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Neonatal abstinence syndrome: Assessment and management
Abstract
A scoring system for the neonatal abstinence syndrome has been devised and implemented as both a clinical and investigative tool. The score monitors the passively addicted infant in a more comprehensive and objective fashion, and facilitates a more precise evaluation of the clinical status of the infant undergoing withdrawal. In addition, the scoring system has been applied in research designed to test the comparative usefulness of various pharmacologic agents currently recommended for the neonatal abstinence syndrome, and has been found useful in following the progression and diminution of withdrawal symptomatology before, during, and after therapy. Furthermore, the scoring system provides a basis ofr developing uniform criteria for the assessment and treatment of the neonate born to the addicted mother.
... Though primary NAS is typically understood as abstinence from opioids, neonates can also develop withdrawal symptoms after exposure to other substances or medication such as tobacco [6], alcohol [7], cocaine [8], selective serotonin reuptake inhibitors (SSRI) and other antidepressants [9], benzodiazepines [10] as well as a combination of opioids and other substances [5]. Many neonatal intensive care units (NICUs) monitor withdrawal symptoms using the Neonatal Narcotic Abstinence Scoring System, also called Finnegan score (FS), which is comprised of 32 clinical signs, each rated by point scores between 0 and 5 [11]. The scores add up to a maximum of 46 points [11]. ...
... Many neonatal intensive care units (NICUs) monitor withdrawal symptoms using the Neonatal Narcotic Abstinence Scoring System, also called Finnegan score (FS), which is comprised of 32 clinical signs, each rated by point scores between 0 and 5 [11]. The scores add up to a maximum of 46 points [11]. The FS was originally designed to assess withdrawal in otherwise healthy term infants from mothers abusing opioids [11,12]. ...
... The scores add up to a maximum of 46 points [11]. The FS was originally designed to assess withdrawal in otherwise healthy term infants from mothers abusing opioids [11,12]. Thus, the validity of the score in other patients receiving neonatal intensive care is unclear, particularly in preterm or term neonates experiencing iNAS [11,12]. ...
BACKGROUND
The severity of the neonatal abstinence syndrome (NAS) may be assessed by the Finnegan score (FS). Since the FS is laborious and subjective, alternative ways of assessment may improve quality of care.
OBJECTIVE
In this pilot study, we examined associations between the FS and routine monitoring data obtained from the electronic health record system.
METHODS
he study included 193 neonates with NAS after intrauterine (n=16) or postnatal opioid exposure (n=177). Routine monitoring data were analyzed at 60 ± 10 min (t–1) and 120 ± 10 min (t–2) before each FS assessment. Within each time period, the mean for each variable was calculated. Readings were also normalized to individual baseline data calculated per patient and parameter. Mixed effects models were applied to assess the effect of the different variables.
RESULTS
Plots of vital parameters against the FS showed heavily scattered data. When controlling for several variables, the best-performing mixed effects model displayed significant effects of individual baseline-controlled mean heart rate (estimate: 0.04; 95%-CI 0.02-0.07) and arterial blood pressure (estimate: 0.06; 95%-CI 0.02-0.09) at t–1 with R2m = 0.11 as goodness of fit.
CONCLUSIONS
Routine electronic data can be extracted and analyzed for correlation with FS data. Mixed effects models show small but significant effects after normalizing vital parameters to individual baselines.
CLINICALTRIAL
N/A. The institutional review board of the Charité – Universitätsmedizin Berlin approved the study (EA2/104/21).
... pharmacological treatment (Finnegan et al., 1975). While the scale encompasses a comprehensive list of withdrawal symptoms, there are downfalls that undermine its utility (Schiff & Grossman, 2019;Timpson et al., 2018). ...
... The Finnegan withdrawal scores were obtained from electronic medical records (Epic, Verona, WI). Per clinical care, newborn nursing staff scored and recorded symptom severity based on assessments performed every 2-4 hours using a modified Finnegan (Finnegan et al., 1975;Timpson et al., 2018). The timing of Finnegan assessments was in alignment with nursing care and infant sleep/feed cycles and did not necessarily occur when the infant was in the crib. ...
... The time stamps throughout the day reflect the time at which the nurse began the assessment. Each sign and symptom were scored separately on a scale between 0 (not observed) and 3-5 (maximum score varies between signs and symptoms) within each 2-4-hour time period per Finnegan protocol (Finnegan et al., 1975;Timpson et al., 2018). Within each time period, the subcomponent scores were summed to obtain a total composite score. ...
Background and purpose: Conventional measures of withdrawal in newborns with prenatal opioid exposure (POE) rely on nursing assessments, including the subjective judgment of infant irritability. This study investigated limb movement actigraphy as a tool for providing an objective, quantifiable measure of underlying distress. Methods: Correlational analyses compared continuous physiological-detected movement actigraphy and clinical intervallic-scored symptomology (modified Finnegan system) obtained from a control cohort of 37 term neonates with POE studied in their crib in the newborn unit (1–8 days). Results: Infants spent 15% crib time in high movement activity (>100 movements/minute; index irritability) and 38% crib time in low activity (0–5 movements/minute; index calm). There was a significant positive association between actigraphy and Finnegan composite score ( r = .28, P = .001) and between actigraphy and subcomponent scores (i.e., central nervous system, gastrointestinal, and metabolic-vasomotor-respiratory). Conclusion: Movement activity via actigraphy captures underlying distress and calm not measured by conventional assessments. Such objective, quantifiable measures can serve to promote equitable assessment and treatment of hospitalized newborns with POE.
... The Finnegan Neonatal Abstinence Scoring System (FNASS), often modified, is a popular tool for assessment of both opioid and non-opioid withdrawal [8][9][10]. The FNASS was designed to systematically assesses signs and symptoms associating with NAS [2,8,11]. ...
... The Finnegan Neonatal Abstinence Scoring System (FNASS), often modified, is a popular tool for assessment of both opioid and non-opioid withdrawal [8][9][10]. The FNASS was designed to systematically assesses signs and symptoms associating with NAS [2,8,11]. The scoring system was developed in full term neonates [8], with prematurity associating with decreased withdrawal signs and symptoms, adding complexity to FNASS focused NAS management [11][12][13][14][15]. ...
... The FNASS was designed to systematically assesses signs and symptoms associating with NAS [2,8,11]. The scoring system was developed in full term neonates [8], with prematurity associating with decreased withdrawal signs and symptoms, adding complexity to FNASS focused NAS management [11][12][13][14][15]. An FNASS-based cutoff has been historically used to identify neonates requiring NAS pharmacologic treatment with FNASS scoring also used to monitor, titrate, and terminate pharmacologic treatment [16]. ...
Objective
We assessed the efficacy of the Eat, Sleep, Console (ESC) model for neonatal abstinence syndrome at a regional referral center by examining non-pharmacological treatments, parental presence, length of stay (LOS), and pharmacological therapy.
Study design
We retrospectively reviewed medical records from 2018 to 2020 to compare neonatal outcomes between the 12 months prior to 12 months post ESC implementation.
Result
A total of 71 neonates pre-ESC and 64 neonates post-ESC implementation were included. There were no statistical differences between pre-ESC vs. ESC periods for pharmacological therapy (34% vs. 27%, p = 0.36) or LOS (median: 5.0 vs. 5.5 days, p = 0.54). During the ESC period, 41% of examined 4-h periods had no parent/caregiver presence. Decreased parental presence associated with pharmacological treatment (p < 0.001).
Conclusion
At our hospital which serves a geographically dispersed patient population, ESC model implementation did not decrease pharmacological therapy rates or LOS. Parental/caregiver presence may be a factor in the ESC model producing maximal benefits.
