The recent trend in infants born exposed to neurotropic substances during pregnancy is increasing at an alarming rate across the United States, posing a public health threat in the form of neonatal abstinence syndrome (NAS). Jodi Jackson, MD, Children’s Mercy Neonatologist and Medical Director of the Shawnee Mission Medical Center (SMMC) level III NICU, has implemented family-centered care initiatives that have improved outcomes for these infants.
This family-centered protocol for NAS has been implemented at the other community hospitals where Children’s Mercy neonatologists serve as medical directors, and now Dr. Jackson is chair of the Kansas perinatal quality collaborative (KPQC) and working on a state wide initiative for NAS.
Hear from Dr. Jackson as she discusses the program and impact it is having on the neonatal population.
Selected Podcast
Help for Opiate Exposed Babies: Family-Centered NAS Care Initiative
Featured Speaker:
From 2012 to present she has worked locally, regionally and in a national collaborative with the Vermont Oxford Network on projects surrounding Neonatal Abstinence Syndrome (NAS). Through this work she has helped to establish a multidisciplinary standardized approach to diagnosis, treatment and family support, incorporating family friendly literature; resulting in decreased NICU admissions and length of hospital stay for those infants at risk. She is presently working in the capacity of her appointment as Chair KPQC on a statewide initiative regarding a standardized, evidence-based approach to families and infants effected by NAS.
Learn more about Jodi Jackson, MD
Jodi Jackson, MD
Jodi Jackson, MD, is an Associate Professor of Pediatrics in the Division of Neonatology at Children's Mercy Kansas City. Originally from Chicago, she graduated from the University Of Illinois School Of Medicine and completed her Pediatric Residency at the Mayo Clinic located in Rochester, Minnesota. She then went on to complete her Neonatal-Perinatal fellowship at Children's Mercy Kansas City in 2002. Through the clinic partnership between Children's Mercy Kansas City and Shawnee Mission Medical Center, she now serves as Medical Director of the NICU at Shawnee Mission Medical Center, as well as the Medical Director of Quality Improvement and Medical Director of the Neonatal Abstinence Syndrome (NAS) Program at SMMC. She also serves as the Chair of the Kansas Perinatal Quality Collaborative (KPQC).From 2012 to present she has worked locally, regionally and in a national collaborative with the Vermont Oxford Network on projects surrounding Neonatal Abstinence Syndrome (NAS). Through this work she has helped to establish a multidisciplinary standardized approach to diagnosis, treatment and family support, incorporating family friendly literature; resulting in decreased NICU admissions and length of hospital stay for those infants at risk. She is presently working in the capacity of her appointment as Chair KPQC on a statewide initiative regarding a standardized, evidence-based approach to families and infants effected by NAS.
Learn more about Jodi Jackson, MD
Transcription:
Help for Opiate Exposed Babies: Family-Centered NAS Care Initiative
Dr. Michael Smith, MD (Host): So, our topic today is help for opioid exposed babies, a family centered care initiative for neonatal abstinence syndrome. My guest is Dr. Jodi Jackson. Dr. Jackson is the medical director of the NICU at Shawnee Mission Medical Center in partnership with Children’s Mercy. Dr. Jackson, welcome to the show.
Dr. Jodi Jackson, MD (Guest): Thank you.
Dr. Smith: So, how often are you treating the neonatal abstinence syndrome?
Dr. Jackson: Well, the incidence has gone up dramatically through the country and Kansas and specifically at Shawnee Mission Medical Center which is the birth hospital that I direct, and this is in partnership with Children’s Mercy Hospital that we have developed our plans of care and our protocols. So, our incidence has increased dramatically from the year 2000. Being a suburban hospital, we are not seeing the same kind of numbers as inner-city hospitals, but we certainly have had a parallel. Throughout Kansas, the numbers, I have the numbers throughout Kansas have increased 900% from 200 - 214. At Shawnee Mission Medical Center, we have mirrored that but probably not to the same degree.
Dr. Smith: Right. So, tell us about the current protocol then for assessing NAS in an at-risk infant.
