Public Health Children and Adolescent Health News and Training for Providers

“Opioid Use in Pregnancy and Neonatal Abstinence Syndrome”

Priya Gulati, MD and Ambar Kulshreshtha, MD, PHD

Emory Department of Family and Preventive Medicine

Women are at highest risk for developing a substance use disorder during their reproductive years. According to a national survey, 5.9% of pregnant women use illicit drugs and 8.5% drink alcohol, resulting in over 380,000 offspring exposed to these substances, creating a significant public health issue. Over 1 in 20 women received an opioid during the first trimester with significant geographic variation; prescription rates were highest in the South and lowest in the Northeast. Substance abuse during pregnancy can lead to life-threatening complications for the mother, such as arrhythmias or uterine rupture, and adverse effects for offspring such as birth defects, low birth weight infants, preterm birth, and neonatal abstinence syndrome (NAS). NAS refers to a postnatal opioid withdrawal syndrome that can occur in 55 to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant. Symptoms of withdrawal can occur within 1-3 days after delivery and range from mild tremors and irritability to fever, excessive weight loss, and seizures. With the opioid epidemic, the incidence of NAS has also increased substantially in the past decades. In Georgia from 2010-2014, there were 1365 hospitalizations with a diagnosis of NAS with an average cost of $52,856 per baby.

Targeted initiatives to address prescribing practices may help to reduce substance use in women of childbearing age and prevent the subsequent development of NAS. Women should receive counseling about the risks and benefits of all medications taken during pregnancy. Primary care physicians treating women of childbearing age are encouraged to practice judicious prescribing of opioids and may want to consider non-opioid alternatives for pain management. Non-pregnant women of childbearing age who are opioid dependent need specific counseling about family planning and the implications of opioid dependence for future pregnancies.  In conjunction with a specialist and the patient, primary care physicians can facilitate withdrawal from opioids before patient becomes pregnant. Pregnant women who are opioid dependent need education about the possibility of NAS, its management, and the possibility of an extended hospital stay for the infant.

Ongoing surveillance including programs to monitor opioid-drug prescribing practices, establishment of opioid dosage thresholds, and standardized protocol for treatment are all necessary to address the opioid epidemic. Identification of infants at risk for NAS is important to ensure early intervention to mitigate signs of withdrawal. Targeted screening (such as the Screening, Brief Intervention, and Referral to Treatment (SBIRT)) enables identification of women at highest risk and is believed to be more cost-effective than universal screening. The main objective in the management of NAS is to promote normal growth and development of the infant. Care of the mother-baby should be collaborative, compassionate, and nonjudgmental, since many mothers feel stigmatized and guilty regarding substance use. Breast-feeding and rooming-in can improve outcomes and promote bonding. First-line pharmacotherapy consists of opioid replacement with oral morphine solution, sublingual buprenorphine, or methadone to minimize signs of withdrawal. Recent evidence suggests that regardless of the treatment option, infants who underwent protocol-specified weaning had significantly fewer treatment days and a shorter hospital stay.  A multidisciplinary approach including primary care providers, substance abuse providers, and public health officials is imperative to curb the epidemic and reduce costs associated with NAS.

References

Bateman BT, Hernandez-Diaz S, Rathmell JP, Seeger JD, Doherty M, Fischer MA, Huybrechts KF.

Patterns of Opioid Utilization in Pregnancy in a Large Cohort of Commercial Insurance Beneficiaries in the United States. Anesthes 2014;120(5):1216-1224.

Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, et al. The 4P’s Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol. 2005;25:368–74.[PubMed]

Chasnoff IJ, Neuman K, Thornton C, Callaghan MA. Screening for substance use in pregnancy: a practical approach for the primary care physician. Am J Obstet Gynecol. 2001;184:752–8. [PubMed]

Chasnoff IJ, Wells AM, McGourty RF, Bailey LK. Validation of the 4P’s Plus screen for substance use in pregnancy. J Perinatol. 2007;27:744–8. [PubMed]

Compton WM, Thomas YF, Stinson FS, et al. : Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry. 2007;64(5):566–576. 10.1001/archpsyc.64.5.566

D’Apolito KC. Assessing neonates for neonatal abstinence: are you reliable? J Perinat Neonatal Nurs 2014;28:220-231 CrossRef | Web of Science | Medline

Desai RJ1, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol. 2014 May;123(5):997-1002.

Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996–1998. Obstet Gynecol. 2003;101:374–9

Flood P, Raja SN. Balance in Opioid Prescription during Pregnancy. Anesthes 2014;120(5):1063-1064.

Patrick SW, Davis MM, Lehmann CU, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol 2015;35:650-655 CrossRef | Web of Science | Medline

SARA of Georgia.  http://www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf

United States Department of H, Human Services. Substance A, Mental Health Services Administration. Center for Behavioral Health S Quality: National Survey on Drug Use and Health, 2012. Inter-university Consortium for Political and Social Research (ICPSR) [distributor].2013. 10.3886/ICPSR34933.v3

USPSTF Recommendation Statement of Illicit Drug Use Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/drug-use-illicit-screening

Volkow ND. Opioids in pregnancy BMJ 2016; 352 :i19

“Hey Baby, Can You Hear Me Now?”

Georgia’s Early Hearing Detection and Intervention (EHDI) Program is a system of care for early identification and intervention of children with congenital hearing impairment. The EHDI Program’s benchmarks are to screen by one month, to diagnose by three months, and to enroll into intervention by 6 months, also known as a 1-3-6 goal.  Children identified as deaf or hard of hearing (D/HH) move through a multi-partner system that begins with initial hospital screening and includes two public and multiple private intervention providers in Georgia. Although navigating intervention resources can be challenging for many families with hearing impaired children, studies show intervention beginning as early as six months of age that includes access to communication can positively impact that child’s speech and language development and consequently their ability to learn.

Georgia’s EHDI program is currently monitoring language development of children identified at birth with hearing loss through the 100 Babies Project.  The purpose of the project is to identify and explore factors that influence language development of D/HH children identified through newborn screening, including maternal and social factors, age of intervention, intensity of intervention and home language.  We suspect that not all children in Georgia are meeting language milestones despite being enrolled in early intervention due to maternal and social factors. Although research supports early intervention by six months of age to attain improved development outcomes for deaf and hard of hearing children, vulnerable populations of children may be at greater risk for not meeting language outcomes despite early intervention.  Results from the evaluation are being used to develop and implement strategies so that newborns and infants identified as D/HH do not fall behind their hearing peers.

Currently, the results of this evaluation further support that early identification by three months and early intervention by 6 months for D/HH children have improved outcomes compared to their peers.  The EHDI program is striving to remove barriers to timely identification, reduce referral time into intervention, and promote the importance of intervention for all D/HH children.  As a provider of essential care for children with hearing loss, it is crucial that you ensure families understand the importance of following up on the newborn hearing screen and enrollment of intervention after a possible diagnosis of permanent hearing loss with Georgia’s Part C Program (Babies Can’t Wait).

If you have any questions about newborn hearing screening or 100 Babies, please contact Kelly Dundon, AuD MPH at Kelly.dundon@dph.ga.gov or 470-283-9259.


TO: Healthcare Submitters and Providers

FROM: The Georgia Department of Public Health, Newborn Screening Program

RE: Newborn Screening Tests and Laboratory Analysis Fee Increase for FY 2017

Summary: During the 2016 legislative session HB751, Item 3052, to provide funds for therapies for children with congenital disorders was passed.  On April 7, 2016, the Department of Public Health published a Notice of Proposed Rule Making to amend Department of Public Health Regulation 511-5-5-04, pursuant to O.C.G.A. § 31-2A-6 and § 31-12-6(f).  As outlined in a memo sent out on July 1, 2016, The Georgia Department of Public Health, Newborn Screening Program proposed a fee increase from $50.00 to $63.00 to cover the Department’s actual cost associated with newborn screening.  This fee increase will enable the Department to screen for Severe Combined Immunodeficiency, a new critical condition added to the newborn screening panel, as well as provide therapies for children with congenital disorders.

