Analysis of the factors that influence the Finnegan Neonatal Abstinence Scoring System

Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant

The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).

Implicit Racial Bias in Evaluation of Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To assess implicit bias by administrating the Modified Finnegan Score (MFS) for quantifying neonatal opioid withdrawal and to evaluate risk of decreased opioid treatment of Black versus White infants.

STUDY DESIGN

Study participants were nurses recruited from a large tertiary care center who received three clinical vignettes portraying withdrawing infants and were randomized to receive an accompanying photo of either a Black or White infant. MFS results were compared for identical vignettes based on race of infant photo.

RESULTS

Out of 275 nurses, 70 completed the survey. In vignette 2, nurses aged ≤35 years scored Black infants lower than White infants (MFS=8.3 ± 2 vs. 9.5 ± 1.2, p=0.012). Nurses with <5 years of experience and ≤10 years of experience also scored Black infants lower for the same vignette (8.2 ± 2.3 vs. 9.6 ± 1.2, p=0.032 and 8.3 ± 2 vs. 9.5 ± 1.2, p=0.0083).

CONCLUSION

Implicit bias may contribute to the difference in opioid treatment.

Improving Outcomes in Infants With Neonatal Abstinence Syndrome With the Eat, Sleep, Console Method

BACKGROUND

Neonatal abstinence syndrome (NAS) is a significant public health concern. A quality improvement project was executed in a neonatal intensive care unit at a large urban hospital. The aim was to address the prolonged hospitalization of infants and exposure to medications to treat NAS.

PURPOSE

The goal was to determine whether the eat, sleep, console (ESC) method decreases the length of stay (LOS) and morphine usage when compared with the Finnegan Neonatal Abstinence Scoring System (FNASS).

METHODS

The inclusion criteria were 36 weeks' or longer gestation and exposure to opiates in utero. The FNASS method was replaced by the ESC method with a refocus on nonpharmacologic care. Data were collected for 6 months during implementation of the ESC method and compared with the 6 months prior to implementation.

RESULTS

The results of the project include: the average LOS decreased from 25.9 days to 13.7 days, a 47% reduction; the rate of scheduled morphine initiation decreased from 58% to 7%, an 88% reduction; as-needed morphine initiation decreased from 33% to 7%, a 79% reduction; and the rate of adjunctive medication initiation decreased from 17% to 0%, a 100% reduction.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The outcomes of LOS and rate of morphine usage were significantly improved when using the ESC method when compared with the FNASS at this facility. The results support future implications including expanding the ESC program to the well newborn population at this facility and other similar units. Further research needs to be done on long-term neurodevelopmental outcomes.

The Eat, Sleep, Console Method: A Literature Review

Neonatal abstinence syndrome (NAS) is a significant public health problem in the United States. The most commonly used tool to assess and treat infants with NAS is the Finnegan Neonatal Abstinence Scoring System (FNASS). The more recently developed Eat, Sleep, Console (ESC) method simplifies assessment of NAS. Current research suggests promising outcomes with the ESC method in areas such as length of hospital stay (LOS) and amount of medication needed to treat NAS. A literature review was conducted to answer the following question: In newborn infants with NAS born at 36 weeks of gestation or older, does the ESC method reduce the use of medication and LOS when compared with the FNASS? All of the studies reporting on LOS and medication usage rates reported a decrease in both when moving to the ESC method from FNASS.

Correlating Scores but Contrasting Outcomes for Eat Sleep Console Versus Modified Finnegan

OBJECTIVES

The Modified Finnegan Neonatal Abstinence Scoring System (M-FNASS) and the newer Eat, Sleep, and Console (ESC) model guide the clinical management of neonatal opioid withdrawal syndrome (NOWS). In this study, we evaluate how the M-FNASS and ESC model directly compare in inpatient practice. We hypothesized that ESC scores would correlate with M-FNASS scores, whereas ESC management would reduce health care use for infants with NOWS.

METHODS

In this retrospective cohort study, we compared management of infants with NOWS admitted to nursery settings. Epoch 1 was managed by using an M-FNASS algorithm. Epoch 2 was scored simultaneously with the M-FNASS and ESC model and managed by using the ESC approach. In the statistical analysis, we compared M-FNASS and ESC scores and outcomes between epochs.

