A Model For Reducing Parental Stress in the NICU.

A Model For Reducing Parental Stress in the NICU.

A good idea that is for sure and stress may be what the infant in the picture is displaying as a reflection of what her parents are feeling!  A growing trend is to include parents in rounds and that is the subject of this piece?  It sounds like a great idea and may feel that way as you have had a personal experience that has been favourable, is the practice in your unit or it just seems to make sense?  It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realised that  I have a bias in this area but was intrigued by the title of the paper.  The study is Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion by Abdel-Latif ME et al from New Zealand and was performed due to the lack of any RCTs on the subject specifically in the NICU.

Before I go on though I have to disclose a few biases.

  1.  I love parents being on rounds so I can speak with them directly and have them ask me any questions they may have after hearing about their infants condition.
  2. Our unit encourages the practice.
  3. We are rolling out the principles of FiCare after being part of the study which encourages parental presence at the bedside for far more than just rounds.For information on implementing FiCare click here
  4. While this study is the only reported RCT on the subject in the NICU, the FiCare results will be published before long.

What is the problem with having families on rounds?

The detractors would say that sensitive information may be more difficult to discuss out in the open for fear that the family will take offence or be hurt.  Another concern may be that teaching will be affected as the attending may not want to discuss certain aspects of care in order to prevent creating fear in the parents or awkwardness in the event that the management overnight was not what they would have done.  Lastly, when patient volumes and acuity are high, having parents ask questions on rounds may lead to excessive duration of this process and lead to fatigue and frustration by all members of the team.

So what does this study add?

This particular study enrolled 72 families of which 63 completed the study.  The study required 60 families to have enough power to detect the difference in having parents on rounds or not.The design was interesting in that the randomisation was a cross over design in which the following applied.  One arm was having parents on rounds and the other without.  The unit standard at the time was to not have parents on rounds.

≤30 weeks 1 week in one arm, one week washout period then one week in the other arm

>30 weeks 3 days in one arm, three day washout and then three days in the other arm

The primary outcome was to see if there would be a significant difference in the Parental Stressor Scale.  table 3

Surprisingly there was no difference across any domains of measuring parental stress.  When we look at questions though pertaining to communication in the NICU we see some striking differences.

Table 2

The families see many benefits to the model of being on rounds.  They appear to have received more information, more contact with the team, contributed more to the planning of the course of their babies care and been able to ask more questions.  All of these things would seem to achieve the goals of having parents on rounds.

So why aren’t parents less stressed?

This to me is the most interesting part of this post.  The short answer is I am not sure but I have a few ideas.

  1.  The study could not be blinded.  If the standard of care in the unit was to not have parents on rounds, what kind of conversations happened after rounds?  Were staff supportive of the families or were they using language that had a glass is half empty feel to it?  Much like I am biased towards having parents on rounds and thanking them for their participation were there any negative comments that may have been unintentional thrown the families way.
  2. Is a little knowledge a dangerous thing?  Perhaps as families learn more details about the care of their baby it gives them more things to worry about.  Could the increase in knowledge while in some ways being pleasing to the family be offset by the concern that new questions raise.
  3. Was the intervention simply too short to detect a difference?  This may have been a very important contributor.  This short period of either a week or two leaves the study open to a significant risk that an event in either week could acutely increase stress levels.  What if the infant had to go back on a ventilator after failing CPAP, needed to be reloaded with caffeine or developed NEC?  With such short intervals one cannot say that while communication was better the parents were not stressed due to something unrelated to communication.  In an RCT these should balance out but in such a small study I see this as a significant risk.

So where do we go from here?

I applaud the authors for trying to objectively determine the effect of parental presence on rounds in the NICU.  Although I think they did an admirable job I believe the longer time frame of the FiCare study and the cluster randomised strategy using many Canadian centres will prove to be the better model to determine effectiveness.  What the study does highlight though in a very positive way is that communication is enhanced by having parents on rounds and to me that is a goal that is well worth the extra time that it may take to get through rounds.  Looking at it another way, we as the Neonatologists may need to spend less time discussing matters after rounds as we have taken care of it already.  In the end it may be the most efficient model around!

