Buprenorphine may present between 40 to 72
hours after birth. Chanson, in her article, discussed the fact
that there is a less severe NAS and withdrawal following maternal buprenorphine dosing throughout
pregnancy. Benzodiazepines and barbiturates may delay
the presentation of withdrawal, and they also exacerbate the symptomatology and Finnegan
scores. Polydrug substance abuse and alcohol exposure may also lead to a more severe and
prolonged withdrawal phase. Symptoms of withdrawal, therefore, may be delayed until seven days
after birth. A recent study in 2014 talks about a biphasic
pattern of withdrawal, where the initial phase may last from one to two weeks, followed by
relapsing course for several weeks thereafter. In terms of pharmacokinetics, the stimulants
cocaine and amphetamine is not so much a withdrawal or a toxicity syndrome, but rather an effect.
These medications actually have a very short halflife, and symptoms can appear before the
halflife. They stimulate the release and block the uptake
of neurotransmitters. They rapidly cross the placenta. Infants often present with hyperactivity,
excessive jitteriness, exaggerated Moros, and exaggerated sucking patterns. It is not
yet resolved if cocaine limits brain development or head growth.
In terms of prescription medications, we see a lot of mothers coming in who are on SSRIs
during the pregnancy. Many of those used during the third trimester may be linked to neonatal
signs of excessive crying and jitteriness, sleep disturbances, feeding disturbances,
hypoglycemia, and seizures. They liken the serotonin syndrome in adults
to what we might see in infants. Where in an adult we see changes in mental status,
autonomic hyperactivity, and neuromuscular abnormalities, we are seeing alterations in
the infant of disturbed response to an environment, jitteriness, sleep patterns that are also
altered. SSRIs may prolong the severity of an infant
who is exposed to opioids inutero. Again, recent reviews are inconclusive as to adverse
neurodevelopmental outcomes in newborns born to women treated with SSRIs.
The toxicology that is most commonly performed is urine toxicology in the infant, which may
provide information a few days up to delivery, and 72 hours after birth. Meconium analysis
can be used to detect maternal opioids and cocaine exposure after the first trimester,
and up to 72 hours after birth. Hair analysis can indicate maternal use in
the last trimester and up to three months postnatal life. And umbilical cord tissue
is fast becoming an easy and rapid collection to foster its use, as well.
In order to assess what is happening with the newborn, a scale was created by Finnegan
in 1986. He noticed significant patterns of behavior and abnormalities that effected the
CNS, GI systems, and the autonomic system. Many times, a [inaudible 21:09] worker will
come up to me and be a little confused, because mom reports a significant history of opioid
use, or she is in a methadone treatment program, and yet the baby’s urines were negative. That
is not unusual to hear. It is not a perfect science. Sometimes the
specimens get lost, they get contaminated, and we don’t always have positive urine toxicology.
That is why clinicians trained in assessment of the newborn and Finnegan scale assessment
are very important. Because we would still want to treat an infant,
even with a negative urine toxicology, if there is a strong maternal history. Those
infants should be scored, and treated appropriately, both with pharmacologic and nonpharmacologic
interventions. Some of the signs we see in the CNS would
include seizures, tremors, highpitched crying, high tone, hyperreflexia, yawning, and sneezing.
Phasamotor problems could include sweating, nasal stuffiness, urinaria, modeling, hypertension.
GI systems include issues with feeding intolerance, vomiting, or diarrhea, poor weight gain because
of a hypermetabolic state. A score of one is given for the least adverse
effect in these categories, and a score of three for the most adverse effect in these
three categories. It is recommended by Hudak in his beautiful
article in “Pediatrics” in 2012 strongly recommended and endorsed by the American Academy of Pediatrics
that Finnegan scoring should start within two hours after birth for those infants that
we are concerned with, and thereafter every four hours.
If this score is greater than 8 for two or more consecutive scores, one should consider
pharmacotherapy. One should consider weaning medication every 24 to 48 hours for two consecutive
scores less than 8, and this dose may be decreased by 10 to 20 percent.
He recommends that medication be discontinued when the morphine dose is less than 0.04 milligram
per kg per day, for methadone, less than 0.05 milligram per kg per day.
I did have time to look at the protocol that was distributed by CHOP, Children’s Hospital
of Philadelphia, and I will tell you that the only difference I saw was that they recommend
medication be discontinued when the morphine dose is less than 0.02 milligram per kg per
day. This is a copy of the modified Finnegan scale.
We train all of our nurses on this scale. They have to go through yearly competencies,
and we try to encourage objective scoring. The infants should all be scored after they’ve
had a feeding, and our nurses actually do a very good job with this.
In terms of pharmacotherapy, according to the American Academy policy statement, there
is no optimum, absolute treatment, although treatment with the same class of drug used
by the mother is preferred. Recommendations would be, one could use morphine,
shortacting medication, starting at 0.04 milligram per kg per dose, every three to four hours.
A longeracting opioid, such as methadone, 0.05 to 0.1 milligram per kg per dose, every
six hours. There are some protocols out there that talk about dosing at every 12hours.
Phenobarbital should be considered as an adjunct to therapy, not as a primary treatment. One
would load with 15 to 20 milligram per kg, and then a maintenance dose of 3 to 4 milligram
per kg per day, while monitoring levels. Benzodiazepine is still considered adjunct
therapy for all polysubstance use, and for moms who have had significant alcohol.
