Baby Steps Clinic

Department of Pediatrics

Moving Forward One Step at a Time

Baby Steps LogoThe Baby Steps Clinic is for families who have a child exposed to substances before birth, which can influence growth, development, learning, and behavior. We know families want the best for their child, and the Baby Steps Clinic can help by offering support, assessment, and interventions. The clinic is here to help every child reach his or her full potential and to support families as they support their child’s development. The Baby Steps Clinic is also recognized as a Promising Practice by the American Academy of Pediatrics. In May 2023 Dr. Dianna Puhr, Medical Director for Baby Steps, spoke on Improving Care for Children & Families Affected by Substance Use for the ETSU Child and Family Health Institute Collaborative Series.

Baby Steps Interprofessional Team:

  • Care coordinator
    • The care coordinator follows your family from pregnancy through early childhood helping to track progress, schedule appointments, serve as the point person for questions, make referrals to other services, and help you navigate aspects of your child's medical, developmental, and emotional needs.
  • Tennessee Early Intervention Specialist
    • The Tennessee Early Intervention Specialist (TEIS) will talk you through various free services available to you to help your child reach optimal development. A plan will be developed between you and the TEIS to fit your needs and best support your family. 
  • Audiologist
    • The audiologist will use age-appropriate objective tests like tympanometry, otoacoustic emissions (OAE) and/or auditory brainstem responses (ABR) to assess your child's entire auditory system from the eardrum to the auditory brain. The audiologist will also ask about your child's listening behavior at home.
  • Speech-language pathologist
    • The speech-language pathologist (SLP) will play with your baby, talk with you, and use age-appropriate tests during your visit. SLPs help babies develop their listening, sound-making, talking, social, play, and feeding skills.
  • Occupational therapist
    • The occupational therapist (OT) will assess your child’s sensory, social, play, and daily living skills by watching your child. The OT will ask how your child sleeps, eats, plays, and learns at home, in child care, or at school.
  • Physical therapist
    • The physical therapist (PT) will observe how your child moves while playing and look for muscle stiffness. The PT will help you to support your child in learning to move, calming himself or herself, and playing to get stronger with better balance
  • Registered dietitian
    • The registered dietitian (RD) will evaluate your baby’s growth and nutrition. The RD will assess your child's nutritional needs and make suggestions for healthy growth.
  • Board-certified pediatrician

 

  • Selected References

    Reddy UM, Davis JM, Ren Z, Greene MF; Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes Workshop Invited Speakers. Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation. Obstet Gynecol. 2017;130(1):10-28. doi:10.1097/AOG.0000000000002054 

    Sweet MA, Appelbaum MI. Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Dev. 2004;75(5):1435-1456. doi:10.1111/j.1467-8624.2004.00750.x 

    Michalopoulos, Charles, Kristen Faucetta, Anne Warren, and Robert Mitchell. Evidence on the Long-Term Effects of Home Visiting Programs: Laying the Groundwork for Long-Term Follow-Up in the Mother and Infant Home Visiting Program Evaluation (MIHOPE). OPRE Report 2017-73. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 

    Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics. 2008;122(4):e922-e937. doi:10.1542/peds.2007-3762 
    Paradis HA, Sandler M, Manly JT, Valentine L. Building healthy children: evidence-based home visitation integrated with pediatric medical homes. Pediatrics. 2013;132 Suppl 2:S174-S179. doi:10.1542/peds.2013-1021R 

    Patrick SW, Burke JF, Biel TJ, Auger KA, Goyal NK, Cooper WO. Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome. Hosp Pediatr. 2015;5(10):513-519. doi:10.1542/hpeds.2015-0024 

    Van Horn A, Powell W, Wicker A, Mahairas AD, Creel LM, Bush ML. Outpatient healthcare access and utilization for neonatal abstinence syndrome children: A systematic review. J Clin Transl Sci. 2019;4(5):389-397. Published 2019 Aug 29. doi:10.1017/cts.2019.407 