Dr. Jackson: So, initially when we looked at the problem of NAS, we noticed it increased and we realized we needed to standardize care and we initially thought we could just standardize how we treated babies medically and when we got into the literature, what we found was that there is so much more than the medical treatment of this problem, that medical treatment is an issue but it is the last issue and there is a lot of things that can be done before and as we dug deeper, we found more and more about what needed to be done.
So, really, to start with, women who are using medications that could affect their baby and cause their baby to have symptoms of withdrawal; we need to talk to them. We need to let them know that this could affect your baby and we need to talk about how their dosing of these medications could be adjusted so that their baby would be less affected and when we talk about women taking medications; it could be prescription medications. They could be in a program because they had been abusing before or they could be actually just being given prescription medications for a specific kind of pain or chronic pain. So, we are not just talking about people who are using illicit or illegal drugs. It's a problem over all populations.
And so, the first thing we discovered is we need to meet with people and to that end we designed some literature to give to families about what to expect and then we devised a protocol that keeps babies with their moms, so what we learned is the thing that we know best is that babies who are having symptoms of withdrawal from medications, specifically let’s talk about opioids because that is what the most literature is. Families can provide a lot of care that would avoid needing medical treatment. So, we call it comfort cares and we have specific ones for specific problems but what it entails is keeping the baby with the family, specifically the mother as much as possible and avoiding removing them for scoring or testing or anything else that we used to do before we realized this issue. So, those two things are kind of the most family oriented and what we do is we enlist the families in helping us to delineate how much problems we are seeing. So, it really is a family issue and we can’t really treat the baby in isolation from the family.
Dr. Smith: So, that’s interesting. But when you look back in because I know there is different assessments that are used, I think for instance there’s the -- is it the Finnegan Scale, I think, are those not initially used then? Is there no scoring of this infant that happens or does that come into play?
Dr. Jackson: So, we do use scoring and there is no great scoring method. We use a modified Finnegan Scale right now, but there is a lot of research going on about different scales that we will be testing out in our institution. But what we do is we identify babies who are at-risk, and we educate the families about the scoring system before they have their baby, preferably way before in a setting that is low stress and educate about things that we will be looking for in a nonjudgmental way, partnering with the families to help us look for things and to help them understand what we do for certain things. So, what we find with the scoring system is that it can indicate if a baby is having problems at certain levels and things that can help so, if a baby is tremorous or shaky, sometimes holding skin to skin makes that better. If a baby is hungry, frequent feedings is going to make that better. Definitely kind of dark, light lit rooms with low stimulation, TVs low, those kinds of things and so, yes, we do start scoring within four hours any baby we identify at-risk. And what we find is that with our comfort care measures, we can keep the scores low, the majority of the time and we have been able to decrease our admit rate for treatment considerably. We have also been able to decrease our treatment rate. So, looking at those numbers, probably around less than 20% at this point are we admitting and even less than that are we treating. Whereas when we started our project, it was close to 100%.
Dr. Smith: Okay, so what it sounds like there is no standard really scoring protocol then, it looks like there are different ideas out there. When it comes to the practitioner, or the nurse who is going to be doing a lot of that scoring; how comfortable are they doing that?
Dr. Jackson: Well, that’s an excellent question. And I guess I would like to correct you in saying there is – the standard that is used right now is the modified Finnegan. That’s what the standard is. Now we are all unhappy with that. So, everybody who is doing work in this area are working to develop a better one. And just because of what you just said, it is a nebulous scale. There are questions about when do we score – what we have taught is when they are being held and quite alert and in the mom’s arms. But I think, old thoughts were the baby had to be removed from the family to be scored which would give one an artificially elevated score. For our program, we have done extensive training in the Finnegan test scoring with simulations and second score validation and competencies and really that’s what it takes with the scoring system, a lot of work, to standardize it to make sure everybody is scoring the same thing and then we also involve the family in the scoring, so they can also be a part of that. But because it is complicated, it takes a lot of training. And it isn’t really straightforward. Not just the numbers that are assigned but when and how to do the assessment.