Neither phenobarb nor benzodiazepine should be considered the first line of treatment
for opioid use. Caricoric and tincture of opium are no longer recommended due to neurotoxic
agents. There are studies out there looking at Clonidine
and buprenorphine treatment for newborns, requiring this. They’re incomplete in terms
of numbers, and it is suggested by the AAP that more studies continue to look at the
use of Clonidine and buprenorphine. Buprenorphine is a sublingual medication. Clonidine, they’ve
had some problems with dosing, in small doses, and some problems with hypotension.
Naloxone should not be used, as it precipitates seizures.
The import of intervention and services should always be considered for these babies, and
that really is our first line of defense. We should consider the impact of the environment
on these infants, and should modify lighting. Calming strategies should be used, such as
gentle rocking, swaddling, and therapeutic bath.
Sensory stimulation can include infant massage, soft music, low lighting. Always, we want
to train parent and caregivers how to handle these infants, calming strategies, therapies
which we employ here, to help these infants who tolerate handling and positioning.
Many of them have such high tone that they cannot even achieve appropriate developmental
postures. Their sensory responses are maladaptive, and many of them have difficulty with feeding.
We also want to maximize nutritional support due to their hypermetabolic state. One should
consider high calorie density formulas, fortified breast milk, and also consider other GI symptomatology
that may need treatment, such as reflux and dysmotility issues.
We work very closely with Division of Child Protection and Permanency, and protective
agencies. We work with the WIC offices. Early intervention referral, outpatient referrals,
and visiting nurse referrals are all made prior to discharge.
We also work with obtaining prescriptions if any child needs to go home on medications
for reflux or constipation, and car seat checks. The longterm outcomes in terms of mortality
are very, very low. There is a report that talks about a possible increased risk of SIDS
in methadone exposed infants, and an increased risk in cocaine exposed infants. That was
one article in 2005, and I have not seen more current literature on this.
The incidence of myoclonic seizures is anywhere from 2 to 11 percent, and in an article published
by our research from last year, we showed some significant delays in the areas of cognitive
and receptive language. I wanted to share with the audience a little
bit about our program here at Children’s Specialized Hospital. It’s a little different, in that
we are not an acute care hospital. We’re an acute pediatric rehab hospital.
Children’s Specialized Hospital, we are the largest pediatric acute rehab hospital in
the United States. We’re a 68bed inpatient hospital. 34 of those beds are dedicated to
infants. We have over 23,000 outpatient visits a year.
Our medical teams include infant and toddler brain injuries, spinal cord, chronic illness,
pain management, and orthopedics. We have more than 200 admissions to the infant team
alone every year. To date, this year, we have 17 babies inhouse, being treated for NAS.
We are a specialty hospital. We are a member of Children’s Hospital Association. Many of
our referrals come from the Tristate area. We are recognized by LeapFrog as one of the
top rehab hospitals in 2014. Our mission and vision is very clear. As an
infant rehabilitation program, we believe our goals are to treat infants, help them
maximize their full potential, educate families, seek to establish evidencebased protocols,
and establish research in clinical areas where we can add meaningfully to the literature.
There’s a beautiful article that came out by Jansen, out of Johns Hopkins in 2007, and
she talks about the basis for NAS and dysfunctional neurobehaviors in newborns. She feels that
it’s due to poor fetal adaptation to changes in maternal vagal tone, in response to opioids.
She feels that this is the basis for the newborn physiologic and neurobehavioral dysregulation.
She also mentioned that chronic opioid exposure may lead to placental insufficiency, and that
treatment should be aimed at moderating both physiologic and epigenetic factors.
Following with this trend of thinking, it is critical that every mother who is identified
as having opioid either use or exposure be followed very closely by…
Dr. Burke:  …obstetricians and addiction
specialists that understand the pathophysiology of opioid exposure, and take that mother successfully
through a pregnancy that will protect her health, and that of the fetus.
I’d like to propose that the components of a program for infant withdrawal would include
nonpharmacologic interventions, staff competency and training with the administration of the
Finnegan scales, a standardized protocol for the initiation of medication administered
detoxification, and a weaning process. Maternal caregiver teaching, with home simulation
testing, identify barriers to discharge. The withdrawal process is complex, and one must
be certain that the infant is stable prior to discharge home.
You should assess the infant’s needs for early intervention and outpatient therapy. You should
provide ongoing support for the mother and the infant upon discharge. And we should continue
with both medical and subspecialty followup where indicated.
We are a rehab hospital, and I have a very large component of therapists that work with
me with our babies who are born going through withdrawal. I have a team of about 16 therapists.
In terms of physical therapy, our therapists are all Masters and PhD trained. They work
with the recruitment of muscles, for ageappropriate and developmental postures.
Again, the neuromuscular tone on some of these babies is so high that it is very hard to
get them into a position that protects their airway and protects the joints.
The therapists work very hard, both with the infants and with the parent or caregiver,
to help them reach that range of motion and not cause injury to any joints for the infant.
