By Alison Knopf
When Loretta Finnegan, MD, a champion of medication-assisted treatment with methadone, developed her famous scoring system for newborns—more than 40 years ago—mother and infant dyad designed to determine the severity of neonatal abstinence syndrome (NAS) due to opioid withdrawal, it was an important step in ensuring that these babies were treated—usually with morphine. Using the Finnegan Neonatal Abstinence Scoring System (FNASS), the hospital assigns a numerical score to 21 subjective clinical signs, and treats the baby accordingly.
However, there is insufficient evidence that FNASS scores should be used for starting or changing pharmacologic treatment for NAS. In addition, obtaining a FNASS score is traumatic: the baby must be disturbed and unswaddled, which only increases the likelihood of high scores for tremors, tone, and crying, researchers wrote last year in Pediatrics.
NICU Not the Best Place
Treating infants with NAS has traditionally been done by putting them in the neonatal intensive care unit (NICU) and gradually decreasing their doses of morphine. Most institutions do reduce length of stay by using a weaning protocol for morphine with the FNASS, but this must be done in a NICU.
There is no evidence that NAS requires a stay in the NICU, the researchers wrote. In fact, the NICU conflicts with rooming-in, which itself has been shown to be an effective intervention with NAS.
“We discontinued the practice of directly admitting infants at risk for NAS to the NICU after birth in an effort to keep the mother-infant dyad intact,” the researchers wrote.
Furthermore, it is the morphine administration that lengthens the stay, so the hospital wanted to see if morphine was really necessary. In most cases, it wasn’t.
The researchers “set out to change the paradigm of how we approached the management of infants with NAS,” specifically by using nonpharmacologic interventions.
Researchers found that keeping these babies out of the NICU and giving them nonpharmacologic treatment—in addition to empowering parents—saves money and time in the hospital. It also means that these babies aren’t labeled. And finally, it sets up the mother and baby for a beneficial interaction that reinforces positive parenting skills.
For the study, researchers at Yale New Haven Children’s Hospital implemented “plan-do-study-act” cycles in response to a 74% increase (from 2003 to 2009) in the number of infants who had been exposed to methadone in utero. Too many of them were staying in the hospital for too long, and the researchers had as a goal reducing the average length of stay by 50%. They far exceeded that goal.
The study, which started in 2010, included 287 methadone-exposed infants. There were no readmissions for treating NAS, and no adverse events.
- Percentage of infants treated with morphine fell from 98% to 14%
- Average length of stay dropped from 22.4 to 5.9 days
- Average costs decreased from $44,824 to $10,289
The researchers developed and implemented eight interventions over a 5-year period:
- Standardized nonpharmacologic care
- Counseled parents prenatally
- Transferred the baby from well-baby nursery to the inpatient unit (with the mother)
- Developed a novel approach to assessment
- Gave morphine as needed, based on infants’ crying, feeding, and sleeping habits
- Empowered parents to care for their babies
- Spread the concepts—and the idea of change—throughout the NICU
The key to nonpharmacologic intervention was the parent—typically, the mother. Parents were strongly encouraged to room-in, to feed their infants on demand, and to take care of the child if he or she cried. Breast-feeding was encouraged, as long as there was no illicit drug use, and the mother was HIV-negative.
The environment included dimmed lights and reduced noise—the opposite of a NICU.
Staff training was required, with the nurses learning to view the nonpharmacologic intervention the same as a medication: “When increased intervention was warranted, the approach was to increase the involvement of the parents before using pharmacologic treatment.”
The parents were empowered by the message that they were the most important treatment for the child: the comfort measures should be performed by the mother or father.
While the FNASS scores were still used in the well-baby nursery and the NICU, the researchers developed their own assessment for babies on the inpatient unit rooming in with the mother. They used three parameters: the infant’s ability to eat, to sleep, and to be consoled.
If it took 10 minutes or more to console a crying baby, if a baby couldn’t sleep for more than an hour, or couldn’t feed, nonpharmacologic measures were increased. Finally, if these didn’t work, morphine was given, as needed. This differs from the rapid morphine scheduled weans done using FNASS.
“Our approach encouraged providers to focus on a small number of clinically relevant factors to assess the need for treatment with morphine,” they wrote. “Ideally, all infants should feed well, sleep well, and be easily consoled. We determined that if infants with NAS met these goals, then treatment was successful irrespective of the FNASS score.”
Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome [Epub ahead of print May 18, 2017]. Pediatrics. 2017;Jun;139(6). doi:10.1542/peds.2016-3360.