"Choose Physical Therapy" for Neonatal Abstinence Syndrome: Clinical Management for Infants Affected by the Opioid Crisis

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project

Introduction

Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes.

Methods

An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM.

Results

Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM.

Discussion

Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

Interventions for Motor Disorders in High-Risk Neonates

Early childhood affords rapid brain development and advancement of the motor system. In High-Risk Infant Follow-Up programs, watchful waiting and monitoring of infants at high risk is shifting toward active surveillance and early diagnosis, followed by immediate targeted very early interventions. Infants with delayed motor skills benefit from developmental care, NIDCAP, and generic or specific motor training. Infants with cerebral palsy benefit from enrichment, targeted skills interventions, and task-specific motor training at high intensity. Infants with degenerative conditions benefit from enrichment but also require accommodations such as powered mobility.

Implementation of Interprofessional Rounds Decreases Neonatal Abstinence Syndrome Length of Stay

OBJECTIVE

Neonatal abstinence syndrome (NAS) occurs due to abrupt discontinuation of chronic fetal exposure to substances used by the mother during pregnancy. As the incidence of NAS continues to increase, medical teams are evaluating strategies to reduce length of stay (LOS). Increased LOS contributes to poorer mother-infant bonding and neurodevelopmental outcomes as well as increased health care cost. As part of an ongoing quality improvement project, the objective of this study was to determine if formal interprofessional rounds affected LOS for infants with NAS.

METHODS

This was a retrospective analysis at a single hospital system to determine if interprofessional rounds had an impact on NAS LOS. On February 5, 2016, introduction of formal weekly interprofessional NAS-specific rounds occurred in addition to daily patient care rounds. Every patient with opioid exposure undergoing Finnegan scoring, treated with weight-based morphine, and &gt;35 weeks gestation was included. Data were collected on LOS and length of therapy for eligible patients. This study evaluated the impact of interprofessional rounds on LOS 17 months after its implementation compared with 13 months immediately preceding.

RESULTS

Among the 119 infants (51 pre and 68 post) meeting inclusion criteria, the median LOS for the post-rounds group was significantly shorter than the pre-rounds group (13 vs 16 days, p = 0.001). The median length of therapy (morphine with or without clonidine) was also significantly shorter in the post-rounds versus the pre-rounds group (8 vs 12 days, p = 0.001).

CONCLUSIONS

Formal weekly interprofessional NAS rounds decreased LOS and length of therapy.

The immediate and long-term effects of prenatal opioid exposure

The opioid epidemic has adversely affected neonates and children, yet the mechanisms by which it impacts this population are not well understood. Not only does prenatal opioid exposure result in short-term consequences shortly after birth, it also creates long-term sequelae that may predispose these children to physical, emotional, psychiatric, cognitive, and socioeconomic problems in the future. This article provides a scoping overview of the long-term effects of antenatal opioid exposure on neonates and children as well as quality improvement and research efforts to understand and mitigate this major public health concern.

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.