Specialized Medical and Developmental Follow-up for Infants and Children with Prenatal Opioid Exposure- The STEP and Next Step Clinics

Opioid use disorder among pregnant women has increased over the last few decades resulting in approximately 2% of infants born with prenatal opioid exposure in the Greater Cincinnati region.  Of those, about one third will require pharmacologic treatment for Neonatal Opioid Withdrawal Syndrome (NOWS), which includes symptoms of neurologic excitability, autonomic instability, and GI dysfunction.  These infants have prolonged birth hospital stays and are at risk for ongoing medical and developmental problems.  Infants and children with prenatal opioid exposure have been shown to have higher rates of motor, speech, cognitive, sensory, and behavioral delays compared to those without prenatal opioid exposure.  Additionally, they have increased rates of vision problems, growth and nutrition concerns, and have higher rates of exposure to perinatally acquired infections including Hepatitis C.  As a result, the American Academy of Pediatrics recommends follow-up for children with prenatal opioid exposure in a specific developmental assessment clinic in addition to developmental, behavioral, and mental health screenings by primary care pediatricians.

In 2015, in response to the high rates of prenatal opioid exposure in our region, we established the NAS (neonatal abstinence syndrome) Clinic as a sub clinic of the Neonatal Intensive Care Unit Follow-up Clinic.  As one of the first clinics dedicated to this population, we were the leaders in identifying the needs of these children through our multidisciplinary approach with a clinical team consisting of physicians and advanced practitioners, nurses, occupational therapists (OT), physical therapists (PT), dietitians, and social workers (SW). 

STEP Clinic Care Timeline

The NAS Clinic was renamed to the STEP (Supporting Those with Opioid Exposures) Clinic in 2024 to reflect the mission of our clinic and as a shift toward a more inclusive name.  We currently serve approximately 500 individual patients per year with nearly 1000 visits at the Burnet and Liberty campus, Northern Kentucky and Centerville neighborhood locations as well as at the Good Samaritan Hospital Follow-up Clinic.  Additionally, we provide telehealth visits for those with limited transportation or who may live a great distance away.  Providers can refer patients to the clinic through Neonatology and indicating the STEP clinic.

The clinic provides transitional care after hospital discharge with the goal of seeing patients within the first few weeks of being home.  As symptoms of NOWS do not fully resolve at the time of discharge, we offer anticipatory guidance for caregivers on how to help manage these symptoms.  If an infant requires outpatient pharmacologic treatment for NOWS, we will also oversee weaning of NOWS treatment medications. Through the first 3 years of life, we conduct targeted medical and developmental screening at various ages to identify problems that may be more prevalent in children with prenatal opioid exposure.  In addition to clinical evaluations by providers and therapists, we perform detailed feeding and growth assessments, Hepatitis C testing at 2-6 months (if applicable), instrument-based vision screening starting at 6 months, visits timed and scheduled with audiology evaluation and researched-certified neurologic evaluations.  Developmental screening includes the General Movements Assessment (GMA) for early detection of motor issues including cerebral palsy, Hammersmith Infant Neurologic Examination (HINE), Infant and Toddler Sensory Profile, Bayley Scales of Infant Development, and the Child Behavior Checklist. Referrals for additional services including outpatient therapy, subspeciality care, and Early Intervention are provided based on these evaluations and screenings.

The Next Step Clinic is a comprehensive, multidisciplinary evaluation and consultation clinic for children with a history of prenatal opioid exposure. Serving as the "next step" in care following the STEP clinic, children ages 2-5 and their caregivers participate in an evaluation with four disciplines: developmental and behavioral pediatrics, occupational therapy, psychology, and speech-language pathology. Needed referrals and resources are shared at the visit based on developmental testing. Families can consent to participate in the research being conducted by the Next Step team as well. Families may participate 1-3 times in the preschool years to ensure preparation for kindergarten.  Additionally, the Next Step Clinic fills an important need to help families navigate the transition from Early Intervention to qualification for preschool services. You can find more information on the Next Step clinic’s related study here.