We have an aquatic therapy pool that is a nice way…
Dr. Burke:  …with the spasticity. We find
that, with good physical therapy and ranging, we do not need to use medication such as Ativan
for tone management. Our OT therapist, Occupational Therapists, work hard with increasing the
motor patterns for infant development. We believe that by increasing and repetition
of motor patterns you imprint for neuronal conditioning. Many of these babies come in
and they are rapid breathers, they’re…
Dr. Burke:  …they’re shallow, and it’s hard for them to eat if they’re breathing
so quickly. We work with a lot of conditioning through
OT to work with chest wall movements and compliance. Ribcage, we try to help descend the ribcage
with kinesio taping. Our speech therapists work with infants who are having problems
with feeding. If you’ve ever worked with a baby going through
withdrawal, they tend to feed rapidly, quickly. They do not pace themselves. Many of them
don’t have a good closure and seal on the nipple. They leak formula. It’s no wonder
they have a hard time gaining weight. Our speech therapists work quite a bit with
oral motor structures, patterns, and pacing for these infants. In some cases the infants
that are having the greatest amount of difficulty, we use vital stim or neuromuscular electrical
stimulation, to help gain the appropriate suck, swallow, breathing patterns for these
babies. We also do a lot with motor planning, in that
we want the babies to be aware of themselves in relationship to their environment. Sensory
input is critical. Babies learn through their senses, and if they are stressed and they’re
not able to pay attention to appropriate sounds, to visual stimulation, to tactile stimulation.
If they keep fighting or pushing away from these stimulus, they will never learn, so
one has to overcome some of their sensory maladaptations in order to get them to learn
how to use their hands, to reach for toys, hands to mouth. This is all necessary, but
you’d be surprised how many of these babies lack these very basic skills.
We want to also work with cognitive processing. Babies learn. If they cry with a wet diaper
it’s important we react, to change the diaper, to reinforce that behavior. That’s appropriate
for young infants. We teach a lot of this to the mothers. Many
of these are firsttime moms, and they really don’t have an idea of what is good parenting,
and especially how to handle a baby who’s crying. We take them through calming strategies
one step at a time, so that they know different interventions. Each child is different. We
customize a behavior mod program for each and every baby.
This is a onepage that looks at our overall program and protocol. The large circle is
on the day of admission. We review all transfer information and history, do physical assessment.
We do a medication reconciliation and family orientation to the program.
Our medication assisted treatment protocol follows along the recommendations of the AAP
guidelines by Hudak. We are a specialty hospital and we get referrals from the Tristate area.
I have some babies coming in on morphine, others coming in on methadone. We do not change
the medication that the baby is admitted on. We continue with that, and we proceed with
a treatment and weaning protocol for either morphine or methadone.
We are starting to look at our outcomes in that regard, and preliminary results show
us that there is no statistical difference in length of treatment or length of stay,
whether we use morphine or methadone for those babies that require medication pharmacotherapy.
If needed, we’ll do electrolytes, CBC, glucose levels.
Our nursing plan of care focuses on the Finnegan scores every four hours, daily weights, weekly
head circumference, and monthly heights, vital signs Q shift and, as needed, continuous monitoring
of skin integrity. Carryover of the therapy protocols as administered
by our therapists, family training in CPR, medication administration not for opioids,
but for medications other than that such as reflux meds, meds for gas, and if there’s
any other medication required, and immunizations as needed.
A nutrition consult is held daily, and we pay high focus on the weight gain and growth
curves on these infants, and their growth velocity trends. Many of them come in at a
severe IUGR status, with growth at the fifth percentile. We work very hard that these infants
tolerate the formula, and that they continue to grow along a growth curve.
Therapy interventions, as I mentioned, include many, many interventions. Our discharge criteria,
all our babies must be discontinued, safely off their medications that were used for pharmacotherapy
for detox. Our Finnegan scores, we like to see all of them less than 8 for a minimum
of 72 hours prior to discharge, once the baby is off their medication.
These babies should all demonstrate ageappropriate weight gain. We also do a BayleyIII developmental
assessment on all our babies with NAS. This is performed by an independent psychologist
who does not treat this infant. We work with DCPP, and work with them to partner
and identify the appropriate caregiver, for time of discharge. We make referrals for visiting
nurse, WIC, early intervention, outpatient therapy if needed. We do car seat safety checks.
We obtain the medications for the mothers. We have a pharmacy on campus, so any other
medications the infant may need we obtain for these mothers prior to discharge. We make
sure that they have formula prior to discharge by using WIC, and we make all of the medical
and subspecialty followup appointments at time of discharge.
Some highlights of our program. Our medication assisted treatment is performed by an experienced
physician. We do a steady taper off narcotics while continuing to monitor for weight gain
and growth. We manage withdrawal seizures and tone with medication, if necessary. We
encourage breastfeeding where appropriate. We continue to provide nutritional support
for weight gain. We treat other symptoms of acute gastritis, dysmotility, or reflux, or
constipation. We do a three channel, 12 hour Pneumogram prior to discharge to ascertain
if the child requires monitoring with an apnea monitor after discharge to home. Our nurses
are all competent and can administer the Finnegan assessment scale.
We do rigorous parent teaching with support and education. After the families have learned
each individual aspect of care be it therapy, be it medication administration, CPR, feeding,
preparation of high calorie formula. We then ask them to do an 8 to 12 hour independent
provision of care, where they provide total care in the hospital. We supervise, but we
do not interrupt their care. If they fail that testing, then we go through the teaching
again, and they repeat another independent provision of care exercise.
We work with a local counseling center here in New Brunswick. It is within walking distance
from our hospital, and they provide an MAT for the mothers who require this. Many mothers
come from counties that are too far from us, so we allow sleeping in, and rooming in, with
the babies. The mothers can walk right up the street,
get their medication and their counseling, and come back and spend the time that they
need with their infants. We also have a nearby WIC office that we work
with, who will provide the checks for WIC, regardless of what county in the state of
New Jersey the mother is from. When she goes home, the checks then come out of the local
office from where she lives. We have an onsite pharmacy that provides any
medications the child might need prior to discharge. We do have a select car service
for some mothers who do not have transportation or a means to get here.
