research leads to decreased hospital says for drug-dependent newborns

Neonatal abstinence syn­drome (NAS) is the term used to describe the constellation of symptoms associated with an infant’s withdrawal from nar­cotics.^1-3  The incidence of NAS has been rising rapidly over the last decade both in Ohio and the United States. Since 2010, the most common drug of exposure in infants born in Ohio has been opioids.⁴  It is not uncommon for infants exposed to opioids in utero to have multiple substance exposures.

scope of the problem

In Ohio, the rate of NAS increased from 14 per 10,000 live births in 2004 to 121 per 10,000 live births in 2013. An estimated 50 percent increase was noted between 2009 and 2011 (The Ohio Children’s Hospital Neonatal Research Consortium, unpublished data, July 2012). There were nearly five admissions for NAS in Ohio per day in 2013 equating to 1,691 inpatient admissions. ⁴ The rate of NAS has increased nationally and Ohio’s rate in 2009 was higher than the national average of 34 per 1,000 live births (Figure 1).

burden on the system

Neonatal abstinence syndrome is a heavy burden on Ohio. In 2013, Medicaid was the payer for approximately 81 percent of hospitalizations for newborns with NAS with a total cost of over $97 million. The cost for each infant with NAS increased from $31,514 in 2004 to $57,897 in 2013, with an average of 14 to 20 days per hospitalization. Payment for NAS claims com­prised less than three percent of total Medicaid claims. ⁴

symptoms of NAS

NAS symptoms are character­ized by neurologic excitability and gastrointestinal dysfunc­tion (Table 1). Infants suffering from withdrawal are evaluated and treated based on the symp­toms exhibited.

There are several NAS scor­ing systems in use; the most widely used is the Finnegan Neonatal Abstinence Scor­ing Tool (FNAST). The FNAST evaluates 21 symptoms of NAS and treatment is based on the score. A newborn who is not experiencing withdrawal, or whose withdrawal is adequately managed, is expected to have a FNAST score of 8 or less.

In Ohio in 2013, 15.3 percent of infants with NAS had feeding difficulties compared to 4 per­cent of all infants in Ohio.4 In addition, 25.5 percent of infants with NAS were low birth weight infants compared to 12.7 percent overall. Twenty-four percent of infants with NAS had respirato­ry symptoms compared with 10 percent of all Ohio infants. Sei­zures were noted in 0.9 percent of infants with NAS compared to 0.2 percent among all Ohio newborns (Table 2).

treatment of NAS

Treatment of infants with NAS includes both pharmacologic and non-pharmacologic measures. Non-pharmacologic treatment is the baseline treat­ment for any infant exposed to intrauterine opioids and at risk for withdrawal. Parents, families and the staff caring for the newborn each assist in the non-pharmacologic management of NAS. Treatment consists of low stimulation activities that may be enough to control withdrawal symptoms and avoid the use of opiates. The components of non-phar­macologic management are low lighting, low stimulation (quiet environment), swaddling, gentle rocking, kangaroo care (skin-to-skin holding), clothed cuddling and small, frequent feedings of higher calorie (22 kcal/oz.) lactose-free formula or breastmilk (if the mother is in a treatment program). The higher calorie feeds meet the high metabolic needs of the infant with NAS for approximately the first week of life.^3,5

Pharmacologic management is offered when non-pharma­cologic management fails to control the symptoms of NAS. Medication treatment is pro­vided with several medications; methadone and morphine are the most frequently used with phenobarbital as an adjunctive therapy.3 The Ohio Children’s Hospital Association NAS Re­search Collaborative found that use of a stringent weaning pro­tocol was the most important predictor of duration of opioid treatment and length of stay. The study also found patients receiving treatment with a protocol that used morphine had a longer duration of phenobarbital use than those using methadone.²