 

High Flow Nasal Cannula: Be Careful Out There

High Flow Nasal Cannula: Be Careful Out There

As the saying goes the devil is in the details.  For some years now many centres worldwide have been publishing trials pertaining to high flow nasal cannulae (HFNC) particularly as a weaning strategy for extubation.  The appeal is no doubt partly in the simplicity of the system and the perception that it is less invasive than CPAP.  Add to this that many centres have found less nasal breakdown with the implementation of HFNC as standard care and you can see where the popularity for this device has come from.

This year a contact of mine Dominic Wilkinson@NeonatalEthics on twitter (if you don’t follow him I would advise having a look!) published the following cochrane review, High flow nasal cannula for respiratory support in preterm infants.  The review as with most cochrane systematic reviews is complete and comes to a variety of important conclusions based on 6 studies including 934 infants comparing use of HFNC to CPAP.

1.  No differences in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD.

2.  After extubation to HFNC no difference in the rate of treatment failure (typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation (typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants).

3.  Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants).

4. Small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC but the RR crosses one so this may be a trend at best.

If one was to do a quick search for the evidence and found this review with these findings it would be very tempting to jump on the bandwagon.  Looking at the review a little closer though there is one line that I hope many do not miss and I was happy to see Dominic include it.

“Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants.”

In his conclusion he further states:

Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.

With so few ELBW infants included and with these infants being at highest risk of mortality and BPD our centre has been reluctant to adopt this mode of respiratory support in the absence of solid evidence that it is equally effective to CPAP in these smallest infants.  A big thank you to our Respiratory Therapy Clinical Specialist for harping on this point over the years as the temptation to adopt has been strong as other centres turn to this strategy.

Might Not Be So Safe After All

Now do not take what I am about to say as a slight against my twitter friend.  The evidence to date points to exactly what he and his other coauthors concluded but with the release of an important paper in May by Taka DK et al, I believe caution is needed when it comes to our ELBW infants.

High Flow Nasal Cannula Use Is Associated with Increased Morbidity and Length of Hospitalization in Extremely Low Birth Weight Infants

This paper adds to the body of literature on the topic as it truly focuses on the outcome of infants < 1000g.  While this study is retrospective in nature it does cover a five year period and examines important outcomes of interest to this population.

The primary outcome in this case was death or BPD and whether HFNC was used alone or with CPAP, this was more frequent than when CPAP was used alone.  Other important findings were the need for multiple and longer courses of ventilation in those who received at least some HFNC.  In these times of overburdened health care systems with goals of improving patient flow, it is also worth noting that there was a significant prolongation of length of stay with use of HFNC or HFNC and CPAP.

One interesting observation was that the group that fared the worst across the board was the combination of CPAP and HFNC rather than HFNC alone.

CPAP (941) HFNC (333) HFNC +/- CPAP (1546)
CPAP d (median, IQR) 15(5-28) 7 (1-19)
HFNC d (median, IQR) 14(5-25) 13 (6-23)
HFNC +/- CPAP 15 (5-28) 14(5-25) 26 (14-39)
BPD or death % 50.40% 56.80% 61.50%
BPD % 42.20% 52.20% 59.00%
Multiple ventiation courses 51.10% 53.10% 64.70%
More than 3 vent courses 17.60% 21.00% 29.40%
Ventilator d (median, IQR) 18(5-42) 25 (6-52) 30 (10-58)

I believe the finding may be explained by the problem inherent with retrospective studies.  This is not a study in which patients were randomized to either CPAP, HFNC or CPAP w/HFNC.  If that were the case one would expect lung pathologies and severity of illness to even ou,t such that differences between groups might be explained by the difference in treatments.  In this study though we are looking though the rearview mirror so to speak.  How could we account for the combination being worse than the HFNC alone?  I suspect it relates to the severity of lung disease.  The babies who were placed on HFNC and did well on it might have had less severe chronic changes.  What might be said about those that had the combination?  Well, one could postulate that there might be some who were extubated to HFNC and collapsed needing escalation to CPAP and then failing that therapy were reintubated.  Another explanation could be those babies who were placed on CPAP after extubation and transitioned before their lungs were ready to HFNC may have failed and lost FRC thereby going back to CPAP and possibly intubation.  Exposure in either circumstance to HFNC would therefore put them at risk of further positive pressure ventilation and subsequent further lung injury.  The babies who could tolerate transition to HFNC without CPAP might be intermediary in their outcomes (as they were found to be) as they lost FRC but were able to tolerate it but consumed more calories leaving less for growth and repair of damaged tissue leading to prolonged need for support.