RESULTS

A total of 158 infants provided 2101 scoring instances for analysis. Demographic characteristics were similar between epochs. ESC scores significantly correlated with overall M-FNASS scores and specific M-FNASS domains. Receiver operating characteristic (ROC) curve analysis revealed that an ESC score containing at least 1 "no" was best predicted by an M-FNASS cutoff value of 7.5 (sensitivity 0.84; specificity 0.70; area under the curve = 0.842). Length of stay (median 9.5 vs 5 days; P = .0002) and initiation (53% vs. 33%; P = .018) and duration of pharmacologic treatment (median 11 vs 7 days; P = .0042), as well as length of stay for infants who were pharmacologically treated (median 15 vs 10 days; P = .0002), were significantly reduced with ESC-based management after adjustment for covariates.

CONCLUSIONS

The ESC approach meaningfully correlates with the M-FNASS to detect NOWS. Management with the ESC approach continues to be associated with reduced health care use when compared with an M-FNASS approach, implying that the ESC approach may facilitate higher-value inpatient care.

Using Simulation in Training Pediatric Residents on Neonatal Abstinence Syndrome Scoring: An Experimental Study

BACKGROUND

Neonatal abstinence syndrome (NAS) is characterized by significant physiological and behavioral signs involving multiple-organ systems in neonates following a prenatal exposure to opioids and other nonopioid drugs. Neonatal abstinence syndrome can result in serious morbidity, and even death, if unrecognized and untreated. The purpose of this study was to develop a simulation model of a standard video training of the Finnegan Neonatal Abstinence Scoring System (FNAS) and investigate the perceptions of comfort and competency of pediatric residents undergoing video or simulation training.

METHODS

Thirty-one pediatric and medicine-pediatric residents participated in this single-blinded randomized intervention study. The experimental group completed demonstrated simulation while the control group received the traditional video instruction. Both groups completed FNAS scoring on a case of a neonate with NAS. The FNAS scores of residents were compared with the scores of 2 expert raters. Pre- and posttraining and preference surveys were obtained from all participants.

RESULTS

Both experimental and control groups scored the FNAS scenario similarly and were also similar to the expert raters. Both groups also reported comparable levels of comfort and competency after the training, though first-year residents reported greater improvement than upper-level residents. The FNAS scores from expert raters were identical for the simulation and video scenarios.

IMPLICATIONS FOR PRACTICE

Although this study showed that a simulation training module can be used as a standardized teaching method to administer the FNAS, it can be cost-prohibitive and daunting to produce. Nursing professionals need to be aware of medical education training around FNAS due to the interdisciplinary nature of care for neonates with NAS. Institutions should consider implementing a diversity of practices and models with an interdisciplinary approach to training assessment of the neonate with NAS.

IMPLICATIONS FOR RESEARCH

A more hands-on, less cost-prohibitive simulation training needs to be developed to teach FNAS administration with a broader range of professionals including interdisciplinary teams of nursing and medical professionals.

Development of an abbreviated symptom score for the neonatal abstinence syndrome

OBJECTIVE

We sought a shortened MOTHER neonatal abstinence syndrome (NAS) and Finnegan score that would retain comparable performance characteristics of the full instrument.

STUDY DESIGN

Retrospective cohort.

RESULTS

In total, 124,170 MOTHER NAS scores between August 2007 and May 2016 from 775 infants (≥36 weeks) were examined. Classification and regression tree model identified the most important subsets of the scored variables. A 9-element shortened scale yielded >90% sensitivity and specificity to predict clinical endpoints based on the full 19-element MOTHER NAS score. Conversion of the data sets to the Finnegan score, and applying the same procedure resulted in a nine-element score with similar performance characteristics.

CONCLUSION

Shortened scoring instruments were identified with the high-predictive power for clinical endpoints based on the 19-element full MOTHER NAS score. There was no substantial variation in performance for age, supporting the current practice of utilizing a single scoring tool regardless of postnatal age.

