Vibrotactile stimulation: A non-pharmacological intervention for opioid-exposed newborns

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.

Hush, little baby: The role of C-tactile afferents in babywearing infants with neonatal opioid withdrawal

Social touch through infant holding, skin-to-skin contact, and infant carrying (babywearing) decreases infant distress and promotes secure attachment. Unknown is the extent to which these effects are the result of the activation of C-Tactile afferents (CTs), the constellation of nerve fibers associated with affective touch, primarily located in the head and trunk of the body. The purpose of the present study was to compare dynamic touch (CTs activated) to static touch (CTs less activated) during a babywearing procedure among infants experiencing Neonatal Opioid Withdrawal Syndrome (NOWS). NOWS is a spectrum of clinical symptoms, including elevated heart rate (HR), associated with withdrawal from intrauterine opioid exposure. We hypothesized that stroking an infant's head during babywearing would amplify the pleasurable effect of babywearing as measured by changes in infant HR. Twenty-nine infants in a Neonatal Intensive Care Unit (NICU) in the Southwestern USA were worn in an infant carrier starting at five days old (M = 5.4, SD = 2.6; 46.2 % White, 26.9 % Latinx, 11.5 % Native American) and physiological readings were conducted daily; heart rates of infants and caregivers were taken every 15-seconds for 5-minutes, before, during, and after babywearing (30 min per phase). Each day infants alternated (randomly) in a static touch (hands-free babywearing) or dynamic touch condition (stroking the top of the infants' head at a velocity of 3 cm/s while babywearing). On average, infants completed 3 dynamic and 3 static babywearing sessions. Hospital and research staff participated in babywearing when a parent was not available (31.0 % of infants were exclusively worn by volunteers, 27.6 % were exclusively worn by parents). We analyzed the data using Hierarchical Linear Models due to the 3-level nested design (N = 29 infants, N = 191 readings, N = 11,974 heart rates). Compared to baseline (infant calm/asleep and without contact), infant's HRs significantly declined during and after babywearing, controlling for pharmacological treatment. These effects were significantly stronger during the dynamic touch condition (reduction in HR of 11.17 bpm) compared to the static touch condition (reduction in HR of 3.74 bpm). These effects did not significantly vary by wearer (mother, father, volunteer). However, differences between the dynamic and static conditions were significantly stronger in earlier babywearing sessions, potentially indicating a learning effect. There was evidence for a calming effect among caregivers as well, particularly in the dynamic touch condition, when caregivers were engaged in active touch. Activation of CTs appears to be an important mechanism in the physiological benefits of babywearing and in the symbiotic role of caregiver-infant attachment.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

Efficacy of a Vibrating Crib Mattress to Reduce Pharmacologic Treatment in Opioid-Exposed Newborns: A Randomized Clinical Trial

Importance

Pharmacologic agents are often used to treat newborns with prenatal opioid exposure (POE) despite known adverse effects on neurodevelopment. Alternative nonpharmacological interventions are needed.

Objective

To examine efficacy of a vibrating crib mattress for treating newborns with POE.

Design, Setting, and Participants

In this dual-site randomized clinical trial, 208 term newborns with POE, enrolled from March 9, 2017, to March 10, 2020, were studied at their bedside throughout hospitalization.

Interventions

Half the cohort received treatment as usual (TAU) and half received standard care plus low-level stochastic (random) vibrotactile stimulation (SVS) using a uniquely constructed crib mattress with a 3-hour on-off cycle. Study initiated in the newborn unit where newborns were randomized to TAU or SVS within 48 hours of birth. All infants whose symptoms met clinical criteria for pharmacologic treatment received morphine in the neonatal intensive care unit per standard care.

Main Outcomes and Measures

The a priori primary outcomes analyzed were pharmacotherapy (administration of morphine treatment [AMT], first-line medication at both study sites [number of infants treated], and cumulative morphine dose) and hospital length of stay. Intention-to-treat analysis was conducted.