Either way, the use of HFNC was found to lead to worse outcomes and in the ELBW infant should be avoided as routine practice pending the results of a prospective RCT on the subject.

Is it a total ban though?

As with many treatments that one should not consider standard of care there may be some situations where there may be benefit.  The ELBW infant with nasal breakdown from CPAP that despite excellent nursing and RRT attention continues to demonstrate tissue damage is one patient that could be considered.  The cosmetic implications and potential for surgical correction at a later date would be one reason to consider a trial of HFNC but only in the patient that was close to being able to come off CPAP.  In the end I believe that if a ELBW infant needs non invasive pressure support then it should be with CPAP but as there saying goes there may be a right time and a place for even this modality.

 

 

Just Text Me! Enhancing Communication With Families

Just Text Me! Enhancing Communication With Families

When you mention electronic medical records to some physicians you get mixed responses.  Some love them and some…well not so much.  These tech heavy platforms promise to streamline workflows and reduce error with drop down menus, some degree of artificial intelligence in providing warnings when you stray too far from acceptable practice but for some who are not so tech savvy they are more of a pain.  I have to admit I am in the camp of believing they are a good thing for patient care as I work in one centre with expanded EMR services and one without and I do find a number of benefits to working with a more robust EMR platform but I respect that not all do.

The cell phone on the other hand is everywhere and even the most tech fearful often carry one including most of the parents we care for.  What caught my eye this month was the article by Globus O The use of short message services (SMS) to provide medical updating to parents in the NICU in which an EMR system is described that sends parents a text message at a pre-specified time regarding their infants condition.  I had a visceral reaction at first thought thinking “would I want my cell phone number sent to families?”, “how much time out of the day would all of this take?” and to be a little old fashioned “can’t we just talk on the phone?”.  I am sure there are many other questions that others would have as well.  Having said that as I read through the paper I warmed to the concept and by the end questioned whether we could do the same!

The Intervention

It turns out the SMS message comes from the EMR and not the personal cell phone of the bedside nurse and is sent out at 9 AM each day.  Each nurse requires only 30 seconds of their day to populate a few questions during the night shift and then the information goes out to the parents.

“The text message includes one-sentence prefaces and conclusions and provides updated information that includes the location of the infant’s crib (room and position), the infant’s current weight and whether medical procedures, such as head ultrasound, cardiac echocardiogram or eye examination, were performed. Information regarding acute events or deterioration of the infant’s medical condition are not included in the SMS, but are delivered personally to the parents in real time.”

This last sentence is important.  The SMS service will not notify the family that their infant is receiving chest compressions but is there to give them “updates”.  The sceptics out there will likely comment that this should be the job of both nursing and medicine to regularly update the families but thinking about it, how many parents are not there everyday and when they are out of sight how many physicians regularly call them to provide them updates?  No doubt there are some but I would think they are not in the majority.

But is it effective?

The measurement in this case was through surveys of nursing and families both pre-implementation and afterwards.  Provided in the table below are the scores (means +/- SD) in the pre and post implementation phases of the program.

Statement Pre-SMSi N=91 Post SMSi N=87 P-value
The physician was available when needed 4.1+/-0.9 4.4+/-0.7 0.002
The physician was patient in answering my questions 4.6+/-0.7 4.9 +/-0.4 0.002
I felt comfortable approaching the physicians 4.3+/-1.0 4.7+/-0.6 0.001
I felt comfortable approaching the nurses 4.4+/-0.8 4.6+/-0.6 0.02
I regularly received information from the physicians regarding my infant’s medical status 3.7+/-1.3 4.1+/-1.1 0.03

These are some pretty powerful outcomes.  The use of what many consider an impersonal form of communication (how many times have I looked at people texting furiously and thought JUST PICK UP THE PHONE!) actually appears to have improved the approachability of the staff in the unit and facilitated information transfer more easily.