Dr. Smith: Let’s talk a little bit about treating NAS. So, you mentioned that there’s – so you get the family involved early obviously, you initiate those comfort care steps that seem to really help. How often does that – is that all you have to do? Or are we still seeing a lot of babies that have to go on to take medication?
Dr. Jackson: Well according to our data here at our center, between 10 and 20% are needing to be treated, which is a considerably lower amount than before. So, of those who need to be treated, the 10-20% over the last several quarters; that’s the other part of what we worked on is how do we treat them in a standardized way? And there isn’t great clear literature on what the best way to do is and we have actually worked together on an international collaborative with the Vermont Oxford Network which is a collaborative of NICUs that do quality work together to come up with our standard approach and what we know about medicine in general is standardization improves outcomes regardless of what is the standard and, so we keep ourselves to a standard. We do peer review to make sure we are practicing the same way and we have a very clear weaning schedule to start medication and wean off in a prescribed way.
Dr. Smith: Going back to what you mentioned, really educating the woman, the family about that their infant might be at risk because of some prescription or whatever is going on in the mom’s life; you mentioned some literature that goes out. How important is that? How important is getting that message out and when you say literature, where is that going? Is that going to like community clinics? How exactly is that being distributed?
Dr. Jackson: So, we have made our own booklets addressing our families and we have shared that regionally and statewide actually so other centers are using it. And I think it is one of the most important things we do. Because they are nice, well-written, reviewed booklets answering questions and they help families realize that they are not the only one going through this. If we have a program with fancy booklets and we put a lot of thought into our booklets that have been actually reviewed by families and by caregivers; it becomes apparent that this is a program in our hospital and that other people have the same problem. So, what I have experienced from families is that this is maybe the biggest impact when they come in and realize there is nothing to be ashamed of, that we are not judging, that we are trying to support them and these are all the things we have done to support – we get a lot more buy in and we get a lot more collaboration with the families which is essential because this is their child that they are going to have to care for and we are just here really to educate and get them through the immediate post-natal period. And having a partnership with the family makes a big difference.
Dr. Smith: So, like in summary then Dr. Jackson. What would you like people and practitioners to know about neonatal abstinence syndrome?
Dr. Jackson: Well, one of the biggest things I would like people to know about and think about is something we haven’t mentioned, so it is not a summary. It’s a new point. But we really need to work as a community to have programs for women who are finding that they have become dependent on narcotics and how to support them before, during and after they give birth and we have learned a lot in the last ten years about what goes on and if women are supported appropriately, medically and psychologically; they can minimize their narcotic use and function well and just have a great experience with their baby. As a society or as a community, really across the country, we don’t have great programs for women before, during and after pregnancy who are using narcotics. And so, one of the things that I like to call to action or people to think about is how can we do better with that. So, what we can do at the healthcare level, I believe we have done an excellent job at our center level doing what we can within the walls of our institution and even going a little bit out by bringing women in ahead of time and helping them with the work of social workers and other caregivers to find programs of support before they come in. To me, that’s the most important part of the whole story is supporting women and families throughout the period especially after having the baby and especially after going home, supporting families to keep them well and healthy and to keep them able to continue to provide the kind of cares their babies need.
Dr. Smith: Well, Dr. Jackson, I think that was a great summary actually and I want to thank you for the work that you are doing and of course thank you for coming on the show today. You are listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.
Help for Opiate Exposed Babies: Family-Centered NAS Care Initiative
Dr. Michael Smith, MD (Host): So, our topic today is help for opioid exposed babies, a family centered care initiative for neonatal abstinence syndrome. My guest is Dr. Jodi Jackson. Dr. Jackson is the medical director of the NICU at Shawnee Mission Medical Center in partnership with Children’s Mercy. Dr. Jackson, welcome to the show.
Dr. Jodi Jackson, MD (Guest): Thank you.
Dr. Smith: So, how often are you treating the neonatal abstinence syndrome?
