NOWS – Planning for Maternal and Infant Discharge

NOWS: Planning for the Maternal-Infant Dyad Discharge

Opioid use disorder (OUD) in the population at large has been paralleled with the increase of opioid use during the pregnancy. Infants exposed to opioid in utero can experience symptoms of withdrawal after birth. Traditionally called neonatal abstinence syndrome (NAS) this condition was recently called, neonatal opioid withdrawal syndrome (NOWS). Additional information is available in the American Academy of Pediatrics (AAP) clinical report, Neonatal Opioid Withdrawal Syndrome (Pediatrics, Nov 2020).

Pregnancy is the preferred period for developing a plan of care that supports health care services for infants with NOWS and their birth parents. Hospital teams can collaborate with families and caregivers to initiate a comprehensive plan that supports the infant and family care during the hospital stay and following discharge. Hospital teams are in a unique position to facilitate access to diverse and multidisciplinary services that may not be available after the hospital discharge.

Early Planning – Benefits for a Safe Discharge

An early start mitigates some of the inherent fragmentation in the care systems and can enable a continuum of family-focused, supportive health services.

Consider implementing a discharge checklist (example provided by Illinois Perinatal Quality Collaborative (ILPQC)) for every parent/infant dyad. A similar checklist can ensure that infants meet clinical discharge criteria and that parents received relevant education, and anticipatory guidance.

A discharge plan/worksheet similar to sample provided by ILPQC can be completed in collaboration with the birth parent/family, hospital care team, and community primary care physicians. Whenever possible, facilitate warm hand-offs to community organizations to optimize care for infants with NOWS and continuous support for the families.

Much of the anticipatory guidance offered to new parents is standard; however, parents with OUD will need extra information and support. Parents in recovery should know that the love for their newborn is the best treatment for an infant experiencing NOWS symptoms. Aside from teaching parents how to soothe an infant with NOWS, hospital pediatricians can offer additional information to parents in recovery.

• Benefits of long-term comprehensive treatment for OUD (residential, out-patient, medication treatment for OUD, psychobehavioral therapy, peer support)
• Safe sleep, breastfeeding and nutrition
• Roles and responsibilities of hospital teams, community partners and child protective services (CPS)
• Selfcare and emotional wellbeing during recovery

Community Care Pre-Planning – A Multipurpose Process

When a family brings their newborn is seen for the first health supervision visit, the community pediatrician may or may not have access to the family health history. The hospital teams can support post-discharge care coordination by utilizing a discharge plan that communicates the following:

• Existing supports, resources and family’s health and recovery goals
• Community referrals made and in place for the infant and for the birth parent
• NOWS symptoms and length of hospital stay
• Pharmacological and/or nonpharmacological interventions to manage NOWS
• Weight and feeding status and progress
• Maternal health history including infection with HIV/AIDS, Hepatitis C virus (HCV) and all available toxicology testing results
• Birth parent medications including medication treatment for OUD

Neonatal hospital teams will benefit from mapping out the resources in their service area so that they can readily facilitate applicable referrals for the family. Refer to the discharge mapping tool (insert hyperlink on mapping tool) available through the ILPQC toolkit, Coordinate and Communicate Safe Discharge.

Individualized Care and Services

Each family is unique, and so are the format, the diversity, and the timing of the services they need. Transparent communication and coordination of discharge between the hospital teams and community pediatricians will facilitate access to appropriate medical, psychosocial, and other resources that support the entire family. A formal plan of care will inform the community pediatrician about the family health history, and about any challenges the family is experiencing.

• Food and housing insecurity
• Social isolation and support people in their daily lives
• History of adverse childhood experiences (ACEs)
• Past trauma
• Health literacy
• Other children at home or in foster care
• Access to transportation
• Legal implications

Plan of Safe Care (POSC)

All infants exposed to opioids prenatally need a plan of safe care (POSC) per the Child Abuse Prevention and Treatment Act (CAPTA). A POSC requires various entities including medical and clinical staff, delivery hospitals, and public health agencies, to collaborate, develop, update, implement, and monitor recovery and care plans for infants and family members affected by substance use during pregnancy.

Regardless of a formal POSC being established, the task of coordinating multiple services for infants and birth parents, combined with an increased risk of adverse postdischarge outcomes, makes formalizing the discharge process critical. Pediatricians can communicate with the delivery team or the neonatologist to get information about every infant, and to build the clinical partnerships and collaborations.

Parents can own their plan of care and they should be supported to participate as active partners in all decisions about their infant’s care. Parents should also be encouraged to share the plan with other physicians and partners who support their health and recovery goals. The POSC should help forge transparent communication between families, caregiver, clinicians, community partners, and child welfare agencies.

Pediatricians have the authority to engage and collaborate with CPS to coordinate care for pregnant people and birth parents with OUD. Pediatricians should be familiar with their state regulations on accessing services available once a POSC has been developed. Answers to questions frequently asked by pediatricians about plans of safe care are available from the AAP (www.aap.org/nows).