SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – A nonpharmacologic approach to neonatal abstinence syndrome (NAS) appears to reduce the use of morphine and may shorten hospital stay, compared with the conventional evaluation that looks at symptoms of opioid withdrawal, a study showed.
“If you focus on the well-being of these infants rather than a list of symptoms, you are much less likely to start medication. Our approach inherently destigmatizes the parents of these infants by allowing them to focus on the same things that any other parent focuses on,” said Matthew Lipshaw, MD, a pediatrician at Yale–New Haven (Conn.) Children’s Hospital.
The conventional system – the Finnegan Neonatal Abstinence Scoring System ( FNASS ) – has been around since the mid-1970s. It guides treatment, which is generally drug based, according to a battery of symptoms of opioid withdrawal that impair eating and sleeping. In FNASS, three consecutive scores of 8 or higher, or two consecutive scores of 12 or higher, trigger the use of morphine or an increased dose. Morphine is decreased if scores less than 8 are achieved for 24 hours.
The novel approach aims instead to avoid drug use. According to Dr. Lipshaw, the nonintrusive approach “assesses infants’ ability to function as infants during their withdrawal.” The approach provides a low-stimulation environment featuring rooming-in by mothers, and frequent feeding of their infants. Dubbed ESC, the approach gauges the ability of an infant to eat 1 ounce or more or breastfeed well, sleep undisturbed for an hour or longer, and be consolable within 10 minutes.
The ESC approach replaced the FNASS at Yale–New Haven Children’s Hospital in 2013. While patient management decisions since then have been based on ESC, FNASS scores have continued to be collected every 2-6 hours. This provided the researchers with the means to conduct a head-to-head comparison of the two systems on the same patients.
The records of 50 consecutive newborns born from March 2014 to August 2015 who had been exposed to opioids for at least 30 days prior to birth were reviewed. The primary outcome was the proportion of infants treated with morphine. Secondary outcomes included disagreements between the two approaches on a daily basis, seizures, 30-day readmissions, and need for more intensive care.
The neonates (56%, female) were mostly white. All were born at greater than 36 weeks’ gestation. Opioid exposure was methadone in 80% of cases and buprenorphine in 14%, with the remaining 6% exposed to hydrocodone, Percocet (acetaminophen/oxycodone), and/or OxyContin (oxycodone).
Morphine was started in 6 (12%) of the 50 patients. If the FNASS protocol had of been followed, 31 (62%) of the infants would have been started on morphine (P less than .01). Over a span of 296 hospital days, when the ESC protocol was used, morphine was not used 87% of the time, morphine use was increased 3% of the time, use was decreased 7% of the time, and use was maintained 3% of the time. If decisions had been made based on the FNASS protocol, the frequency of nonuse, increased use, decreased use, and maintained use of morphine would have been 53%, 26%, 12%, and 10%, respectively (all P less than .01).
The use of morphine was less than the FNASS recommendation on 78 days (26% of the total days). Moreover, the FNASS scores on the days following the decreased use of morphine were lower by an average of 0.9 points and were decreased in 69% of cases. The ESC protocol led to greater morphine use than recommended by the FNASS protocol on only 2 days. Both times, the FNASS score was increased the following day.
No adverse events occurred during the study.
“These findings are significant because nearly all institutions use the Finnegan score to guide management, and most research has used Finnegan-based medication thresholds to evaluate new medical therapies. Our point is that if you base your assessment on function, many of these infants may not need medication at all. We have had dramatic reductions in length of stay, which allows these infants to get home and minimize the interruption in this crucial period for maternal-child bonding in these high-risk patients,” Dr. Lipshaw said at the Pediatric Academic Societies meeting.
So far, only the Boston Medical Center has implemented the new system. This does not surprise Dr. Lipshaw: “Most places have been using a symptom-based approach for decades. It requires major buy in from physicians and nurses who have been doing things differently for a long time.”
He said is not deterred, however, and pointed to ongoing efforts by colleagues at Yale–New Haven Hospital and Boston Medical Center that are underway that could led to the ESC’s use in a network of hospitals in New Hampshire and Vermont.
The study was sponsored by Yale–New Haven Children’s Hospital and was not funded. Dr. Lipshaw reported having no relevant financial disclosures.
