neonatal abstinence syndrome · 2018-11-14 · neonatal abstinence syndrome: reconsidering the...

Neonatal Abstinence Syndrome: Reconsidering the Standard Approach

Matthew Grossman, M.D.Assistant Professor of Pediatrics

Yale School of MedicineQuality and Safety Officer

Yale-New Haven Children’s Hospital

DISCLOSURE

The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report.

Source: http://familytalk.ca/heroin/Patrick, et al. Journal of Perinatology. 2015; 35:650-655

Opioids in the US

Prescriptions grew 4-fold over

last decade

More deaths than car

accidents

91 people die each day from

opioids

In 2012, enough opioids were

prescribed to give every adult

in the US one prescription

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2000 2003 2006 2009 2010 2011 2012

NA

S p

er

10

00

Ho

sp

ital

Bir

ths

Year

Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to

2012. J Perinatol. Apr 30 2015.

Patrick SW, et. al. Neonatal Abstinence Syndrome and Associated Healthcare Expenditures – United States, 2000-2009. JAMA. 2012 May 9;307(18):1934-40.

Incidence of NAS in the US, 2000-2012

Source: Grossman Family Album

Langenfeld, et al. Drug and Alcohol Dependence 2005;77:31–6.

Source: http://wings.buffalo.edu/aru/preprohibition.htm

Jackson L, et al. Archives of Disease in Childhood 2004;89: F300–4.

Source: http://olivier-dogot.blogspot.com

Coyle MG. Journal of Pediatrics 2002;140:561–4

Source: http://www.bad-drug.net

Source: http://www.projectknow.com

MS Brown et al. Journal of Perinatology 2014; (1-6)

Agthe, et al. Pediatrics 2009;123:e849–56.

Source: http://www.recovery.org

Standard Approach

Medications

NICU

Finnegan Scores

Medication Dosing

Staff cares for the baby

0

5

10

15

20

25

30

2003-June 2006 July 2006-2009

LOS

(da

ys)

Length of Stay: Methadone-Exposed Infants

P <.02

Medication Studies

DTO vs. DTO plus clonidine: 17 days vs. 12 days

Morphine vs. Phenobarbitone: 8 days vs. 12 days

Morphine vs. DTO 30 days vs. 27 days

DTO vs. DTO plus Phenobarbitone 79 days vs. 38days

Methadone vs. Morphine 17 days vs. 24 days











0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2003 2004 2005 2006 2007 2008 2009 2010

% T

rea

ted

wit

h M

orp

hin

e

Year

Percent of NAS Patients Treated with Morphine

UCL 47.1

LCL 0.00.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

LE

NG

TH

OF

ST

AY

(D

ay

s)

ADMIT DATE

Mean=22.5

Length of Stay: Methadone exposed infants

The standard approach: why?

Medications


Abraham, et al. J Obstet Gynaecol Can 2010;32(9):866–871

Intervention 1

Focus on non-pharmacologic care

26

UCL

29.1

LCL 0.00.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

LE

NG

TH

OF

ST

AY

(D

ay

s)

ADMIT DATE


Standardized non-pharm care

Mean=22.5

Mean=13.2


Medications

NICU

Source: http://medicine.yale.edu

Source: http://adamandsarahcoats.blogspot.com

Intervention 2

Direct transfer to the general inpatient unit

32

UCL

32.5

CL

10.2

LCL 0.00.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1/30

/08

6/1

2/0

8

7/18

/08

10/1

5/0

8

12/1

/08

1/13

/09

2/7

/09

4/6

/09

5/13

/09

6/1

4/0

9

9/1

0/0

9

10/5

/09

12/1

8/0

9

2/2

3/10

3/19

/10

6/2

3/10

9/2

3/10

11/2

3/10

12/1

8/1

0

2/1

7/11

3/8

/11

4/2

7/11

5/19

/11

7/2

6/1

1

9/1

6/1

1

10/7

/11

12/1

/11

12/2

6/1

1

2/1

1/12

4/1

7/12

5/13

/12

6/8

/12

7/16

/12

9/2

7/12

10/1

4/1

2

11/1

7/12

1/2

5/13

2/2

3/13

3/2

1/13

4/1

5/13

5/2

1/13

6/9

/13

8/2

1/13

9/2

6/1

3

11/2

1/13

11/3

0/1

3

12/3

0/1

3

2/4

/14

3/2

6/1

4

4/1

9/1

4

5/10

/14

LE

NG

TH

OF

ST

AY

(D

ay

s)