... Se sospecha que los recién nacidos padecen SA neonatal si presentan alguno de los signos que se enumeran a continuación: disfunción del sistema nervioso central (SNC) que incluye las siguientes características: grito agudo, inquietud con duración del sueño de menos de 1-3 horas después de la alimentación, reflejos hiperactivos, temblores, hipertonía, movimientos mioclónicos, convulsiones generalizadas; alteraciones metabólicas, vasomotoras y respiratorias incluyen: transpiración, fiebre, bostezos frecuentes, estornudos (> 3 veces por intervalo), Tabla 1: Escala de Finnegan. Puntaje del síndrome de abstinencia (6) . aleteo nasal, frecuencia respiratoria mayor a 60 respiraciones por minuto sin retracciones, apnea; disfunción gastrointestinal incluye: succión excesiva (frenética), mala alimentación, hiperfagia, generalmente asociada con un aumento de peso deficiente, regurgitación o vómitos proyectiles, deposiciones sueltas o acuosas (6) . ...
... Puntaje del síndrome de abstinencia (6) . aleteo nasal, frecuencia respiratoria mayor a 60 respiraciones por minuto sin retracciones, apnea; disfunción gastrointestinal incluye: succión excesiva (frenética), mala alimentación, hiperfagia, generalmente asociada con un aumento de peso deficiente, regurgitación o vómitos proyectiles, deposiciones sueltas o acuosas (6) . La escala de Finnegan evalúa 21 de los signos más comunes del síndrome de abstinencia de drogas neonatal y se puntúa sobre la base de la importancia patológica y la gravedad de los síntomas adversos, que a veces requieren tratamiento farmacológico; se considera que una puntuación igual o superior a 8 y menor de 12 corresponde a la presencia de SA leve, entre 12 y 16 a SA moderado y más de 16 a SA severo (7) . ...
... If the signs became severe, treatment with medication was provided, usually an opioid or sedative or both, and the infant was transferred to the NICU for close monitoring. The assessment of NAS severity required a systematic approach and scoring systems began to be developed and were being used as in adults, in infants with withdrawal signs from prenatal exposure to heroin and/or methadone treatment during pregnancy (5)(6)(7). The assessment also helped to identify the infants who needed pharmacologic treatment. ...
... The seminal paper on NAS by Finnegan et al. did not mandate NICU care and used the term "comprehensive care" for the needs of the maternal/fetal dyad (27). This term was only "rediscovered" recently as part of the recognition of the critical importance of compassionate care and the importance of the mother in the amelioration of NAS (5). ...
Since the first use of methadone to treat OUD in pregnancy in the 1970s, there has been a long, controversial, and confusing history of studies, regulatory actions, and practice changes that have clouded an accurate perception of methadone's use in pregnancy. This review will trace this history with a focus on the effect of methadone exposure during pregnancy on neonatal abstinence syndrome (NAS). A new laboratory measure, the serum methadone/metabolite ratio (MMR), has provided a tool for documenting the profoundly dynamic nature of perinatal metabolism. Continuous induction of metabolic enzymes during pregnancy requires dose adjustments and dose frequency changes. The concept of “fetal methadone dosing” emphasizes that relative stability of methadone levels in the fetus is an important consideration for methadone dosing in pregnancy. Finally, the effects of the societal “war on drugs” on pediatric management of neonatal withdrawal risks will be discussed, as well as the importance of comprehensive services for mother and child including the “rooming-in” approach of neonatal care which has considerably replaced the older NICU care model of maternal/infant separation.
... A small proportion of guidelines also suggested alternative drugs such as methadone (9%) [28,32] as a first-line treatment and clonidine (27%) [18,22,23,32,33,37] as a second-line, but they did not provide dosing regimens for these. Most guidelines suggested that reductions in medication doses should only be considered when there had been 48-72 h of clinical stability as indicated by at least three consecutive Finnegan scores of <8 [45]. ...
... Indeed, this tool was used by >89.5% of participants from Canada, one of the primary countries publishing NAS CPGs, despite the tool's significant limitations [49]. The FNASS was developed by Finnegan et al. in 1975 as a research tool to distinguish the severity of withdrawal and response to pharmacological treatment in infants with known narcotic exposure who were full-or near-term, bottle-fed and treated with medications that are not used today, including paregoric, diazepam and tincture of opium [45]. It, and other assessment tools, including the Eat, Sleep, Console (ESC) tool developed by Grossman et al. (2017) [50] have never been validated for non-opioid exposure or for impact on neurodevelopmental or longer-term outcomes, considering the potential neurotoxicity of many of the medications that are used to treat NAS [51]. ...
Background:
The prevalence of neonatal abstinence syndrome is increasing, but the number and quality of clinical practice guidelines available are unknown. This systematic review aimed to identify, appraise and evaluate clinical practice guidelines for neonatal abstinence syndrome.
Methods:
A systematic search of databases and the grey literature was conducted between 1 June and 1 July 2022. Full-text guidelines published by national or state-wide institutions were included. The recommendations from each guideline were extracted. The AGREE-II instrument was used to assess guideline quality. Sufficient-quality scores were defined as >60 and good-quality scores were >80 for each domain of AGREE-II.
Results:
A total of 1703 records were identified, and 22 guidelines from the United States, Australia, Canada and the United Kingdom, published between 2012 to 2021, were included. The quality scores were low, with median scores of 37/100 for stakeholder involvement, 33/100 for methodology, 34/100 for applicability and 0 for editorial independence. Scope and purpose scored 72/100, and presentation scored 85/100. Sixteen (73%) guidelines did not meet the cut-offs for clinical use.
Conclusion:
Many guidelines were of insufficient quality to guide clinical practice for neonatal abstinence syndrome. This emphasises the need for high-quality studies to inform clinical practice guidelines, improve care and reduce the risk of poor outcomes in these high-risk infants.
... 4 Clonidine and phenobarbital have been used in this role; however, phenobarbital use is discouraged in AAP guidance due to well-documented adverse neurodevelopmental outcomes leaving clonidine as the principal second-line agent. 5,11 Despite the addition of clonidine, there remains a subset of infants who are unable to wean opioid therapy, warranting consideration of a third-line agent. ...
... To assess the severity of withdrawal symptoms, all patients at risk for NOWS at our institution are evaluated using the modified Finnegan score every three hours. 11 Infants with three consecutive scores ≥8 or two consecutive scores ≥12 were started on oral morphine 0.4 mg/mL after optimization of nonpharmacologic care. Per protocol, morphine 0.04 -0.1 mg/kg/dose was given orally every three hours with the initial dosing dependent upon Finnegan scores at therapy initiation. ...
OBJECTIVE
We describe a single center experience with gabapentin as adjunctive therapy in infants with neonatal opioid withdrawal syndrome (NOWS).
METHODS
We performed a retrospective chart review of infants receiving gabapentin for NOWS. Data points collected included patient’s sex, gestational age, maternal opioid exposure, NOWS medication dosing and length of therapy, number of failed wean attempts, time to successful morphine wean and duration of morphine wean, length of stay in the neonatal intensive care unit (NICU), and NOWS medications at discharge.
RESULTS
Six infants received gabapentin as adjunctive treatment for NOWS. All infants failed 2–4 morphine weans before initiation of gabapentin despite the addition of clonidine. All infants that received gabapentin were successfully weaned off morphine. The time to wean off morphine after gabapentin initiation varied from 4–35 days. Maximum gabapentin doses ranged from 15 – 42.7 mg/kg/day. Five infants were discharged from the NICU on gabapentin.
CONCLUSIONS
Gabapentin appeared to facilitate successful morphine weans in six patients with NOWS who were previously unable to wean despite the initiation of clonidine.
... [8] Protocols and guidelines are used in some units to titrate medications, achieving adequate sedation and patient comfort. [9][10][11] Unfortunately, one medication cannot be recommended for use in all patients. Each sedative or analgesic medication has characteristic adverse effects; therefore, medicines should be selected carefully according to the individual patient and clinical scenario. ...