    Stumbras, K., Rankin, K., Caskey, R. et al. Guidelines and Interventions Related to the Postpartum Visit for Low-Risk Postpartum Women in High and Upper Middle Income Countries. Matern Child Health J 20 (Suppl 1), 103–116 (2016). https://doi.org/10.1007/s10995-016-2053-6 

    Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics. 2013;131(3):e1009-e1024. doi:10.1542/peds.2012-3931 

    Smith VC, Wilson CR; COMMITTEE ON SUBSTANCE USE AND PREVENTION. Families Affected by Parental Substance Use. Pediatrics. 2016;138(2):e20161575. doi:10.1542/peds.2016-1575 
    Fill MA, Miller AM, Wilkinson RH, et al. Educational Disabilities Among Children Born With Neonatal Abstinence Syndrome. Pediatrics. 2018;142(3):e20180562. doi:10.1542/peds.2018-0562 
    Lloyd, Margaret H. & Akin, Becci A. & Brook, Jody, 2017. "Parental drug use and permanency for young children in foster care: A competing risks analysis of reunification, guardianship, and adoption," Children and Youth Services Review, Elsevier, vol. 77(C), pages 177-187. 

    National Academies of Sciences, Engineering and Medicine. (2016). Parenting matters: Supporting parents of children ages 0–8. Washington, DC: The National Academies Press. 

    U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. Washington, DC: Author. Retrieved from https://addiction.surgeongeneral.gov/supplementary-materials 

     

  • Team-member Publications and Presentations

    Peer-Reviewed Manuscripts 

    • Bailey, B.A., Chroust, A., Justice, N., & Wood, D. (in press). Utilization and accuracy of various methods to assess opioid use during pregnancy and at delivery: How well are we determining which newborns need to be monitored for the development of neonatal opioid withdrawal syndrome (NOWS)? Journal of Substance Use. 
    • Bailey, B. A., Shah, D. S., Boynewicz, K. L., Justice, N. A., & Wood, D. L. (2022). Impact of in utero opioid exposure on newborn outcomes: beyond neonatal opioid withdrawal syndrome. The Journal of Maternal-Fetal & Neonatal Medicine, 35(25), 9383-9390. 
    • Boggs, T., & Ferguson, N. (2016). A little PEP goes a long way in the treatment of pediatric feeding disorders. Perspectives of the ASHA Special Interest Groups, 1(13), 26-37.
    • Boynewicz, K., Campbell, S., & Chroust, A. (2023). Early identification of atypical motor performance of infants with prenatal opioid exposure. Physical Therapy & Rehabilitation Journal, 35(3), 359-365. DOI: 10.1097/PEP.0000000000001021
    • Gersch, H., Shah, D., Chroust, A., Wood, D., & Bailey, B. (2023). Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome? The Journal of Maternal-Fetal & Neonatal Medicine, 36(1) 221706. DOI: 10.1080/14767058.2023.2211706  
    • Shah, D., Turner, E., Chroust, A., Duvall, K., Wood, D., & Bailey, B. (2022). Marijuana use in opioid-exposed pregnancy increases risk of preterm birth. The Journal of Maternal-Fetal & Neonatal Medicine, 35(2), 8456-8461. https://doi.org/10.1080/14767058.2021.1980532 
    • Isbell, C. (November 2022). Feeding in infants born substance exposed: A sensory-based, family-centered approach. American Occupational Therapy Associations Sensory Integration and Processing Special Section Quarterly. (11-22).
    • Hite, M. K., Chroust, A. J., Proctor-Williams, K., & Lowe, J. L. (2024). Newborn Hearing Screening Results for Infants With Prenatal Opioid Exposure in Southern Appalachia. Journal of Speech Language and Hearing Research, 67(4), 1268-1280. doi:10.1044/2024_JSLHR-23-00492. Epub 2024 Mar 22. PMID: 38517271. 

