Scoring tools for NOWS/NAS - Finnegan Neonatal Abstinence Scoring System
- 31 items
- Symptoms are weighted
- Guidelines for pharmacologic treatment at score of 8 or greater
- MOTHER score (modified Finnegan score)
- 19 items (which contribute to total score)
- Items weighted differently
- Some Finnegan items eliminated and others added
- Guidelines for treatment based on score rather than weight
- Lipsitz Neonatal Drug-Withdrawal Scoring System
- 11 items
- Items scored for severity and gives guidelines for treatment
- The Neonatal Withdrawal Inventory – 8 point checklist
- The Neonatal Narcotic Withdrawal Index – 6 signs plus others
- Credit: Anne Johnston, MD
- Jones, Fielder. Preventive Medicine 2015
- NOW Assessment: MOTHER NAS Scale
- NAS score is not the sole determining factor in the decision to start pharmacotherapy for NAS
- Score can be affected by
- State of infant
- Painful stimuli
- Order of score
- “Motive” of scorer
All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs. - All NOW instruments have common features of summing item scores and/or weighting the severity of presenting signs.
- NOW evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization.
- Scores above a threshold trigger medication initiation to reduce NOW severity – no or delayed treatment can result in morbidity or mortality.
- Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers.
- Medication amount is increased then gradually decreased until the neonate is stable without medication.
- Sarkar, Donn. J Perinatol 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev 2011
- NOW: Measurement and Response
Short-acting opioids (morphine sulfate, dilute tincture of opium) - Short-acting opioids (morphine sulfate, dilute tincture of opium)
- Methadone
- Inpatient treatment and inpatient to outpatient treatment
- Symptom versus weight based
- Allows for shorter length of stay (with outpatient treatment)
- Endorsed by the AAP (2012)
- (Several studies including MS Brown et al (2015) which revealed shortened duration of treatment with methadone)
- Dilute tincture of opium and phenobarbital (Coyle et al, 2002)
- Decreased severity of withdrawal, decreased length of stay
- Buprenorphine (Kraft et al, 2011)
- Shorter length of stay in buprenorphine treated infants
- Well tolerated
- Clonidine (Agthe et al, 2009)
- Oral clonidine as adjunct to short-acting opioids
- Shortens the duration of therapy, no short-term cardiovascular side effects observed
- NOWS: Pharmacologic Treatment
NOWS: Non-pharmacologic Treatment - Breastfeeding is associated with reduced severity of withdrawal, delayed onset, decreased need for Rx (Abdel-Latif et. al., 2006)
- Rooming-in decreased the need for Rx, length of Rx, and LOS (Abrahams et. al., 2007)
- Waterbeds decreased amount of medication needed (Oro et. al., 1988)
- Acupuncture (Filippelli et. al., 2012)
- Kangaroo therapy or skin to skin
- Decreased environmental stimuli
- Frequent small demand feeds
- Pacifiers
- Swaddling, containment, holding, vertical rocking
- Provider, nursing attitudes
- Image credits: www.susquehannahealth.org; www.simplymotherhood.com
NOW occurs in the majority of all prenatally opioid-exposed neonates. - NOW occurs in the majority of all prenatally opioid-exposed neonates.
- Medication to treat NOW is required in approximately 50% of the cases.
- NOW following prenatal exposure to an opioid agonist is best assessed with a standard scoring tool and best treated with an opioid medication.
- Patients and the providers who treat them will be best served through having a range of medication options from which to tailor treatment.
- As treatment for maternal opioid dependence advances, so must neonatal treatment (i.e., buprenorphine in the infant may be an important medication for treatment of buprenorphine exposure in utero)
- Osborn et al. Cochrane Database Syst Rev 2010
All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs. - All NAS instruments have common features of summing item scores and/or weighting the severity of presenting signs.
- NAS evaluation is recommended every 3 to 4 hours during hospitalization; surveillance should last for several days after birth and for entire hospitalization.
- Scores above a threshold trigger medication initiation to reduce NAS severity – no or delayed treatment can result in morbidity or mortality.
- Stabilization on medication promotes regular eating and sleeping patterns, weight gain, and improved interaction with caregivers.
- Medication amount is increased then gradually decreased until the neonate is stable without medication.