... Sedation and analgesia methods used to comfort patients vary significantly between PICUs worldwide. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Few studies have investigated pediatric sedation practices in the Middle Eastern and North African regions. Accumulating more data will help improve patient care and ensure the comfort of PICU patients. ...
Background: Sedation practices in pediatric intensive care units (PICUs) vary significantly worldwide. This study aimed to explore the current sedation and analgesia practices among paediatric intensivists in Saudi Arabia. Methods: This web-based survey was conducted among pediatric intensive care physicians in Saudi Arabia. The survey investigated the participating PICUs, physicians' demographic data, and sedation/analgesia practices. Results: Of the 160 physicians included, the response rate was 67% (n = 108). Of the 100 participants who provided location information, 51% (n = 51) were from the central region of Saudi Arabia. Approximately two-thirds of the participants were consultants, and 48.1% had >10 years of experience. Most respondents practised in general PICUs and routinely assessed sedation and analgesia levels. The COMFORT-Behavior and Face, Legs, Activity, Cry, and Consolability scales were popular (42.6%). More than half of the respondents (52/98) did not practice daily sedation interruption. Furthermore, 78.3% of the respondents assessed patients for withdrawal, whereas only 25% used delirium screening scores. Infusions were preferred over interrupted doses to provide comfort for mechanically ventilated patients. The first-choice infusions were midazolam for sedation and fentanyl for analgesia. Dexmedetomidine was preferred when a third agent was required. Sedation protocols were used by 41.2% of the respondents and were mainly physician-led (75.2%). Various nonpharmacological measures were used to provide patient comfort, and parents often participated in their application. Conclusions: The practice of sedation varies significantly between pediatric intensivists, and formal assessment for delirium is infrequently done in PICUs in Saudi Arabia.
... 4 NOWS involves a large spectrum of withdrawal symptoms that manifest shortly after birth and can include disturbances of the central nervous system (prolonged high-pitched crying, disturbed sleep, increased muscle tone, tremors, mottled skin, and temperature dysregulation), respiratory system (tachypnea, tachycardia, and congestion) and gastrointestinal system (poor oral feeding, vomiting, and diarrhea). [5][6][7] The initial diagnosis and treatment of NOWS are complicated by variations in the presentation and intensity of withdrawal symptoms after birth. 8 Moreover, symptom variability is affected by an array of other prenatal factors, such as the type, timing, duration, and dosage of opioid exposure during pregnancy, 9 as well as maternal polysubstance use, including the use of tobacco and psychotropic medications during pregnancy. ...
... Before referral to this tertiary care facility with specialized NOWS care, infants are assessed at the birth hospital on the basis of the reported history of maternal substance use during pregnancy, as well as urine and meconium toxicology screening. The development of withdrawal symptoms is typically monitored in the birth hospital NICU or newborn nursery by using the modified Finnegan scoring system 6,21 . After severe NOWS is identified and pharmacotherapy treatment is initiated, the NOWS treatment team at the tertiary care facility receives the referral from the partner acute care facility to ensure a timely transition and continuity of care, with the goal of transferring the infant to tertiary care by DOL 14. ...
Objective:
Many infants with neonatal opioid withdrawal syndrome (NOWS) from prenatal exposure to opioids require transfer to a pediatric inpatient unit for medication weaning. The purpose of this study is to assess the difference in the duration of medication weaning between infants transferred by day of life (DOL) 14 versus later (DOL 15 and after) to a tertiary care setting for pharmacological and nonpharmacological management of NOWS.
Methods:
This single-site retrospective cohort study uses medical chart data from infants with NOWS transferred to specialized care between May 2016 and June 2021 (n = 87). The primary outcome is length of medication weaning, calculated as the number of days between transfer from the NICU to a tertiary care setting and the cessation of pharmacotherapy.
Results:
The majority of the infants in this sample are transferred from acute to tertiary care after DOL 15 (62% versus 38% by DOL 14). The predicted number of days to wean is 14.2 among those infants transferred by DOL 14, whereas the duration of weaning is 6.6 days longer among the later transfer group (20.8 days), adjusting for key covariates. The duration of weaning is also prolonged among infants with greater NOWS symptom severity and with prenatal exposure to psychotropic medications.
Conclusions:
Delayed treatment prolongs NOWS symptoms and increases the burden on the health care system. Earlier referral from NICUs to pediatric inpatient units with environmental supports could reduce prolonged medication exposure and length of hospitalization for infants diagnosed with NOWS.
... [8] Protocols and guidelines are used in some units to titrate medications, achieving adequate sedation and patient comfort. [9][10][11] Unfortunately, one medication cannot be recommended for use in all patients. Each sedative or analgesic medication has characteristic adverse effects; therefore, medicines should be selected carefully according to the individual patient and clinical scenario. ...
... Sedation and analgesia methods used to comfort patients vary significantly between PICUs worldwide. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] Few studies have investigated pediatric sedation practices in the Middle Eastern and North African regions. Accumulating more data will help improve patient care and ensure the comfort of PICU patients. ...
... Open access to the development of clinical assessment tools. These tools, which include the Finnegan Neonatal Abstinence Severity Score-the most widely used NAS assessment tool today-led to rapid decline in fatalities from NAS. 6 Newborn withdrawal has now become an uncommon direct cause of infant death and most infants with PDE will be discharged in a relatively healthy condition from hospital after birth. 7 Unfortunately, longer-term outcomes, even beyond early childhood, of infants with PDE are unclear. ...
Introduction
Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The Joining the Dots cohort study uses linked population data to understand the relationship between services, therapeutic interventions and outcomes of children with PDE.
Methods and analysis
Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0.
Ethics and dissemination
Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome.
... One approach has focused on providing non-pharmacologic care along with the adoption of the Eat, Sleep and Console (ESC) assessment tool instead of the more traditional Finnegan Neonatal Abstinence Scoring System (FNASS) [4][5][6]. The ESC assessment tool and approach was first conceived by Grossman et al. at Yale and subsequently developed into a formal ESC approach as a quality improvement initiative and has been widely adopted in clinical practice [7,8]. ...
Objective
To evaluate outcomes in opioid exposed neonates (OENs) assessed by the Eat, Sleep, Console (ESC) tool compared to the Finnegan Neonatal Abstinence Scoring System (FNASS).
Methods
Retrospective analysis of a statewide database of OENs from 2017 to 2020 with birthing hospitals classified based on the assessment tool used. Four main outcomes were examined using multivariable and Poisson logistic regression models.
Results
Of 2375 OENs, 42.1% received pharmacotherapy (PT) with a consistent decrease in PT, length of treatment (LOT), and length of stay (LOS) over the study period. There was no change in use of mother’s own milk (MoM). While outcomes were significantly associated with several specific variables, there were no differences in outcomes between assessment methods.
Conclusion
While there was a significant decrease over time in PT, LOT, and LOS, improvements were independent of the assessment tool used and likely related to the increased use of non-pharmacologic care.
... A widely used scoring instrument to assess severity of neonatal opioid withdrawal is the Finnegan neonatal abstinence scoring system (FNAS) which includes 21 scored elements [2,3]. One variant with a high degree of overlap is the MOTHER NAS scale (MNAS) with 19 scored elements [4]. ...
Objective
Chervoneva et al. (2020) developed an abbreviated score (sMNAS-9) derived from full modified Finnegan MOTHER NAS scale (MNAS) for evaluating severity of NOWS. We sought to develop NOWS treatment algorithms for clinical decision rules based on scores utilizing the shorter sMNAS.
Study design
This was a retrospective study of 373 infants with NOWS scored with MNAS and treated with morphine between 2007 and 2016. The infants were randomly split into training/test sets. The training set was used to derive optimized cutoff values for sMNAS-9 scores. The independent set evaluated the sMNAS-9 clinical decision rules based on full MNAS in NOWS morphine and buprenorphine treatment algorithms.
