National Clinical Guidelines for the management of drug use in pregnancy, birth and the early develo

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National Clinical Guidelines for the management
of drug use during pregnancy, birth and the early
development years of the newborn
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• How did this project come about?
• How were the guidelines developed?
• What credibility do the guidelines have, can we
  rely on them?
• What do the guidelines recommend?
• How can we use them in our service?

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• How did this project come about?

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History of the Project

• 1993 Vic Fogarty Report Child Protection
• 1998-9 NSW Child Death Review
• 2001 nationally based discussions IGCD
  (Intergovernmental Committee on Drugs with
  National Expert Advisory Committees on Alcohol,
  Tobacco Illicit Drugs)
• 2002 NSW Health NAS (Neonatal Abstinence
  Syndrome) Management Guidelines

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• 2003 Langton project to review NAS literature
• Proposal submitted to IGCD by SA
• Scope extended to include
• licit substances (alcohol, tobacco)
• early childhood
• Late 2003 Proposal accepted by IGCD
• NSW Health and SA Health lead agencies
• Early 2004 Funding to NSW Health

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• How did this project come about?
• How were the guidelines developed?

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The Proposal required that they be

• National
• Clinical
• Evidence based
• Use Kettil Bruun process

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National All Jurisdictions

• State
• Territory
• Federal

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Evidence base

• Overall, little reliable evidence on the effects
  of drug and alcohol use in pregnancy, or on
  developmental effects
• Highest levels of evidence for tobacco

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Levels of Evidence Adapted from NHMRC 1999
 
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Life stages

• Pre conception
• Pregnancy
• Birth
• Early years of infant

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Kettil Bruun Process

• Trigger papers
• Discussant papers
• Expert Workshop

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Topics 1

• Opioids
• NAS
• Current protocols woman
• Current protocols NAS

• Alcohol
• Tobacco
• Cannabis
• Benzodiazepines
• Amphetamines
• Cocaine
• Inhalants

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Topics 2

• Vertical transmission BBVs
• Obstetric complications
• Pain management in labour

• Breastfeeding
• Psychosocial aspects
• Continuing support into the early years
• Indigenous issues

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Trigger papers

• Reviews of evidence by experts
• Review of literature
• Levels of evidence where possible
• Writing trigger papers

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Discussant papers

• Review trigger papers for
• Coverage of literature
• Identification of main issues
• Formulation of draft guidelines
• Identification of gaps

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• Main workshop Indigenous workshop
• Drafting of guidelines
• Corrections by authors workshop groups

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Participants

• Midwives
• DA physicians
• Drug and alcohol workers
• Psychologists
• Social workers
• General practitioners

• Obstetricians
• Neonatologists
• Nurses
• Psychiatrist
• Policy analysts
• Researchers

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Consultation

• Two phases
• Phase 1
• Consumers
• Clinicians
• Professional organisations

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Consultation

• Phase 2
• Government bodies including
• Drug and alcohol sections
• Child protection
• Justice health
• Aboriginal and Torres Strait Islander health

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Current Progress

• Guidelines approved by IGCD September 05
• Endorsed by MCDS out of session 2 December 05

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• How did this project come about?
• How were the guidelines developed?
• What credibility do the guidelines have, can we
  rely on them?

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Who should use the guidelines?

• All health care practitioners working with
  pregnant women experiencing a drug or alcohol use
  problem, particularly drug dependency, but
  including other drug uses such as bingeing.

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• How did this project come about?
• How were the guidelines developed?
• What credibility do the guidelines have, can we
  rely on them?
• What do the guidelines recommend?

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• Antenatal care
• Facilitation of engagement of the woman her
  family with services
• Appropriate referral for specialist assessment
  care
• Appointment of a case manager care team with
  fluent processes between hospital community
  settings (addressing individualised care plan)
• Specific treatment for drug alcohol use eg
  counselling, methadone maintenance, relapse
  prevention
• Adequate monitoring of fetal growth, infant
  development/welfare maternal welfare
• Assertive follow up antenatally postnatally

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Postnatal Care

• Consideration should be given to
• Timing of discharge
• Contraception
• SUDI/SIDS education
• Cultural specific support education
• Education regarding signs symptoms of NAS
  administration of medication, if required

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Preparation for Discharge.

• Thorough discharge plan to be developed with
  family service providers that addresses
• Parenting ability
• Stability Psychosocial issues
• Drug Health Mental Health
• Environmental issues
• Material goods preparation for the baby
• Child Protection Issues
• Service stream responsibilities accountabilities

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Blood-borne viruses (BBVs)

• Human Immunodeficiency Virus (HIV)
• Hepatitis B
• Hepatitis C
• Advice re Vertical transmission, use of
  caesarean section, medication, follow up of
  infant.

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Breastfeeding

• Mothers who are drug dependent should be
  encouraged to breast feed with appropriate
  support precautions
• Should be recognised that skin to skin contact is
  important regardless of choice of infant feeding
• Encouraging breastfeeding is preferred to
  avoiding breastfeeding

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Considerations with breastfeeding advice

• The woman should be informed about the likely
  effects on the infant of the drugs she is using
• The woman should be assisted to plan minimum
  exposure of the infant to the effects of these
  drugs
• The risks for each individual woman should be
  weighed against the benefits of breastfeeding
• harm minimisation approach

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Breastfeeding

• Tobacco
• NRT
• Alcohol
• Opioids
• Benzodiazepines
• Psychostimulants
• Cannabis
• BBV

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Specific Drug Groups

• Tobacco NRT
• Alcohol
• Opioids
• Amphetamines
• Cocaine
• Cannabis
• Benzodiazepines (unprescribed use)

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To receive an electronic copy

• Leave email details with Jill
• Email Jill jmola_at_doh.health.nsw.gov.au

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• How did this project come about?
• How were the guidelines developed?
• What credibility do the guidelines have, can we
  rely on them?
• What do the guidelines recommend?
• How can we use them in our service?

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• How to implement the guidelines?
• Individual level
• Service level

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Implementing the guidelines Identify

• Challenges
• Barriers
• Helpful aspects
• Available resources

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Implementation

• Individual level
• Clinical Practice Guidelines?
• Training?
• Service level
• Policy?
• Clinical Governance Committee?
• Strategic Plan?

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Identify

• Local client needs and risk indicators
• Not all women will need the same level of
  intervention
• Criteria for care pathways
• eg high risk, low risk, needs referral out
• THEN

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How to maintain the principles of

• Expert referral assessment
• Multidisciplinary care
• Multiagency collaboration
• Continuity of care and carers
• Keeping the woman engaged in care

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Also

• Case management, case discussions / meetings
• Systems of communication
• Care of NAS, extended hospital stay
• Discharge planning
• Community follow up

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Resources

• What resources are available?
• What are gaps in local capacity?
• eg
• What referral services are available?
• What secondary consultation services are
  available? i.e.
• Who can clinicians ring for advice after hours or
  in emergency situations?
• Where are those numbers kept e.g. in AE?

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• Management of women refusing DA specialist care
  , or social work referral
• Women having no antenatal or inadequate care