Care of the infant with neonatal abstinence syndrome: strength of the evidence

Neurodevelopmental, Mental Health, and Parenting Issues in Preterm Infants

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG)

Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.

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.

Whole body massage for newborns: A report on non-invasive methodology for neonatal opioid withdrawal syndrome

BACKGROUND

Infants with in-utero exposure to opioids are at risk Neonatal Opioid Withdrawal Syndrome (NOWS) and non-pharmacological methods of care, like swaddling, quiet ambient environment are routinely recommended but are not systematically studied. We hypothesized that opioid exposed infants can tolerate whole body massage while hospitalized.

METHODS

This is a prospective observational study (August 2017 to January 2019) and infants of mothers having a history of opioids use (OUD) were included. Infants received whole body massage for 30 minutes from birth till discharge home. Infants heart rate (HR), respiratory rate (RR), systolic (sBP) and diastolic blood pressure (dBP) were recorded prior to and at the end of massage session.

RESULTS

The pilot study enrolled 30 infants. The mean birth weight and gestational age were 38±1 weeks and 2868±523 grams, respectively. All massage sessions were well tolerated. There was marked decrease in HR, systolic and diastolic BP and RR, (p < 0.01) in all study infants post massage, more profound among infants with NOWS (p < 0.01) than without NOWS.

CONCLUSIONS

Whole body massage is very well tolerated by infants with in-utero opioid exposure. Infants with NOWS had marked decrease in their HR and BP from their baseline after massage.

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..

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Australian Foster Carers' Views and Concerns Regarding Maternal Drug Use and the Safety of Breastmilk

Parental substance misuse and mental health issues are major factors associated with infant placement into out-of-home care. Such placements may result in disruption and/or cessation of breastfeeding. Provision of breastmilk to infants in out-of-home care (OOHC) is desirable in terms of infant health and development, and also in supporting maternal caregiving. However, little is known about how breastfeeding is supported for infants in out-of-home care. This study used an online survey to explore the facilitation of breastfeeding in the context of OOHC and foster carers' management of expressed breastmilk (EBM). Foster carers were generally open to the idea of maternal breastfeeding and infants in their care receiving EBM from their mothers. However, the majority of respondents expressed concern regarding the safety of EBM for infant consumption due to the possibility of harmful substances in the milk. Concerns regarding the safety of handling EBM were also prevalent. These concerns caused foster carers to discard EBM. Findings suggest foster carers' may lack knowledge related to maternal substance use and breastmilk. Better integration between health care and social service systems, where the voices of mothers, foster carers and child protection workers are heard, is necessary to develop solutions enabling infants living in OOHC access to their mother's breastmilk.

Pharmacological Prevention of Neonatal Opioid Withdrawal in a Pregnant Guinea Pig Model

Newborns exposed to prenatal opioids often experience intense postnatal withdrawal after cessation of the opioid, called neonatal opioid withdrawal syndrome (NOWS), with limited pre- and postnatal therapeutic options available. In a prior study in pregnant mice we demonstrated that the peripherally selective opioid antagonist, 6β-naltrexol (6BN), is a promising drug candidate for preventive prenatal treatment of NOWS, and a therapeutic mechanism was proposed based on preferential delivery of 6BN to fetal brain with relative exclusion from maternal brain. Here, we have developed methadone (MTD) treated pregnant guinea pigs as a physiologically more suitable model, enabling detection of robust spontaneous neonatal withdrawal. Prenatal MTD significantly aggravates two classic maternal separation stress behaviors in newborn guinea pigs: calling (vocalizing) and searching (locomotion) - natural attachment behaviors thought to be controlled by the endogenous opioid system. In addition, prenatal MTD significantly increases the levels of plasma cortisol in newborns, showing that cessation of MTD at birth engages the hypothalamic-pituitary-adrenal (HPA) axis. We find that co-administration of 6BN with MTD prevents these withdrawal symptoms in newborn pups with extreme potency (ID50 ∼0.02 mg/kg), at doses unlikely to induce maternal or fetal withdrawal or to interfere with opioid antinociception based on many prior studies in rodents and non-human primates. Furthermore, we demonstrate a similarly high potency of 6BN in preventing opioid withdrawal in adult guinea pigs (ID50 = 0.01 mg/kg). This high potency appears to run counter to our pharmacokinetic studies showing slow 6BN transit of both the placenta and maternal blood brain barrier in guinea pigs, and calls into question the preferential delivery mechanism. Rather, it suggests a novel receptor mechanism to account for the selectively high potency of 6BN to suppress opioid dependence at all developmental stages, even in adults, as compared to its well-established low potency as a classical opioid antagonist. In conclusion, 6BN is an attractive compound for development of a preventive therapy for NOWS.

