Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis

Neonatal Opioid Withdrawal Syndrome Treatment Guidelines and Birth Hospital Utilization

BACKGROUND AND OBJECTIVES

In November 2020, the American Academy of Pediatrics published guidelines for management of neonatal opioid withdrawal syndrome (NOWS), recommending nonpharmacologic treatment as the first-line approach, unless pharmacologic treatment is needed for severe NOWS. Using data from tertiary care pediatric hospitals, we examined the impact of the guidelines on use of pharmacotherapy, length of stay, and NICU admission for infants with NOWS.

METHODS

We extracted birth hospitalization data for newborns diagnosed with NOWS discharged from 2019 to 2022 from the Pediatric Health Information System. We compared hospital utilization and pharmacologic treatment pre- and postguidelines and used interrupted time series regression to examine trends over time.

RESULTS

We included N = 824 newborns (n = 434 pre, n = 390 post) with NOWS from 11 hospitals. The use of pharmacologic treatment was significantly lower in the postguidelines period (59.0% pre versus 50.3% post; P = .01). Median length of stay was similar pre and post (P = .55). NICU admission was significantly lower in the postguidelines period (78.6% pre versus 46.7% post; P < .001), with an immediate decrease (β = -23.0%; P < .001) and a decrease over time in the postguidelines period (β = -0.7% per month; P = .03). Most hospitals reduced pharmacologic treatment (8 of 11; 73%) and NICU use (10 of 11; 91%) postguidelines.

CONCLUSIONS

There was a reduction in the use of pharmacologic treatment and NICU utilization for infants with NOWS after the release of American Academy of Pediatrics guidelines for NOWS management.

Opioid Medical Detoxification Compared to Opioid Agonist Treatment during Pregnancy: A Scoping Review

Opioid use disorder (OUD) is highly prevalent, affecting up to 1% of pregnancies. The current standard of care for the management of OUD during pregnancy has been maintained with opioid agonist treatment (OAT), using either methadone or buprenorphine. OAT use has been associated with a risk of neonatal abstinence syndrome (NAS), which requires a longer neonatal length of stay for monitoring and possible pharmacological treatment. As a result, opioid medical detoxification (OMD) was proposed as an alternative strategy to reduce the stigma associated with OAT and to eliminate the risk of NAS by detoxifying or tapering pregnant persons during their pregnancy before delivery; however, the safety and effectiveness of OMD during pregnancy have not been established. This scoping review aims to summarize recent evidence related to maternal, obstetrical, and neonatal outcomes of OMD in comparison to OAT maintenance. This review also provides recommendations for future research initiatives to fill gaps in managing this patient population.

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal: A Post Hoc Subgroup Analysis of the ESC-NOW Randomized Clinical Trial

Importance

The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown.

Objective

To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool.

Design, Setting, and Participants

This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024.

Exposure

Opioid treatment for NOWS and the ESC care approach.

Main Outcomes and Measures

For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics.

Results

In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001).

Conclusion and Relevance

When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later.

Trial Registration

ClinicalTrials.gov Identifier: NCT04057820.

Implementation of a Nurse-Driven Eat-Sleep-Console (ESC) Treatment Pathway at a Community Hospital for Treatment of Neonatal Opioid Withdrawal Syndrome in an Effort to Improve Short-term Outcomes

BACKGROUND

The Chandler Regional Medical Center (CRMC) neonatal intensive care unit (NICU) began a phased implementation of Eat-Sleep-Console (ESC) for the management of those at risk for neonatal opioid withdrawal syndrome (NOWS).

PURPOSE

The purpose of this initiative is to track short-term outcomes as well as the program's effect on nursing workflow and job performance rating/satisfaction.

METHODS

A retrospective review of the ESC implementation process at CRMC from the years 2018-2020. The study consisted of 3 epochs: (1) traditional pharmacologic management; (2) parent-led ESC management; and (3) parent/nurse-led ESC management. Length of stay (LOS), treatment pathway assignment, and proportion of infants treated with pharmacologic agents were compared between epochs. In addition, a survey of NICU nursing staff was distributed to measure nurses' perceptions and attitudes towards the ESC program and the management of infants with NOWS.

RESULTS

The proportion of infants treated via ESC increased (0%, 53%, and 100%), with an associated decrease in LOS (18.4, 10.5, and 9.3 days) during each epoch of the study period. Thirty-seven nurses completed the survey, with 94% of nurses reporting being comfortable caring for ESC patients and 89% feeling supported in their ESC nursing assignments, with only 11% stating that caring for ESC patients significantly alters their other nursing care processes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementation of an ESC treatment program for infants with NOWS significantly decreased LOS and the proportion of infants treated pharmacologically. This phased implementation process was not associated with self-reported negative nursing perceptions of the program and its treatment goals/outcomes.

Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome: An Ecological View of Non-Pharmacologic Interventions for Feeding Success

The number of infants diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) has increased. The expression of NAS/NOWS symptoms differs and typically begins within the first few days of life, considered a critical period for feeding skill establishment, nourishment, and attachment. Non-pharmacologic interventions may be deployed to reduce or eliminate the need for replacement opioids while targeting outcomes like feeding dysfunction. Critical care providers can benefit from a structured examination of disordered feeding experiences to inform their selection of non-pharmacologic interventions. This structure can be provided using the Ecology of Human Performance model.