Results

Analyses were performed on 181 newborns who completed hospitalization at the study sites (mean [SD] gestational age, 39.0 [1.2] weeks; mean [SD] birth weight, 3076 (489) g; 100 [55.2%] were female). Of the 181 analyzed infants, 121 (66.9%) were discharged without medication and 60 (33.1%) were transferred to the NICU for morphine treatment (31 [51.7%] TAU and 29 [48.3%] SVS). Treatment rate was not significantly different in the 2 groups: 35.6% (31 of 87 infants who received TAU) and 30.9% (29 of 94 infants who received SVS) (P = .60). Adjusting for site, sex, birth weight, opioid exposure, and feed type, infant duration on the vibrating mattress in the newborn unit was associated with reduction in AMT (adjusted odds ratio, 0.88 hours per day; 95% CI, 0.81-0.93 hours per day). This translated to a 50% relative reduction in AMT for infants who received SVS on average 6 hours per day. Among 32 infants transferred to the neonatal intensive care unit for morphine treatment who completed treatment within 3 weeks, those assigned to SVS finished treatment nearly twice as fast (hazard ratio, 1.96; 95% CI, 1.01-3.81), resulting in 3.18 fewer treatment days (95% CI, -0.47 to -0.04 days) and receiving a mean 1.76 mg/kg less morphine (95% CI, -3.02 to -0.50 mg/kg) than the TAU cohort. No effects of condition were observed among infants treated for more than 3 weeks (n = 28).

Conclusions and Relevance

The findings of this clinical trial suggest that SVS may serve as a complementary nonpharmacologic intervention for newborns with POE. Reducing pharmacotherapy with SVS has implications for reduced hospitalization stays and costs, and possibly improved infant outcomes given the known adverse effects of morphine on neurodevelopment.

Trial Registration

ClinicalTrials.gov Identifier: NCT02801331.

Assessment of a hearing protection device on infant sleep in the neonatal intensive care unit

Premature infants often require prolonged hospitalisation in the neonatal intensive care unit (NICU) where they are exposed to adverse noise that may disrupt sleep and further compromise recovery and developmental outcomes. This single-session trial assessed the effects of a novel circumaural hearing protection device (DREAMIES®; NEATCAP Medical LLC) on sleep in 10 premature infants (mean 34.1 weeks GA) in a Level III NICU. Using polysomnography (PSG), the infant's sleep was compared between three interfeed periods throughout which DREAMIES® was ON or OFF. Each infant received the same condition order, OFF1-ON-OFF2. The PSG 30 s epochs were scored by a rater masked to the condition as Quiet Sleep, Active Sleep, Indeterminate Sleep, and Wake. There was a 14.1% increase in sleep from OFF1 to ON (p = 0.05) and an 18.4% decrease in sleep from ON to OFF2 (p = 0.02); an analogous inverse effect was observed for wake (χ2  = 5.03, p = 0.08). There was a main effect of DREAMIES on active sleep (χ2  = 7.4, p = 0.025) due to more active sleep for ON1 (46%) compared with OFF2 (32%; p = 0.074). No significant effect was observed for quiet sleep or indeterminate sleep. On average, the sound level was 51 dBA (range 36-113 dBA) and did not differ significantly among the three periods. The strongest relationship between the minute-by-minute maximum sound level and movement actigraphy was observed for the OFF1 condition (ρ0.301, p < 0.001). These findings suggest that DREAMIES® may augment sleep in premature infants by reducing acute episodes of adverse noise in the NICU.

Actigraphy: Metrics reveal it is not a valid tool for determining sleep in neonates