- NAS: Measurement and Response
- Sarkar, Donn. J Perinatol. 2006; Jansson, Velez, Harrow. J Opioid Manag 2009; Jansson, Velez. Pediatr Rev, 2011
Later Outcomes - Cognition in opioid and non-opioid-exposed infants
- Psychomotor in opioid and non-opioid-exposed infants
- Cognition in opioid and non-opioid-exposed infants
- Psychomotor in opioid and non-opioid-exposed infants
- Behaviour in opioid and non-opioid-exposed infants
- Favors non-opioid-exposed
- Later Outcomes (continued)
- Baldacchino et al. BMC Psychiatry 2014
- A Model of Integrated
- Pharmacotherapy and Behavioral Treatment
- Designed and Implemented to Help Women and Children
- Trauma and Addiction Treatment
- Early Intervention Services
- Maternal-Child Psychotherapy
- Outcomes without Horizons
- UNC Horizons saves North Carolina
- an estimated
- $3,366,815 every year
- Prenatal Care
- Postnatal Care
- Substance Abuse Treatment
- Staff trained on trauma-informed care:
- Staff realizes the widespread impact of trauma and understands potential paths for healing
- Staff recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system
- Staff responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings
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- Team includes: OB, Nurse practitioner (NP), peer-support specialist, and therapist
- NP provides primary obstetrical care and manages women taking Suboxone prescribed by the OB
- Peer-support provides assistance and access to community resources and services
- Therapists provides counseling
- Psychiatrist is available as-needed for evaluation and medication management
- Fielder, Johnson, Jones, Australian nursing & midwifery, 2015
- Team educates women on recovery and SUD and supports autonomy
- Team collaborates with nursery staff to educate women about NAS
- Incentives to participate in services include:
- Assistance with parking
- Gas vouchers
- Mommy Bucks
- Transportation
- Recognition and Management
- Referral and Long-Term Follow-up for Exposed Infants
- DSS involvement
- This can and should be seen as supportive, not punitive
- Often past history with DSS precludes acceptance
- CDSA referral from the nursery
- Can be difficult depending on county and resources
- Ongoing treatment for mother and family
- Learn your local resources
- Preschool when available
- PCP, OB/GYN, Pediatrician
- Engage all players before delivery for planning
- Early testing in mother during gestation in addition to mother and baby at delivery is key
- Evidence-based protocols exist for Labor & Delivery and Newborn
- Anesthesiologist
- Newborn Nursery Team
- Infant assessment, Finnegan Scales, non-pharmacologic treatments, encourage breastfeeding
- Neonatal Critical Care Team
- Symptomatic Infants, Acute Withdrawal
- DSS involvement
- This can and should be seen as supportive, not punitive
- Often past history with DSS precludes acceptance
- Visit from child therapist within first week of delivery, even if in NICU
- Focus on infant strengths, learning infant cues (Hug Your Baby)
- Continue on going parent education (twice per week)
- At 6 weeks: Referrals for developmental assessments (Early Intervention) including Speech/Language, Occupational Therapy, Physical Therapy, and Social-Emotional Assessment
- Support Dyad: Weekly Child Parent Psychotherapy (CPP)
- Further support via Parent Education during Substance Use Treatment
- Attachment-based parenting program: Circle of Security-Parenting© http://circleofsecurity.net
- Nurturing Parenting Program for Substance Abuse http://www.nurturingparenting.com/
- Hug Your Baby http://www.hugyourbaby.org/
- Child Parent Psychotherapy http://www.nctsn.org/sites/default/files/assets/pdfs/cpp_general.pdf
- Postnatal Evidence-Based Tools
- Parents need continued education and support at home
- In the first few months, these infants can be difficult to sooth/irritable, have difficulties transitioning and maintaining sleep, and have feeding issues
- This can put infants at risk for insecure attachment
- Parents frequently have other stressors
- Researchers have found that mothers with substance abuse histories:
- Have repeated relationship disruptions
- Report more irritable babies
- Are less sensitive in interactions
- Are less emotionally engaged
- Are less attentive
- Have less positive affect
- Children from families with substance abuse issues have higher rates of insecure and disorganized attachment.
- Treatment for NAS occurs during the pregnancy, post-delivery, and in the home
- Treatment for mother, infant, and the dyad
- Focus on strengthening attachment relationship
- Focus on helping parents learn to read and respond to their infants’ cues
- Referrals to early intervention paramount
Summary - 1. Different behavioral interventions and medication assisted treatments can help to increase treatment engagement and reduce drug use among pregnant and/or parenting women
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- 2. Neonatal abstinence signs and symptoms can be increased or minimized in response to the care provided as well as other factors. Providers play a key role in helping to support resilience among mothers and their children who have been prenatally opioid-exposed
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- 3. The SAMHSA Block Grant provides elements of effective care for pregnant and parenting women.
- First page credits: “side view of pregnant woman” by imagerymajestic; “mother-child-family-happy-love-1039765/” by the danw; “family eating at the table” by skeeze
Contact: - Hendrée E Jones, PhD
- Executive Director, UNC Horizons
- Professor, Department of Obstetrics and Gynecology
- School of Medicine
- University of North Carolina at Chapel Hill
- 127 Kingston Drive
- Chapel Hill, NC 27514 USA
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- Hendree_Jones@med.unc.edu
- Direct Line: 1-919-445-0501
- Main Office: 1-919-966-9803
- Fax: 1-919-966-9169
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