Managing the Mother-Baby Dyad Affected by Substance Disorder: A Statewide Quality Collaborative Initiative

Neonatal abstinence syndrome (NAS)/Neonatal opioid withdrawal syndrome (NOWS) and substance abuse disorder (SUD) rates are undeniably linked with the outcomes of mothers and babies. This essential relationship emphasizes the importance of quality improvement work done jointly, treating mother and infant as a dyad, not as separate entities. In 2020 the Missouri Hospital Association (MHA) partnered with Show-Me ECHO, a state-funded telehealth project, to initiate a state-wide quality improvement (QI) project to improve and standardize care delivery to the mother-baby dyad affected by SUD. Fourteen hospitals participated across the state of Missouri from January 2021 through December 2022. Through the ECHO model and technical implementation support, 100% of collaborative participating birth centers implemented a non-pharmacologic policy for the care of the substance-exposed newborn. In addition, maternal SUD screening increased by 67.3% (57.5% to 96.2%), infant transfer rates were reduced by 24%, and safe care discharge plans increased by 37% for infants and 144% for mothers. Further, the collaboration between MHA and the Show-Me ECHO demonstrates the feasibility of cross-sector efforts to create synergy to improve and standardize the care of the mother-infant dyad affected by SUD.

ArtSpective™ for Perinatal Substance Use: Feasibility of an Arts-Based Intervention Addressing Stigma

OBJECTIVE

The purpose of this proof-of-concept pilot study was to test the initial feasibility and limited efficacy of ArtSpective™ for perinatal substance use (PSU), a novel, arts-based intervention designed to decrease stigmatizing attitudes toward PSU.

METHODS

Using a pre-post mixed methods quasi-experimental design, ArtSpective™ for PSU was pilot tested for proof of concept among a convenience sample of 11 undergraduate and graduate students with experience in maternal-infant nursing from a Midwestern U.S. nursing school. As a proof-of-concept pilot study, we evaluated feasibility (acceptability, demand, and implementation) and limited efficacy. Participants completed presurveys and postsurveys that included satisfaction items, demographic items, and an adapted version of the Attitudes About Drug Use in Pregnancy Scale and participated in a focus group. Focus group data were analyzed using constant comparative methods, and survey data were analyzed using descriptive statistics and Wilcoxon signed rank tests.

RESULTS

Participants reported high demand and satisfaction with the intervention and provided recommendations to improve scalability. ArtSpective™ demonstrated significant improvement in stigma toward PSU (pre vs. post: p = .003; d = .633).

CONCLUSION

ArtSpective™ for PSU demonstrated initial feasibility and limited efficacy for improving nurse attitudes toward PSU. Efforts are needed to further test this novel intervention, adapt it to augment existing educational interventions, and improve its scalability.

Evaluating the Impact of Eat, Sleep, Console in Neonatal Abstinence Syndrome Treatment for Infants Exposed to Substance Use In Utero

OBJECTIVE

An increase in maternal use of licit or illicit substances, alcohol, and tobacco has resulted in an increased incidence of neonatal abstinence syndrome (NAS). In recent years, NAS management has shifted to initiating an Eat, Sleep, Console (ESC) approach prior to pharmacologic treatment. The objective of this study was to evaluate the impact of ESC in combination with pharmacologic treatment in the management of NAS for infants exposed to substance use in utero.

METHODS

This single system, multisite, retrospective cohort study evaluated infants with known exposure to substance or polysubstance use in utero or those who had signs and symptoms of withdrawal with a positive toxicology screen. The primary outcome of rate of pharmacologic therapy initiated was evaluated pre and post implementation of ESC. Secondary outcomes included hospital length of stay, day of life that pharmacologic therapy was initiated, and an evaluation of the ESC guideline. A subgroup analysis with similar outcomes was also performed for patients with maternal polysubstance use.

RESULTS

A total of 2843 patients were screened, and 50 patients were randomly selected for -inclusion in both pre- and post-groups. The rate of pharmacologic therapy initiated post implementation of ESC decreased from 58% to 30% (p < 0.01). In the post-group, there was a decrease in the number of -patients requiring scheduled morphine (33%, p < 0.01) and duration of pharmacologic therapy (14.6 days vs 6.47 days, p < 0.01).

CONCLUSIONS

Implementing an ESC guideline decreased the length of stay and rate of pharmacologic intervention needed for infants with NAS at our institution.

Growing together: Optimization of care through quality improvement for the mother/infant dyad affected by perinatal opioid use

The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.

Strategies to improve delivery of equitable and evidence-informed care for pregnant and birthing people with a substance use disorder in acute care settings: A scoping review protocol

This protocol outlines a proposed scoping review to characterize evidence on implementation and quality improvement (QI) strategies that aim to improve equitable, evidence-informed care delivery for pregnant and birthing people with substance use disorder (SUD) in acute care. Untreated SUD during pregnancy is associated with an increased risk of overdose and severe maternal morbidity. Acute care settings are one important place to deliver equitable, evidence-informed clinical care. While clinical practice guidelines for substance use treatment and care of pregnant and birthing people with SUD exist, there are gaps in implementation. Our population of interest is pregnant and birthing people with SUD in an acute care setting. We will include US-based studies that describe or evaluate implementation or QI strategies, including experimental, observational, and descriptive studies published from 2016 to 2023. The proposed scoping review will be conducted in accordance with JBI methodology for scoping reviews and registered at OSF (registration number: BC4VZ). We will search MEDLINE (PubMed), CINAHL Complete (EBSCO), Scopus (Elsevier), and APA PsychInfo (Ovid) for published studies. Conference proceedings and Perinatal Quality Collaborative websites will be searched for grey literature. Two reviewers will independently screen then extract studies that meet inclusion criteria using a data extraction tool. The completion of this scoping review will help illuminate strengths and gaps in research and practice that aim to inform substance use treatment and care in acute care settings for pregnant and birthing people with SUD.

Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity

Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

Regional tissue oxygenation in asymptomatic neonates at high risk for neonatal abstinence syndrome and impact of non-pharmacologic interventions: A case report

BACKGROUND

Improving neonatal abstinence syndrome (NAS) management is an important concern, and objective measures of its physiologic impact remain elusive. We sought to determine whether near-infrared spectroscopy (NIRS)-derived tissue oxygenation (rSO2) and fractional tissue oxygen extraction (FTOE) demonstrated physiologically plausible changes correlating with standard NAS scoring.

METHODS

Thirty subjects (mean 39 weeks' GA and 3 127 g BW) underwent cerebral and peripheral muscle NIRS monitoring on Days of Life (DOL) Three, Five, and Seven. We examined correlations between NAS scores and FTOE and assessed the impact of non-pharmacologic swaddling and cuddling.

RESULTS

No statistically significant correlations between NAS scores and FTOE were observed; however, plausible trends were demonstrated between NAS scores and cerebral measurements. Buprenorphine-exposed babies (57%) showed significantly lower FTOE when swaddled (DOL7).

CONCLUSIONS

Tissue oxygenation monitoring demonstrates potential to provide objective, clinically relevant physiologic information on infants at risk for NAS. Further study is required to determine whether NIRS-derived measures could assist in individualizing NAS care.

Prevalence and Predictors of Early Intervention Referral Among Substance-Exposed Newborns

OBJECTIVES

Substance-exposed newborns (SENs) are at risk for developmental delay(s). Early intervention (EI) access, key to addressing these risks, is inequitable. Objectives were to: 1. determine prevalence of EI referral in the Colorado Hospitals Substance-Exposed Newborn Quality Improvement Collaborative; and 2. evaluate predictors of referral.

METHODS

Within participating Colorado Hospitals Substance-Exposed Newborn hospitals, maternal-infant dyads with exposure to medications for opioid use disorder (MOUD), illicit/prescription opioids, and/or nonopioid substances were included on the basis of electronic medical record documentation. χ2, Fisher's exact, and analysis of variance tests evaluated differences in maternal/infant characteristics by referral. Multivariable Poisson regression models assessed the independent association of characteristics with referral.

RESULTS

Among 1222 dyads, 504 (41%) SENs received EI referral. Infants born to mothers with non-MOUD (adjusted risk ratio [aRR] 2.15, 95% confidence interval [CI] 1.67-2.76) and polysubstance (aRR 1.58, 95% CI 1.26-1.97) exposure were less likely to receive referral compared with infants born to mothers with MOUD exposure. Those with private (aRR 1.26, 95% CI 1.03-1.55) or self-pay/no insurance (aRR 12.32, 95% CI 10.87-13.96) were less likely to receive referral compared with infants with public insurance.

CONCLUSIONS

Less than half of identified SENs received EI referral, with variation by substance exposure and maternal insurance status. Systems to ensure equitable access to services are crucial.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

A mini review of what matters in the management of NAS, is ESC the best care?

As the use of opioids and polysubstance by pregnant women has increased over the years, there has also been a sharp increase in cases of neonatal abstinence syndrome (NAS). Classically, infants affected by NAS have been cared for in neonatal intensive care units resulting in an increase of healthcare expenditure and resource utilization as well as separation from the families. Consequently, the Eat, Sleep, and Console (ESC) tool was developed and promoted as a novel method that focuses on maternal/infant dyad during hospital stay while decreasing the use of pharmacological interventions and therefore decreasing the length of stay and healthcare expenditure. Thus, it has been implemented in several hospitals in the United States. Although the training of staff has been proposed and the interventions of sleep, eat, and console are defined, there still exists a lack of standardization of this practice specifically in regard to the type of associated non-pharmacological practices as well as the reports of its short- and long-term outcomes.

Assessing the Eat, Sleep, Console model for neonatal abstinence syndrome management at a regional referral center

OBJECTIVE

We assessed the efficacy of the Eat, Sleep, Console (ESC) model for neonatal abstinence syndrome at a regional referral center by examining non-pharmacological treatments, parental presence, length of stay (LOS), and pharmacological therapy.

STUDY DESIGN

We retrospectively reviewed medical records from 2018 to 2020 to compare neonatal outcomes between the 12 months prior to 12 months post ESC implementation.

RESULT

A total of 71 neonates pre-ESC and 64 neonates post-ESC implementation were included. There were no statistical differences between pre-ESC vs. ESC periods for pharmacological therapy (34% vs. 27%, p = 0.36) or LOS (median: 5.0 vs. 5.5 days, p = 0.54). During the ESC period, 41% of examined 4-h periods had no parent/caregiver presence. Decreased parental presence associated with pharmacological treatment (p < 0.001).

CONCLUSION

At our hospital which serves a geographically dispersed patient population, ESC model implementation did not decrease pharmacological therapy rates or LOS. Parental/caregiver presence may be a factor in the ESC model producing maximal benefits.