We have bedside accommodations for our mothers and babies. We also have the Ronald McDonald
House. We coordinate all services for discharge, including collaboration with DCPP, early intervention,
outpatient [inaudible 42:22] . We also do telemedicine visits. We use the
VGo, it is a telemedicine robot. I meet with the families after discharge, where I can
actually see the child, the parent, and the visiting nurse in the home. They are free
to ask questions, and we can continue to provide continuity of care.
We also make appointments for our pediatrician, and our neurodevelopmental pediatrician, who
continues to do the Bayley assessment at threemonth intervals.
In terms of our developmental milestones, as I mentioned, we have a feeding specialist
who works with those infants who are struggling. We have a physical therapist, who addresses
the gross motor needs. OT works with visual and auditory sensory inputs.
We have recreation therapists and cuddlers, who continue to work with the parents and
families when the mothers can’t be there at night. We have cuddlers who are there to hold
and comfort these babies. We have child life specialists, who teach Mothers infant massage,
and continue with parenting classes, and I’ve a psychologist, who performs the Bayley Scales
of Assessment at time of discharge. One example that one may want to emulate is
our model for Inpatient Therapy Program for NAS. Our babies get anywhere from 6 to 12
sessions per week, if needed, for speech therapy. Five to six for PT, five to six for OT.
Infant massage may occur one to two times, first with the child life specialist, and
thereafter with the mother or caregiver, who is trained. Therapeutic bath may be anywhere
from three to five sessions per week, our aquatic pool one to two sessions, our cuddlers
one to three, and parent instruction occurs daily with nursing.
I work with the mothers at time of admission. I think one of the biggest challenges is to
help Mothers feel secure, that they are supported, that they are in good hands here. We’re a
nonjudgmental, nonpunitive hospital. We’re here to help both the mother and the
child. Our greatest hope is after discharge to home we have a trained mother who is taking
care of herself, who is compliant with her own program, and works with DCPP and outside
agencies for continued surveillance and monitoring of mom and the baby.
We’ve had very good success. Our mothers love the program here. They tell their friends
about it. They said they feel that they can trust us, and they’re more likely to stay
compliant if they feel that they are respected. We are very proud of our program.
This is a picture of our aquatic therapy pool, which is delightful. There’s nothing that
a mother loves more than to get a little bathing suit for her baby, and watch them in the water.
This is a therapist who is administering vital stim for a baby who is having problems feeding.
The next picture shows contingency learning, this one is infant massage. This one is showing
a range of modifications for adaptive positioning for sensory awareness, and interaction with
the baby’s environment. We do a lot of what we believe are really
good interventions for the babies and for the mothers. We weren’t sure if it was enough.
We started to look at our outcome measures from the years 2009 to ’13. We had 42 infants
during that time period enrolled. We had Bayley testing on only 28 of them,
and the reason for that is that, as I stated, most infants coming in with NAS are full term.
Our program here, our Infant Therapy Program, does Bayley assessment for outcomes on our
preemies, our high risk preemies. Those that are on ventilators and TPN, and extreme prematurity.
We never thought to look at full term babies who were struggling with NAS. As time went
on, we recognized that we were recommending babies for outpatient feeding, for gross motor,
or OT therapy. We said, “Maybe we should start doing Bayleys on these infants, and see if
we’re finding anything.” That’s why we only had at that time Bayleys
for 28 infants, because it was late into our outcome measures that we realized we wanted
to start doing this. Our overall length of stay during this time period for these babies
coming to us from NICUs… That’s the other thing I should mention. Babies
coming to us are often coming from NICUs, wellbaby nursery, or pediatric floors in the
Tristate area. Very often, we’re getting babies coming to us because they are failing in their
weaning process in acute care. These were babies who were started on either
morphine or methadone. They were struggling with their detox. At about 10 to 11 days of
life they were doing better, they were getting ready to go home. Then there was a surge,
as they were coming off their medication. There was a surge in their Finnegan scores
up to very high numbers, 14s and 15s. It was felt at that time that these babies
needed to come to us for ongoing treatment, as they were perhaps a different infant than
the majority of babies with NAS who go home. We believe that is the case.
We don’t, certainly, see the hundreds of babies who are born with NAS. We get a small subset,
and we believe these are infants who perhaps show a different demographic, or a different
physiology in terms of weaning, than some of their counterparts.
The discharges to home were 75 percent for the mothers, 25 percent for foster family.
Medication assisted treatment, 50 percent came in to us on morphine, 50 percent on methadone.
All 100 percent of these babies were weaned off their medications.
Finnegan scores at time of discharge were less than 6. They all achieved ageappropriate
weight gain, of which 70 percent still required high calorie formula.
All babies had a normal Pneumogram. All caregivers successfully completed the independent trial
and provision of care in the hospital. All went home with involvement with visiting nurse
and DCPP organization. When we started to realize that these full
term babies, who otherwise would have never been identified as having some issues, we’re
saying, “Wow. There’s something to this. Should we start to look at the outcomes in development
for our NAS patients, comparing them with nonexposed peers.”
We wrote up a protocol, which was approved by Western RIB in May of 2013, and we did
a retrospective chart review. Our hypothesis was that infants diagnosed with NAS demonstrate
developmental delays compared to infants without NAS.
We used the Bayley normative data, which was historical data. We excluded premature infants,
or those who were considered medically fragile with any number of serious illnesses, such
as congenital heart disease, significant lung disease, chromosomal congenital anomalies.