Study of emerging sleep-wake patterns in neonates is important for promptly identifying and treating abnormal sleep behaviours to ensure healthy infant development and neurobehavioral outcomes. Current methods to assess sleep are costly, labour intensive, and particularly difficult to implement in fragile, hospitalised infants requiring intensive medical care. The aim of the present study was to assess the validity of actigraphy as a tool for detecting sleep in preterm infants, using polysomnography (PSG) as the "gold standard". A total of 10 neonates (mean [SD] 35.8 [1.2] weeks post-menstrual age; five female) hospitalised since birth for prematurity each participated in one 8-10 hr session during which PSG and actigraphy were recorded simultaneously. Inter-feed minute-by-minute PSG Sleep-Wake scores were compared to concurrent actigraph epochs categorised as either "Sleep" or "Wake" using three separate movement-per-minute thresholds (≤20, ≤40, ≤80). Tool validity was assessed using five metrics. A key finding was that for each of the movement thresholds there was high agreement rate, sensitivity, and predictive value of sleep (85.2%-97.2%), whereas specificity and predictive value of wake remained low (12%-46%). Receiver operating characteristic curve analysis also revealed low discriminatory power of actigraphy for estimating sleep (area under the curve = 0.636; Youden's Index J = 0.2173). Lack of sufficient minutes of autonomous wake periods among infants was identified as a key limitation in actigraphy. Findings from the present study suggest actigraphy cannot be validated for Sleep/Wake discrimination in preterm infants and that proper validation requires sufficient data from periods of both Sleep and Wake.

The benefits of underwater vibrostimulation in the rehabilitation of children with impaired hearing

INTRODUCTION

Early intervention is crucial for the optimal speech and language development of children with impaired hearing. Underwater vibrostimulation could help develop behavioural reactions to low-frequency stimuli immediately after diagnosis and facilitate aural rehabilitation after hearing aid (HA) or cochlear implant (CI) activation.

GOALS

To determine the limits of underwater vibrotactile stimuli perception and to measure the effect of vibrostimulation training on the aural rehabilitation of young children.

METHODS

Two adults and three children with congenital hearing loss participated in the first part of the study. Pure tones between 100 and 4000 Hz and natural broadband sounds were delivered under water while the participants were sitting in a pool. The lower thresholds of perception and the maximum comfortable levels were measured and the subjective sensations were recorded. In the second part of the study, 15 children <3 years old were presented with the same stimuli until they developed stable conditioned reactions to the stimuli. The time until the development of "hearing behaviour" and the number of fitting sessions after HA or CI activation were compared between the vibrostimulation group and a control group who did not receive such training.

RESULTS

In the first part of the study, participants were most sensitive to 100-400 Hz stimuli, while the stimuli >1000 Hz did not evoke any sensations. The vibrations were felt across all body parts and produced hearing-like sensations in the ear. In the second part of the study, children in the vibrostimulation group required fewer fitting sessions and developed "hearing behaviour" sooner than the control group.

CONCLUSIONS

Underwater vibrostimulation is a promising new method of early aural rehabilitation that could be recommended for implementation in paediatric audiology centres.

Stabilizing breathing pattern using local mechanical vibrations: comparison of deterministic and stochastic stimulations in rodent models of apnea of prematurity

Mechanical stimulation has been shown to reduce apnea of prematurity (AOP), a major concern in preterm infants. Previous work suggested that the underlying mechanism is stochastic resonance, amplification of a subthreshold signal by stochastic stimulation. We hypothesized that the mechanism behind the reduction of apnea length may not be a solely stochastic phenomenon, and suggest that a purely deterministic, non-random mechanical stimulation could be equally as effective. Mice and rats were anesthetized, tracheostomized, and mechanically ventilated to halt spontaneous breathing. Two miniature motors controlled by a microcontroller were attached around the abdomen. Ventilation was paused, stimulations were applied, and the time to the rodent's first spontaneous breath (T) was measured. Six spectrally different signals were compared to one another and the no-stimulation control in mice. The most successful deterministic stimulation (D) at reducing apnea was then compared to a pseudo-random noise (PRN) signal of comparable amplitude and frequency. CO₂%, CO₂ stabilization time (T_s), O₂ saturation (SpO₂%), and T were also measured. D significantly reduced T compared to no stimulation for medium and high amplitudes. PRN also reduced T, without  a difference between D and PRN. Furthermore, both stimulations significantly reduced T_s with no significant differences between the respective stimulations. However, there was no effect of D or PRN on SpO₂%. The lack of differences between D and PRN led to an additional series of experiment comparing the same D to a band-limited white noise (WN) signal in young rats. Both D and WN were shown to significantly reduce T, with D showing statistical superiority in reduction of apnea. We further speculate that both deterministic and stochastic mechanical stimulations induce some form of mechanotransduction which is responsible for their efficacy, and our findings suggest that mechanical stimulation may be effective in treating AOP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-021-00203-x.