A Review of Feeding Practices in Infants With Neonatal Abstinence Syndrome

BACKGROUND

There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero.

PURPOSE

To synthesize current feeding methods and practices used for infants diagnosed with NAS.

METHODS/SEARCH STRATEGY

PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding."

FINDINGS/RESULTS

Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding.

IMPLICATIONS FOR PRACTICE

Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS.

IMPLICATIONS FOR RESEARCH

Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.

Factors Associated With the Need for Pharmacological Management of Neonatal Opioid Withdrawal Syndrome

BACKGROUND

Neonatal opioid withdrawal syndrome (NOWS) is a significant and growing health problem that affects more than 23,000 infants annually, with an estimated hospital cost of more than $720 million.

PURPOSE

The purpose of this study was to examine factors associated with the need to initiate medication for the treatment of NOWS.

METHODS

A retrospective review of medical records was conducted of 204 infants born to mothers who used opioids during pregnancy from April 2011 to September 2017. Associations between maternal, infant, and environmental factors and the need for neonatal pharmacological management were examined using χ, t tests, and regression analysis.

RESULTS

Of 204 neonates exposed to opioids prenatally, 121 (59%) developed symptoms of NOWS, requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages (37.7 weeks vs 36.4 weeks; P < .001), and mothers were present at the neonate's bedside for a lower proportion of their total hospital stay (57% vs 74% of days; P < .001). Maternal factors associated with the need for neonatal medication treatment included the mother's reason for opioid use (P = .014), primary type of opioid used (P < .001), tobacco use (P = .023), and use of benzodiazepines (P = .003).

IMPLICATIONS FOR PRACTICE

This research provides information regarding the proportion of infants exposed to opioids prenatally who develop NOWS that requires treatment, as well as maternal, infant, and environmental factors associated with the need for neonatal medication use.

IMPLICATIONS FOR RESEARCH

Future research is needed to examine these relationships prospectively in a larger and more diverse sample.

Feasibility of auricular acupressure as an adjunct treatment for neonatal opioid withdrawal syndrome (NOWS)

BACKGROUND

The opioid epidemic in the United States continues to threaten public health. As a result of this crisis, neonatal opioid withdrawal syndrome (NOWS) has risen exponentially and requires a multitude of non-pharmacologic treatments to ensure healthy neonatal outcomes. Methods: This feasibility study implemented an acupressure protocol as informed by the Near-Term Infant (NTI) conceptual framework for the treatment of NOWS. Aims of this study were to assess provider training, effective integration of acupressure within the standard of care, and acceptance of this treatment by mothers and healthcare providers. Results: With maternal consent, a total of 12 participants were enrolled and underwent auricular acupressure. Nurse Practitioners were credentialed (75%) and effectively administered neonatal acupressure (100%) in accordance with the study protocol. Mothers were very satisfied with acupressure for the treatment of NOWS (Client Satisfaction Questionaire-8 mean scores 3.8-4.0 of a possible 4.0), and the majority of healthcare providers were supportive (66%, mean scores 3.6 to 4.0 out of possible 5). Conclusions: Auricular acupressure was successfully implemented within the standard of care for NOWS. Future studies should incorporate outlined suggestions and include qualitative measures of acceptance as well as randomized controlled trials to evaluate efficacy.