The Bayley, to review for you, the BayleyIII. There is a BayleyII out, but the latest one
is the BayleyIII. It’s designed for use for infants between the ages of 1 month to 42
months. It is a standardized tool that is derived
from the assessment of 1,700 children, with classifications derived from a normative bellshaped
curve. The Bayley subsets are in the areas of cognition, receptive and expressive language,
gross, and finemotor. The descriptive classifications include your
scoring on the left. Those scores on the Bayley of 69 and below were classified as extremely
low outcomes, 70 to 79 borderline, and so forth.
This is the composite curve for the infants that we tested first, is the normative curve
for Bailey. The normal curve is in the yellow blocks, and you can see it takes a typical
bellshaped curve, starting with extremely low, going up to very superior.
We broke out our curves by function. Here we have the curve, looking, comparing, the
normal Bailey curve versus the scores on our patients in pink, for motor, and you can see
the distribution. Not too bad, but we didn’t have any children in the superior or very
superior category. Here we have the cognitive curve. Again, yellow
is the normal curve, and our patients are the dark blue lines. The language, yellow
is normal, and the green curve is our patient population.
When we looked at this, our end was 28 out of 42 infants that we looked at. For cognitive
scores, seven percent scored in the borderline ranges, 70 to 79. Seven percent scored in
the extremely low range for cognition, below 69.
For total motor scores, four percent scored in the borderline range. For total language,
29 percent scored in the borderline range, of these 28 patients, and 11 percent scored
in the extremely low range. Our mean age of testing was 58 days.
Some key points to remember when we talk about statistical analysis. The Bayley was established
as an historical control group using normative population, who were evaluated for the development
of the BayleyIII. One group of infants totaled 1,700 infants aged 1month to 42months, which
is the entire standard population of the BayleyIII. A second, smaller control group of 300 infants
were used, which we used we were able to pull out from the Bayley, with permission from
them, that were matched more closely in age to our group, with a mean age of 60 days.
Again, our population was 58 days. Our statistician used a standard sample of
two sets of analyses. The two sample ttests comparing the mean composite scores for infants
with NAS versus control, and the ChiSquare test comparing descriptive categories for
NAS infants and control. This was the ttest comparing the composite
scores, the Bayley standard score with a mean of 100 and a standard deviation of 15. And
the ChiSquare, again, looking at the Bayley percentages versus our study group. The Bayley,
again, the smaller group of 100 versus our study group of 28. This was the ChiSquare
test looking at motor…
Dr. Burke:  So when we looked at the scores, what we found was that the mean language and
cognitive scores were statistically lower, T less than .001 in our NAS group, compared
to a Bayley sample of 1,700 for the total Bayley standard, and a smaller group of agematch
controls of 300. We did not find significance noted when comparing male gender, of which
there were 57 percent. We thought this was, indeed, very significant.
We do note that this is a very small sample size. There needs to be continued data collection.
We noted significant scores in the domains of language and cognition that were lower
in the NAS group versus historical normative group. We also noted that we did have some
delays in discharge due to caregiver identification. We did publish this paper. That was in “Clinical
Pediatrics,” in 2014. Since then, our neurodevelopmental pediatricians
have followed up on the original 28 infants after their discharge to home. They’ve so
far been able to follow up on 16 of these children, of which we have data for 12.
Of the 12 that they’ve been following up, both in their second assessment, which was
anywhere from 3.6 to 8.3 months of age, or their third assessment, anywhere from 10 to
18andahalf months of age, they were still finding significant deficits in the area of
cognition, in the lowaverage realm, 45 percent. 60 percent having issues in a total language
deficits. 36 percent had lower scores as compared to
their first assessment, so that was a trend we weren’t expecting to see. 54 percent had
fine motor deficits. One patient presented with emerging oppositional behavior at 18
months of age, one possibly with autistic spectrum needs to be followed more closely,
and one with nystagmus. Because of the emergence of fine motor deficits
in addition to our previously identified language in cognitive deficits, we were concerned that
this might be an indication of more global delays rather than isolated deficits.
This is just a slide showing the comparison between our first study group at time of discharge,
and our followup from January, 2014 to June, 2015.
Again, looking at our data, we feel that there is more work to be done. We seem to be obtaining
infants from referral hospitals where the infant is failing their first phase of weaning,
and coming in along this fivephasic curve after two weeks of life.
So perhaps this represents a different type of patient than most of the infants that are
either treated in acute care or discharged to home.
We think we should start to stratify infants, based on the severity of their admission Finnegan
scales, into two groups. Those whose scores are less than 8, and those greater than 8,
and compare that with their Bayley scores. We should evaluate the impact of treatment
with morphine versus methadone on daily scores. We should continue to impose standardized
weaning protocols based on evidencebased literature, and we should identify emerging patterns of
difficult behavior or visual issues in longterm followup.
So, I think I kept it down to an hour [laughs] and I want to thank you for your patience
and your attendance. I open it up, I guess, Linda, to online chat and discussion.
Linda:  I’m going to facilitate questions for you, Dr. Burke, but first of all…
Dr. Burke:  Thank you. Linda:  …let me thank you. That was an
excellent presentation, and I’m certain that everybody listening really appreciated it
and got a lot out of it. You covered a lot of the questions that were
submitted originally. You covered a lot of it in your presentation, so I’m going to jump
around a little bit, and hit some of the highlights. First of all, when you talked about infants
that present with Neonatal Abstinence Withdrawal Syndrome, you’ve presented a range, from 55
to 94 percent. Am I correct with that? Can you talk a little bit about why such a range?