Prenatal Opioid Exposure: Neurodevelopmental Consequences and Future Research Priorities

Neonatal opioid withdrawal syndrome (NOWS) has risen in prevalence from 1.2 per 1000 births in 2000 to 5.8 per 1000 births in 2012. Symptoms in neonates may include high-pitched cry, tremors, feeding difficulty, hypertonia, watery stools, and breathing problems. However, little is known about the neurodevelopmental consequences of prenatal opioid exposure in infancy, early childhood, and middle childhood. Even less is known about the cognitive, behavioral, and academic outcomes of children who develop NOWS. We review the state of the literature on the neurodevelopmental consequences of prenatal opioid exposure with a particular focus on studies in which NOWS outcomes were examined. Aiming to reduce the incidence of prenatal opioid exposure in the near future, we highlight the need for large studies with prospectively recruited participants and longitudinal designs, taking into account confounding factors such as socioeconomic status, institutional variations in care, and maternal use of other substances, to independently assess the full impact of NOWS. As a more immediate solution, we provide an agenda for future research that leverages the National Institutes of Health Environmental Influences on Child Health Outcomes program to address many of the serious methodologic gaps in the literature, and we answer key questions regarding the short- and long-term neurodevelopmental health of children with prenatal opioid exposure.

The Possibility of Early Discharge for Newborns Being Monitored for Neonatal Abstinence Syndrome Based on Modified Finnegan Score Distributions

We tested the hypothesis that Modified Finnegan Neonatal Scoring System (MFNSS) scores can guide early discharge at 72 hours for newborns at risk for neonatal abstinence syndrome (NAS). A retrospective cohort study with a primary outcome of early discharge of newborns at risk for NAS using mean MFNSS scores recorded before pharmacologic treatment was performed. Quantile regression was used to develop percentile curves of mean MFNSS scores. A total of 202 term newborns at risk for NAS with 5066 mean MFNSS scores recorded before pharmacologic treatment were studied. Sixty-eight of 121 (56%) newborns not treated at 72 hours had mean MFNSS scores <50th percentile and only 1 was ultimately treated (1.5%, 95% confidence interval: 0% to 8%). No newborns with mean MFNSS scores <25th percentile at 72 hours were treated. Newborns at risk for NAS with mean MFNSS scores <50th percentile can be safely discharged by 72 hours if families can assure close outpatient follow-up.

The Epidemic of Neonatal Abstinence Syndrome, Historical References of Its' Origins, Assessment, and Management

Neonatal abstinence syndrome (NAS) refers to a constellation of signs that are present in some newborn infants resulting from the abrupt cessation of passive transfer of maternal opioids used during pregnancy. The classic NAS refers to infants born to mothers who used opioids during pregnancy, but the term has broadened to include infants whose mothers have used or abused other psychoactive substances during pregnancy that contribute to the expression of the syndrome. Pregnant women who use opioids do so illicitly, and/or as medically prescribed for pain relief, and/or as medication assisted treatment for opioid dependence. The first case of NAS in infants and the subsequent treatment (or lack thereof) was reported in 1875 and was called Congenital Morphinism. By 2012, the incidence of NAS increased to more than 30 per 1,000 hospital live births, along with an increase in the number of infants being treated pharmacologically for NAS, resulting in an increase in the length of stay and healthcare expenses. We present historical references on NAS, the various factors and events that led to its increasing prevalence and today's current epidemic. We also review the current tools to assess infants with NAS and treatment options in its management.

Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA

OBJECTIVE

To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS.

DESIGN, SETTING AND PARTICIPANTS

This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded.

METHODS

A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution.

RESULTS

Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively.

CONCLUSION

The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.

Judging the Neonatal Abstinence Syndrome Assessment Tools to Guide Future Tool Development: The use of Clinimetrics as Opposed to Psychometrics

In the face of the current Neonatal Abstinence Syndrome (NAS) epidemic, there is considerable variability in the assessment and management of infants with NAS. In this manuscript, we particularly focus on NAS assessment, with special attention given to the popular Finnegan Neonatal Abstinence Score (FNAS). A major instigator of the problem of variable practices is that multiple modified versions of the FNAS exist and continue to be proposed, including shortened versions. Furthermore, the validity of such assessment tools has been questioned, and as a result, the need for better tools has been suggested. The ultimate purpose of this manuscript, therefore, is to increase researchers' and clinicians' understanding on how to judge the usefulness of NAS assessment tools in order to guide future tool development and to reduce variable practices. In short, we suggest that judgment of NAS assessment tools should be made on a clinimetrics viewpoint as opposed to psychometrically. We provide examples, address multiple issues that must be considered, and discuss future tool development. Furthermore, we urge researchers and clinicians to come together, utilizing their knowledge and experience, to assess the utility and practicality of existing assessment tools and to determine if one or more new or modified tools are needed with the goal of increased agreement on the assessment of NAS in practice.