    Invited Presentations 

    • Chroust, A. (July 14, 2022). Infant Motor and Cognitive Development. Higher Education Workgroup FF22. AIMHiTN, virtual. 
    • Chroust, A. (August 16, 2019). Risk Factors Associated with the Severity of Neonatal Abstinence Syndrome. A Tough Pill to Swallow- Addressing the Epidemic of Prescription Drug Abuse. Kingsport, TN. 
    • Johnson, M., Isbell, C., Boggs, T. (2023).  Nutrition & Feeding Considerations for Infants and Young Children with Prenatal substance exposure. University of Washington- Community Feeding Teams Meeting. May 23, 2023. (Oral presentation, invited).
    • Isbell, C. (November 17, 2023). Building Self-Regulation in Infants and Toddlers: A Sensory Integration Perspective. National Association for the Education of Young Children. Nashville, TN. 


     Presentations in Professional Meetings 

    • Agarawal, D. Shah, D., & Chroust, A. (2022). Postpartum Mental Health in Women with Opioid Use Disorder: Results of Preliminary Data. Southern Society for Pediatric Research. New Orleans, LA, February 10-12, 2022. 
    • Boynewicz, K., Chroust, A., & Campbell, S. (2022). Atypical Early Detection of Atypical Motor Performance of Infants at Risk Secondary to Neonatal Opiate Withdrawal Syndrome. American Physical Therapy Association’s Combined Sections Meeting. San Diego, CA. February 23-25, 2023. (Poster presentation, accepted). 
    • Boynewicz, K., Chroust, A., & Johnson, M. (2022). What do you know about prenatal drug exposure? Motor, cognitive, neurobehavior and the gut-brain connection. Academy of Pediatric Physical Therapy. Portland, OR, Nov 18-20, 2022. (Oral presentation, accepted).  
    • Boynewicz, K., Street, K., Binns, D., Bumett, C., Bankston, M., Patterson, S., & Chroust, A. (2022). Visual Stress Cues and Atypical Eye Movements During a Visual Task in Infants with Prenatal Opioid Exposure. Academy of Pediatric Physical Therapy. Portland, OR, Nov 18-20, 2022. (Poster presentation, accepted).  
    • Chroust, A., Boynewicz, K., Thomas, K., Wahlquist, A., Clark, W.A. (2023). Gut Microbiota in Infants Exposed to Opioids In Utero. Society for Research in Child Development. Salt Lake City, UT. March 23-25, 2023. (Poster presentation, accepted). 
    • Creasman, J. Chroust, A., Boynewicz, K., & Schetzina, K. (2022). Analyzing the Effects of Feeding Type and Prenatal Substance Exposure on Infant Weights. ETSU Annual Pediatric Conference. Johnson City, TN. August 6, 2022. *1st Place poster award
    • Jain, M., Shah, D., & Chroust, A. (2022). Does Integrated Management of Opioid Use Disorder Affect Outcomes of Neonatal Abstinence Syndrome Diagnosis: Results of Preliminary Data. Southern Society for Pediatric Research. New Orleans, LA, February 10-12, 2022.
    • Johnson, M., Chroust, A. Boynewicz, K., Bonner, C., Kromash, J., & (2022). Neonatal Opioid Withdrawal Syndrome and the Impact on Early Growth in Infants. Academy of Nutrition and Dietetics: Food & Nutrition Conference and Expo. Orlando, FL. October 8-11, 2022. (Poster presentation, accepted).
    • Johnson, M., Isbell, C., Boggs, T. (2022).  Prenatal drug exposure: Interprofessional approaches to improving pediatric feeding outcomes.  Academy of Nutrition and Dietetics: Food & Nutrition Conference and Expo. Orlando, FL. October 9, 2022.(Oral presentation, accepted).
    • Johnson, M., Pham, A., Duvall, K., Greenman, M., Price, R., Bishop, K., Bundy, K., Schetzina, K. (2023). Perinatal substance exposure: A retrospective chart review of outcomes in the rural primary care setting.  Academy of Nutrition and Dietetics: Food & Nutrition Conference and Expo. Denver, CO. October 7-10, 2023. (Poster presentation, accepted).
    • Johnson, M., Wahlquist, A., Thomas, K., Clark, A., Boynewicz, K., Chroust, A. (2023). Comparing maternal diet and fecal SCFA profiles of infants with and without prenatal opioid exposure. American Society of Nutrition Conference. Boston, MA. July 22-25, 2023.  (Poster presentation, accepted). 
    • Puhr, D., Pirozzi, E., Tuell, D., Schetzina, K. (2023). Three Years Experience Enhancing the Medical Home for Children with Prenatal Drug Exposure and Their Families with Baby Steps. American Academy of Pediatrics National Conference & Exhibition. Washington, DC. Oct 20-24. (Poster presentation, accepted)
    • Isbell, C. (March 21, 2024). Interprofessional Approach of Feeding in Prenatally Substance-Exposed Infants and Toddlers. American Occupational Therapy Association Annual Inspire Conference 2024. Orlando, FL. 
    • Isbell, C. (April 20, 2023). OT in an Interprofessional Clinic for Young Children Exposed to Drugs in Utero. American Occupational Therapy Association Annual Inspire Conference. Kansas City, MO. 
    • Isbell, C. (March 31, 2022). Promoting Occupations of Prenatally Drug-exposed Infants and Toddlers: A Sensory Integration Approach. American Occupational Therapy Association Annual Inspire Conference 2022. San Antonio, TX. 
  • Feeding Education Materials 0-6 Months