Dr. Burke:  I think that’s because of the degree of training of the staff who are scoring
these infants. That is my best guess. This is in the literature, and it is a very high
variance, that 55 to 94 percent. I do believe it’s in part the level of education
and training of the staff who are working with these infants, and also in part related
to the substances of abuse that the infant may have been prenatally exposed to, so that
there may be a range when they present. Very often, term infants are sent home at
three or four days of life, and they may not be presenting until four or five days, depending
on the halflife of the drugs that they’ve been exposed to.
Linda:  That’s certainly a good segue into a couple of other really critical questions.
One of the things that folks ask repeatedly and you’ve touched on, was that sometimes
symptoms don’t present until seven days, depending upon drugs, depending upon severity.
What does this mean in terms of early discharge from a hospital? When the various hospitals
start to look at their protocols, what does it mean in terms of how long they keep an
infant for observation? Are there recommendations around that?
Dr. Burke:  I think each hospital will be very specific, but I would give some general
guidelines. If you have a history of a very high risk infant, I would at least keep for
three days. Any symptomatology at all, I would extend it by a few days.
I think there needs to be very close followup with protective agencies such as DCPP or visiting
nurse that will also be working with the family in the community, for possible rebound or
initiation of high Finnegan scores. I don’t know that we can train parents competently
in the administration of a Finnegan score in the home, and that’s why I would draw upon
the expertise of community agencies that they have very close followup with the families,
as well as close discussion with the pediatricians in the community.
We’ve heard of a few children who have gone home and have come back to our local acute
care facility through the ER, in severe withdrawal. Linda:  That’s actually one of the questions.
If an infant begins to exhibit withdrawal and other symptoms after going home, what
should the parents do? Dr. Burke:  They should call their pediatrician
immediately, and I would advocate that they go to the emergency room with these children.
Because they are at risk for high metabolic states, hypertension, and if the pediatrician
can see the child in the office, fine. If it’s on off hours, I would still call the
pediatrician’s office and then go to the emergency room.
Linda:  Dr. Burke, one of the questions that came in, and you’ve talked a lot about your
nonpharmacological interventions, and really stressed the importance of that. One of the
questions that came in was, what is the evidence behind the Rule of 24, and why do you manage
these babies in a NICU as opposed to a general setting?
Dr. Burke:  Again I’m at an acute care hospital, we’re specialty. But I think you need trained
individuals to know how to administer the therapies. I’m a neonatologist, and I know
what we do in the NICU. I know what also goes on, on the pediatric floors, and I’m concerned
with the infants on the pediatric floors. They are loud, noisy, sometimes they are put
into a room that is relatively dark, and I don’t know if they get the proper…
You know, the mission statements at most acute care hospitals are not to administer therapy,
so I don’t know if they have staff that can speak to the needs of these infants, be it
sensory input, motor input, difficulties with feeding. I just do not know if a general ped
floor can handle it. I do feel, at least in the NICUs, there’s
a little bit more specialty training, especially among nurses on feeding difficult patients.
You can certainly get consultations with PT, OT, and speech. I just do not know the frequency
with which that would be carried out. And of course, the physiologic parameters, once
these babies start to withdraw. Again, you want staff that are highly trained
in assessment with the Finnegan scale, as well as knowing when and how to initiate pharmacotherapy
if necessary. Linda:  I know that we are focusing primarily
on babies that are prenatally exposed to opioids. There were lots of questions around exposure
to alcohol, and whether or not there are withdrawal symptoms in alcohol exposed babies, and how
do you manage that? How do you identify babies that are fetal alcohol exposed?
Dr. Burke:  As you know, fetal alcohol is an entity unto itself, and I daresay that’s
another webinar for another day. But we do know that most infants who have been exposed
to alcohol inutero are severe IUGR, severe microcephaly, with a very definite physical
stigmata. The flattened nasal bridge, the flattened
philtrum. These children absolute had an embryopathy related to fetal alcohol, it’s pretty distinct.
Their IUGR is way more severe, even than what we see in the opioid exposed babies.
What we know from the literature is that the alcohol exacerbates withdrawal in opioid exposed
infants, but inandof itself, the greater issues are weight gain and growth, growth restriction
and retardation, severe mental deficiencies. Not necessarily developmental, but more related
to IQ. But you’re not going to know that in that newborn period.
Linda:  You talked about the babies that come to you are often transferred from other
hospitals, and obviously having more difficulties with weaning, and possibly have come back
in. Talk a little bit about the impact of other factors during pregnancy aside from
Mother using opioids, whether that’s other risk factors for highrisk pregnancy, and how
that may affect these babies. Dr. Burke:  Are you speaking in terms of
other substances of abuse, or medical conditions? Linda:  Both. polysubstance abuse, late entry
into prenatal care, whether or not mom obviously poor nutrition. Any of those other factors
that may impact these babies. You summed up a lot, and that’s not considered an illegal
substance. Dr. Burke:  As far as polysubstance abuse,
again, it’s going to a very skilled obstetrician to work with this mother and get her to come
forward, and be honest, and submit to regular screening and testing. Because that’s the
only way knowing at least what’s in mom’s urine, how we can start to focus her management.
Certainly, good nutrition is critical for all pregnant moms.
