Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome

Breastfeeding and Formula Selection in Neonatal Abstinence Syndrome

OBJECTIVE

This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants.

STUDY DESIGN

Retrospective cohort study of neonates ≥35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants.

RESULTS

After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually.

CONCLUSION

We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss.

KEY POINTS

· Best formula choice for a neonatal abstinence syndrome (NAS) infant is unknown.. · Many NAS moms cannot breastfeed.. · Low lactose formula has no impact on NAS outcomes..

Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses

BACKGROUND

Up to 95% of neonates exposed to opioids in utero experience neonatal opioid withdrawal syndrome at birth. Nonpharmacologic approaches (e.g., breastfeeding; rooming-in; skin-to-skin care) are evidence-based and should be implemented. These approaches, especially breastfeeding, rely on engagement of the neonates' mothers to help deliver them. However, little is known about the structural and social dynamic context barriers and facilitators to implementing maternal-delivered nonpharmacologic care.

METHODS

Using a qualitative descriptive design, perinatal nurses from a Midwest United States hospital family birthing center, neonatal intensive care unit, and inpatient pediatric unit were interviewed. These units were involved in caring for mothers and neonates affected by opioid use. Telephone interviews followed a semi-structured interview guide developed for this study, were audio-recorded, and lasted about 30-60 min. Interviews were transcribed verbatim and independently analyzed by five investigators using the constant comparative method. Themes were discussed until reaching consensus and subsequently mapped to a conceptual model adapted for this study.

RESULTS

Twenty-one nurses participated in this study (family birth center, n = 9; neonatal intensive care, n = 6; pediatrics, n = 6). Analysis resulted in four major themes: 1) Lack of education and resources provided to staff and mothers; 2) Importance of interdisciplinary and intradisciplinary care coordination; 3) Flexibility in nurse staffing models for neonatal opioid withdrawal syndrome; and 4) Unit architecture and layout affects maternal involvement. Minor themes supported each of the four major themes. All themes mapped to the conceptual model.

CONCLUSIONS

This study provides a more comprehensive understanding of the barriers and facilitators affecting implementation of maternal involvement in nonpharmacologic care of newborns with neonatal opioid withdrawal syndrome. Future efforts implementing nonpharmacologic approaches must consider the context factors affecting implementation, including structural and social factors within the units, hospital, and broader community.

Development and Implementation of a Mobile Tool for High-Risk Pregnant Women to Deliver Effective Caregiving for Neonatal Abstinence Syndrome: Protocol for a Mixed Methods Study

Background

The United States continues to experience an alarming rise in opioid use that includes women who become pregnant and related neonatal abstinence syndrome (NAS) in newborns. Most newborns experiencing NAS require nonpharmacological care, which entails, most importantly, maternal involvement with the newborn. To facilitate positive maternal-newborn interactions, mothers need to learn effective caregiving NAS strategies when they are pregnant; however, an enormous gap exists in the early education of mothers on the symptoms and progression of NAS, partly because no education, training, or other interventions exist to prepare future mothers for the challenges of caring for their newborns at risk for NAS.

Objective

In this paper, we describe a mixed methods, multistage study to adapt an existing mobile NAS tool for high-risk pregnant women and assess its usability, acceptability, and feasibility in a small randomized controlled trial.

Methods

Stage 1 will include 20 semistructured interviews with a panel of neonatology experts, NAS care providers, and mothers with experience caring for NAS-affected newborns to gather their recommendations on the management of NAS and explore their perspectives on the care of these newborns. The findings will guide the adaptation of existing mobile NAS tools for high-risk pregnant women. In stage 2, we will test the usability, acceptability, and feasibility of the adapted mobile tool via surveys with 10 pregnant women receiving opioid agonist therapy (OAT). Finally, in stage 3, we will randomize 30 high-risk pregnant women receiving OAT to either receive the adapted mobile NAS caregiving tool or usual care. We will compare these women on primary outcomes—maternal drug relapse and OAT continuation—and secondary outcomes—maternal-newborn bonding; length of newborn hospital stays; readmission rates; breastfeeding initiation and duration; and postpartum depression and anxiety at 4, 8, and 12 weeks postpartum.

Results

This project was funded in July 2020 and approved by the institutional review board in April 2020. Data collection for stage 1 began in December 2020, and as of January 2021, we completed 18 semistructured interviews (10 with NAS providers and 8 with perinatal women receiving OAT). Common themes from all interviews will be analyzed in spring 2021 to inform the adaptation of the NAS caregiving tool. The results from stage 1 are expected to be published in summer 2021. Stage 2 data collection will commence in fall 2021.

