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Best practice №33

Communicate directly with the outpatient primary care provider prior to the newborn leaving the hospital to review the hospital course and discuss follow-up

transition-of-care

by Alexandra Iacob, Angela Huang, Kathryn Ponder, Lisa Chyi, Pamela Aron-Johnson, Priya Jegatheesan

Last updated October 7th, 2020

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Overview

The treating physician within the hospital setting should communicate directly with the outpatient primary care provider (pediatric or family medicine provider) prior to the newborn leaving the hospital to review the hospital course, inform the primary care provider of social issues, discuss feeding plans, and ensure timely follow-up appointments are available within 24–72 hours of discharge from the hospital. In addition to the primary care provider, scheduling of home visit(s) by a nurse and/or social worker is ideal if available (see Best Practices #25, #29 and #31).

Why we are recommending this best practice

  • Newborns exposed to illicit or non-medicinal uses of substances during pregnancy are at risk of withdrawal, as well as ongoing neurodevelopmental and other challenges.  They require high risk or other close follow-up care to ensure early identification of and intervention for potential adverse outcomes.

  • Primary care providers should be aware of the current feeding regimen to ensure that the newborn continues to receive adequate caloric intake for growth and development and to adjust as necessary.

  • Newborns who are initially breastfed by women on medication assisted treatment (MAT) and whose mothers stop breastfeeding may be at higher risk of experiencing a recrudescence of withdrawal symptoms. Although the risk is minor, as breastmilk concentrations of both methadone and buprenorphine are low, primary care providers should be informed. 

  • Subacute signs of neonatal abstinence syndrome (NAS) may last up to six months.

  • Drug exposure in utero is a marker of environmental risk. Caretaker involvement, family resources, and community resources are protective factors that can improve long-term outcomes for children.

Strategies for implementation

Consider a NAS discharge checklist for inpatient providers and primary care providers caring for exposed newborns, which should ideally be incorporated into the electronic health record.
Baby M

Baby M

Baby M no longer needs pharmacologic therapy and will be ready to go home soon. In preparation for that transition, the pediatrician who has cared for Baby M in the hospital calls the pediatrician who will care for Baby M as an outpatient. During the phone call, the pediatrician describes Kayla and Baby M’s social and medical history, summarizes the hospital course, and suggests all aspects of care after discharge.

References

  • Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarko L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid- exposed infants. Acta Paediatr. 2013;102(11):1060-1066.
  • Messinger DS, Bauer CR, Das A et al. The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics. 2004;113(6):1677-1685.
  • Bada HS, Bann CM, Whitaker TM et al. Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures. Pediatrics. 2012;130(6):1479-1488.

Alexandra Iacob

MD

Dr. Alexandra Iacob is a Neonatal-Perinatal Fellow at University of California, Irvine (UCI) based out of UCI Medical Center and Miller Children's and Women's Hospital Long Beach. While in fellowship, she is also pursuing a Master in Public Health at Johns Hopkins University. She is passionate about improving neonatal outcomes across all socioeconomic classes via both quality improvement projects and policy efforts. She is particularly interested in neonatal abstinence syndrome and the impact it has on the mother, the baby, and the family as a whole.

Angela Huang

MPH, RNC-NIC

Angela Huang is a clinical nurse in the Neonatal Intensive Care Unit at Santa Clara Valley Medical Center,  where she is also a nurse coordinator managing and leading quality improvement and research projects.  She is actively involved in hospital-wide and county-wide opioid use reduction initiatives, specifically outcome improvement for mother/infant dyads with a history of substance use and exposure.  Angela is also the co-chair for the CPQCC Maternal Substance Exposures Workgroup which is assessing the statewide scope of NAS and NAS management practices.

Kathryn Ponder

MD, MMS

Dr. Ponder is a neonatologist with East Bay Newborn Specialists, working in the neonatal intensive care units at the UCSF Benioff Children’s Oakland, John Muir Walnut Creek, and Alta Bates hospitals. She is also the director of the John Muir High Risk Infant Follow-Up clinic. She has revised her practice’s guidelines for the care of infants with Neonatal Abstinence Syndrome and is leading a quality improvement initiative at John Muir to implement these changes. She has previously conducted research and published in the fields of developmental/placental biology and maternal health. She continues to be interested in the developmental origins of disease and optimizing neurodevelopmental outcomes for infants.

Lisa Chyi

MD

Dr. Lisa Chyi is a practicing neonatologist at Kaiser Walnut Creek.  She is co-chair for the CPQCC Maternal Substance Exposures Workgroup which is assessing the statewide scope of NAS and NAS management practices.  She also helped develop the NAS management guideline and oversees NAS patient care for the Kaiser Northern California region.

Pamela Aron-Johnson

RN

Pamela  has been at UCI Medical Center in Irvine, California for 35 years in several roles including staff nurse in the NICU for 17 years, Outpatient Nurse Manager for Primary and Specialty Services, and currently the Quality and Patient Safety Advisor for the NICU and OB departments. She is also a member of the Data Committee Advisory Group for CPQCC, and is the data nurse coordinator at UCI for both CPQCC and CMQCC. 

Priya Jegatheesan

MD

Dr. Priya Jegatheesan is the Chief of Newborn Medicine and the Regional NICU Director for Santa Clara Valley Medical Center in San Jose, California, an institution committed to the medically underserved. Her main area of interest is outcomes and data-driven quality improvement. She established a comprehensive computerized database system in the SCVMC NICU that enables prospective data collection for quality improvement  and research.  She also actively participates in CPQCC’s Perinatal Quality Improvement Panel and chaired the QI infrastructure sub-committee for 2 years.  She became a member of the Society for Pediatric Research in 2014 and has actively participated in clinical research. She is currently the study site Principal Investigator for a NIH funded multi-center study evaluating ondansetron (5HT3 antagonist) for prevention of neonatal abstinence syndrome in newborns born to mothers who had chronic opioid use during pregnancy. She is a passionate champion for optimizing care of newborns exposed to substances during pregnancy to prevent neonatal abstinence syndrome by promoting mother-infant couplet care.