Result
Clinical decision rules based on sMNAS-9 yielded sensitivities of 88% or higher and specificities of 85% or higher for predicting the respective rules based on full MNAS.
Conclusion
The sMNAS-9 scoring instrument is expected to yield similar clinical decisions in treatment of NOWS.
... There are several evaluation scales. The most commonly used screening tool is the Finnegan Neonatal Abstinence Scoring System (5,6). The Lipsitz Neonatal Drug Withdrawal Scoring System is another commonly used and simpler screening assessment (7). ...
The common use of prescription opioids is increasing to treat chronic pain (1). Approximately 80% of new heroin users have engaged in illicit opioid use
(2,3,4). In utero exposure to opioids manifests as neonatal abstinence syndrome (NNAS) at birth in 60 to 95% of cases.
There are several evaluation scales. The most commonly used screening tool is the Finnegan Neonatal Abstinence Scoring System (5,6). The Lipsitz
Neonatal Drug Withdrawal Scoring System is another commonly used and simpler screening assessment (7). Currently, there is no evidence of superiority
of an assessment tool comparing to another (8). They help to list clinical signs, assess severity, and monitor progress to adapt the therapeutic attitude.
We don’t have prevalence studies to estimate both the frequency of this scourge and its therapeutic management in Algeria . We reported two cases of
neonatal weaning, highlighting the difficulties of anticipating this syndrome and establishing an optimal treatment protocol with locally available
therapeutic alternatives.
... Scoring is assessed by the primary nurse and is completed based on both nurse and family observations every three to four hours in the infant's room (Anbalagan & Mendez, 2023). The first version of this tool was developed to provide an objective measurement and assessment of symptoms experienced by an infant born with NAS (Finnegan et al., 1975). ...
Introduction: Neonatal abstinence syndrome (NAS) is a growing epidemic across the globe. Infants diagnosed often require resource-intensive nursing care and are at risk for future complex health conditions. A shift in approaches to care for this population has been identified as a priority health care need across Canada. Objectives: This discussion paper aims to highlight the current shift in care for the NAS population, focusing on the Finnegan Neonatal Abstinence Scoring Tool (FNAST) and the Eat, Sleep, Console (ESC) model of care. Methods: A comprehensive search strategy was developed to explore the current trend in care for infants diagnosed with NAS: the transition from the FNAST to the ESC model of care. Four scholarly databases (CINAHL, PubMed, Cochrane, and Google Scholar) were searched. Relevant articles were critically analyzed for their implications on infant and family health, family experience, health system outcomes, and nursing practice. Discussion: In our review of the literature, the FNAST was the most used tool when caring for infants diagnosed with NAS. Although this tool has guided care for infants for decades, it presents some limitations, including subjectivity, invasive and lengthy assessments, and lack of collaboration. Many facilities across Canada are shifting to the ESC model of care as an alternative model. It has potential to address challenges of the care guided by the FNAST, with the ESC model emphasizing non-pharmacological care, a focus on the birth-parent–infant dyad, and dedication to a function-based assessment. Conclusion: Further efforts are needed to support the real-world implementation of evidence-based models of care for this population.
... When the opioid supply is terminated from the mother upon birth, the receptor's sensitivity is heightened, triggering an augmented response to the absence of opioids. This heightened response explains NAS's hyperexcitability and withdrawal symptoms [7,8]. Figure 2 summarizes the overall pathophysiology of NAS along with various leading clinical features. ...
Neonatal abstinence syndrome (NAS) highlights the intricate interplay between maternal substance use during pregnancy and the challenges neonates face from the distressing global opioid crisis. This comprehensive review captures the multilayered landscape of NAS, encircling its underlying mechanisms, epidemiology, diagnostic intricacies, clinical manifestations, continuing developmental impacts, treatment paradigms, and the crucial role of multidisciplinary care. The core pathophysiology of NAS involves the transplacental passage of addictive substances, activating chemical dependence in the maturing fetus, which is characterized by neurotransmitter dysregulation, neuroadaptations, and receptor sensitization. A diverse clinical presentation ranges from central nervous system hyperactivity and autonomic dysregulation to gastrointestinal manifestations, necessitating homogenous assessment tools such as the Finnegan Neonatal Abstinence Scoring System. The demand for a multilayered approach is essential for comprehensive management, involving pharmacological interventions like morphine or methadone and non-pharmacological strategies such as swaddling. The complications of NAS are not only limited to but are also well beyond infancy, leading to behavioral, longstanding cognitive, and socioemotional consequences. Addressing these developmental arcs demands decisive longitudinal monitoring and early interventions. NAS management is fundamentally multidisciplinary, requiring the teamwork of nurses, social workers, psychologists, pediatricians, and neonatologists. Apart from the clinical realm, managing the psychosocial needs of families traversing NAS requires resources and empathy. A crucial comprehensive approach is essential to confront the challenges and limitations of NAS. From early identification and prevention to longstanding support through pharmacological, non-pharmacological, and psychological channels, it creates a holistic structure that emerges as the basis for understanding the complicated relationship between maternal substance use and its impact on neonates. An amalgamation of community engagement, society, policy initiatives, and medical expertise is essential to mitigate the repercussions of NAS and adopt healthier outcomes for affected infants.
... These symptoms can include tremors, increased muscle tone, seizures, temperature instability, tachypnea, and poor feeding, among others [2]. The degree of severity of NAS is typically classified using the Finnegan Neonatal Abstinence Scoring System (FNASS) [7] with FNASS scores between 0 and 3 considered normal; scores between 4 and 7 considered mild; and a score of 8 or above considered severe NAS, requiring pharmacological treatment [8]. The literature regarding the prevalence of SSRI-and SNRI-induced NAS is limited. ...
Introduction: Depression among expectant adults is increasing. This may contribute to newborns experiencing withdrawal symptoms following in utero exposure to antidepressants. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the most commonly prescribed classes of antidepressants. Newborns with Neonatal Abstinence Syndrome (NAS) following fetal opioid exposure receive systematic screening and pharmacological treatment based on results from the Finnegan Neonatal Abstinence Scoring System (FNASS). In contrast, newborns exposed to SSRIs/SNRIs may not receive routine screening, thus SSRI-/SNRI-induced NAS may go undiagnosed and untreated, due to the lack of awareness of the consequences of SSRI-SNRI exposure in utero. Methods: We will search electronic databases (Ovid MEDLINE, Ovid Embase, The Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and grey literature) from inception to July 2021 for relevant articles. Two independent reviewers will eliminate duplicate articles, screen to select relevant articles, extract quantitative data pertaining to FNASS scores and assess for risks of biases. Results: Upon conducting this systematic review, we hypothesize the results will support our objective of determining the prevalence of NAS among neonates exposed to SSRIs/SNRIs in utero. Majority of neonates diagnosed with moderate to severe opioid-induced NAS receive systematic screening and pharmacological treatment. In contrast, neonates exposed to SSRIs/SNRIs may not be systematically screened, and so go on to be untreated. This is concerning considering the potential adverse effects related to untreated NAS Discussion: We plan to use the results of our meta-analysis to yield a summary of average FNASS scores in neonates exposed to SSRIs or SNRIs in utero (primary outcome). In addition, we aim to compare the resulting FNASS summary score against the proportion of neonates who received pharmacological treatment for NAS (secondary outcome). Conclusion: In conducting our proposed systematic review, we aim to determine the severity of SSRI-/SNRI-induced NAS using the FNASS scoring tool, the prevalence of newborns who receive pharmacological treatment for this condition, and to emphasize the development of standardized evidence-based guidelines for the treatment of newborns with SSRI-/SNRI-induced NAS.