Conclusions

The findings of this study have the potential to improve NAS care and maternal-newborn outcomes and lead to commercialized product development. If effective, our new tool will be well suited to tailoring for other high-risk perinatal women with substance use disorders.

Trial Registration

ClinicalTrials.gov NCT04783558; https://clinicaltrials.gov/ct2/show/NCT04783558

International Registered Report Identifier (IRRID)

DERR1-10.2196/27382

Engaging Mothers to Implement Nonpharmacological Care for Infants With Neonatal Abstinence Syndrome: Perceptions of Perinatal and Pediatric Nurses

BACKGROUND

Little is known about nurse perceptions regarding engagement of mothers in implementation of nonpharmacological care for opioid-exposed infants.

PURPOSE

This study was designed to describe perinatal and pediatric nurse perceptions of (1) engaging mothers in the care of opioid-exposed infants and (2) facilitators and barriers to maternal engagement.

METHODS

This study used a qualitative descriptive design to interview perinatal and pediatric nurses in one Midwest United States hospital. Interviews were conducted via telephone using a semistructured interview guide and audio recorded. Audio files were transcribed verbatim and thematically analyzed using the constant comparative method.

RESULTS

Twenty-one nurses participated in the study, representing a family birth center, neonatal intensive care unit, and pediatric unit. Five major themes resulted from analysis: (1) vulnerability and bias; (2) mother-infant care: tasks versus model of care; (3) maternal factors affecting engagement and implementation; (4) nurse factors affecting engagement and implementation; and (5) recommendations and examples of nursing approaches to barriers. Minor themes supported each of the major themes.

IMPLICATIONS FOR PRACTICE

Nurses must engage mothers with substance use histories with empathy and nonjudgment, identify and promote maternal agency to care for their infants, and engage and activate mothers to deliver nonpharmacological care during the hospital stay and following discharge.

IMPLICATIONS FOR RESEARCH

Findings suggest interventions are needed to improve (1) nursing education regarding maternal substance use and recovery, (2) empathy for substance-using mothers and mothers in treatment, and (3) identification and support of maternal agency to provide nonpharmacological care to withdrawing infants.

A Mixed-Methods Study to Investigate Barriers and Enablers to Nurses' Implementation of Nonpharmacological Interventions for Infants With Neonatal Abstinence Syndrome

BACKGROUND

The incidence of neonatal abstinence syndrome has increased significantly as a result of the opioid epidemic. A lengthy hospitalization is often required to treat the infant's withdrawal symptoms. A comprehensive understanding of factors that influence nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome is needed.

PURPOSE

To investigate barriers and enablers to nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome through the lens of the Theoretical Domains Framework, which provides a structure to examine factors that influence healthcare providers' behavior related to the implementation of evidence-based practice and interventions in clinical practice.

METHODS

A convergent parallel mixed-methods study was conducted. Qualitative data were collected using semistructured interviews and quantitative data were collected using a tailored Determinants of Implementation Behavior Questionnaire with neonatal nurses. Findings from the interviews and surveys were merged through joint review to compare and contrast themes.

RESULTS

Enablers and barriers to nurses' implementation of nonpharmacological interventions included education, experience, ability to implement nonpharmacological interventions, parental participation, stigmatization, lack of managerial/organizational support, staffing ratios, internal and external resources, and stress. Knowledge, Skills, Beliefs About Capabilities, Social/Professional Role and Identity, Organization, and Emotion of the Theoretical Domains Framework aligned with these themes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Findings from this study will inform the development of programs to improve nurses' implementation of nonpharmacological interventions and health and utilization outcomes in infants with neonatal abstinence syndrome. Furthermore, future work should focus on the development of programs to improve nurses' implementation of nonpharmacological interventions, with specific strategies aimed to mitigate marginalization of vulnerable patient populations.

The Infant Cuddler Study: Evaluating the effectiveness of volunteer cuddling in infants with neonatal abstinence syndrome

Objectives

St. Michael's Hospital launched a volunteer cuddling program for all infants admitted into the neonatal intensive care unit in October 2015. The program utilizes trained volunteers to cuddle infants when caregivers are not available. This was a pilot study to assess the impact of a volunteer cuddle program on length of stay (LOS) and feasibility of implementation of the program.