Very often we see that the moms with the worst nutrition have some of the smallest babies,
both in terms of weight and head circumference. So again, that screening and that working
very closely with the moms, and making sure that we can get them to go to centers that
will work with them as highrisk, and to give them the appropriate medications they require.
Maternal factors other than the poor nutrition would be, of course, monitoring these women.
They might be victims of abuse themselves, that should be determined, and a safe haven
needs to be guaranteed to these mothers, where they will not be going back into a home where
there is violence. Certainly any other medical conditions, maternal
hypertension, seizures. I have had several moms come in…
As you know pregnancy can augment the appearance of collagen vascular diseases. I have a lot
of Mothers who started out with a relatively normal pregnancy, and developed Lupus or Raynaud’s
Phenomenon, many with severe arthritis and they get started on pain medications and get
hooked on the prescription pain medication. Those women need to be followed very closely,
not only for their exposure to pain meds, possibly the need for Methadone, but also
their own issues with their medical complications. I have one mother right now that is suffering
from severe Raynaud’s. Again, we want to be open to suggestion that many of these moms
have not only problems with substance abuse, but also their own medical complexities as
well. Which will always impact on the developing fetus.
Linda:  One of the issues that comes up a lot for families that are involved in the
child welfare system is this issue of breastfeeding, and people not understanding the importance
of breastfeeding. Can you talk a little bit about decisions about breastfeeding? Like
when it’s OK, when it might be contraindicated? Dr. Burke:  Yes. Again, I am not the law
of the land. [laughs] And so I really read up very closely on all the issues, by American
Academy of OBGYN, American Academy of Pediatrics, World Health Organization, and they strongly
recommend that moms be able to breastfeed, and I do support that.
I believe the only contraindication is in situations of HIVpositivity in the mother,
and where suboxone is used. Many providers of treatment for moms during pregnancy are
not schooled enough in what should be given to pregnant moms. Most of them should be transitioned
off of the suboxone, because of the component of naloxone in it, and transitioned to subutex.
I believe there are many providers out there that still need more education in this arena.
Other than suboxone, it is recommended that moms on methadone or buprenorphine be allowed
to breastfeed. It helps with bonding, certainly helps with immune protection of the infant,
as well as nourishment. And the studies have shown that the amounts
of methadone that cross into the breast milk are so very, very small that you can hardly
measure them. So it is strongly recommended that moms be allowed to continue to breastfeed
where possible. There are some other indications that if moms
have screens where there are illicit drugs, then they should not be allowed. That’s why
it’s very important that as pediatricians we work closely with DCPP and other agencies
that can do some of the detective work for us, to help us make these medical decisions.
Linda:  You mentioned that for the majority of your infants they’re going home with mothers.
In the event that they may go home to another outofhome care placement, what do you recommend
for those caregivers in terms of interventions, things that they can do to mediate some of
these effects? Dr. Burke:  Once there has been a caregiver
identified by DCPP or the courts, we take them through the same training and education
process that we would for a biological mother. So we put them through all the training in
terms of calming strategies, feeding strategies, how to make the medication if they’re require
extra medications for reflux. We bring them through all of that, and we
make sure that they are followed up the same way, with medical subspecialty followup, as
well as with DCPP and visiting nurse. Linda:  Again, Dr. Burke, I realize I’m jumping
around a lot with this. I’m trying to cover as many of these questions as possible. But
there were lots of questions around screening and testing babies at birth. I realize a lot
of those infants are transferred to you and not necessarily born in your hospital, but
can you talk a little bit about that testing process, and what you would recommend?
Dr. Burke:  I think it’s a process that is filled with frustrations. When I talk to my
colleagues in acute care centers, most of them have access to urine toxicology. I think
all hospitals probably have the ability to do urine screens, urine toxicology, on the
newborns. Again, some of those yield positive results,
some of them negative results, even where you have a positive history in the mothers.
In those cases, I would opt to rely on the history, and monitor those children very closely
for signs of withdrawal. We also know that there are a few hospitals
in New Jersey that are doing research on the hair analysis and umbilical cords. I think
those are probably expensive tests to do, unless you are in a research facility.
But over time as the research comes out on that and indicates whether or not we should
be using hair or umbilical cord analysis once that statement is made I would hope that the
expense for doing these testing is not cost prohibitive, and more acute care facilities
will be able to follow up. Clearly, there are much more positive results
that will be yielded with both hair and umbilical cords. So, again, it can be frustrating because
you have a mother who may be in treatment with methadone throughout the pregnancy, or
illicit drugs. She tells you that, and the baby’s urine screen is negative.
I would not let that stop me. I would go ahead, monitor this child very closely for withdrawal
symptomatology. Linda:  It’s interesting, you talked a lot
about the importance of understanding mom’s prenatal history and certainly also understanding
babies. But the difference between getting a positive
tox for the purpose of identifying a baby that is subject to abuse and neglect, versus
getting that information, prenatal history and the baby’s toxicology, to really determine
the best interest of the mom and the baby. What are the right interventions for that
baby? Why is that so important? This speaks a lot
to the work that you’re doing around the Bayley, as well, but can you talk about why it is
important to really understand, not from an abuse and neglect perspective, but really
to understand the needs of that baby and the mom?
Dr. Burke:  Again, you want to have an open relationship with the mother because, first
of all, you want her to have a successful and safe pregnancy. You want her to be able
to come to term with the baby, to carry to term, to have a healthy infant as much as
possible, good nutrition and good support of the mother.