... Morphine and methadone are routinely used as initial treatment of NOWS in eligible infants, with eligibility loosely defined based on Finnegan scoring, a tool that is widely used to diagnose NOWS but has not been appropriately validated. 9 Methadone has two enantiomeric forms, the d-and l-isomers. The l-isomer exhibits a 10-fold higher affinity for the μ-opioid receptor than the d-isomer, and both racemic methadone and the l-isomer are used in the clinic. ...
Introduction:
Neonatal Opioid Withdrawal Syndrome (NOWS) is a condition that often occurs in neonates born to mothers who received methadone treatment for opioid use disorder during pregnancy. Early identification and treatment of infants at risk of NOWS may improve clinical outcomes.
Objective:
The purpose of this study was to evaluate whether maternal and umbilical cord plasma concentrations of methadone and its metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), could predict the need for NOWS treatment.
Methods:
The study included 11 opioid-dependent mother-infant dyads, where the mothers were treated with methadone at 34 weeks' gestation or later. Maternal and cord plasma concentrations of methadone and EDDP were determined.
Results:
Six out of the 11 infants required treatment for NOWS. Maternal methadone plasma concentrations were comparable between infants requiring and not requiring NOWS treatment (329.1 ± 229.7 ng/ml vs. 413.2 ± 329.8 ng/ml). However, the average cord plasma methadone concentration in infants who did not require NOWS treatment was 2.9-fold higher than in those who required the treatment (120.0 ± 88.6 ng/ml vs. 40.9 ± 24.4 ng/ml), although the difference was not statistically significant. The ratios of maternal-to-cord methadone plasma concentrations were significantly higher in patients who required treatment for NOWS compared with those who did not (7.7 ± 1.9 vs. 3.5 ± 1.6, p = 0.003). Maternal and cord plasma EDDP concentrations and the maternal-to-cord plasma EDDP concentration ratios did not differ between patients who required and did not require treatment for NOWS.
Conclusions:
The results suggest that methadone permeability across the blood-placental barrier may affect in utero exposure to methadone, and the maternal-to-cord methadone plasma concentration ratio could be a potential biomarker for predicting the need for NOWS treatment.
... This has led to a five-fold increase in the diagnosis of neonatal opioid withdrawal syndrome (NOWS), which as of 2016 affects 8.8 infants per 1000 live births. 1 NOWS is a multi-system disorder involving the central and autonomic nervous systems, as well as the respiratory and gastrointestinal systems. 2 Infants with persistent withdrawal signs are often treated with pharmacotherapeutic doses of morphine or other replacement opioids. ...
Infants with neonatal opioid withdrawal syndrome (NOWS) commonly receive morphine treatment to manage their withdrawal signs. However, the effectiveness of this pharmacotherapy in managing the infants' withdrawal signs varies widely. We sought to understand how information available early in infant monitoring can anticipate this treatment response, focusing on early modified Finnegan Neonatal Abstinence Scoring System (FNASS) scores, polygenic risk for opioid dependence (polygenic risk score, PRS), and drug exposure. Using k-means clustering, we divided the 213 infants in our cohort into 3 groups based on their FNASS scores in the 12 hours before and after the initiation of pharmacotherapy. We found that these groups were pairwise significantly different for risk factors, including methadone exposure, and for in-hospital outcomes, including total morphine received, length of stay, and highest FNASS score. While PRS was not predictive of receipt of treatment, PRS was pairwise significantly different between a subset of the groups. Using tree-based machine learning methods, we then constructed network graphs of the relationships between these groups, FNASS scores, PRS, drug exposures, and in-hospital outcomes. The resulting networks also showed meaningful connection between early FNASS scores and PRS, as well as between both of those and later in-hospital outcomes. These analyses present clinicians with the opportunity to better anticipate infant withdrawal progression and prepare accordingly, whether with expedited morphine treatment or non-pharmacotherapeutic alternative treatments.
... Generally, symptoms are categorized as central nervous system disturbances (eg, generalized seizures, tremors), metabolic/vasomotor/ respiratory disturbances (eg, sweating, tachypnea), and gastrointestinal disturbances (eg, poor feeding, vomiting). 6,7 The management of NOWS is largely pharmacological, with titrated morphine being the standard medication used to stabilize symptoms. 1 Nonpharmacological management is individualized to the symptoms that the neonate is experiencing, and may include low stimulation environments, gentle handling, and soothing techniques (eg, breastfeeding, swaddling, skin-to-skin contact). ...
Objective:
To identify evidence on pain assessment during acute procedures in hospitalized neonates at risk of neonatal opioid withdrawal syndrome (NOWS).
Introduction:
While all neonates are routinely exposed to various painful procedures, neonates at risk of NOWS have longer hospital stays and are exposed to multiple painful procedures. NOWS occurs when a neonate is born to a birth parent who identifies as having sustained opioid use (such as morphine or methadone) during pregnancy. Accurate pain assessment and management during painful procedures is critical for minimizing the well-documented adverse effects of unmanaged pain in neonates. While pain indicators and composite pain scores are valid and reliable for healthy neonates, there is no review of evidence regarding procedural pain assessment in neonates at risk of NOWS.
Inclusion criteria:
Eligible studies will include those reporting on hospitalized pre-term and full-term neonates at risk of NOWS having pain assessments (ie, behavioral indicators, physiological indicators, validated composite pain scores) during and/or after exposure to an acute painful procedure.
Methods:
This review will follow the JBI scoping review methodology. Databases to be searched will include MEDLINE (Ovid), CINAHL (EBSCO), Embase, PsyclNFO (EBSCO), and Scopus. The relevant data will be extracted by 2 reviewers using a modified JBI extraction tool. The results will be summarized in narrative and tabular format, including the components of participants, concept, and context (PCC).
Review registration:
Registered with Open Science Framework https://osf.io/fka8s.
... The American Academy of Pediatrics [39,40,41,42] and other experts [43,44,45,46,47,48,49] agree that opioid replacement is the ideal pharmacological treatment for opioid NAS. An alcohol-free oral morphine sulfate preparation often is recommended as initial therapy, as is a morphine hydrochloride solution [50,51,52,53,54,55,56]. ...
The ASAM Handbook on Pain and Addiction provides clinical guidance to health care professionals who treat patients with co-occurring pain and addiction. Produced by the largest medical society dedicated to the improvement of addiction care, the handbook takes an evidence-based approach. Its advice is based on the current scientific literature and the advice of well-regarded organizations and government agencies, including NIDA, CDC, SAMHSA, PCSS-O, and ASAM itself. The ASAM Handbook is organized in five sections, which cover the core concepts of pain and addiction; diagnosis and treatment; treating pain in patients with, or at risk for, addiction; treating substance use disorders (SUD) and addiction in patients with co-occurring pain; and adapting treatment to the needs of specific populations. Each chapter concludes with suggestions for further reading on the topics discussed. The Handbook is ideal for primary care practitioners, mental health clinicians, addiction clinicians, and pain clinicians who wish to bridge the knowledge gap related to treating patients suffering from both pain and addiction.
... This results in the CNS, ANS and GI symptoms observed [16]. The original Finnegan scoring tool is the only validated withdrawal assessment tool in existence for NOWS, and is only validated for term infants [21,22]. Modified versions of the Finnegan scoring tool are used by many hospitals across the United States to assess for NOWS in both preterm and term infants, despite not being validated [23,24]. ...
Objective
Compare Neonatal Opioid Withdrawal Syndrome (NOWS) in preterm and term infants.
Study design
Single center, retrospective chart review of all in-utero opioid exposed infants born between 2014 and 2019. Withdrawal symptoms were assessed using Modified Finnegan Assessment Tool.
Results
Thirteen preterm (PT), 72 late preterm (LPT), and 178 term infants were included. Preterm and LPT compared to term infants had lower peak Finnegan scores (9/9 vs. 12) and received less pharmacologic treatment (23.1/44.4 vs. 66.3%). Similar onset, peak symptoms, and treatment duration was observed in LPT and term infants.