Methods

A mixed methods approach was utilized to measure both quantitative and qualitative impact. A pilot cohort study with a retrospective control group assessed the feasibility of implementing a volunteer cuddling program for infants with neonatal abstinence syndrome (NAS). Length of stay was used as a surrogate marker to measure the impact of cuddling on infants being treated for Neonatal Abstinence Syndrome. Focus groups using semi-structured interviews were conducted with volunteers and nurses at the end of the pilot study.

Results

LOS was reduced by 6.36 days (U=34, P=0.072) for infants with NAS in the volunteer cuddling program. Focus groups with both bedside nurses and program volunteers described a positive impact of cuddling programs on infants, families, staff, and volunteers alike.

Conclusions

The study results suggest that the volunteer cuddling program may reduce LOS in infants with NAS and have potential economic savings on hospital resources. However, larger prospective cohort studies are needed to confirm these results.

Occupational Therapy Management Strategies for Infants With Neonatal Abstinence Syndrome: Scoping Review

With opioid use in North America rising, there is a growing incidence of neonatal abstinence syndrome (NAS). Infants with NAS experience withdrawal signs that interfere with their occupational performance in activities of daily living. This scoping review aims to identify the non-pharmacologic interventions currently used in the treatment of infants with NAS that fall within the scope of the occupational therapy profession. Searching three databases, articles were independently reviewed by two authors to meet defined inclusion criteria. Forty-five articles were included, and the interventions identified and organized according to the Person-Environment-Occupation Model. The non-pharmacologic interventions identified fall within the scope of the occupational therapy profession. Initiating occupational therapy services in an acute care setting may have the potential to improve occupational performance and engagement for these infants from an early age.

Outcome Differences in Neonates Exposed In-Utero to Opioids Managed in the NICU Versus Pediatric Floor

OBJECTIVE

The aim of the study is to determine length of stay and length of treatment in infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU) compared to those in the pediatric floor.

METHODS

Retrospective cohort of infants ≥34 weeks gestation admitted with diagnosis of NAS at a single regional perinatal referral center from July 2014 to October 2015. A standardized NAS protocol for both the NICU and pediatric floor, which included guidelines for the initiation of oral morphine, escalation, and weaning, was followed. Initial location of treatment, NICU or pediatric floor, was determined by physiological stability following birth. Statistical analysis included 1-way analysis of variance and chi-square. Multivariable analysis was performed using generalized linear models to account for confounding.

RESULTS

The study included 235 infants, 80 (34%) were cared for in the NICU. Infants in the NICU had a longer length of stay (27.1 ± 19.1 vs 14.2 ± 10.2 days, P < 0.01), and length of pharmacological treatment (18.0 ± 19.9 vs 9.0 ± 10.2 days, P < 0.01) compared to those on the pediatric floor, respectively. Forty-seven infants were transferred from the NICU to the pediatric floor for the remainder of their hospital stay with a mean time on the pediatric floor of 17.4 ± 14.5 days. After controlling for confounding, admission to the NICU was associated with an increased length of treatment of 12.6 days (95% confidence interval 8.3-16.8) and length of stay of 12.3 days (95% confidence interval 7.9-16.6).

CONCLUSIONS

In our population, admission to the pediatric floor compared to the NICU was associated with a shorter length of stay, and a shorter length of pharmacological treatment. Our data suggest that caring for infants with NAS outside of the NICU setting has the potential to improve short-term outcomes and reduce associated costs.

Managing infants born to mothers who have used opioids during pregnancy

The incidence of infant opioid withdrawal has grown rapidly in many countries, including Canada, in the last decade, presenting significant health and early brain development concerns. Increased prenatal exposure to opioids reflects rising prescription opioid use as well as the presence of both illegal opiates and opioid-substitution therapies. Infants are at high risk for experiencing symptoms of abstinence or withdrawal that may require assessment and treatment. This practice point focuses specifically on the effect(s) of opioid withdrawal and current management strategies in the care of infants born to mothers with opioid dependency.