Implementation of ESC QI Initiative in Neonatal Unit Setting and Adaptation During the Pandemic

OBJECTIVES

To improve outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) admitted to NICU by implementing a quality improvement (QI) initiative incorporating "eat, sleep, console" (ESC) as a withdrawal evaluation tool and promotion of nonpharmacological interventions. Secondarily, we evaluated the impact of the coronavirus disease 2019 pandemic on QI initiative and outcomes.

METHODS

We included infants born ≥ 36 weeks gestation and admitted to NICU with a primary diagnosis of NOWS between December 2017 and February 2021. (preintervention; December 2017-January 2019, postintervention; February 2019-February 2021). We compared cumulative dose, duration of opioid treatment, and length of stay (LOS) as our primary outcomes.

RESULTS

The average duration of opioid treatment decreased from 18.6 days in the preimplementation cohort (n = 36) to 1.5 days in the first-year postimplementation (n = 44) with a reduction in cumulative opioid dose from 5.8 mg/kg to 0.6 mg/kg and decrease in the proportion of infants treated with opioids from 94.2% to 41.1%. Similarly, the average LOS decreased from 26.6 to 7.6 days. In the second-year postimplementation during the coronavirus disease 2019 pandemic (n = 24), there was an increase in average opioid treatment duration and LOS to 5.1 and 12.3 days respectively, but cumulative opioid dose (0.8 mg/kg) remained significantly lower than the preimplementation cohort.

CONCLUSIONS

ESC-based quality improvement initiative led to a significant decrease in LOS and opioid pharmacotherapy in infants with NOWS in NICU setting. Despite the impact of the pandemic, some of the gains were sustained with adaptation to ESC QI initiative.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention

BACKGROUND

Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes.

METHODS

A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation.

DISCUSSION

The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT0522662. Registered February 4^th, 2022.

A Prolonged Treatment Associated With Absent Septum Pellucidum in Neonatal Abstinence Syndrome: A Case Report

Neonatal abstinence syndrome (NAS) involves a widely variable treatment course among affected individuals. Prognostic indicators that would help predict length of hospital stay and individualize treatment would be valuable to newborns, parents, and hospital staff, including advanced practice registered nurses. We describe a newborn with a prolonged NAS treatment course necessitating high doses of opioids and phenobarbital, found to have an isolated absent septum pellucidum (ASP). We hypothesize a mechanism for an association between an ASP and a difficult NAS treatment course. Should this be substantiated by other cases, it could provide a valuable prognosticator and indicate alternate treatment pathways.

Potential problems and solutions of opioid-based treatment in neonatal opioid withdrawal syndrome (NOWS): a scoping review protocol

INTRODUCTION

Rates of neonatal opioid withdrawal syndrome (NOWS) have paralleled the rise of opioid use during pregnancy. While short-term phenotypic symptoms of NOWS are well defined, molecular implications and long-term effects are not well understood. Preferred and first-line of treatment for NOWS includes non-pharmacological interventions; however, more than half of the NOWS neonates will need pharmacologics, with opioids as the primary pharmacological treatment. While effective at reducing symptoms, treating NOWS with opioids is paradoxical given that molecular and long-term developmental consequences with such exposure are unknown. There is a pressing need for a synthesis of current and potential/ novel treatment options for NOWS.

METHODS AND ANALYSIS

Following a published framework, a scoping review will be conducted to evaluate NOWS treatment, including established treatment methods and novel methods that may warrant future research and consideration. Using broad search terms, as well as Medical Subject Headings terms, a comprehensive search of PubMed, Cochrane Library, Google Scholar, CINAHL, Web of Science and Scopus, as well as references of selected literature, will take place, followed by a screening procedure to identify included and excluded articles. Included studies must address NOWS treatment, or opioid withdrawal treatment of any age group, that may or may not have been tested in preclinical or clinical models. Results will summarise the current pharmacological and non-pharmacological treatment methods for NOWS, as well as potential novel treatments with a specific interest in non-opioid pharmacological interventions.

ETHICS AND DISSEMINATION

This scoping review aims to broadly search preclinical and clinical literature as it relates to treatment of NOWS, including potential novel treatments with a specific interest in non-opioid pharmacological interventions. Given that this study does not directly involve human subjects or animal subjects research, Institutional Review Board (IRB) or Institutional Animal Care and Use Committee (IACUC) approval is not required. Results of this scoping review will be disseminated at conferences and submitted for publication in a peer-reviewed journal.

Safety and Efficacy of Buprenorphine-Naloxone in Pregnancy: A Systematic Review of the Literature

The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.

Future Newborns with Opioid-Induced Neonatal Abstinence Syndrome (NAS) Could Be Assessed with the Genetic Addiction Risk Severity (GARS) Test and Potentially Treated Using Precision Amino-Acid Enkephalinase Inhibition Therapy (KB220) as a Frontline Modality Instead of Potent Opioids