Study design and rationale for a randomized controlled trial to assess effectiveness of stochastic vibrotactile mattress stimulation versus standard non-oscillating crib mattress for treating hospitalized opioid-exposed newborns

The incidence of Neonatal Abstinence Syndrome (NAS) continues to rise and there remains a critical need to develop non-pharmacological interventions for managing opioid withdrawal in newborns. Objective physiologic markers of opioid withdrawal in the newborn remain elusive. Optimal treatment strategies for improving short-term clinical outcomes and promoting healthy neurobehavioral development have yet to be defined. This dual-site randomized controlled trial (NCT02801331) is designed to evaluate the therapeutic efficacy of stochastic vibrotactile stimulation (SVS) for reducing withdrawal symptoms, pharmacological treatment, and length of hospitalization, and for improving developmental outcomes in opioid-exposed neonates. Hospitalized newborns (n = 230) receiving standard clinical care for prenatal opioid exposure will be randomly assigned within 48-hours of birth to a crib with either: 1) Intervention (SVS) mattress: specially-constructed SVS crib mattress that delivers gentle vibrations (30–60 Hz, ~12 μm RMS surface displacement) at 3-hr intervals; or 2) Control mattress (treatment as usual; TAU): non-oscillating hospital-crib mattress. Infants will be studied throughout their hospitalization and post discharge to 14-months of age. The study will compare clinical measures (i.e., withdrawal scores, cumulative dose and duration of medications, velocity of weight gain) and characteristic progression of physiologic activity (i.e., limb movement, cardio-respiratory, temperature, blood-oxygenation) throughout hospitalization between opioid-exposed infants who receive SVS and those who receive TAU. Developmental outcomes (i.e., physical, social, emotional and cognitive) within the first year of life will be evaluated between the two study groups. Findings from this randomized controlled trial will determine whether SVS reduces in-hospital severity of NAS, improves physiologic function, and promotes healthy development.

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice.

OBJECTIVES

To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials.

SELECTION CRITERIA

We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication.

MAIN RESULTS

We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.

Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review

Background

Neonatal withdrawal secondary to in utero opioid exposure is a growing global concern stressing the psychosocial well-being of affected families and scarce hospital resources. In the ongoing search for the most effective treatment, randomized controlled trials are indispensable. Consistent outcome selection and measurement across randomized controlled trials enables synthesis of results, fostering the translation of research into practice. Currently, there is no core outcome set to standardize outcome selection, definition and reporting. This study identifies the outcomes currently reported in the literature for neonates experiencing withdrawal following opioid exposure during pregnancy.

Methods

A comprehensive literature search of MEDLINE, EMBASE and Cochrane Central was conducted to identify all primary research studies (randomized controlled trials, clinical trials, case-controlled studies, uncontrolled trials, observational cohort studies, clinical practice guidelines and case reports) reporting outcomes for interventions used to manage neonatal abstinence syndrome between July 2007 and July 2017. All “primary” and “secondary” neonatal outcomes were extracted by two independent reviewers and were assigned to one of OMERACT’s core areas of “pathophysiological manifestation”, “life impact”, “resource use”, “adverse events”, or “death”.

Results

Forty-seven primary research articles reporting 107 “primary” and 127 “secondary” outcomes were included. The most frequently reported outcomes were “duration of pharmacotherapy” (68% of studies, N = 32), “duration of hospital stay” (66% of studies, N = 31) and “withdrawal symptoms” (51% of studies, N = 24). The discrepancy between the number of times an outcome was reported and the number of articles was secondary to the use of composite outcomes. Frequently reported outcomes had heterogeneous definitions or were not defined by the study and were measured at different times. Outcomes reported in the literature to date were mainly assigned to the core areas “pathophysiologic manifestations” or “resource use”. No articles reported included parent or former patient involvement in outcome selections.

