Advancing Best Practice for Neonatal Abstinence Syndrome

Department of Pediatrics - Winter 2017 

 Moira Crowley, MD

As the epidemic of narcotics use among adults spread across the United States, neonatologists began to see a corresponding epidemic in NICUs--more and more narcotic-exposed newborns. Current estimates are that one newborn exposed to opioids in utero is born every 25 minutes in the United States. The result may be a baby suffering from Neonatal Abstinence Syndrome (NAS), which produces fever, diarrhea, poor feeding and potentially seizures and death in already fragile infants.

University Hospitals Rainbow Babies & Children’s Hospital neonatologists are part of a unique collaborative in Ohio, the Ohio Children’s Hospital Neonatal Abstinence Syndrome Consortium (OCHNAS) that helped define a standardized protocol for the care of babies born with NAS. Through a series of multi-site studies, this protocol has led to a reduction of the length of time a newborn needs to stay in the NICU for treatment and how long that newborn needs pharmacological treatment. Ideally, it may also reduce the number of newborns who need pharmacological intervention for NAS.

“The key is strict adherence to the entire protocol from initiation of therapy through weaning off of medication,” says Moira Crowley, MD, Director, Fetal Consultative Service, Co-Director, Neonatal ECMO Program, and Neonatologist, UH Rainbow Babies & Children’s Hospital; Assistant Professor of Pediatrics, Case Western Reserve University School of Medicine.

The protocol trains care providers to ensure consistent application of a single scoring tool, the modified Finnegan scale, based on the frequency of more than 20 symptoms, such as fever, vomiting and excessive crying. The score serves as a determinant for whether an opiate-exposed newborn requires pharmacological intervention in addition to the standard non-pharmacologic tactics, such as a low stimulation environment, skin-to-skin or close contact with parents or caregivers, regular swaddling, and breastfeeding, when appropriate.

The OCHNAS implemented this standardized protocol across six Ohio children’s hospitals to measure the impact of uniform application. Hospitals that adopted it saw a significant decrease in the duration of opioid treatment and a decrease in inpatient hospital stay. Since then, the coalition has partnered with the Ohio Perinatal Quality Collaborative (OPQC) to spread adoption of the Ohio protocol and to launch studies that will refine it further. The protocol is now in use in 54 level 2 and level 3 NICUs across Ohio to gauge effectiveness. The results from this study group will be published in late 2016.

“We know that any exposure to an opioid can have negative developmental effects on a newborn,” Dr. Crowley says. “The outcomes of these studies will define key milestones for treatment progress, including making improvements to the non-pharmacological interventions, so we can get more children through NAS with less exposure to additional opioids. We’re eager to share our results with hospitals around the country who are struggling to identify and treat the many infants with NAS they see.”

Advocating to reduce opioid exposure on a national level

Michele Walsh, MD, MSE, Chief of Neonatology at UH Rainbow Babies & Children’s Hospital and Professor of Pediatrics at Case Western Reserve University School of Medicine, testified in April 2016 before the United States Senate Homeland Security and Government Reform Committee about the importance of a comprehensive approach to reducing opioid exposure, including better education for physicians, dentists, and other prescribers about appropriate pain treatments, how narcotics should be limited as treatment for pain, and how to recognize the signs of addiction.

“Never have I seen a public health epidemic of such severity as the current opiate epidemic among our citizens,” Dr. Walsh stated. “We must focus our efforts on a cohesive national strategy that attacks every facet of this complicated problem.”

Contact Drs. Crowley and Walsh at Peds.Innovations@UHhospitals.org.