In this nonsystematic review and opinion, including articles primarily selected from PubMed, we examine the pharmacological and nonpharmacological treatments of neonatal abstinence syndrome (NAS) in order to craft a reasonable opinion to help forge a paradigm shift in the treatment and prevention of primarily opioid-induced NAS. Newborns of individuals who use illicit and licit substances during pregnancy are at risk for withdrawal, also known as NAS. In the US, the reported prevalence of NAS has increased from 4.0 per 1000 hospital births in 2010 to 7.3 per 1000 hospital births in 2017, which is an 82% increase. The management of NAS is varied and involves a combination of nonpharmacologic and pharmacologic therapy. The preferred first-line pharmacological treatment for NAS is opioid therapy, specifically morphine, and the goal is the short-term improvement in NAS symptomatology. Nonpharmacological therapies are individualized and typically focus on general care measures, the newborn-parent/caregiver relationship, the environment, and feeding. When used appropriately, nonpharmacologic therapies can help newborns with NAS avoid or reduce the amount of pharmacologic therapy required and the length of hospitalization. In addition, genetic polymorphisms of the catechol-o-methyltransferase (COMT) and mu-opioid receptor (OPRM1) genes appear to affect the length of stay and the need for pharmacotherapy in newborns with prenatal opioid exposure. Therefore, based on this extensive literature and additional research, this team of coauthors suggests that, in the future, in addition to the current nonpharmacological therapies, patients with opioid-induced NAS should undergo genetic assessment (i.e., the genetic addiction risk severity (GARS) test), which can subsequently be used to guide DNA-directed precision amino-acid enkephalinase inhibition (KB220) therapy as a frontline modality instead of potent opioids.

Quality Improvement Targeting Non-pharmacologic Care and As-needed Morphine Improves Outcomes in Neonatal Abstinence Syndrome

Despite the rising incidence of neonatal abstinence syndrome (NAS), there remains wide practice variation in its management. Many recent studies have focused on implementing new symptom scoring systems, typically as part of larger improvement interventions. Despite the continued use of the Finnegan Scoring System, we performed a quality improvement project to reduce the day of life at discharge and cumulative opioid exposure for newborns with NAS.

METHODS

We developed a protocol for NAS treatment emphasizing early transfer to general pediatric units, maximization of non-pharmacologic care, and use of as-needed morphine whenever pharmacologic treatment is required. Outcome metrics were the day of life at discharge and cumulative morphine exposure. As a process measure, we also monitored the day of life at transfer to general pediatric units. In addition, we utilized statistical process control charts to track changes in performance.

RESULTS

Twenty-eight patients met the inclusion criteria for analysis over 24 months following project initiation. Day of life at discharge decreased by 61% (20.0 versus 7.89 days, P < 0.001), and cumulative morphine exposure decreased by 81% (13.66 versus 2.57 mg morphine, P ≤ 0.001). Day of life at transfer to general pediatric units decreased by 49% (11.13 versus 5.7 days, P = 0.002). There were no readmissions or other identified adverse events.

CONCLUSIONS

We achieved significant improvements in NAS outcomes using improved non-pharmacologic care and as-needed morphine. Moreover, the improvement did not require transitioning to a new scoring system. These results support the efficacy and safety of as-needed morphine for NAS management.

Using the Eat Sleep Console Model to Promote Optimal Care and Outcomes for Infants With Neonatal Abstinence Syndrome: A Nurse-Driven, Multidisciplinary Initiative

BACKGROUND

A nurse led a team of providers in a quality improvement (QI) project to positively impact inpatient care and outcomes for infants with neonatal abstinence syndrome (NAS). The Eat Sleep Console (ESC) model was implemented to promote rooming-in and family-centered care as part of a nonpharmacological treatment approach.

PURPOSE

To compare the ESC model with the traditional Finnegan treatment approach to describe differences in infants' pharmacotherapy use (morphine), length of stay (LOS), weight loss, consumption of mother's own milk by any feeding method within 24 hours of discharge, Neonatal Intensive Care Unit (NICU) use, and Pediatric Unit utilization.

METHODS

The QI project was conducted at a single hospital site with more than 1700 deliveries per year in the Midwestern United States. A comparative effectiveness study design was used to evaluate the ESC model.

RESULTS

The ESC model impacted care and outcomes for infants with NAS, contributing to a significant reduction in morphine treatment, decrease in LOS among morphine-treated infants, increase in weight loss in infants who did not require morphine treatment, less NICU use, and greater Pediatric Unit utilization. A nonsignificant increase was found in the number of infants who consumed their mother's own milk by any feeding method in the 24-hour period prior to discharge.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Results may be helpful for hospitals striving to optimize care for infants exposed to opioids, using assessments of eating, sleeping, and consoling to guide individualized treatment decisions and to reduce morphine use.

Exploring Perinatal Nursing Care for Opioid Use Disorder: Knowledge, Stigma, and Compassion

The opioid epidemic has greatly increased the number of pregnant women with opioid use and newborns exposed to opioids in utero. Mothers with opioid use disorder can face stigma by nurses in perinatal care settings, contributing to negative care experiences. A survey was distributed to nurses caring for mothers and newborns exposed to opioids in a large urban hospital in the Pacific Northwest United States (n = 89) from March to July 2019. Survey measures included participant characteristics, attitude toward substance use in pregnancy and postpartum (stigma, compassion satisfaction, comfort, and knowledge), and open-ended questions. Relationships among variables and questionnaire items were examined using Pearson's correlations, 2-sample t tests, and simultaneous multiple linear regression. Qualitative description was used to analyze open-ended questions. Nurses' stigma was negatively correlated with compassion satisfaction (r = -0.63), feeling knowledgeable (r = -0.36), and comfortable in providing care to this population (r = -0.44). Nurses identified defensiveness, lack of trust, and inadequate social support as key challenges in this patient population. Nurses suggested more support for mothers and nurses, increased nursing education, and clinical guidelines to improve clinical practice and foster therapeutic relationships. Findings highlight potential strategies to improve nursing care for chemically dependent mothers and their infants. These strategies may offer practical approaches to reduce stigma, develop therapeutic relationships, and improve patient outcomes.