One other important finding was that when surveyed pre-intervention staff were somewhat sceptical that this would help and moreover were concerned that it would interfere too much with work flow in the day.  Evaluations afterwards did not support these fears and many felt it was an improvement.  In the end the total time spent on this by nursing was estimated to be no more than 30 seconds of each day!  From the parent’s standpoint they certainly saw this as an improvement.

The Future

At least in our centre we are moving slowly but steadily towards a fully functioning EMR.  Will we have this capability in the software that we use?  After reading this I hope so.  I can see how receiving a daily morning message would prime the family to interact with staff on rounds.  The added benefit is that by knowing that the information would be ready at 9 AM, families could be present with questions already formulated in their minds.  How often do we encourage families to be on rounds and have them listen to a tremendous amount of information and then turn to them with the standard “any questions?”.  While I am sure many of us try and explain matters in lay terms, giving parents a change to mull over the issues first could well enhance the interaction they have with our team in a meaningful way.

Time to look into whether this is possible…

How many preterm infants can we safely care for at once?

How many preterm infants can we safely care for at once?

We have been seemingly under siege over the last year or so by a relentless flow of preterm infants through our units in the city.  Peaks and valleys for patient census come and go for the most part but this almost unwavering tendency to be filled to the rafters so to speak is unusual.  Much has been said and will continue to be acknowledged that we are all doing incredible work, that we are dedicated and putting patients first but where is the breaking point?  When does fatigue lead to errors no matter how well intentioned and selfless we are.  In those cases when it is not a matter of being selfless but we are mandated to come in fatigue is no less an issue.

Like many units in North America and in other parts of the world, rates of neonatal sepsis have been on the decline but during a recent peak in both acuity and volume in the region we saw a spike in the rate of culture proven sepsis.  At a time when we were at our busiest our sepsis rate worsened which raised many eyebrows as to what could be contributing.  It is tempting to blame it on patient volumes but what is the actual evidence to support such a claim.  This is the thrust of this piece and I hope you find the topic of some relevance to you as we continue on this journey of a higher state of patient volumes in the city.

Nurse to Patient Ratio is Likely Important

This has to be important right?! NICUs come in many shapes and sizes but if you can staff appropriately with 1:1, 1:2 and 1:3 ratios based on patient acuity if you had enough nurses would your sepsis rates be ok?  To answer this a useful study is by Jeannie P. Cimiott et al entitled Impact of staffing on bloodstream infections in the neonatal intensive care unit.  The study group was actually from an RCT on hand hygiene and this study was a reanalysis of the data to determine for infants with confirmed sepsis what impact nursing hours had in the context of a patient with their first positive blood culture.   In her study there were 2675 infants in two New York level III NICUs that had 224 positive blood cultures.  The impact of nursing hours on risk of infection was dramatic.

The NICU with greater nursing coverage had a significantly decreased risk (HR, 0.21; 95% CI, 0.06-0.79) of bloodstream infection. Moreover, the more RN hours per nursing intensity weight was associated with a 79% reduction in the risk of bloodstream infection in the unit with greater nursing work hours.  m_poa60015f1Looking also at the impact of greater nursing hours on time to infection demonstrated the following curve. From the graph one can see that two patients both of which develop an infection at 100 days of life have markedly different chances of survival based on the staffing level.  The Neonatologist, RRT, dietician could all be the same but if the nursing hours are lacking the patient is more likely to die.  A very significant concern indeed!

What Effect Does The Percentage of Preterm Babies In The Unit Have On The Rate of Infections?

The next question may be answered by looking at a study from this year by Goldstein et al entitled Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?  This study looked retrospectively at a 17 year period between 1997 and 2014 to determine the risk of systemic infection from two standpoints; occupancy and percentage of infants < 32 weeks.  In other words they were looking at whether the presence of many smaller babies in the units increases such risk of infection specifically.  This was a rather large study population of 19810 infants of which 446 had confirmed late onset sepsis.  Not surprisingly 70% of the cases of sepsis were with CONS.