Infants in Drug Withdrawal: A National Description of Nurse Workload, Infant Acuity, and Parental Needs

Infants in drug withdrawal have complex physiological and behavioral states, requiring intensive nursing care. The study objectives were to describe acuity, parental needs, and nurse workload of infants in drug withdrawal compared with other infants. The design was cross-sectional and involved secondary nurse survey data from 6045 staff nurses from a national sample of 104 neonatal intensive care units. Nurses reported the care of 15 233 infants, 361 (2.4%) of whom were in drug withdrawal. Three-fourths of hospitals had at least 1 infant in drug withdrawal. In these hospitals, the mean number of infants in drug withdrawal was 4.7. Infant acuity was significantly higher among infants in drug withdrawal. Parents of infants in drug withdrawal required significantly more care to address complex social situations (51% vs 12%). The number of infants assigned to nurses with at least 1 infant in withdrawal (mean = 2.69) was significantly higher than typical (mean = 2.51). Given infant acuity and parental needs, policies legislating patient-to-nurse ratios should permit professional discretion on the number of patients to assign nurses caring for infants in drug withdrawal. Managers and charge nurses should consider the demands of caring for infants in drug withdrawal in assignment decisions and provide support and education.

Comparison of Neonatal Abstinence Syndrome Manifestations in Preterm Versus Term Opioid-Exposed Infants

BACKGROUND

Twenty percent to 40% of infants exposed to in utero opioid were delivered preterm. There is currently no neonatal abstinence syndrome (NAS) scoring tool known to accurately evaluate preterm opioid-exposed infants. This can lead to difficulties in titrating pharmacotherapy in this population.

PURPOSE

To describe NAS symptoms in preterm opioid-exposed infants in comparison with matched full-term controls.

METHODS

This was a retrospective cohort study from a single tertiary care center of methadone-exposed infants born between 2006 and 2010. Using modified Finnegan scale scores recorded every 3 to 4 hours beginning at 6 hours of life until 24 to 48 hours after medication discontinuation, NAS symptoms was compared between 45 preterm infants and 49 full-term matched controls. Concurrent neonatal medical diagnoses were also compared.

RESULTS

The median gestational age in the preterm group was 35 weeks (interquartile range [IQR] = 33-36) versus 39 weeks (IQR = 38-40) in the term group. Preterm infants scored less frequently for many items including sleep disturbance (24.4% vs 46.2%), tremors (77.9% vs 89.7%), muscle tone (87.9% vs 97.4%), sweating (2.1% vs 9.4%), nasal stuffiness (11.9% vs 20.5%), and loose stools (7.0% vs 14.3%) than full-term controls. Preterm infants scored more frequently for hyperactive moro reflex (26.4% vs 5.5%), tachypnea (19.3% vs 16.1%), and poor feeding (24.6% vs 11.8%).

IMPLICATIONS FOR PRACTICE

Provider awareness of differences in manifestations of preterm and term infants with NAS, as well as concurrent prematurity diagnoses that can influence NAS scoring, is needed. These findings mandate the development of a modified NAS scoring tool for the preterm NAS population.

IMPLICATIONS FOR RESEARCH

A preterm NAS scoring tool needs to be developed and validated to more accurately evaluate and treat preterm opioid-exposed infants.

Patterns of Disruptive Feeding Behaviors in Infants With Neonatal Abstinence Syndrome

BACKGROUND

Severe irritability in infants with neonatal abstinence syndrome often impacts their ability to feed successfully, which challenges a mother's ability to demonstrate this most basic parenting skill. There is little empiric evidence to guide recommendations for practice in this population.

PURPOSE

Describe the infant behaviors that disrupt feeding in infants with neonatal abstinence syndrome.

METHODS

A mixed-method approach was used to describe digitally recorded infant feeding behaviors. Qualitative methodology was first used to identify categories of behaviors during the feeding. The categories were used as a coding scheme to identify the temporal sequence, duration, and frequency of behaviors observed during a feeding.

RESULTS

The behavior categories that disrupted feeding were identified as fussing, resting, crying, and sleeping/sedated. Infants spent almost twice as much time in fussing as in feeding. The majority of the infants were fussing between 1 and 11 minutes during the feeding, and fussing disrupted feeding in every subject at least once. Feeding behavior occurred only 24% of the time, while fussing and crying occurred 51%. Fussing was the primary transitional behavior from one category to another. Infants who did not complete their feeding had nearly twice the mean number of fussing episodes as those who completed their feeding.

IMPLICATIONS FOR PRACTICE

Fussing is a transitional state and appears to provide an opportunity to test interventions that help the mothers re-engage their infants in feeding. The frequency of the behavioral transitions provides a measure of irritability that has not been previously described in this population.

IMPLICATIONS FOR RESEARCH

Additional study is needed to evaluate the impact and contributions of maternal behaviors and external variables on infant behavioral transition.