Medication management is based on the severity of symptoms or the scoring tool used; therefore, consistent scoring is a necessity. In an effort to establish consistent scoring, inter-observer reliability was undertaken by Dayton Children’s Hospital Newborn Intensive Care Unit in 2012. Inter-observer reliability was established with over 90 percent of nursing and medical staff achieving greater than 90 percent reliability with the FNAST. The inter-observer reliability resulted in an immediate decrease in treatment by an average of 10 days. This was followed by implementation of a standard­ized protocol for methadone weaning that also resulted in a further decrease in the length of stay (Figure 2). NAS staff education, inter-observer reliability and adherence to a weaning protocol have decreased length of treatment and length of stay for NAS.⁹

legislation

Several legislative bills were passed in 2014 to provide better monitoring of newborns with intrauterine substance exposure and assist in the diagnosis and treatment of NAS. A prescriber or their delegate may now access the Ohio Automated Rx Reporting System (OARRS) for information related to the mother of a patient if the information is for the purpose of providing medical treatment to a newborn or infant diagnosed as opioid dependent.6

In addition, all maternity units, newborn care nurseries and maternity homes are required to report all newborns born to Ohio residents who are dependent on opioids.⁷

Tennessee is the only state that explicitly criminalizes drug use during pregnancy. Several other states consider drug use in pregnancy child abuse or child neglect. There has been concern voiced by maternal-child health care providers that criminalizing drug use in pregnancy would cause pregnant women to delay or avoid seeking prenatal care.

Ohio initiatives

There are multiple initiatives in Ohio and nationwide to address the problem of NAS. The Ohio Perinatal Quality Collaborative (OPQC) is currently working on a statewide quality improve­ment project with an aim “to increase the identification of and compassionate treat­ment for full-term infants born with NAS, thereby reducing the length of stay for these infants by 20 percent across partici­pating sites by June 30, 2015” (OPQC, Neonatal Abstinence Syndrome Project, 2012).

The Maternal Opiate Medical Support (M.O.M.S.) Project was announced in 2011 with a goal of supporting interven­tions and prenatal treatments that will serve 300 women. The project also intends to shorten the length of stay in NICUs by offering mothers counseling, medication assisted treatment and case management (Ohio Department of Mental Health and Addiction Services, 2015).

The Ohio Children’s Hospital Association (OCHA) NAS Research Collaborative is study­ing types of drug exposures and co-exposures in Ohio’s children’s hospitals. The collaborative is also documenting current treatment and standardizing treatment with the goal to identify the treatment associ­ated with the best outcomes, shortest length of treatment and shortest length of stay (OCHA).

There are multiple ongoing projects in the state of Ohio to identify and treat the growing number of infants with NAS. The treatment goals are based on a consistent evaluation and scoring system with the aim to decrease the length of post-birth exposure to opiates as well as maximize the non-pharmaco­logic management of NAS.

Dayton initiatives

Promise to Hope-Mother to Baby is a pilot project based at Miami Valley Hospital. The program provides free prenatal care and a physician dedicated to supervising the drug treatment of pregnant women. The program began accepting patients May 11, 2015, and intends to serve 100 women in the first year. Pregnant women using drugs can call 937-208-4814 for information.

Brigid’s Path is a facility that is being planned to allow infants to go through withdrawal out­side the hospital and in an envi­ronment that is more like home. Brigid’s Path will provide care for withdrawing babies and their families. (http://www.brigidspath.org)

references

1. American Academy of Pedi­atrics Committee on Drugs. Neonatal drug withdrawal. Pediatrics. 2008;e540-e560. doi:10.1542/peds.2011-3212.
2. Hall ES, Wexelblatt SL, Crow­ley M, Grow JL, Jasin LR, et al. A multicenter cohort study of treatments and hospital outcomes in neonatal absti­nence syndrome. Pediatrics. 2014;134(2):e527-e534.
3. Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;e540-e560. doi:10.1542/ peds.2011-3212.
4. Ohio Department of Health. Neonatal Abstinence Syndrome (NAS) in Ohio, 2004-2013. Preliminary Report. 2015. 
5. Ohio Perinatal Quality Collab­orative. Provision of 22-calo­rie, lactose free formula for infants with NAS. 2014. 
6. Ohio Revised Code. 4729.80 Information provided from drug database – record of re­quests – confidentiality. 2014. 
7. Ohio Revised Code. 3711.30 Reports of opioid depen­dence. 2014. 
8. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syn­drome and associated health care expenditures: United States 2000-2009. Journal of the American Medical Associ­ation. 2012;9;307(18):1934-40. doi: 10.1001/jama.2012.3951.