The evolution of the science of kangaroo (mother) care (skin-to-skin contact)

In the early 1970s, researchers in Ohio, USA, investigated the effects of "Extra Contact" between mothers and their infants early after birth. The "Extra Contact" consisted of the skin-to-skin holding of the newborn infant on the mother's bare chest as soon as possible after birth. In the mid 1970s, Rey and Martinez in Bogota Colombia started investigating the same care method and they called it "Kangaroo Care" (KC). Infants are held upright, skin-to-skin on the mother's bare chest. KC, also referred to as Kangaroo Mother Care or Skin-to-Skin Contact, has been and continue to be investigated for its effects on a plethora of infant, maternal and family outcomes. Evolution of our understanding of the advantages of KC has dramatically changed the care of infants including at risk infants. This article provides a look at the past and present. It also provides insight on how we can shape the future to provide the optimal care for infants, mothers, and the whole family.

Neonatal Abstinence Syndrome: An Integrative Review of Neonatal Acupuncture to Inform a Protocol for Adjunctive Treatment

BACKGROUND

The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes.

PURPOSE

The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS.

METHODS/SEARCH STRATEGY

An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included.

FINDINGS/RESULTS

A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain.

IMPLICATIONS FOR PRACTICE

This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS.

IMPLICATIONS FOR RESEARCH

Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.

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

In response to the opioid crisis, the American Physical Therapy Association has strongly advocated for physical therapy as a safe alternative to pharmacological pain management through the "#ChoosePT" campaign and the dedication of a PTJ special issue to the nonpharmacological management of pain. Physical therapists not only play an important role in the rehabilitation of the nearly 2 million adolescents and adults addicted to prescription opioids but also provide care to infants born to mothers with various drug addictions. This Perspective article explores the incidence, pathophysiology, and risk factors for neonatal abstinence syndrome and describes the clinical presentations of withdrawal and neurotoxicity in infants. Discipline-specific recommendations for the physical therapist examination and plan of care, including pharmacological management considerations, are outlined. Nonpharmacological management, including supportive care, feeding, parent education, social aspects of care, and follow-up services, are discussed from a physical therapy perspective. Finally, this article reviews developmental outcomes in infants with neonatal abstinence syndrome and reflects on challenges and future directions of research in this area.

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.

A Scoping Review of Acupuncture as a Potential Intervention for Neonatal Abstinence Syndrome

Objective: Neonatal abstinence syndrome (NAS) has risen drastically over the past decade. Infants with NAS experience extreme discomfort and developmental delays when going into withdrawal. Management includes multiple supportive and nonpharmacologic therapies as first-line treatments in an effort to reduce or prevent the need for medication management. Acupuncture has demonstrated efficacy in adults experiencing withdrawal from addictions, as well as for treating many other conditions in pediatric patients who have similar symptoms to withdrawal. The purpose of this review is to evaluate the safety and efficacy of acupuncture for neonates in withdrawal. Materials and Methods: This review was guided by the Arksey and O'Malley methodological framework, and analysis was performed based on a social ecological model. The PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] statement was used to organize selected publications, and a flow chart was created to display the search process. PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Databases were searched for relevant publications. Results: Acupuncture appears to be safe and effective for reducing withdrawal symptoms in infants, and, thus, should be considered as an additional nonpharmacologic treatment option for NAS.

Survey of Neonatal Intensive Care Unit Nurses' Use of a Motion/Sound Infant Seat

BACKGROUND

Perinatal substance exposure is an increasing concern in infants being cared for in neonatal intensive care units. Current recommendations support nonpharmacologic treatments for this population of infants. Multimodal (motion, sound) seats are often employed to soothe infants.

PURPOSE

The purpose of this study was to survey neonatal intensive care unit nurses on their practices regarding the use of a motion/sound infant seat.

METHODS

Sixty-six nurses (52% of 126 total nurses) completed the survey about their self-disclosed practices that included (1) reasons for use; (2) rationale for choice of settings of motion and sound; (3) duration of time infants spent in seat in one session; (4) perception of positive infant response; (5) who places infants in the seat; and (6) nursing instructions dispensed prior to use.

RESULTS

Chief reasons for use were infant state, lack of persons to hold infants, and a diagnosis of neonatal abstinence syndrome. Rationale for choice of motion and sound settings included trial and error, prior settings, personal preferences/patterns, assumptions, and random selection. Nurse responses regarding the amount of time the infant was placed in the seat in a single session ranged from 10 to 360 minutes, with determining factors of infant cues, sleeping, feeding, and someone else to hold the infant.

IMPLICATIONS FOR PRACTICE

As nonpharmacologic treatments evolve, nurses need guidelines for safe, effective interventions to care for infants.