     Nutrition: 

    • 0-6 months is a time where your baby will be growing a lot, so frequent feedings are needed to keep them full and happy. Recommended feeding times are: 
      • Birth-2 months: 2 to 4 ounces every 3 to 4 hours (6-8 times per day) 
      • 2-4 months: 3 to 6 ounces every 4 to 6 hours (4-6 times per day) 
      • 4-6 months: 6 to 8 ounces every 4 to 6 hours (4-6 times per day)
    • If you have concerns about the formula you are using, speak with your pediatrician before switching. 
    • Some spit up is normal. If your baby has a lot of spit up, or seems to be in pain during or after feeding, talk with your pediatrician. 
    • For the first 6 months of life (of until solid foods are introduced) you should only feed your baby breastmilk or formula. Do not give your baby water, cow's milk, or any other beverage. 
    • Until your child turns 1, they should not have honey. 

    How to Know Your Baby is Hungry: 

    • Bringing hands to their mouth. 
    • Turning head towards bottle. 
    • Puckering, smacking, or licking lips. 
    • Opening and closing of the mouth. 
    • Clenching their hands. 
    • Becoming more alert or active. 
    • Sucking on things such as hands or clothes. 

    Signs to Watch for That Your Baby is Stressed When Feeding: 

    • Sudden stiffness in their body. 
    • Nose flaring/brow raising. 
    • Drool or milk escaping from their mouth while eating. 
    • Short and fast breaths that are weak. 
    • Gulping or gurgling sounds coming from their throat. 
    • Coughing/choking. 
    • Uncontrolled sucking on nipple. 
    • A lack of rhythm with your baby's sucking and swallowing when feeding. 
    • Follow your baby's cues. If they stop sucking, the feeder should tilt the bottle to slow the flow of milk. When your baby begins to suck again, tilt the bottle back towards the baby for milk to enter the nipple to allow them to have control of their feeding time. 

    Positioning: 

    • "Kangaroo care" Skin-to-skin contact where parent holds baby against bare skin. This encourages bonding with baby before/after feeding and helps emotional and physical development. 
    • Use blankets, towels, or pillows (U pillow or regular) to prop up the back of your arm during feeding to help keep your arm from getting tired and allow for a more secure hold of baby. 
    • Holding your baby semi-upright during feeding can help. It allows for better swallowing and breathing. 
    • Holding your baby upright for 20-30 minutes after feeding may help reduce the large spit ups. 
    • Do not prop the bottle for feeding. 

