Innovative Approaches to Treating Neonatal Abstinence Syndrome

July 31, 2018 | ASTHO Staff

The incidence of neonatal abstinence syndrome (NAS) has increased dramatically over the past decade, placing a significant burden on the healthcare system in terms of the costs associated with extended hospital stays required to care for these newborns. In 2012, annual costs related to NAS admissions in the United States totaled $316 million. Many types of drugs or substances contribute to the severity of an infant’s withdrawal symptoms, but in-utero exposure to opioids is often considered the primary cause of NAS, also referred to as neonatal opioid withdrawal symptom (NOWS). Providing active neonatal care through nonpharmacologic interventions allows for parental bonding, promotes consistent breastfeeding, and results in improved outcomes, such as decreased length of stay, and reduced hospital costs.

To learn more about successful approaches to identifying and treating NAS, ASTHO spoke to Bonny Whalen, MD, newborn pediatrician and newborn nursery medical director at the Children’s Hospital at Dartmouth-Hitchcock (CHaD). Whalen also leads the Northern New England Perinatal Quality Improvement Network (NNEPQIN) regional collaborative on improving care for newborns with in-utero opioid exposure and participates in ASTHO’s multistate breastfeeding learning community.

From 2012-2014, Whalen and the CHaD team implemented a unique model of caring for infants at risk for NAS or NOWS, focusing on educating and empowering mothers and other caregivers to be more involved in managing their babies’ withdrawal symptoms. By improving family-centered care, the model aims to decrease the need for pharmacologic therapy and, ultimately, both the length of stay and hospital costs. The approach involves standardizing protocols for prescribing medications, scoring, and weaning, and providing a comfortable rooming-in environment. The model also encourages breastfeeding when medically appropriate, feeding when infant is hungry, and providing skin-to-skin contact during feeding and assessments.

Prenatal family education, family involvement in monitoring symptoms, decreased use of neonatal intensive care unit beds, and nonpharmacologic treatment resulted in several promising outcomes. The average length of stay for newborns treated with medications decreased from 17 days to 12, for example, and the model helped drive down the hospital’s costs by more than $10,000 per infant. “This model of care has positively impacted maternal attachment and bonding with babies, and has decreased parental and infant stress,” says Whalen.

In an effort to scale and spread these improvements throughout other hospitals, Whalen helped start a regional learning collaborative in 2015 focused on opportunities for quality improvement and improving care for opioid-exposed newborns. Fortunately, NNEPQIN had already laid the groundwork for this collaborative, which includes regional conferences, monthly webinars, peer strategy sessions, and quarterly trainings on a novel function-based, baby-centered assessment and care method.

NNEPQIN and CHaD also partnered with the New Hampshire Department of Health and Human Services (DHHS) and the department’s division for children, youth, and families (DCYF) on several activities to improve care for infants at risk for NAS, including:

• Serving on and advising the governor’s prenatal substance exposure task force on issues related to opioid-and substance-exposed newborns.
• Collecting and sharing data with DHHS on the number of opioid-exposed newborns and infants assessed for NAS.
• Developing a model template (“Plan of Safe Care”) for perinatal providers to help ensure infants are discharged from the hospital to safe home environments.
• Proposing a draft state notification system for all substance-exposed infants, as well as for those requiring a referral to DCYF to develop a safe discharge plan.
• Piloting a comprehensive newborn screening card to help hospital staff accurately identify all infants exposed to opioids in utero.
• Encouraging mother-child bonding during the hospital stay when possible.

Faculty at CHaD, the Yale New Haven Children’s Hospital, and the Boston Medical Center also developed a new method for assessing infants with NAS based on the infant’s ability to eat, sleep, and be consoled (ESC). This new assessment tool is being considered as an alternative to the widely-used Finnegan Neonatal Abstinence Scoring System and may significantly reduce pharmacologic treatment and length of stay among infants with NAS. Whalen and her colleagues are currently studying the efficacy and safety of the tool through a formal quality improvement project at CHaD and in partnership with other hospitals in Maine, Massachusetts, New Hampshire, and Vermont, Maine, and Massachusetts hospitals. Preliminary data involving 50 infants shows that only 12 percent of infants started morphine treatment under the new ESC assessment method. By contrast, if the traditional Finnegan score had been used, 62 percent of those infants would have received pharmacologic treatment based on the criteria. This alternative model also helped decrease the length of stay from 22.5 to 5.9 days without readmissions or other adverse events.

While these partnerships provide enhanced capacity and flexibility to implement innovative care approaches for NAS, Whalen noted that receiving financial support and additional resources from the state health agency, managed care organizations, and charitable foundations will help drive the work and mission even further.

“Awareness, champions at the individual hospital level, coordinated care, and safe transitions to home are vital to treating and preventing NAS,” emphasizes Whalen. “Encouraging collaboration between obstetricians, addiction treatment counselors, neonatal providers—including pediatricians—and neonatologists, social workers, nurses, and lactation consultants to provide care for women and infants with perinatal opioid exposure can be very helpful in making rapid and effective changes to reduce the incidence of NAS.”

Whalen offered additional suggestions to promote non-traditional, innovative approaches to treating NAS. She and her colleague, nurse midwife Daisy Goodman, co-developed a toolkit with resources for obstetricians and addiction treatment providers on how to improve care for both mothers who have substance use disorders and for their infants and families. They are also in the process of creating additional educational materials and informational videos on NAS, including guidance on how to care for newborns’ withdrawal symptoms in the hospital and at home.