IMPLICATIONS FOR RESEARCH

Further research is necessary to ascertain the responses of withdrawing infants and to establish guidelines and education for use of the motion/sound infant seat.

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.

Feeding Infants with Neonatal Abstinence Syndrome: Finding the Sweet Spot

PURPOSE

The purpose of this study is to learn how caregivers who are expert in feeding infants with neonatal abstinence syndrome (NAS) successfully feed these infants during withdrawal.

DESIGN/SAMPLE

Focus group methodology was used to gather information from self-identified experts from three large regional NICUs. Twelve NICU nurses and speech therapists participated in open-ended, recorded discussions. Detailed flip chart notes were taken, reviewed, and verified by the participants before the group ended.

RESULTS

Four major themes emerged verified by the participants: (1) optimal medication management, (2) follow the baby's cues, (3) calm and comfortable, and (4) nurture the relationship. Participants reported using both common and creative techniques. Keeping the infant calm was crucial to being successful, as well as maintaining good control of withdrawal signs. Feeding the infant facing away from them to avoid eye contact was used, as well as vertical rocking, continuous butt patting, bundling, "shhing" sound, and a novel feeding position.

Specialized Care of Women and Newborns Affected by Opioids With a CORE Team of Nurses

Staff on a mother-baby unit of a large suburban Level II facility identified the need to provide specialized nursing care to women affected by opioids. The manager of the unit recognized inconsistencies in care and frustration expressed by women and staff. She recruited a CORE (Champion for our Opiate patients using Respectful and Relevant Engagement and Education) group of staff nurses to care for these women. CORE nurses received specialized education and resources and served as the primary nurses for women admitted to the unit with a positive urine drug screening result or a history of drug use during pregnancy. Having a CORE team has brought a consistent approach when providing care to families affected by opioids.

Ohio Perinatal Quality Collaborative Improves Care of Neonatal Narcotic Abstinence Syndrome

OBJECTIVES

Neonatal abstinence syndrome (NAS) after an infant's in-utero exposure to opioids has increased dramatically in incidence. No treatment standards exist, leading to substantial variations in practice, degree of opioid exposure, and hospital length of stay.

METHODS

The Ohio Perinatal Quality Collaborative conducted an extensive multi-modal quality improvement initiative with the goal to (1) standardize identification, nonpharmacologic and pharmacologic treatment in level-2 and 3 NICUs in Ohio, (2) reduce the use of and length of treatment with opioids, and (3) reduce hospital length of stay in pharmacologically treated newborns with NAS.

RESULTS

Fifty-two of 54 (96%) Ohio NICUs participated in the collaborative. Compliance with the nonpharmacologic bundle improved from 37% to 59%, and the pharmacologic bundle improved from 59% to 68%. Forty-eight percent of the 3266 opioid-exposed infants received pharmacologic treatment of symptoms of NAS, and this rate did not change significantly across the time period. Regardless of the opioid used to pharmacologically treat infants with NAS, the length of treatment decreased from 13.4 to 12.0 days, and length of stay decreased from 18.3 to 17 days.

CONCLUSIONS

Standardized approaches to the identification and nonpharmacologic and pharmacologic care were associated with a reduced length of opioid exposure and hospital stay in a large statewide collaborative. Other states and institutions treating opioid-exposed infants may benefit from the adoption of these practices.

Comparison of Time to First Dose of Oral Morphine in the Treatment of Neonatal Abstinence Syndrome

OBJECTIVE

To compare time to first dose of oral morphine used in the treatment of neonatal abstinence syndrome (NAS) in a neonatal intensive care unit (NICU) versus a special care nursery (SCN) setting.

METHODS

A retrospective chart review was completed of patient data from two community hospitals in a single health network. Infants born at either facility between January 2013 and August 2015 were eligible for inclusion in the study if treated for NAS with a course of oral morphine. The primary outcome was time from birth to first dose of oral morphine. Secondary outcomes included details about the morphine treatment course, length of stay, and complications from NAS.