Dr. Jackson: Well, the incidence has gone up dramatically through the country and Kansas and specifically at Shawnee Mission Medical Center which is the birth hospital that I direct, and this is in partnership with Children’s Mercy Hospital that we have developed our plans of care and our protocols. So, our incidence has increased dramatically from the year 2000. Being a suburban hospital, we are not seeing the same kind of numbers as inner-city hospitals, but we certainly have had a parallel. Throughout Kansas, the numbers, I have the numbers throughout Kansas have increased 900% from 200 - 214. At Shawnee Mission Medical Center, we have mirrored that but probably not to the same degree.
Dr. Smith: Right. So, tell us about the current protocol then for assessing NAS in an at-risk infant.
Dr. Jackson: So, initially when we looked at the problem of NAS, we noticed it increased and we realized we needed to standardize care and we initially thought we could just standardize how we treated babies medically and when we got into the literature, what we found was that there is so much more than the medical treatment of this problem, that medical treatment is an issue but it is the last issue and there is a lot of things that can be done before and as we dug deeper, we found more and more about what needed to be done.
So, really, to start with, women who are using medications that could affect their baby and cause their baby to have symptoms of withdrawal; we need to talk to them. We need to let them know that this could affect your baby and we need to talk about how their dosing of these medications could be adjusted so that their baby would be less affected and when we talk about women taking medications; it could be prescription medications. They could be in a program because they had been abusing before or they could be actually just being given prescription medications for a specific kind of pain or chronic pain. So, we are not just talking about people who are using illicit or illegal drugs. It's a problem over all populations.
And so, the first thing we discovered is we need to meet with people and to that end we designed some literature to give to families about what to expect and then we devised a protocol that keeps babies with their moms, so what we learned is the thing that we know best is that babies who are having symptoms of withdrawal from medications, specifically let’s talk about opioids because that is what the most literature is. Families can provide a lot of care that would avoid needing medical treatment. So, we call it comfort cares and we have specific ones for specific problems but what it entails is keeping the baby with the family, specifically the mother as much as possible and avoiding removing them for scoring or testing or anything else that we used to do before we realized this issue. So, those two things are kind of the most family oriented and what we do is we enlist the families in helping us to delineate how much problems we are seeing. So, it really is a family issue and we can’t really treat the baby in isolation from the family.
Dr. Smith: So, that’s interesting. But when you look back in because I know there is different assessments that are used, I think for instance there’s the -- is it the Finnegan Scale, I think, are those not initially used then? Is there no scoring of this infant that happens or does that come into play?
Dr. Jackson: So, we do use scoring and there is no great scoring method. We use a modified Finnegan Scale right now, but there is a lot of research going on about different scales that we will be testing out in our institution. But what we do is we identify babies who are at-risk, and we educate the families about the scoring system before they have their baby, preferably way before in a setting that is low stress and educate about things that we will be looking for in a nonjudgmental way, partnering with the families to help us look for things and to help them understand what we do for certain things. So, what we find with the scoring system is that it can indicate if a baby is having problems at certain levels and things that can help so, if a baby is tremorous or shaky, sometimes holding skin to skin makes that better. If a baby is hungry, frequent feedings is going to make that better. Definitely kind of dark, light lit rooms with low stimulation, TVs low, those kinds of things and so, yes, we do start scoring within four hours any baby we identify at-risk. And what we find is that with our comfort care measures, we can keep the scores low, the majority of the time and we have been able to decrease our admit rate for treatment considerably. We have also been able to decrease our treatment rate. So, looking at those numbers, probably around less than 20% at this point are we admitting and even less than that are we treating. Whereas when we started our project, it was close to 100%.
Dr. Smith: Okay, so what it sounds like there is no standard really scoring protocol then, it looks like there are different ideas out there. When it comes to the practitioner, or the nurse who is going to be doing a lot of that scoring; how comfortable are they doing that?