Conclusions
Preterm and LPT infants have lower Finnegan scores and require less pharmacologic therapy for NOWS. It is unclear if this is because our current assessment tool does not capture their symptoms or if they truly have less withdrawal. Onset of NOWS is similar in LPT and term infant, thus LPT infants do not require prolonged hospital monitoring for NOWS.
... 3 For nearly 50 years, the severity of neonatal opioid withdrawal syndrome has largely been assessed with the use of subjective, observerrated scales -specifically, the Finnegan Neonatal Abstinence Scoring Tool or a modified version of this tool -and the decision to treat affected infants pharmacologically with opioids and other medications has relied on Finnegan severity thresholds. 2,[4][5][6][7][8][9] Despite concerns that this assessment tool overestimates the need for pharmacologic treatment, 10,11 clinical management has remained largely dependent on its use in the absence of an evidence-based alternative. 12 In 2014, Grossman and colleagues proposed the Eat, Sleep, Console approach for the assessment of infants with opioid withdrawal. ...
Background:
Although clinicians have traditionally used the Finnegan Neonatal Abstinence Scoring Tool to assess the severity of neonatal opioid withdrawal, a newer function-based approach - the Eat, Sleep, Console care approach - is increasing in use. Whether the new approach can safely reduce the time until infants are medically ready for discharge when it is applied broadly across diverse sites is unknown.
Methods:
In this cluster-randomized, controlled trial at 26 U.S. hospitals, we enrolled infants with neonatal opioid withdrawal syndrome who had been born at 36 weeks' gestation or more. At a randomly assigned time, hospitals transitioned from usual care that used the Finnegan tool to the Eat, Sleep, Console approach. During a 3-month transition period, staff members at each hospital were trained to use the new approach. The primary outcome was the time from birth until medical readiness for discharge as defined by the trial. Composite safety outcomes that were assessed during the first 3 months of postnatal age included in-hospital safety, unscheduled health care visits, and nonaccidental trauma or death.
Results:
A total of 1305 infants were enrolled. In an intention-to-treat analysis that included 837 infants who met the trial definition for medical readiness for discharge, the number of days from birth until readiness for hospital discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group (adjusted mean difference, 6.7 days; 95% confidence interval [CI], 4.7 to 8.8), for a rate ratio of 0.55 (95% CI, 0.46 to 0.65; P<0.001). The incidence of adverse outcomes was similar in the two groups.
Conclusions:
As compared with usual care, use of the Eat, Sleep, Console care approach significantly decreased the number of days until infants with neonatal opioid withdrawal syndrome were medically ready for discharge, without increasing specified adverse outcomes. (Funded by the Helping End Addiction Long-term (HEAL) Initiative of the National Institutes of Health; ESC-NOW ClinicalTrials.gov number, NCT04057820.).
It is desirable to avoid drug use during pregnancy considering the effects on the fetus and newborn. However, some women may need drug treatment for illness before pregnancy or during pregnancy. This study aims to obtain information on drug selection in drug therapy for pregnant women, focusing on neonatal drug withdrawal syndrome (NAS).
Therefore, we analyzed the expression tendency of NAS using the “Japanese Adverse Drug Event Report database (JADER)” in single-agent and multiple-drug administration. The drugs reported to cause NAS were psychotic drugs such as antidepressants and antianxiety drugs. As a result of analyzing the drug onset tendency in single-agent administration, escitalopram oxalate, alprazolam, and zolpidem tartrate were more likely to cause onset than other drugs. In the comparison of monotherapy and multiple drug therapy of each drug, aripiprazole was more likely to cause onset in two-drug use, and risperidone, quetiapine fumarate, sodium valproate, sertraline hydrochloride, fluvoxamine maleate, and paroxetine hydrochloride hydrate in three- or more drug use. In addition, 7 cases were “unrecovered” and “with sequelae” in multiple drug use, which was higher than in the case of single agent administration. Therefore, it is necessary to pay attention to the onset and aggravation of the disease due to multiple drug use. We believe that these results will help drug selection in drug therapy for pregnant women with psychiatric disorders.
Background
Brexpiprazole is a second-generation antipsychotic approved in Japan in 2018; however, information on placental passage and breast milk transfer remains limited. In this report, the patient, a 30-year-old pregnant woman with schizophrenia, was medicated with brexpiprazole, risperidone, and quetiapine.
Methods
The study used high-performance liquid chromatography–tandem mass spectrometry to determine the concentrations of brexpiprazole, quetiapine, risperidone, and its active metabolite (paliperidone) in maternal and neonatal plasma, cord venous plasma, and breast milk. Maternal plasma samples were obtained approximately 2 and 8 hours after the last administration of antipsychotics on the day of delivery and at the estimated drugs' trough time on days 1, 3, and 5 after delivery.
Results
The maternal plasma concentrations of brexpiprazole, quetiapine, and paliperidone increased by approximately 3.5-fold on the fifth day compared with those on the day of delivery, whereas the risperidone concentration remained almost constant. Moreover, the neonatal plasma concentrations of the 4 drugs immediately after birth were indistinguishable from the umbilical cord concentrations and gradually decreased, except for risperidone. Relative infant doses of these compounds were below 1.1%.
Conclusions
Pregnancy status notably alters the pharmacokinetic properties of antipsychotics. Therefore, close and careful monitoring of clinical symptoms should be considered during pregnancy and after delivery. Although brexpiprazole is transferred to neonates through the placenta, breastfeeding is still possible because the relative infant dose value of this drug was much less than 10%.
Importance
The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown.
Objective
To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool.
Design, Setting, and Participants
This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks’ gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024.
Exposure
Opioid treatment for NOWS and the ESC care approach.
Main Outcomes and Measures
For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics.
Results
In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001).
Conclusion and Relevance
When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later.
Trial Registration
ClinicalTrials.gov Identifier: NCT04057820
Purpose
Infants prenatally exposed to opioids exhibit withdrawal symptomology that introduce physiological noise and can impact newborn hearing screening results. This study compared the referral rate and physiological noise interpreted by number of trials rejected due to artifact on initial newborn hearing screenings of infants with prenatal opioid exposure (POE) and infants with no opioid exposure (NOE). Furthermore, within the POE group, it examined the relationship of referral rates with severity of withdrawal symptomology, and with maternal and infant risk factors.
Method
This study used a retrospective cohort design of electronic medical records from six delivery hospitals in South-Central Appalachia. Newborn hearing screenings were conducted using automated auditory brainstem response (ABR) for 334 infants with POE and 226 infants with NOE. Severity of withdrawal symptomology was measured using the Modified Finnegan Neonatal Abstinence Scoring Tool, which includes observation of behaviors that introduce physiological noise.
Results
There was no significant difference in newborn hearing screening referral rate between infants with POE and infants with NOE. Referral rate was not affected by maternal or infant risk factors. Infants with POE had statistically significant higher artifact (defined as rejected ABR sweeps) than infants with NOE. There was a strong positive correlation between Finnegan scores and artifact but not referral rates. Sensitivity and specificity analysis indicated artifact decreased substantially after Day 4 of life.
Conclusions
Referral rates of infants with POE were similar to those of infants with NOE. Nevertheless, the withdrawal symptomology of infants with POE introduces physiological noise reflected as artifact on ABR, which can affect efficiency of newborn hearing screenings.
Newborn neurobehavior enables us to identify individual differences and temperament, differential susceptibility and to identify at-risk-infants. Neurobehavioral and biological (e.g., epigenetic) pathways set the stage for the “goodness-of-fit” between infant and caregiver manifest in dyadic interaction and mutual regulation. Preterm infants in particular struggle to develop mutual regulation because of the demands of internal/external stimulation. Changing caregiver behavior to better-fit infant neurobehavioral profiles in a dynamic repair-and-expand model can improve infant regulation and mental health.
