By Christina Falgier, MD, Essentia Health St. Mary’s Children’s Hospital, Neonatology, Section Chair
While the number of infants with neonatal abstinence syndrome (NAS) has decreased in our NICU at Essentia Health St. Mary’s Children’s Hospital in Duluth, it remains a significant problem for our patients and their families.
In the past year, approximately 6 percent of our annual admissions required NICU care for treatment of NAS. This represents a decline from previous years, with a recent peak of 12 percent of our annual admissions. However, we remain significantly above our previous steady baseline of 1-2 percent of our annual admissions prior to 2010. Additionally, infants are often in the hospital for weeks if therapy with oral morphine is needed, and we have had many days in the past where infants with NAS accounted for 50 percent or more of our daily census.
We have worked to streamline the care of the NAS patient during the birth hospitalization. Newborns exposed to long acting opioids in utero, such as methadone and buprenorphine, now remain in the hospital for 4 days after birth to monitor for the development of significant NAS symptoms. This is done using a standardized scoring system. Parents receive support and instruction in how to care for their infant using positioning and holding techniques, strategies to minimize environmental stress, and other calming techniques by our NICU therapies team and nursing staff.
The infant is transferred to the NICU for initiation of oral morphine therapy if scoring criteria are met. The parents are encouraged to continue to provide care to their baby, including breastfeeding, if appropriate.
When morphine therapy is needed, it is titrated based on infant symptom scores. We have historically used the Modified Finnegan Scoring System. This system scores infants based on the comprehensive signs of withdrawal, which includes GI, CNS, and autonomic systems. The current trend in treatment is to focus on babies that have symptomatology that interferes with their ability to do what babies need to do, which is eat, sleep, and calm. Based on the recent literature, we are in the process of moving to the Eat, Sleep, Console (ESC) scoring system. The goals of the switch are to focus on maximizing non-medication management, thereby decreasing the number of infants that require oral morphine therapy. This approach recognizes that if infants can meet their basic needs by maximizing parental response to their symptoms, then oral morphine therapy is not needed. We expect to see a significant decrease in the number of patients needing NICU admission for oral morphine therapy and, consequently, in the length of hospitalization.
Upon discharge from the hospital, close monitoring of these infants continues with frequent follow-up with their primary care clinician, who continues to monitor weight gain and provides support for symptom management. We are also seeing these infants in our NICU Follow-up Clinic to monitor their growth and development, providing referrals for therapies and psychological support as needed. Many of these infants are placed in foster care at the time of discharge and the general feeling is that more of these parents are working on reuniting with their infants than we have seen in the past.
In addition to multidisciplinary care of the infant with NAS, our colleagues in OB/GYN have established a prenatal clinic at a local opioid treatment program, called ClearPath. This is a new program in 2018 with outcome data not yet available, but it has been well received and mothers report feeling better prepared to deal with their infant’s withdrawal symptoms.
One of the challenges we face in Duluth is how to provide specialty support to our rural physician and advanced practice colleagues. Our referral area is geographically large, covering the Arrowhead area of Minnesota to International Falls, Northwest Wisconsin, and a portion of the Upper Peninsula of Michigan. Ideally, many of these infants with NAS symptoms could be cared for at their birth hospital, but support for the physicians and staff is lacking. Telemedicine is currently being developed in our neonatology department to provide not only emergent/urgent support to the ill neonate, but also non-urgent consultations. Our goal is eventually to be able to provide care for the infant with NAS at their birth hospital, keeping the parents close to home and to their support system. Initial rollout to surrounding hospitals will begin this fall.
Ultimately, the success of this approach lies in whether we can put the parent-infant dyad (usually this is the mother) at the center of the care. Literature suggests doing so significantly decreases the need for medication therapy, decreases the total dose of morphine in the instances that medication is needed, decreases length of stay and costs of medical care, improves breastfeeding rates, improves parental feelings of bonding, and decreases stigma. Families affected by NAS deserve nothing less.