Conclusions

Inconsistent selection and definition of primary and secondary outcomes exists in the present literature of pharmacologic and nonpharmacologic interventions for managing opioid withdrawal in neonates. No studies involved parents in the process of outcome selection. These findings hinder evidence synthesis to generate clinically meaningful practice guidelines. The development of a specific core outcome set is imperative.

Systematic mixed-study review of nonpharmacological management of neonatal abstinence syndrome

BACKGROUND

Neonatal abstinence syndrome is a multisystem disorder resulting from exposure to maternal addictive substance use in pregnancy. Withdrawal is characterized by neonatal tremors, feeding difficulties, and sleep disruption. The aim of this systematic review is to explore the nonpharmacological management of infants at risk of neonatal abstinence syndrome after prenatal exposure.

METHODS

A systematic mixed-study review was conducted. A search of CINAHL, MEDLINE, AMED, PsycARTICLES, PsycINFO, and Web of Science was performed for relevant articles published between January 2007 and June 2018. Quantitative and qualitative data were extracted and thematic analysis undertaken. The findings were synthesized as a narrative summary.

RESULTS

Fourteen studies were included in the review, of which nine were quality improvement initiatives and five explored complementary therapies. The most common components of nonpharmacological management were consolation therapy and rooming-in of mother and baby. Implementation strategies incorporated family integrated care and practitioner training in the evaluation of neonatal withdrawal. When nonpharmacological management was applied, there was a reduction in the need for pharmacotherapy and a shorter hospital stay for newborns. Potential barriers to effective management included unreliable assessment tools, judgmental practitioner attitudes, and limited breastfeeding promotion.

CONCLUSIONS

Providing and optimizing nonpharmacological management for the infant at risk of neonatal abstinence syndrome improves outcomes by reducing their length of hospital stay and the need for pharmacotherapy.

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.

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.

Neonatal Abstinence Syndrome: An Uncontrollable Epidemic

There is an uncontrollable epidemic of drug abuse, with the misuse of opioids the most alarming. Along with the increase in opioid abuse, there exists a concomitant upsurge in the number of neonates experiencing neonatal abstinence syndrome (NAS) due to the effects of the mother's withdrawal from the drug. Neonates experiencing NAS exhibit various nervous system, gastrointestinal, and respiratory untoward symptoms. Diagnosis is determined by taking an accurate maternal history and assessment of clinical signs and symptoms. Clinical management strategies include pharmacologic and nonpharmacologic therapies. Nursing care is evidence based, includes nonpharmacologic therapies, and focuses on prevention and support.

Quantifying Movement in Preterm Infants Using Photoplethysmography

Long-term recordings of movement in preterm infants might reveal important clinical information. However, measurement of movement is limited because of time-consuming and subjective analysis of video or reluctance to attach additional sensors to the infant. We evaluated whether photoplethysmogram (PPG), routinely used for oximetry in preterm infants in the neonatal intensive care unit (NICU), can provide reliable long-term measurements of movement. In 18 infants [mean post-conceptional age (PCA) 31.10 weeks, range 29-34.29 weeks], we designed and tested a wavelet-based algorithm that detects movement signals from the PPG. The algorithm's performance was optimized relative to subjective assessments of movement using video and accelerometers attached to two limbs and force sensors embedded within the mattress (five infants, three raters). We then applied the optimized algorithm to infants receiving routine care in the NICU without additional sensors. The algorithm revealed a decline in brief movements (< 5 s) with increasing PCA (13 infants, r = - 0.87, p < 0.001, PCA range 27.3-33.9 weeks). Our findings suggest that quantitative relationships between motor activity and clinical outcomes in preterm infants can be studied using routine photoplethysmography.

A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool: Challenges in Obtaining Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome

BACKGROUND

Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs.

PURPOSE

This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses.

METHODS

One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training.

RESULTS

Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology.

IMPLICATIONS FOR PRACTICE

Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time.

IMPLICATIONS FOR RESEARCH

This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.