Supporting perinatal individuals with opioid use disorder and their newborns experiencing neonatal abstinence syndrome: impressions from patients and healthcare providers

Background: Facilitating maternal-newborn involvement and care is critical for improving outcomes for perinatal individuals receiving opioid agonist therapy (OAT) and newborns experiencing Neonatal Abstinence Syndrome (NAS). Comprehensive education strategies are needed to prepare pregnant individuals receiving OAT for navigating the perinatal period.Objectives: Identify facilitators to successful care of perinatal individuals receiving OAT and newborns experiencing NAS via interviews with perinatal individuals and healthcare providers. The goal of identifying this information is to inform a future educational tool development.Methods: Ten perinatal individuals receiving OAT and ten healthcare providers participated in interviews conducted via phone or video conference using semi-structured, open-ended questions. Data were analyzed separately for the two groups and later merged across samples using a qualitative descriptive content analysis approach to identify themes.Results: Under the overarching theme of empowerment to improve outcomes for perinatal women, four themes arose from perinatal and provider interviews: 1) Preparation for Child Protective Services (CPS) involvement, 2) Healthcare providers shape experience through stigma and support 3) Caring for newborns with NAS, and 4) Managing health and resources during postpartum.Conclusion: Perinatal participants emphasized the importance of self-advocacy while navigating healthcare and social systems. Providers highlighted the importance of communicating expectations to empower patients. Education is needed for pregnant individuals receiving OAT on what to expect during pregnancy and postpartum, as well as for providers to help them optimally support their perinatal patients receiving OAT.

Redefining Child Protection: Addressing the Harms of Structural Racism and Punitive Approaches for Birthing People, Dyads, and Families Affected by Substance Use

There has been growing attention on the effect of substance use, including opioid use disorder, on pregnant and birthing people and their infants. Although effective medication treatment for opioid use disorder is the standard of care, racial disparities are evident in access during pregnancy. Structural racism affects treatment access and approaches to reporting to child welfare services. Black people and their newborns are more likely to be drug tested in medical settings, and Black newborns are more likely to be reported to child welfare services. Child welfare models often focus on substance use as being the dominant issue that drives risk for abuse or neglect of a child, and current reporting practices, which vary by state, contribute to these disparities. This commentary proposes an alternate way of thinking about family-based support. We suggest changes to law, institutional policy, clinical care, and ideology. Specifically, we propose realigning around shared goals of supporting the birthing person-infant dyad and recognizing that substance use is not synonymous with abuse or neglect; creating an anonymous notification process outside of the child welfare system to meet federal data-collection requirements; limiting perinatal drug testing and requiring written, informed consent for parental and neonatal testing; and developing integrated care teams and hospital settings and policies that support dyadic care.

Neonatal abstinence syndrome and mother's own milk at discharge

OBJECTIVE

To describe factors impacting receipt of mother's own milk (MOM) at discharge among California infants diagnosed with neonatal abstinence syndrome (NAS).

STUDY DESIGN

Cohort study of the California Perinatal Quality Care Collaborative's Maternal Substance Exposure Database for infants with NAS and gestational age ≥ 34 weeks from 2019 to 2020.

RESULT

245 infants with NAS were identified. Variables with an increased likelihood of being discharged on MOM included maternal medication assisted treatment (p = 0.001), use of maternal addiction services (p < 0.001), receiving donor human milk (p = 0.001), being treated in the well baby unit (p < 0.001), rooming-in (p < 0.001), and kangaroo care (p < 0.001). Among infants with NAS for whom MOM was recommended (n = 84), rooming-in was the only factor associated with being discharged on MOM (p = 0.002); receiving formula was the only inversely associated factor (p < 0.001).

CONCLUSION

Results suggest supporting the mother-infant dyad and using non-pharmacologic treatment methods, such as rooming-in, increase receipt of MOM at discharge.

Length of Stay Among Infants with Neonatal Abstinence Syndrome and Risk of Hospital Readmission

OBJECTIVES

To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database.

METHODS

Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn.

RESULTS

Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p < 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories.

CONCLUSIONS

Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.

Technical Report: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding or the provision of human milk a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention and The Joint Commission monitor breastfeeding practices in United States hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding. Efforts to improve breastfeeding rates must acknowledge existing disparities and the impact of racism in promoting equity in breastfeeding education, support, and services.

Impact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To compare prenatal exposures, hospital care processes, and hospitalization outcomes for opioid-exposed newborns before and during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

In this multicenter retrospective analysis, data were collected from 19 Massachusetts hospitals, including 5 academic and 14 community hospitals. The pre-COVID-19 cohort was defined as births occurring during March 1, 2019-February 28, 2020, and the COVID-19 cohort was defined as births occurring during March 1, 2020-December 31, 2020. Opioid-exposed newborns born at ≥35 weeks of gestation were included. Differences in prenatal substance exposures, hospital care processes, and neonatal opioid withdrawal syndrome (NOWS) outcomes, including pharmacologic treatment for NOWS (PharmTx), length of stay (LOS), and as-needed (prn) treatment failure rates, were evaluated.

RESULTS

There were 663 opioid-exposed newborns in the pre-COVID-19 group and 476 in the COVID-19 group. No between-group differences were seen in prenatal substance exposures or the need for PharmTx. Compared with the pre-COVID-19 group, in the COVID-19 group there was less rooming-in after maternal discharge (53.8% vs 63.0%; P = .001) and less care in the pediatric unit setting (23.5% vs 25.3%; P = .001), longer LOS (adjusted risk ratio, 1.04; 95% CI, 1.01-1.08), and a higher rate of breast milk receipt at discharge (aOR, 2.03; 95% CI, 1.22-3.39). Within the subset of academic centers, more infants failed prn treatment in the COVID-19 group (53.8% vs 26.5%, P = .02; aOR, 3.77; 95% CI, 0.98-14.5).

