Antenatal Opioid Exposures and Associated Outcomes Through Early Childhood July 19, 2016

1. Antenatal Opioid Exposures and Associated Outcomes Through Early Childhood July 19, 2016 • Sharon McAllister, OTR/L • Debra McSweeney, PT, MSPT • Edmund N. Ervin Pediatric Center, MGMC

2. Objectives • Understand the effects of maternal substance use on the brain of a neonate. • Learn about the short and long-term developmental outcomes for infants exposed to substance in-utero. • Discuss the components of care needed to address the current and future needs for infants/children and their families

3. Disclosures We have no relevant financial or nonfinancial relationships within the products or services described, reviewed, evaluated or compared in this presentation.

4. Level II Nursery Services at Maine General Medical Center • Orders for OT and PT are received on all babies with a diagnosis of substance exposure/NAS; babies are seen within 24-48 hours of order received (except on weekends). • Our program focuses on: • Direct services to address needs – state regulation, feeding, handling, development, attachment • Parent education • Discharge planning and coordination with our community resources, such as… • CDS • Home nursing • Maine Families • Direct PT or OT services - outpatient

5. ModifiedFinnegan Scoring for NAS

6. Eat, Sleep, Console (ESC)

7. FRAMEWORK: Developmental Care • The creation of an environment for the infant and young childthat minimizes stress and increases regulation while providing developmentally appropriate experiences for the child and family • Facilitate child-parent bonding and attachment • Established through coaching and modeling and establishing a safe community across all caregivers

8. Interventions in Developmental Care • Support the physiological organization of the individual infant and young child • Enhance the physiological stability • Protect sleep rhythms • Develop healthy and efficient feeding patterns • Promote growth, maturation and development

9. Goals of Developmental Care INFANT • Reduce stress • Conserve energy and enhance recovery • Promote growth and well being • Support emerging behaviors at each stage of neurodevelopmental maturation

10. Goals of Developmental Care FAMILY • Encouragement and support of parents as primary caregiver role • Enhance family emotional and social well-being and attachment • Provide knowledge related to the care of a high risk infant and the awareness of developmental concerns related to their birth history and the potential challenges they may experience • Resources available to the infant and family

11. Impact of improved regulation • Improved attention • Improved eye contact • Improved learning • Improved sleep • Improved eating • Improved social skills • Improved motor • Improved direction following • Improved speech

12. Assessment of the Infant Characteristics of the Infant, Caregiver and the Environment as well as the Task being asked of the infant Intervention and Treatment on Individualized needs Individual Environment Task

13. Factors Impacting Developmental Care and Early Development • Environment • Noise • Lighting • Visual stimulation • Positioning • Tempurature • Olfactory • Tactile • Caregivers • coordination • Infant • Condition of infant • Infant’s level of maturity and gestational age • Behavioral responses to care

14. Interventions Incorporated in Early Developmental Care • Handling and positioning • Including support for procedures • Engaging in cue-based care • Clustering nursing/infant care to provide longer periods of sleep • Reduction of noxious environmental stimulation • Encouraging parent visitation, involvement in care and kangaroo care

15. The goal is to identify an infant or child’s cues and respond appropriately. • Identification alone does not help.

16. Infants do remember!

17. INFANT CUES : COMMUNICATION

18. INFANT STATE :COMMUNICATION/CUES

19. STATE • categorizing level of central nervous system arousal • awake/alert Quiet/Alert Hyperalert Hypoalert

20. INFANT STATE :COMMUNICATION / CUES

21. Self-regulatory strategies for infants

22. Calming input for infants • Deep pressure: rhythmic patting, holding, swaddle, baby sling, massage • Vestibular input/movement: gentle rocking, gentle swinging • Low lights, warm lighting • Predictability/structure • Soft voices • Decreased background noise • Calming music • Therapeutic use of self

23. Guidelines for Developmental Intervention • Introduce sensory stimuli gradually and methodically • Key in on the infant/child’s response to stimuli and adapt accordingly • Infant/child’s age as well as medical conditions are critical • Include parents/caregivers • Each infant/child responds differently to sensory input and therefore the ability to individualize is key to supporting an infant/child’s progression

24. High Risk Infants and Potential Developmental Outcomes • Visual • Auditory • Cognitive impairments • Motor impairments • Speech and Language Delays/ Disorders • Learning Difficulties • Attention • Behavioral Concerns • Impaired social skills

26. Readiness to Feed

27. Feeding-related Psychosocial MilestonesBirth to 3 month“Homeostasis”

28. Feeding-related Psychosocial Milestones4 to 6 months“Attachment”

29. Developmental Milestones and Feeding SkillsBirth to 5 months

30. “Red Flags” • Hypotonia (decreased muscle tone) • Hypertonia (increased muscle tone) • Poor tolerance to handling and daily care • Altered quality of movement • Poor postural control • Poor eye contact with caregivers • Poor state regulation • Social risk factors • Arching or stiffening of body during feedings • Irritability or lack of alertness during feedings • Prolonged feeding times (longer than 30 minutes) • Frequent spitting up • Less than normal weight gains • Less than optimal intake

32. The identification of infants and children at risk is critical to our ability to ensure appropriate early intervention services to ensure optimal outcomes and to provide timely management.

33. The Effects of parental opioid use of the parent-child relationship and children’s developmental and behavioral outcomes” • A systematic review of published reports (2019 Jan 12 Child Adolescent Psychiatry Mental Health) found that children of parents with opioid use disorders showed greater disorganized attachment; they were less likely to seek contact and more avoidant than children in the control group. The children also had increased risk of emotional and behavioral issues, poor academic performance, and poor social skills. Younger children had increased risk of abuse or neglect, or both, that later in life may lead to such difficulties as unemployment, legal issues, and substance abuse.

34. In Australia in 2017 researchers compared the academic progress of 2234 students who had a history of prenatal drug exposure with a group of students with similar demographics but not born with NAS. The mean test scores of the children born drug exposed were lower than those of their counterparts. The results worsened as the students aged into high school.

35. Researchers in Tennessee in Sept of 2018 analyzed close to 7,200 children aged 3 to 8 years enrolled in the state’s Medicaid program. The study found 1 in 7 children with a history of opioid exposure in the womb required services for developmental delays.

36. Why is regulation important? • When children are able to regulate, • Less vulnerable to impact of stress • Improve academic success • Readiness to learn in all 5 domains of development • Social/emotional • Motor • Language • Cognition • Adaptive

37. We know that most of these children will have developmental and educational CONCERNS, Please keep the lines of COMMUNICATION open with with a primary care provider, medical specialist, clinic, case managers or therapist and maintain a CONNECTION to ensure continuity of monitoring and care with ongoing assessments.

38. ` THANK YOU !