Steps to Final Adoption: The fee increase has been approved by DPH as outlined in a memo sent out on July 1, 2016.  At their September 8, 2016, meeting the Department of Community Health (DCH) board voted for final adoption of a rate increase to reimburse Medicaid providers for the new fee amount. The next step in the approval process is for the Centers for Medicare and Medicaid Services (CMS) to provide approval.  Upon final approval from CMS and DCH, the fee increase will be universally adopted for newborn screening specimen collection in the state of Georgia. We will send a letter of notification, which will also include an effective date.

If you have additional questions, feel free to contact Judith Kerr, Interim Child Health Screening Program Manager at (404) 657-2878 or judith.kerr@dph.ga.gov.


Out of the Mouths of Babes – How Family Physicians Can Ease the Child Dental Crisis in Georgia

A family physician or pediatrician typically sees a child and their family about 13 times for routine checkups and vaccinations.  Each of these visits presents an opportunity for you and your clinical staff to review risk factors for oral disease.  In the U.S., tooth decay is the most prevalent chronic disease of childhood, five times more common than asthma.  Research has shown that from 1994-2004, 28 percent of 2-5 year-olds experience tooth decay.  Which is an increase of 15 percent from the prior decades.  We also know that if family has poor oral health status, so will their children.

What Can Family Physicians Do to Turn a Frown Upside Down for Our Children?

For all children and their families it’s important to educate them and hit these main points:

  • Educate parents about good oral health habits for them and their children
  • Explain why primary teeth are important
  • Encourage that they brush teeth regularly with a smear of fluoridated toothpaste
  • Encourage regular dental visits
  • Outline proper dietary habits

Start providing fluoride varnish application in your practice!

Effective 2015, physicians can offer this service to Medicaid children with a new CPT code 99188.  Georgia’s Department of Public Health has a small staff dedicated to expanding fluoride varnish in primary care physicians’ offices around the State.  Please see the contact below and consider adding this benefit to your practice.  For more information, please outreach to the following:

Carol C. Smith, RDH, MSHA, Director of Oral Health

Maternal and Child Health

Georgia Department of Public Health

2 Peachtree Street, 11-222

Atlanta, Georgia 30303-3142

Phone 404-657-3138

Fax: 404-657-7307

Carol.smith@dph.ga.gov


Upcoming Public Health Webinars

Innovations in Transition from Pediatric to Adult Health Care – March 28th at 12:30 pm- 1:30 pm

Please click the link to register for the March 28th webinar.

https://attendee.gotowebinar.com/register/3914880808966364419

 

Congenital Syphilis   – April 25th at 12:00 pm- 1:00 pm

Please click the link to register for the April 25th webinar.

https://attendee.gotowebinar.com/register/246382253124167683


Georgia Shape 

Under the leadership of Georgia Governor Nathan Deal, Georgia SHAPE is a network of partners, agencies and athletic teams committed to improving the health of Georgia’s young people by offering assistance and opportunity to achieve a greater level of overall fitness. Click here to learn more about Georgia Shape.


Low THC Oil Registry

Department of Public Health (DPH), in close consultation with the Georgia Composite Medical Board, has developed a Low THC Oil Registry for patients and caregivers who qualify to carry an identification card under Georgia House Bill 1.

What diseases are covered by the law?

The law lists eight diseases which qualify for the Low THC Oil Registry:

(1) cancer, when the disease has reached end stage, or the treatment produces related wasting illness, recalcitrant nausea and vomiting;
(2) seizure disorders related to diagnosis of epilepsy or trauma related head injuries;
(3) severe or end stage amyotrophic lateral sclerosis (also known as ALS, or Lou Gehrig’s Disease);
(4) severe or end stage multiple sclerosis,
(5) severe or end stage Parkinson’s disease;
(6) severe or end stage sickle cell disease;
(7) Crohn’s disease; and (8) mitochondrial disease