CONCLUSIONS

Among the hospitals in our collaborative, hospital processes for NOWS, including care setting, rooming-in, and LOS were negatively impacted in the COVID-19 group, particularly in academic medical centers.

Developments in Nursing Practice to Address Substance Use in the Perinatal Period

Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.

Global research production in neonatal abstinence syndrome: A bibliometric analysis

BACKGROUND

Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.

AIM

To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.

METHODS

Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.

RESULTS

A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.

CONCLUSION

Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.

Global research production in neonatal abstinence syndrome: A bibliometric analysis

BACKGROUND

Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.

AIM

To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.

METHODS

Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.

RESULTS

A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.

CONCLUSION

Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.

Risk Factors Associated with Perinatal Relapse to Opioid Use Disorder

The recent opioid epidemic in the United States has led to rising prevalence of maternal opioid use disorder (OUD). First-line treatment for maternal OUD involves the use of opioid agonist pharmacotherapy, such as methadone or buprenorphine, in addition to cognitive behavioral therapy and counseling. The management of maternal OUD can become overwhelming for both patients and clinicians, especially during the early postpartum period. Therefore, it is imperative that clinicians understand the impact of additional stressors in caring for these patients. Maternal chronic opioid dependence can lead to neonatal opioid withdrawal syndrome after birth. This multisystem condition affects neonatal neurobehavioral functioning and has significant human and socioeconomic consequences. First-line treatment for this syndrome involves intensive nonpharmacologic comforting measures, with maternal presence and involvement being central to ensuring the success of such measures. In this review, we describe the factors that place pregnant and postpartum women with OUD at risk of returning to illicit opioid use. We evaluate these multifaceted personal, social, societal, and systemic factors to inform the development of future clinical care initiatives.

Neonatal Opioid Withdrawal Syndrome: A Comparison of As-Needed Pharmacotherapy

BACKGROUND AND OBJECTIVE

Methadone and morphine are commonly administered medications for neonatal opioid withdrawal syndrome (NOWS). Infants are increasingly treated with as-needed or "pro re nata" (PRN) medication. The optimal pharmacologic agent for PRN treatment of NOWS has not been examined. This study's objective is to compare NOWS hospital outcomes between infants treated with PRN methadone versus morphine.

METHODS

We performed a retrospective cohort study of infants pharmacologically treated for NOWS across 4 Massachusetts hospitals between January 2018 and February 2021. Infants born ≥36 weeks gestation with prenatal opioid exposure treated with PRN methadone or morphine were included. Mixed effects logistic and linear regression models were employed to evaluate differences in transition rates to scheduled dosing, length of stay, and number of PRN doses administered depending on PRN treatment agent.

RESULTS

There were 86 infants in the methadone group and 52 in the morphine group. There were no significant differences in NOWS hospital outcomes between groups in adjusted models: transition to scheduled dosing (methadone 31.6% vs morphine 28.6%, adjusted odds ratio 1.21, 95% confidence interval [CI] 0.87-1.19), mean length of stay (methadone 15.5 vs morphine 14.3 days, adjusted risk ratio 1.06, 95% CI 0.80-1.41), and the mean number of PRN doses (methadone 2.3 vs morphine 3.4, adjusted risk ratio 0.65, 95% CI 0.41-1.02). There was an association with nonpharmacologic care practices and improved NOWS hospital outcomes.

CONCLUSIONS

There were no significant differences in NOWS hospitalization outcomes based on pharmacologic agent type; nonpharmacologic care practices were most strongly associated with improved NOWS hospitalization outcomes.

Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants

Neonates born to mothers taking opioids during pregnancy are at risk for neonatal opioid withdrawal syndrome (NOWS), for which there is no recognized standard approach to care. Nonpharmacologic treatment is typically used as a first-line approach for management, and pharmacologic treatment is added when clinical signs are not responding to nonpharmacologic measures alone. Although morphine and methadone are the most commonly used pharmacotherapies for NOWS, buprenorphine has emerged as a treatment option based on its pharmacologic profile and results from initial single site clinical trials. The objective of this report is to provide an overview of NOWS including a summary of ongoing work in the field and to review the state of the science, knowledge gaps, and practical considerations specific to the use of buprenorphine for the treatment of NOWS as discussed by a panel of experts during a virtual workshop hosted by the National Institutes of Health.

Opioids and the developing brain: time to rethink perinatal care for infants of opioid-dependent mothers

Illicit use of opioids is a global health crisis with major implications for women and children. Strategies for managing opioid use disorder (OUD) in pregnancy have been tested over the past 40 years, but studies have focused on maternal and pregnancy outcomes, with less attention given to long-term follow-up of exposed children. Here, we provide a narrative review of recent advances in the assessment and management of neonatal opioid withdrawal syndrome (NOWS), and we summarise evidence from multiple domains-neuroimaging, electrophysiology, visual development and function, neurodevelopment, behaviour, cognition and education-which suggests that prenatal opioid exposure modifies child development. Further studies are required to determine the optimal management of pregnant women with OUD and babies with NOWS. We identify knowledge gaps and suggest that future study designs should evaluate childhood outcomes, including infant brain development and long-term neurocognitive and visual function.