RESULTS

A total of 54 patients (19 NICU patients and 35 SCN patients) fulfilled inclusion criteria for the study. The primary outcome of median time from birth to first dose of oral morphine did not differ between the two groups (42.5 hrs [NICU] vs 43 hrs [SCN], p=0.53). No significant differences were found between the morphine regimens used in the two units. The median length of hospital stay (27 days [NICU] vs 26 days [SCN], p=0.66) and median length of NICU/SCN stay (26 days [NICU] vs 23 days [SCN], p=0.75) were not statistically significantly different. Time between transfer to the NICU or SCN and administration of the first dose of oral morphine was significantly shorter in the SCN setting (28 hrs [NICU] vs 4 hrs [SCN], p=0.009).

CONCLUSIONS

This study found that infants treated for NAS had similar treatment in an NICU and an SCN. No difference was observed in time from birth to initiation of medication therapy. In addition, no differences were seen in all but one marker for quality of care including length of stay and cumulative morphine dose. Infants treated for NAS, whether in an NICU or SCN setting, can receive similar treatment and comparable outcomes.

Nonopioid Management of Neonatal Abstinence Syndrome

BACKGROUND

Current standard therapy for moderate to severe neonatal abstinence syndrome (NAS) includes opioid administration and often results in separation of mother and infant. Impaired maternal-infant bonding and extended neonatal opiate exposure may be associated with adverse developmental outcomes. Increased use of nonopioid adjunctive NAS therapies may decrease postnatal opioid exposure and length of stay (LOS), thereby promoting positive developmental outcomes for NAS-affected infants.

PURPOSE

To review the efficacy of rooming-in care and acupuncture as nonpharmacologic adjunctive agents to reduce the magnitude of postnatal opioid exposure and LOS.

METHODS

PubMed, Ovid Medline, Embase, and CINAHL databases were searched for primary studies on rooming-in care and acupuncture as adjunctive treatments for NAS; 8 are included in this review.

FINDINGS

Rooming-in care may decrease postnatal opioid exposure and LOS in NAS-affected infants. Acupuncture is safe in NAS patients; however, its definitive effect on narcotic use and length of hospitalization are inconclusive.

IMPLICATIONS FOR PRACTICE

Rooming-in care should be offered to NAS patients. Strong evidence does not exist to recommend acupuncture as a routine NAS treatment.

IMPLICATIONS FOR RESEARCH

Additional randomized clinical trials are necessary to assess the efficacy of acupuncture and to confirm the effect of rooming-in care on NAS outcomes, and delineate optimal elements of a rooming-in care model.

Management of neonatal abstinence syndrome in the newborn nursery

Maternal drug use and neonatal abstinence syndrome (NAS) are being seen across the United States. NAS occurs with withdrawal disturbances in response to the cessation of the pregnancy exposure. The clinical presentation of a newborn with NAS can include gastrointestinal, neurologic, vasomotor and respiratory symptoms. Assessment of newborns with NAS can often present as a challenge to maternal-child nurses. Treatment can include supportive care as well as pharmacologic therapies.

Neonatal Abstinence Syndrome:The Experience of Infant Massage

Babies born to women who have used opioids during pregnancy frequently develop withdrawal symptoms following birth. Although a consistently used protocol is not available to treat these infants, interventions commonly used include a pharmacological regimen and supportive care such as swaddling, frequent feedings, decreased sensory stimulation, and protection from skin breakdown (Murphy-Oikonen, Montelpare, Bertoldo, Southon, & Persichino, 2012). A qualitative study was designed to better understand how infant massage might impact these babies’ behavior and the mothers’ relationship with their babies. Themes derived from the data include empowerment, enjoyment and bonding, and calm and comfort. The themes suggest that infant massage helps alleviate withdrawal symptoms in infants while fostering a connection between mother and child.

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.

Lactation and the Substance-Exposed Mother-Infant Dyad

Pregnant and postpartum women with substance use disorders have very unique needs and can present challenges to healthcare providers who are not familiar with how to evaluate and respond properly to their necessities. One such situation frequently arises when women with substance use disorders wish to breast-feed. There are many benefits and challenges to this practice that are specific to this population, and treating practitioners are often unclear on how to address them. The purpose of this article is to identify barriers to lactation in substance-exposed dyads and to provide strategies to mitigate these barriers and for promoting lactation in appropriate women with substance use disorders who wish to breast-feed.