ADMIT DATE

Direct transferto inpatient unit

Mean=10.2



Mean=22.5

Mean=13.2


Medications

NICU

Finnegan Scores

“The infant with a score of “7” or less was not treated with drugs for the abstinence syndrome because, in our

experience, he would recover rapidly with swaddling and demand feedings. Infants whose score was “8” or above

were treated pharmacologically”

Finnegan LP, et al. Assessment and treatment of abstinence in the infant of the drug- dependent mother. Int Clin Pharmacol Biopharm. 1975;12(1–2):19–32

Problems with the Finnegan

• Long lengths of stay and lots of meds

• Purpose of treatment is to get the scores below threshold

• Must disturb the infant and exacerbate signs of withdrawal

• Can be slow to respond

• Powerful and potentially harmful meds to give to treat a sneeze or a yawn

Intervention 3

Discontinuation of the Finnegan Scoring tool and adoption of a

functional scoring approach

38

1)Can the baby eat?

2)Can the baby sleep?

3)Can the baby be consoled?

ESC Study

• Analyzed 50 consecutive NAS babies admitted to our general inpatient unit from March 2014 to August 2015

• Assessed every 2-6 hours using the FNASS, but did not guide management

• Management decisions based on ESC

Outcomes

1. Proportion of infants treated with morphine vs. proportion predicted to be treated with morphine using the FNASS approach

2. Days the two approaches disagreed

3. FNASS scores the day after the two approaches disagreed

Results

12%

62%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Received Morphine (ESC) Would Have Received Morphine (Finnegan)

Proportion of Infants that Received Morphine

NAS infants (n=50)

p<.001

Results

• On 78 days (26.4%) the ESC Led to LESS Morphine than Predicted by The Finnegan• The following day, the average Finnegan score decreased by 0.9

points, and decreased in 69% of cases.

• On 2 days (0.7%) the ESC Led to MORE Morphine than Predicted by The Finnegan• In both cases the average Finnegan score increased by 1.7 Points

the next day

Results

• No readmissions

• No seizures

• No ICU transfers

Source: http://www.mdnews.com


Medications

NICU

Finnegan Scores

Medication Dosing

Intervention 4

Decrease in morphine up to 3 times per day

48

Intervention 5

PRN Dosing

UCL

16.9

LCL 0.00.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1/30

/08

7/2

/08

8/3

0/0

8

11/1

9/0

8

1/13

/09

2/1

9/0

9

5/5/

09

6/1

3/0

9

9/1

0/0

9

10/2

1/0

9

2/2

/10

3/12

/10

6/2

3/10

10/1

0/1

0

12/1

0/1

0

2/9

/11

3/8

/11

5/10

/11

6/1

0/1

1

9/1

0/1

1

10/7

/11

12/1

/11

1/5/

12

4/3

/12

5/13

/12

6/2

6/1

2

8/2

0/1

2

10/1

2/1

2

11/1

7/12

1/2

5/13

3/6

/13

4/4

/13

5/2

1/13

7/4

/13

9/1

0/1

3

11/2

0/1

3

11/3

0/1

3

1/12

/14

2/1

9/1

4

4/1

2/1

4

5/10

/14

6/1

4/1

4

6/2

6/1

4

8/7

/14

9/2

3/14

11/1

9/1

4

1/6

/15

2/1

6/1

5

4/1

4/1

5

LE

NG

TH

OF

ST

AY

(D

ay

s)

ADMIT DATE


Mean=10.2

Mean=7.7


Rapid medweaning

Prenatalcounseling

Spread to NICU team

Novel assessment tool on inpatient unit


Mean=22.5

Mean=13.2


Medications

NICU

Finnegan Scores

Medication Dosing

Staff cares for the baby

Cleveland, et al., JOGNN;43(3): 318-329

How do moms feel?

Addiction is misunderstood

Guilty

Judged

Mistrusting of nurses

“His nurse was like ‘his muscles are locking up because of his junkie mom’. I didn’t want to visit, I would call before and if that nurse was there, I wouldn’t even go.

“…because we’re gonna leave and he’s gonna cry and they’re gonnaleave him crying because they’re gonna be like, ‘you know what? His parents are jerks!’”

if you’re using while you’re pregnant, you have a problem; a big problem . . . and you need help. You obviously don’t care about your- self, about anything, except the drug. Make it a little bit easier on that mother if she’s showing initiative . . . if she’s taking the time to be there. If she loves her child, you can see it and you can feel it. If it’s obvious that she’s there for the baby then embrace it; make it easier. You don’t know what her circumstances are. You don’t know what she’s been through or how hard her life has been. You don’t know what she was feeling when she was pregnant . . . if she was being abused, if she was poor. Whatever the reason she was using while she was pregnant . . . you just don’t know. So, try to make it easier for her.