The authors examined hazard ratios to determine whether occupancy or proportion of infants < 32 weeks had an effect on risk and determined that the average occupancy did not correlate with risk of infection but did for the category of infants < 32 weeks.  Interestingly the HR for this was 1.03 with a CI that touches 1 so I am not sure how they make this claim but in the end they conclude:

“For each additional percentage of infants <32 weeks gestation in the unit, neonates had an increased late-onset sepsis hazard of 2% (HR 1.02, 95% CI: 1.00, 1.03) over their NICU hospitalization.”

For arguments sake let’s say this is a real effect.  I do have to call into question the diagnosis of sepsis.  I could not find mention of the definition of sepsis in this cohort and with so many CONS infections I do worry that some of these were in fact contaminants.  Did they draw one or two blood cultures in each instance?  How many of these if they had would have had one positive and the other negative?  Having just a few of these labelled as contaminants may have negated any effect seen.

What About The Nurses?

You also can’t ignore the fact that while they looked at occupancy they made no attempt to control for the amount of staff.  To not do so I think misses a very important point.  Whether your unit is functioning at 60, 70, 80 or more occupancy while giving a measure of patient volumes tells you nothing about the coverage for such patients.  In a well staffed unit with adequate nurse to patient ratios there might be minimal risk of error.  If assignments though that are ideally 2:1 are stretched to 3 or 4: 1 that is likely where the errors start to come in.

Coming back to our situation that likely mirrors many other centres across the globe I believe all of this comes down to ensuring a safe environment to care for our patients.  A safe environment means having enough staff to cover the number of patients and that includes medical, RRTs, dieticians and others.   The message from all of this is that to do our best we need the right amount of staff to do it.  We can handle the volume, just provide us with the resources to handle it.  If it is money that we are hoping to save consider the amount of dollars that could be saved by avoiding prolonged stays from infection and all the associated morbidities that follow.

Then there is the increase in mortality to consider and I for one will not even begin to put a price on that.

Is It Time To Use Sustained Lung Inflation In NRP?

Is It Time To Use Sustained Lung Inflation In NRP?

As I was preparing to settle in tonight I received a question from a reader on my Linkedin page  in regards to the use of sustained inflation (SI) in our units.  We don’t use it and I think the reasons behind it might be of interest to others.  The concept of SI is that by providing a high opening pressure of 20 – 30 cm H2O for anywhere from 5 to 15 seconds one may be able to open the “stiff” lung of a preterm infant with RDS and establish an adequate functional residual capacity.  Once the lung is open, it may be possible in theory to keep it open with ongoing peep at a more traditional level of 5 – 8 cm of H20.

The concept was tested 25 years ago by Vyas et al in their article Physiologic responses to prolonged and slow-rise inflation in the resuscitation of the asphyxiated newborn infant.  In this study, 9 newborn infants were given a relatively short 5 second sustained inflation and led to earlier and larger lung volumes with good establishment of FRC.  Like many trials in Neonatology though sceptics abound and here we are 25 years later still discussing the merits of this approach.

As I have a warm place in my heart for the place that started my professional career whenever I come across a paper published by former colleagues I take a closer look.  Such is the case with a systematic review on sustained inflation by Schmolzer et al.  The inclusion criteria were studies of infants born at <33 weeks. Their article provides a wonderful assessment of the state of the literature on the topic and I would encourage you to have a look at it if you would like a good reference to keep around on the topic.  What it comes down to though is that there are really only four randomized human studies using the technique and in truth they are fairly heterogeneous in their design.  They vary in the length of time an SI was performed (5 – 20 seconds), the pressures used (20 – 30 cm H2O), single or multiple SIs and lastly amount of oxygen utilized being 21 – 100%.  In fact three of the four studies used either 100% or in one case 50% FiO2 when providing such treatments.

What Did They Show?