Outcomes associated with the use of medications for opioid use disorder during pregnancy

AIM

To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes.

DESIGN

Retrospective cohort analysis of claims, encounter and pharmacy data.

SETTING

Pennsylvania, USA.

PARTICIPANTS

We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017.

MEASUREMENTS

We examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy.

FINDINGS

Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy.

CONCLUSIONS

Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.

Increasing usage of mother's own milk in neonates at risk of neonatal abstinence syndrome: MOM-NAS quality improvement initiative

OBJECTIVE

To increase the usage rate of mothers' own milk (MOM) among neonates with prenatal opioid exposure from a baseline average of 47% to an average of 75% over two years.

STUDY DESIGN

Between October 2018 and December 2020, we implemented various Plan-Do-Study-Act cycles that involved engaging providers in postpartum counseling for mothers with opioid dependence, using electronic medical records to track the rate of counseling, providing NAS educational materials to parents, and establishing a rooming-in unit. Our outcome measure was the provision of MOM to eligible neonates, while our process measure was the rate of postpartum counseling.

RESULTS

During this initiative, we witnessed a special cause variation with an increase in the usage rate of MOM from a baseline of 47% to a 27-month average of 85% by December 2020.

CONCLUSION

A series of quality improvement efforts resulted in increased usage of MOM among infants at risk of NAS.

Reduction of Need for Treatment and Length of Hospital Stay Following Institution of a Neonatal Abstinence Syndrome Rooming-In Program in Ontario, Canada

PURPOSE

To assess the impact of a rooming-in program for babies at risk of Neonatal Abstinence Syndrome (NAS) in one community hospital centre, in Belleville, Ontario.

DESIGN AND METHODS

This retrospective chart review was conducted at Belleville General Hospital. The hospital developed a rooming-in program for newborns at risk of NAS in July 2015. Charts on all infants born to mothers using opioids in the 24 months prior to and after the implementation of our program, who met the inclusion criteria, were examined.

RESULTS

The study consisted of 15 babies in the Special Care Nursery (SCN) group and 19 babies in the rooming-in group. Rooming-in is associated with a reduction in the need for treatment with morphine [rooming-in group (1/19, 5.3%), SCN group (14/15, 93.3%), p < 0.01], shorter length of stay in hospital [rooming-in group (days = 5), SCN group (days = 20), p < 0.01], improved exclusive breast and/or breast milk-feeding rates [rooming-in group (17/19,89.5%), SCN group (1/15,6.7%), p < 0.01] and lower total hospital cost [rooming-in group ($6458.00), SCN group ($17,851.00), p < 0.01].

CONCLUSION

Our study demonstrates that rooming-in programs for babies born to mothers using opioids has benefits in terms of quality of care and health care resource utilization.

PRACTICAL IMPLICATIONS

These findings show that rooming-in can be successfully implemented in a community hospital.

Nurses' Descriptions of Interactions When Caring for Women With Perinatal Substance Use Disorders and Their Infants

The purpose of this review is to describe health care interactions between nurses and women with perinatal substance use disorders, including interactions with their infants from the perspective of the nurses. Findings from 11 qualitative inclusion articles were synthesized using a metasummary approach. The majority of articles showed that nurses experience problematic interactions when providing care to women with perinatal substance use disorders and their infants, although some results indicated that some nurses engage in interactions that are assuring. Six types of conflictual interactions were identified: inadequate care, distressing, condemning, deficient knowledge, rejecting, and dissatisfying. Two types of therapeutic interactions were identified: compassionate and supportive. The findings underscore the importance of managing stigma, enhancing knowledge of the science of addiction processes, and promoting best practices when caring for this population.

Cost of neonatal abstinence syndrome: an economic analysis of English national data held in the National Neonatal Research Database

OBJECTIVE

To determine the incidence of neonatal abstinence syndrome (NAS) across neonatal units, explore healthcare utilisation and estimate the direct cost to the NHS.

DESIGN

Population cohort study.

SETTING

NHS neonatal units, using data held in the National Neonatal Research Database.

PARTICIPANTS

Infants born between 2012 and 2017, admitted to a neonatal unit in England, receiving a diagnosis of NAS (n=6411).

MAIN OUTCOME MEASURES

Incidence, direct annual cost of care (£, 2016-2017 prices), duration of neonatal unit stay (discharge HR), predicted additional cost of care, and odds of receiving pharmacotherapy.

RESULTS

Of 524 334 infants admitted during the study period, 6411 had NAS. The incidence (1.6/1000 live births) increased between 2012 and 2017 (β=0.07, 95% CI (0 to 0.14)) accounting for 12/1000 admissions and 23/1000 cot days nationally. The direct cost of care was £62 646 661 over the study period. Almost half of infants received pharmacotherapy (n=2631; 49%) and their time-to-discharge was significantly longer (median 18.2 vs 5.1 days; adjusted HR (aHR) 0.16, 95% CI (0.15 to 0.17)). Time-to-discharge was longer for formula-fed infants (aHR 0.73 (0.66 to 0.81)) and those discharged to foster care (aHR 0.77 (0.72 to 0.82)). The greatest predictor of additional care costs was receipt of pharmacotherapy (additional mean adjusted cost of £8420 per infant).

CONCLUSIONS

This population study highlights the substantial cot usage and economic costs of caring for infants with NAS on neonatal units. A shift in how healthcare systems provide routine care for NAS could benefit infants and families while alleviating the burden on services.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.