Sim Case 3

Are signs of withdrawal present?

If Yes to Question 1, is timing of withdrawal consistent with known opioid exposure? 

Are co-exposures present that may be contributing to signs of withdrawal?

Are nonpharmacologic care interventions (NPIs) maximized to fullest extent possible in infant’s clinical setting?

Takes > 10 min to coordinate feeding or breastfeeds < 10 min or feeds < 10 mL (or other age-appropriate duration/volume) due to NOWS/NAS?

Sleeps < 1 hour due to NOWS/NAS?

Takes > 10 min to console (or cannot stay consoled for at least 10 min) due to NOWS/NAS?

Consoling Support Needed

Formal Parent/Caregiver Huddle to be performed to formally review NPIs to be increased further?

Full Care Team Huddle to be performed to formally consider all possible etiologies for symptoms, re-assess if NPIs are maximized to the fullest extent possible, and determine if NOWS/NAS medication treatment is needed?

Management Decision

Parent/Caregiver Presence Since Last Assessment

Rooming-in (i.e., caring for infant in their own room with earlier caregiver response to infant stress or hunger cues)

Parent/caregiver presence to help calm and care for infant

Skin-to-skin contact when caregiver fully awake/alert to help organize infant feeding behaviors, calming & sleep

Holding by parent/caregiver/cuddler to help calm infant & aid in sleep (with caregiver fully awake/alert)

Safe & effective swaddling (e.g., extremities swaddled in flexed position, blanket snug, no extra blanket around baby’s face)

Optimal feeding (e.g., baby offered feedings when showing hunger cues & fed till content)

Non-nutritive sucking with infant’s hand, pacifier, adult caregiver’s washed or gloved finger

Quiet, low light environment to help limit overstimulation of infant (e.g., tv volume down, quiet “white noise” machine or phone app)

Rhythmic movement provided by parent/caregiver or infant calming device (e.g., “jiggling” or infant swing in presence of alter adult)

Additional help/support in room (e.g., other parent, family member, friend, cuddler, staff member, recovery coach, DCYF worker)

Limiting # of visitors & duration of visit(s) to minimize disruptions in infant’s care environment & sleep

Clustering care & assessments with infant’s awake times (e.g., RN & infant provider perform assessment together after infant feedings)

Safe sleep/fall prevention (e.g., infant sleeps on back, safely swaddled, in own sleep space)

Parent/caregiver self-care & rest (e.g., identifying another adult to care for infant so parent can rest or take a walk/break)