This is where things get interesting.  SI works in the short term by reducing the likelihood that an infant will need mechanical ventilation at 72 hours with a number needed to treat of only 10!  In medicine we normally would embrace such results but sadly the results do not translate into long term benefits as the rate of BPD, mortality and the combined outcome do not remain significant.  Interestingly, the incidence of a symptomatic PDA needing treatment with either a medical or surgical approach had a number needed to harm of 11; an equally impressive number but one that gives reason for concern.  PDAAs the authors speculate, the increased rate of PDA may be in fact related to the good job that the SI does in this early phase.  By establishing an open lung and at an earlier time point it may well be that there is an accentuation in the relaxation of the pulmonary vasculature and this leads to a left to right shunt that by being hemodynamically significant helps to stent the ductus open at a time when it might otherwise be tending to close.  This outcome in and of itself raises concern in my mind and is the first reason to give me reason to pause before adopting this practice.

Any other concerns?

Although non-significant there was a trend towards increased rates of IVH in the groups randomized to SI.  There is real biologic plausibility here.  During an SI the increased positive pressure in the chest could well simulate a similar effect to a pneumothorax and impede the passive drainage of blood from the head into the thorax.  In particular, longer durations and/or frequent SIs could increase such risk.  Given the heterogeneous nature of these studies it is difficult to know if they all had been similar in providing multiple SIs could we have seen this cross over to significant?

I believe the biggest concern in all of this though is that I would have a very hard time applying the results of these studies to our patient population.  The systematic review addresses the question about whether SI is better than IPPV as a lung recruitment strategy in the preterm infant with respiratory distress.  I have to say though we have moved beyond IPPV as an initial strategy in favour of placement of CPAP on the infant directly after birth.  The real question in my mind is whether providing brief periods of SI followed by CPAP of +6 to +8 is better than placement on CPAP alone as a first strategy to establish good lung volumes.

If I am to be swayed by the use of SI someone needs to do this study first.  The possibility of increasing the number of hemodynamically significant PDAs and potentially worsening IVH without any clear reduction in BPD is definitely placing me firmly in the camp of favouring the CPAP approach.  Having said all that, the work by the Edmonton group is important and gives everyone a glimpse into what the current landscape is for research in this field and opens the door for their group or another to answer my questions and any others that may emerge as this strategy will no doubt be discussed for years to come.

Mandatory Drug-Testing in Pregnancy: Lesson learned.

Mandatory Drug-Testing in Pregnancy: Lesson learned.

 

Original Post

I don’t know if you missed it but I did until tonight.  We don’t have this in Canada but there have been some US states that have been doing so for the past while.  You may find the following link very interesting that explains the positions of each state in regards to drug use in pregnancy. The intentions were good to protect the unborn child but the consequences to mother’s who tested positive were of great concern.  While testing of mothers for drug use has been done off and on for years what made this different was that the confirmation of drug use was deemed to be a criminal offense with the results handed over to the police.

As this article from March 4th indicates the practice has been ongoing in Tennessee for at least a year and a pilot project was planned for Indiana this year.  According to the article the situation in Tennessee came with some significant risk to the mother if found to have a positive screen.

“Lawmakers in Tennessee last year increased drug screenings of expectant mothers and passed a law allowing prosecutors to charge a woman with aggravated assault against her unborn baby if she was caught using illicit drugs. The penalty is up to 15 years in prison.”

The law may seem harsh and in my eyes is but it came in response to the tidal wave of drug addiction and neonatal withdrawal in the US as was identified in the article from the NEJM in 2015 entitled Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs.  The impact on neonatal ICUs in the US can be seen in the following graphs which demonstrate not only the phenomenal rise in the incidence of the problem but in the second graph the gradually prolonging length of stay that these patients face.  trend copyAside from the societal issues these families face and the problems their infants experience, the swelling volume of patients NICUs have to contend with are quite simply overwhelming resources with time. Although I reside in Canada, it is the trend shown that likely motivated some states to adopt such a draconian approach to these mother-infant dyads.

There are so many questions that would arise from such an approach.