    Tips to Support Your Baby's Feeding: 

    • Give breaks when you notice your baby seems tired or stops sucking. 
    • Do not twist the nipple in and out of the mouth to increase flow. 
    • Feed the baby on a consistent schedule. See nutrition section.

    How to Know Your Baby is Done Eating: 

    • You should feed on your baby's cues. 
    • If your baby is showing signs of discomfort, then they are done eating. 

    Helpful Tips: 

    • Keep lights dim and the room quiet. 
    • Try to limit quick or startling movements to keep your baby comfortable. 
    • Use pacifier before feedings. (This may also assist in readiness for bottle feedings.) 
    • Slow rocking at 1 rock per second while feeding. 
    • Be comfortable while feeding. 
    • Limit phone and technology use during feeding. 
    • If your baby is sleepy during feeding, gently use a cool washcloth to wake them. 
  • Feeding Education Materials 6-12 Months

     Nutrition: 

    • Continue breastmilk or formula until 12 months of age to support growth and development 
      • Babies 6-12 months of age should have 28-32 ounces of breastmilk or formula per day. 
    • Start one solid food at a time. Give each new food for 3-4 days. If baby gets a rash, vomiting, or wheezing, stop that food and see a doctor. 
    • Introduce a variety of foods including meats, cereal, veggies, fruit, yogurt, eggs, and fish. 
    • It is important to add iron and zinc rich foods after your baby is 6 months, especially if you are breastfeeding. 
      • These include iron fortified infant cereals (oatmeal/rice) and meats. 
    • Suggest trying veggies next, then fruits. 
    • Remember your baby's tummy is still growing, so give small amounts of food at each feed. 
    • Avoid juice for the first year. Use juice only if baby is constipated. If constipated, then a small amount of prune, pear, or apple may help. 
    • No cow's milk or honey the first year. 

    How to Know Your Baby is Ready for Solid Foods: 

    • Your baby is interested in watching you or others eat. 
    • Your baby is able to sit up, grab, gesture, and want to touch other foods that are not their milk. 

    How to Start Solid Food: 

    • Start with a soft or thin mashed food like a stage 1-baby food or cereal. 
    • Place the food in front of them on the spoon or on their high chair tray and let them explore this new food or texture. 
    • Let your baby get messy and explore or eat their food with their hands. 
    • Sit with your baby at mealtime. Your baby learns how to eat by watching you. 
    • Once your baby is easily eating thin and mashed foods, you may give thicker foods or small pieces of soft or meltable foods they can pick up and feed themselves. 
    • Do not force any foods or react negatively! Show encouragement and be positive. Follow your baby's cues when they are ready to begin and stop eating. 

    Where to Feed: 

    • High Chair Feeding: 
      • If you notice your baby seems to lean or cannot sit on the floor without falling over, they may need more support in their high chair! 
      • Try putting a rolled up towel behind the baby's back or on either side of the baby for support. 
    • Adult's Lap: 
      • Sit the baby on an adult's lap. 
      • Position baby's back snuggly against your body. 
      • Always keep one arm around their waist. 
    • Other Tips: 
      • Prop/sit baby up for at least 30 minutes after they are finished eating to help prevent spitting up. 
      • Sit directly in front of your child when feeding them. 
      • Try to avoid feeding in areas that have a lot of noise and distractions like the TV. 

    Exploring New Foods: 

    • Let your child touch and explore their foods before trying them. 
    • Playing with food will allow your child to learn about different foods. 
    • Your child may need to see a new food 10-20 times before wanting to eat it. 

    Helpful Tips: 

    • Eating with your child during meal time can help them learn routines and strengthen their independence. 
    • Talk with your baby and limit distractions from your phones and screens.
    • Be patient and do not force feed your baby if uncomfortable. 
    • A little gagging can be a normal response to new foods. Do not react negatively. 
    • Praise what your child can do! 
    • Have fun and enjoy mealtimes together.