Dr. Jackson: Well, that’s an excellent question. And I guess I would like to correct you in saying there is – the standard that is used right now is the modified Finnegan. That’s what the standard is. Now we are all unhappy with that. So, everybody who is doing work in this area are working to develop a better one. And just because of what you just said, it is a nebulous scale. There are questions about when do we score – what we have taught is when they are being held and quite alert and in the mom’s arms. But I think, old thoughts were the baby had to be removed from the family to be scored which would give one an artificially elevated score. For our program, we have done extensive training in the Finnegan test scoring with simulations and second score validation and competencies and really that’s what it takes with the scoring system, a lot of work, to standardize it to make sure everybody is scoring the same thing and then we also involve the family in the scoring, so they can also be a part of that. But because it is complicated, it takes a lot of training. And it isn’t really straightforward. Not just the numbers that are assigned but when and how to do the assessment.
Dr. Smith: Let’s talk a little bit about treating NAS. So, you mentioned that there’s – so you get the family involved early obviously, you initiate those comfort care steps that seem to really help. How often does that – is that all you have to do? Or are we still seeing a lot of babies that have to go on to take medication?
Dr. Jackson: Well according to our data here at our center, between 10 and 20% are needing to be treated, which is a considerably lower amount than before. So, of those who need to be treated, the 10-20% over the last several quarters; that’s the other part of what we worked on is how do we treat them in a standardized way? And there isn’t great clear literature on what the best way to do is and we have actually worked together on an international collaborative with the Vermont Oxford Network which is a collaborative of NICUs that do quality work together to come up with our standard approach and what we know about medicine in general is standardization improves outcomes regardless of what is the standard and, so we keep ourselves to a standard. We do peer review to make sure we are practicing the same way and we have a very clear weaning schedule to start medication and wean off in a prescribed way.
Dr. Smith: Going back to what you mentioned, really educating the woman, the family about that their infant might be at risk because of some prescription or whatever is going on in the mom’s life; you mentioned some literature that goes out. How important is that? How important is getting that message out and when you say literature, where is that going? Is that going to like community clinics? How exactly is that being distributed?
Dr. Jackson: So, we have made our own booklets addressing our families and we have shared that regionally and statewide actually so other centers are using it. And I think it is one of the most important things we do. Because they are nice, well-written, reviewed booklets answering questions and they help families realize that they are not the only one going through this. If we have a program with fancy booklets and we put a lot of thought into our booklets that have been actually reviewed by families and by caregivers; it becomes apparent that this is a program in our hospital and that other people have the same problem. So, what I have experienced from families is that this is maybe the biggest impact when they come in and realize there is nothing to be ashamed of, that we are not judging, that we are trying to support them and these are all the things we have done to support – we get a lot more buy in and we get a lot more collaboration with the families which is essential because this is their child that they are going to have to care for and we are just here really to educate and get them through the immediate post-natal period. And having a partnership with the family makes a big difference.
Dr. Smith: So, like in summary then Dr. Jackson. What would you like people and practitioners to know about neonatal abstinence syndrome?
Dr. Jackson: Well, one of the biggest things I would like people to know about and think about is something we haven’t mentioned, so it is not a summary. It’s a new point. But we really need to work as a community to have programs for women who are finding that they have become dependent on narcotics and how to support them before, during and after they give birth and we have learned a lot in the last ten years about what goes on and if women are supported appropriately, medically and psychologically; they can minimize their narcotic use and function well and just have a great experience with their baby. As a society or as a community, really across the country, we don’t have great programs for women before, during and after pregnancy who are using narcotics. And so, one of the things that I like to call to action or people to think about is how can we do better with that. So, what we can do at the healthcare level, I believe we have done an excellent job at our center level doing what we can within the walls of our institution and even going a little bit out by bringing women in ahead of time and helping them with the work of social workers and other caregivers to find programs of support before they come in. To me, that’s the most important part of the whole story is supporting women and families throughout the period especially after having the baby and especially after going home, supporting families to keep them well and healthy and to keep them able to continue to provide the kind of cares their babies need.
Dr. Smith: Well, Dr. Jackson, I think that was a great summary actually and I want to thank you for the work that you are doing and of course thank you for coming on the show today. You are listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to www.childrensmercy.org. That’s www.childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.