Intervention 6

Empowering messaging

Source: http://potomachospital.blogspot.com

Old Protocol New Protocol Goal: suppress withdrawal

signs

NICU: Mom visits

Finnegan Scores: treat the number

“supportive care”

“feed on demand”

Morphine

Surprise!

Staff takes care of infant

Goal: have infant function as a normal neonate

Mother and child together

Eat/Sleep/Console: treat the infant

SUPPORTIVE CARE

No feeding schedule

Meds on page 3

Prenatal preparation

Staff coaches parents

UCL

10.8

LCL 0.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1/30

/08

7/12

/08

11/1

0/0

8

1/2

1/0

9

4/6

/09

6/1

3/0

9

9/1

8/0

9

12/2

3/0

9

3/19

/10

9/1

8/1

0

12/1

0/1

0

2/2

1/11

4/2

7/11

7/4

/11

9/2

9/1

1

12/1

/11

2/1

1/12

5/7/

12

6/2

6/1

2

10/9

/12

11/1

7/12

2/2

3/13

3/2

8/1

3

5/2

2/1

3

8/2

1/13

11/2

0/1

3

12/1

0/1

3

2/1

1/14

4/1

9/1

4

6/8

/14

6/2

6/1

4

9/8

/14

11/1

4/1

4

1/9

/15

3/11

/15

5/2

6/1

5

7/17

/15

8/2

2/1

5

10/2

1/15

12/4

/15

4/2

8/1

6

7/7/

16

8/3

1/16

9/2

7/16

10/2

9/1

6

12/2

1/16

1/19

/17

3/3/

17

4/3

/17

4/3

0/1

7

5/2

8/1

7

6/2

5/17

LE

NG

TH

OF

ST

AY

(D

ay

s)

ADMIT DATE



Rapid medweaning

Prenatalcounseling

Spread to NICU team

Meds as needed

Empoweringmessaging

Novel assessment tool on inpatient unit

Mean=5.9

Mean=7.7

Mean=10.2

Mean=13.2

Mean=22.5


0

5

10

15

20

25

30

35

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Ave

rag

e L

en

gth

of

Sta

y (

Da

ys)

Year

Length of Stay (days)

Protocol Change:More aggressive weans

Discontinued FinneganScoring

Transfers directly fromWBN to Floor

NICU includedin effort

Focus on supportivemanagement

More aggressive weans

Average Length of Stay - Methadone Exposed Infants

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

% T

rea

ted

wit

h M

orp

hin

e

Year

Percent of NAS Patients Treated with Morphine

% Treated with Morphine

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

2008 2009 2010 2011 2012 2013 2014 2015 2016

Pe

rce

nt

Tre

ate

d

Date

Percent Treated with Morphine

0

0.1

0.2

0.3

0.4

0.5

0.6

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Ave

rag

e m

axim

um

mo

rph

ine

do

se (m

g/d

ose

)

Year

Average Maximum Morphine Dose

Average maximum morphinedose (mg/dose)

p < .001

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

% B

rea

stfe

ed

ing

Year

Breastfeeding Rate

% Breastfeeding

0

10000

20000

30000

40000

50000

60000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

To

tal C

ost

($

)

Year

Total Average Cost of NAS Care

Total Cost ($)

p < .001

Boston Medical Center

• Had been using FNASS approach

• Finnegan prioritization from June-November 2016

• Developed ESC approach as a scoring tool

• Piloting since December 2016

Eat, Sleep, Console

Flowsheet

TIME

EATING

Poor feeding due to NAS – Y/N

SLEEPING

< 1 hr after feeding due to NAS – Y/N

CONSOLABILITY

Please rate the infant’s consolability:

Soothes with little support – 1

Soothes with some support – 2

Soothes with great support – 3

Did the infant require >10 minutes to console – Y/N

Boston Medical Center – Results

• Use of morphine decreased from 82% to 40%

• Length of stay decreased from 18 days to 10 days

• No readmissions

Additional Spread

Long-Term Outcomes

?

Conclusions

▪ Hugs before drugs

▪ Empower families

▪ Rooming-in

▪ Non-Pharmacologic care as 1st line treatment

▪ ESC approach

▪ PRN meds

▪ Ask why


Acknowledgements

David Hersh, MD

Adam Berkwitt, MD

Erin Nozetz, MD

Marcelle Applewaite, RN

Kim Carter, RN

Liz O’Mara, RN

Matt Bizzarro, MD

Yogangi Malhotra, MD

Jonathan Miller, MD

Camisha Taylor, RN

Rachel Osborn, MD

neonatal abstinence syndrome · 2018-11-14 · neonatal abstinence syndrome: reconsidering the...

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