Because our preliminary studies are starting to show us that some of these babies, who
are otherwise full term, are presenting with some possible delays in their developmental
milestones, or in the areas of motor and language, it would be very important to continue with
the screening of these infants. Most of these babies who don’t come to us,
and perhaps are treated in acute care and go home. As full term babies, they are not
being screened, and I am worried that some of those infants may not be getting the early
services they require. I don’t know that pediatricians, a busy pediatric
office, is able to screen these infants. So, some of this might be helpful from our perspective
to work with community pediatricians and say, “You know, that baby that did come through
us, we are concerned is showing some delays. We are going to refer to early intervention
and continue surveillance of that child.” Because I really believe if we can make an
impact in the early days for these children, and give them the therapies they require,
they may not require full services by the time they get to school age.
Linda:  Thank you very much. One of the questions that has come up during the course of your
presentation, and I think it’s a natural question to ask, is, you have a marvelous array of
services. You have a marvelous program, you have a wide range of staff working with you.
How do you fund it? How is it funded? Dr. Burke:  We work with insurance companies.
We are a nonprofit, we do work with the insurance companies. In fact, many of them are asking
us for continued research in these areas and to collaborate with other hospitals.
Because they are trying to understand themselves what the needs are of the infant, and we do
work very closely with the insurance companies. Oh, I’m sorry, my colleague is here. And with
Medicaid as well, with HMO Medicaid and with Medicaid services.”
Linda:  Was that David? Dr. Burke:  That’s David, yes.
Linda:  [laughs] Dr. Burke, I have a couple more minutes and I think you’ve started off,
we’ve started off, by talking about that there’s a wide variation in hospital protocols and
clinical pathways for both identifying and treating infants with neonatal abstinence,
certainly infants that are prenatally exposed to substances.
For hospitals that may not have the ability to provide the wide range of services that
you do, if you were to recommend certain elements that you think should be there in all clinical
pathways for these babies, what are the things you think are the most essential?
Dr. Burke:  Again, we do have the luxury of being able to provide a tremendous array
of services. But if I were to venture into a model for hospitals, whether they be acute
care or any other type of hospital, you want to make sure that the information you have
is as correct and available as possible, in terms of maternal screens, and infant screens,
and history. With a positive history, I would monitor that
baby very closely in the nursery. If that child is showing positive signs of withdrawal,
it might do you well to train some of your staff on the administration of the Finnegan,
so that if a child requires pharmacotherapy, we feel that it is a reliable score.
For the child that is withdrawing, I would always start with the nonpharmacologic interventions.
Perhaps you can train cuddlers, or volunteers, to help in this. I would propose that, at
least to the hospital administration. I don’t know if you would have enough staff, so I
would work with cuddlers and volunteers. Very often, working in nurseries is where many
volunteers like to be of service. If you need to treat, either the NICU is trained
in the protocols for treatment and pharmacotherapy, or send them to a center that is confident
and trained. Because detox is a very risky business, and you want to make sure that you
take that child through a slow and steady course, without risking a rebound.
You would certainly want to, also, engage DCPP and community services to help you with
the discharge planning, and, where possible, try to either test these children or make
referral for EIP in the community, where they will test the children to see if they need
ongoing therapies, or referral for EIP. Also, I feel very strongly that no baby who
is going through withdrawal should be discharged home while he is still actively withdrawing.
I do not believe there are enough pediatricians who have the time to monitor these babies,
and I don’t even know if there are enough community services.
We have gotten back a few babies who went home, who were still on medication. Those
babies had a very negative outcome. One had seizures, one went into cardiac arrest. So
detox for a baby, just like adults, needs to be handled seriously and by experts in
the field. Laura:  We know that we have all six of these
states. We have a few other folks who are on the call with us today, but most of the
people who are on the call today are partners in this six state initiative, trying to address
this just as you are in New Jersey. Is there anything you would want to say to
these six sites about your recommendations for moving forward, or what you think is critically
important? This is your chance to provide us all with some recommendations.
Dr. Burke:  I would love to see us continue to work and collaborate, because I think putting
the best minds together from whatever states are interested in helping to further the medical
care for the mothers, the screening for the mothers, services for the mothers, and then
ongoing services for the initiation of care for infants.
Regardless of the setting, but I think we have to put our heads together and think about
cost factors, what that would look like in terms of the financial picture and structure.
I do believe these infants require ongoing care and supervision in a specially trained
center. Of course, I am an advocate for ongoing acute
rehabilitation for those infants that do require it, and to organize community services as
best as possible, so that these children don’t get lost.
Linda:  I appreciate your time. I know you’ve put a significant amount of time, and energy,
and thought into this presentation, and we all greatly appreciate it. We all look forward
to continuing to talk with you and work with you in the future.
For all of the rest of you on the call, we’re going to be looking at questions, and a process
for providing feedback to you on some of the questions that were not addressed. Certainly,
those that pertained to mother’s treatments. There were a lot interesting questions around
cross systems collaboration, and Dr. Burke just touched on the importance of that as
well. We will be getting back to you on that. We
expect that our next month will be more of a dialogue between the sites, as opposed to
expert presentation, and then we will probably follow that up with another expert presentation
in November, so we look forward. We had a total of 95 people join on today,
and we know that Dr. Burke said that in some cases there were multiple people in an office.
So, good turnout for today’s webinar. We appreciate all of you being on.
Dr. Burke:  Thank you, Linda, and your colleagues. And to the participants, I look forward to
ongoing dialogue, to tackle what is a very big health care issue in this country.
Linda:  Thank you so much for your time.

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