  1.  What if a mother refuses testing as is the option in Indiana.  Would Child and Family services be called simply on the suspicion?
  2. What if a mother received prescription opioids for chronic back pain or used an old prescription in the days before she was tested after a fall to ease her pain?
  3. Then there is the Sharapova situation 321A803200000578-3488204-image-a-20_1457728964889where a mother could conceivably take a medication that she is unaware is on a list of “banned substances”.  What about Naturopathic or herbal supplements that might test positive?
  4. Then what about false positive tests?

 

The ramifications of any of the above situations on the family unit could be devastating.  Interestingly this year the courts in Indiana passed a law that prevents health care providers from releasing the results of such toxicology screens to police without a court order so indeed there would need to be suspicion.  In the end though is it right?

Tennessee Sings a New Tune

As surprised as I was to hear about the situation in Tennessee just now I was equally surprised to come across a U.S. Supreme Court ruling handed down March 21st, 2001 that has ruled that subjecting mothers to such testing in hospitals is unconstitutional.  This may disclose my ignorance of US law but I would have thought if the US Supreme Court says you cannot do something the states would follow along but at least in Tennessee that was not the case…until now.

March 23rd the law in Tennessee is changing as the state has chosen not to renew the legislation after a two year trial period saw about 100 women arrested.  For more information on this decision see Assault Charges for Pregnant Drug Users Set to Stop in Tennessee.

Where do we possibly go from here?

I found this whole storyline shocking but I am taking some solace in knowing that this was a very limited experiment in one state.  Neonatal abstinence is a problem and a big one at that.  Criminalizing mothers though is not an effective solution and to me the solution to this problem will need to involve a preventative approach rather than one of punishment.  A first step in the right direction will be to stem the tide of liberal use of prescription opioids in pregnancy as was suggested in the BMJ news release in January of this year.  In the end if we as medical practitioners are freely prescribing such medications to the mothers we care for perhaps we should look in the mirror when pointing fingers to determine fault.  So many of the mothers and the infants we care for may well be victims of a medical establishment that has not done enough to prevent the problem.

Update

While screening women presenting to the hospital in labour or their newborns for that matter may seem like a wise choice, the request to procure a sample remains just that.  It is a request and in collecting consent is needed.  This was the advice at least I was given by the Canadian Medical Protective Association.  It does create an interesting situation though in the mother who refuses to have her or her baby submit a urine specimen.  Should we assume that a woman who refuses testing is in fact using an illicit substance or is she merely choosing to not have a wasted test when she knows that she is not using anything?  How do we as practitioners view this decision and do we jump to a verdict of guilt immediately?  I suspect the answer is that most of us would assume so especially if we are using a targeted screening approach in which we are only approaching those mothers who we suspect are using.

The secondary question becomes the “so what”? What I mean by this is how will our management change if we know or don’t know?  If we suspect use and the baby is demonstrating signs of withdrawal abstinence scoring will start.  If the source of the symptoms are unknown would we not just treat with phenobarbital to cover the possibility that there is more than one drug at play here?  I used to be on the side of the argument that felt we had to know and therefore pushed for such screening but in the end will it really change our management?  Not really.

This past month the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion on opioid use in pregnancy. The important points to share with you are the following and I would agree with each.

  • Screening for substance use should be part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Screening based only on factors, such as poor adherence to prenatal care or prior adverse pregnancy outcome, can lead to missed cases, and may add to stereotyping and stigma. Therefore, it is essential that screening be universal
  • Urine drug testing has also been used to detect or confirm suspected substance use, but should be performed only with the patient’s consent and in compliance with state laws.
  • Breastfeeding should be encouraged in women who are stable on their opioid agonists, who are not using illicit drugs, and who have no other contraindications, such as human immunodeficiency virus (HIV) infection. Women should be counseled about the need to suspend breastfeeding in the event of a relapse.

The issue of consent seems to be firmly in place based on this position and as I mention above I think that is a good thing.  The question of breastfeeding comes up frequently and it is good to see ACOG take a clear view on this as I have often thought that the benefits of the same plus the administration of small quantities of the drug in the milk may have a double benefit in reducing symptoms.

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