Neonatal-perinatal medicine is a relatively new subspecialty of pediatrics. However, during the last half century, there has been significant improvement in patient outcomes, reflecting increased use of evidence-based medicine in routine clinical practice. The clinical practice of neonatology is changed from providing ventilation and survival to avoiding lung and brain injury and promote neurodevelopmental outcome. The survival at age of viability and survival with complex congenital problems has been steadily raising.
The purpose of this chapter is not to provide an exhaustive review but rather to highlight some concepts of newborn care including recent updates.
The first half of chapter addresses normal newborn care while the second part presents some common neonatal diseases and issues resulting in admission to Neonatal intensive Care Unit (NICU).
Opioid use disorders (OUD) during pregnancy are related to neonatal opioid withdrawal syndrome (NOWS). R,S-methadone used to treat OUD and NOWS can penetrate the placenta. High neonatal brain extracellular fluid (bECF) levels of R,S-methadone can induce respiratory depression in newborns. The purpose of this work was to estimate neonatal bECF and saliva levels to establish the neonatal R,S-methadone salivary thresholds for respiratory depression after maternal oral dosing despite the sparse data in pregnancy and newborn populations. An adult physiologically-based pharmacokinetic (PBPK) model for R,S-methadone after intravenous and oral administration was constructed, vetted, and scaled to newborn and pregnancy populations. The pregnancy model predicted the R-methadone and S-methadone doses transplacentally transferred to newborns. Then, the newborn PBPK model was used to estimate newborn exposure after such doses. After maternal oral dosing of R,S-methadone (43.8 mg/day), the neonatal plasma levels were below the respiratory depression threshold. Further, the bECF levels were above the analgesia threshold for more than 96 h. The salivary thresholds for the analgesic effects of R-methadone, S-methadone, and R,S-methadone were estimated herein at 1.7, 43, and 16 ng/mL, respectively. Moreover, the salivary thresholds for the respiratory depression of R-methadone and R,S-methadone were estimated at 58 and 173 ng/mL, respectively. Using neonatal salivary monitoring of methadone can be useful in ensuring newborns' safety during maternal OUD treatment.
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).
Many pediatric patients with burn injuries may be initially treated in a hospital where pediatric specialized care, including resources and trained personnel may be limited. This includes resuscitation in adult emergency departments and inpatient care in mixed adult-pediatric burn units. The intent of this review is to provide a compilation of topics for the adult trained pharmacist or other healthcare practitioner on the management of pediatric patients with burn injuries. This article focuses on several key areas of pharmacologic burn management in the pediatric patient that may differ from the adult patient, including pain and sedation, fluid resuscitation, nutrition support, antimicrobial selection, anticoagulation, and inhalation injury. It is important that all clinicians have resources to help optimize management of burn injuries in the pediatric population as, in addition to burn injury itself, pediatric patients have different pharmacokinetics and pharmacodynamics affecting which medications are utilized and how they are dosed. This article highlights several key differences between pediatric and adult patients, providing an additional resource to assist adult trained pharmacists or other healthcare practitioners with making clinical decisions in the pediatric burn population.
OBJECTIVE
Chervoneva et al (2020) developed an abbreviated score (sMNAS-9) for evaluating NOWS symptoms. We sought to develop NOWS treatment algorithms for clinical decision rules based on sMNAS-9 instead of the full modified Finnegan MOTHER NAS scale (MNAS) scores.
STUDY DESIGN
This was a retrospective study of 373 infants with NOWS treated with morphine between 2007–2016. The infants were randomly split into training/test sets. The training set was used to derive cutoff values for sMNAS-9 scores for optimal sensitivities and specificities. The independent test set evaluated the agreement of the clinical decision rules based on sMNAS-9 with full MNAS in NOWS morphine and buprenorphine treatment algorithms.
RESULT
Clinical decision rules based on sMNAS-9 yielded sensitivities of 88% or higher and specificities of 85% or higher for predicting the respective rules based on full MNAS.
CONCLUSION
The sMNAS-9 scoring instrument is expected to yield similar clinical decisions in treatment of NOWS
This is a protocol for a Cochrane Review (intervention).
The objectives are as follows: To assess if acupuncture reduces the treatment duration of neonatal abstinence syndrome(NAS) in newborn infants, reduces adverse events and reduces length of hospital stay.
Background:
Neonatal abstinence syndrome (NAS) is a collection of symptoms that neonates may experience following antenatal exposure to substances that induce withdrawal. Optimal management remains unknown, and there is variation in management and outcomes.
Objectives:
To describe the management, length of hospitalization, and adverse events in near-term and full-term neonates with NAS for whom treatment (pharmacotherapy and/or supportive care) was initiated in the neonatal intensive care unit (NICU).
Methods:
A chart review was conducted of neonates admitted to the NICU of Surrey Memorial Hospital, Surrey, British Columbia, who received treatment for NAS between September 1, 2016, and September 1, 2021.
Results:
A total of 48 neonates met the inclusion criteria. Opioids represented the most frequent type of antenatal exposure. Polysubstance exposures occurred in 45 (94%) of the neonates. Morphine was given to 29 (60%) of the neonates, and phenobarbital to 6 (13%); 5 of these neonates received both medications. The average duration of morphine treatment was 14 days, and the average length of hospitalization (all patients) was 16 days. All of the neonates experienced adverse events; in particular, 9 (30%) of the 30 who received pharmacotherapy were too sedated to feed, compared with 0% of the 18 with no pharmacotherapy.
Conclusions:
The common finding of polysubstance antenatal exposure, involving predominantly opioids, was associated with scheduled morphine pharmacotherapy for the majority of patients, prolonged hospitalization, and frequent adverse events. Pharmacotherapy for NAS was associated with levels of sedation that interfered with feeding in neonates.
Objectives:
To improve outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) admitted to NICU by implementing a quality improvement (QI) initiative incorporating "eat, sleep, console" (ESC) as a withdrawal evaluation tool and promotion of nonpharmacological interventions. Secondarily, we evaluated the impact of the coronavirus disease 2019 pandemic on QI initiative and outcomes.
Methods:
We included infants born ≥ 36 weeks gestation and admitted to NICU with a primary diagnosis of NOWS between December 2017 and February 2021. (preintervention; December 2017-January 2019, postintervention; February 2019-February 2021). We compared cumulative dose, duration of opioid treatment, and length of stay (LOS) as our primary outcomes.
Results:
The average duration of opioid treatment decreased from 18.6 days in the preimplementation cohort (n = 36) to 1.5 days in the first-year postimplementation (n = 44) with a reduction in cumulative opioid dose from 5.8 mg/kg to 0.6 mg/kg and decrease in the proportion of infants treated with opioids from 94.2% to 41.1%. Similarly, the average LOS decreased from 26.6 to 7.6 days. In the second-year postimplementation during the coronavirus disease 2019 pandemic (n = 24), there was an increase in average opioid treatment duration and LOS to 5.1 and 12.3 days respectively, but cumulative opioid dose (0.8 mg/kg) remained significantly lower than the preimplementation cohort.
Conclusions:
ESC-based quality improvement initiative led to a significant decrease in LOS and opioid pharmacotherapy in infants with NOWS in NICU setting. Despite the impact of the pandemic, some of the gains were sustained with adaptation to ESC QI initiative.
Neonatal abstinence syndrome (NAS) has been of increasing concern. Studies suggest that prenatal exposure to buprenorphine may be preferred to methadone in regard to neonatal withdrawal. Our aim was to determine whether the incidence and severity of NAS are different between babies prenatally exposed to methadone or buprenorphine in pregnancy. This retrospective analysis of infants ≥ 35-weeks-old exposed to methadone/buprenorphine alone or in conjunction with other substances in utero. They were divided into four groups: 1—methadone alone (Met), 2—buprenorphine alone (Bup), 3 and 4—those exposed to methadone and buprenorphine, respectively, in conjunction with other drugs (Met+ and Bup+). The frequency of NAS treatment, duration of treatment (LOT) and length of stay (LOS) were compared between groups. Of the 290 mothers, 59% were in the Met group, 18% in the Bup group, 14% in the Met or Bup and another opiate group, and 9% took methadone or buprenorphine plus various other substances. Infants born to Met/Met+ mothers had a four-times higher likelihood of developing NAS (p < 0.001). There was no difference in the LOS (p = 0.08) or LOT (p = 0.11) between groups. The buprenorphine treatment in pregnancy decreased the risk of babies developing NAS. However, once the NAS required pharmacological treatment, the type of maternal prenatal exposure did not affect the LOS or LOT.
Objectives
The US opioid epidemic contributes to a growing population of children experiencing neonatal abstinence syndrome (NAS) and adverse childhood experiences (ACEs). A review of the developmental impacts of the opioid crisis highlights that both prenatal exposure to teratogens and ACEs can result in developmental delay and disabilities. Training for the early intervention/early childhood (EI) systems is needed to enable them to meet the needs of this growing population.
Methods
To address this, an IRB-approved online training on best practices for NAS, developmental monitoring and referral, and trauma-informed care was created for Ohio EI providers who provided informed consent to participate. The feasibility of utilizing an online training was assessed. Knowledge on opioid addiction, NAS, ACEs, and early intervention provider characteristics were collected for 2973 participants.
Results
Within 6 months, the training reached providers in all Ohio counties and seventeen other states. 57% of providers reported caring for one or more children with a caregiver who has confirmed opioid use. 31% reported these children had experienced four or more ACEs. Providers’ ACEs awareness was moderately associated with their experiences with prenatally-exposed youth. There was a significant increase in knowledge following training. Differences in post-training knowledge differed only by county-level opioid death rates, where those providers with low-medium opioid death rates reported more awareness of children with prenatal opioid exposure compared to participants who lived in a county with medium and medium-high opioid death rates.
Conclusions
Online-training is feasible for closing gaps in the early intervention system.
Objective:
The objective of this study is to investigate the effects of maternal perinatal depression symptoms and infant treatment status for neonatal abstinence syndrome (NAS) on maternal perceptions of infant regulatory behavior at 6 weeks of age.
Methods:
Mothers and their infants (N = 106; 53 dyads) were recruited from a rural, White cohort in Northeast Maine. Mothers in medication-assisted treatment (methadone) and their infants (n = 35 dyads) were divided based on the infant's NAS pharmacological treatment (n = 20, NAS+ group; n = 15, NAS- group) and compared with a demographically similar, nonexposed comparison group (n = 18 dyads; COMP group). At 6 weeks postpartum, mothers reported their depression symptoms Beck Depression Inventory-2nd Edition) and infant regulatory behaviors [Mother and Baby Scales (MABS)]. Infant neurobehavior was assessed during the same visit using the Neonatal Network Neurobehavioral Scale (NNNS).
Results:
Mothers in the NAS+ group showed significantly higher depression scores than the COMP group (p < .05) while the NAS- group did not. Across the sample, mothers with higher depression scores reported higher infant "unsettled-irregularity" MABS scores, regardless of group status. Agreement between maternal reports of infant regulatory behaviors and observer-assessed NNNS summary scares was poor in both the NAS+ and COMP groups.
Conclusions:
Postpartum women in opioid recovery with infants requiring pharmacological intervention for NAS are more at risk for depression which may adversely influence their perceptions of their infants' regulatory profiles. Unique, targeted attachment interventions may be needed for this population.
Introduction
Research participation during undergraduate years has a powerful influence on career selection and attitudes toward scientific research. Most undergraduate research programs in academic health centers are oriented toward basic research or address a particular disease focus or research discipline. Undergraduate research programs that expose students to clinical and translational research may alter student perceptions about research and influence career selection.
Methods
We developed an undergraduate summer research curriculum, anchored upon a clinical and translational research study developed to address a common unmet needs in neonatal nurseries (e.g., assessment of neonatal opioid withdrawal syndrome). Program topics reflected the cross-disciplinary expertise that contributed to the development of this “bedside to bench” study, including opioid addiction, vulnerable populations, research ethics, statistics, data collection and management, assay development, analytical laboratory analysis, and pharmacokinetics. The curriculum was delivered through three offerings over 12 months, using Zoom video-conferencing due to restrictions imposed by the COVID-19 pandemic.
Results
Nine students participated in the program. Two-thirds reported the course enhanced their understanding of clinical and translational research. Over three-quarters reported the curriculum topics were very good or excellent. In open-ended questions, students reported that the cross-disciplinary nature of the curriculum was the strongest aspect of the program.
Conclusion
The curriculum could be readily adapted by other Clinical and Translational Science Award programs seeking to provide clinical and translational research-oriented programs to undergraduate students. Application of cross-disciplinary research approaches to a specific clinical and translational research question provides students with relevant examples of translational research and translational science.
Objective:
The opioid epidemic has led to a surge in diagnoses of neonatal opioid withdrawal syndrome (NOWS). Many states track the incidence of NOWS by using the P96.1 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for "neonatal withdrawal symptoms from maternal use of drugs of addiction." In October 2018, an ICD-10-CM code for neonatal opioid exposure (P04.14) was introduced. This code can be used when an infant is exposed to opioids in utero but does not have clinically significant withdrawal symptoms. We analyzed the effect of the P04.14 code on the incidence rate of NOWS (P96.1) and "other" neonatal drug exposure diagnoses (P04.49).
Methods:
We used private health insurance data collected for infants in the United States from the first quarter of 2016 through the third quarter of 2021 to describe incidence rates for each code over time and examine absolute and percentage changes before and after the introduction of code P04.14.
Results:
The exclusive use of code P96.1 declined from an incidence rate per 1000 births of 1.08 in 2016-2018 to 0.70 in 2019-2021, a -35.7% (95% CI, -47.6% to -23.8%) reduction. Use of code P04.49 only declined from an incidence rate of 2.34 in 2016-2018 to 1.64 in 2019-2021, a -30.0% (95% CI, -36.4% to -23.7%) reduction. Use of multiple codes during the course of treatment increased from an average incidence per 1000 births of 0.56 in 2016-2018 to 0.79 in 2019-2021, a 45.5% (95% CI, 24.8%-66.1%) increase.
Conclusion:
The introduction of ICD-10-CM code P04.14 altered the use of other neonatal opioid exposure codes. The use of multiple codes increased, indicating that some ambiguity may exist about which ICD-10-CM code is most appropriate for a given set of symptoms.
Objective:
Breastfeeding is the optimal source of nutrition for all infants, but there are limited data on feeding outcomes in infants with neonatal abstinence syndrome (NAS) who are admitted in the neonatal intensive care unit (NICU).
Methods:
A retrospective cohort study was conducted at a level II/III NICU. Study sample consisted infants with a diagnosis of NAS and those diagnosed with respiratory distress syndrome. The primary outcome was attainment of independent oral feeds, defined as the number of days to transition from full-tube to full oral feeds. Secondary outcomes included length of hospital stay and method (breast or bottle) of oral feeds at the start, at attainment of independent oral feeds, and at hospital discharge.
Results:
Infants with NAS took significantly longer to attain independent oral feeds than controls (P = .021) and received significantly fewer breastfeeds at the start of oral feeds, at independent oral feeds, and at hospital discharge (P = .000). There was no difference in length of hospital stay between groups.
Conclusion:
These results suggest that infants with NAS can experience difficulties achieving independent oral feeds and are less likely to receive breastfeeds. Additional support is required to enhance oral feeds in infants with NAS in the NICU.
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