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As our nation continues to be in the throes of the worst opioid epidemic in its history, a serious but not widely recognized consequence is the surge in newborns born to mothers who used opioids during pregnancy. These babies can experience painful opioid withdrawal symptoms, known as Neonatal Abstinence Syndrome (NAS).
An estimated 24,000 babies that were born in 2013 experienced symptoms of opioid withdrawal in the U.S., a five-fold increase since 2000. That is an average of one baby born every 20 minutes with NAS. While each newborn responds differently to withdrawal, the symptoms can include tremors, loud pitched screams, trouble breathing, sweating, fever, and the inability to eat. Most of these symptoms begin 24 to 72 hours after birth and can last up to five days.
How do health care providers assess whether a baby is going through withdrawal and the best way to treat them? The most commonly used assessment tool to help providers treat newborns with NAS, known as the Finnegan Neonatal Abstinence Scoring System (FNASS), is based on 31 symptoms of opioid withdrawal and is administered every four hours during a newborn’s hospital stay. The tests measure excessive high-pitched crying for more than five minutes, hyperactive motor reflex, and mild tremors when disturbed.
Based on the scores from this assessment, babies with severe symptoms begin medication therapy, and are usually treated by substituting another opioid like morphine or methadone that can be gradually reduced to manage the slow withdrawal process. However, some researchers are now questioning if there are better alternatives to this approach.
A new way of assessing and treating newborn opioid withdrawal
Dr. Matthew Lipshaw and his team of researchers at Yale Children’s Hospital developed a new approach to assessing and treating infants with symptoms of withdrawal that does not automatically result in administering medications to babies. Babies with NAS were evaluated on three symptoms: eating, sleeping, and consolability (ESC). Based on this assessment, babies with NAS were given a non-medication intervention that involved providing them with a low-stimulation environment and having their mothers stay in the room with them and feed them frequently, with the goal of helping alleviate their symptoms without use of an opioid and ultimately reducing the amount of time they needed to stay in the hospital.
Using this approach, Dr. Lipshaw and his team demonstrated a dramatic decrease in the use of medication treatments for babies experiencing symptoms of withdrawal. Between March 2014 and August 2015, researchers reviewed cases of 50 babies with prenatal exposure to opioids. They estimated that, using the traditional approach, 30 infants would have been given a medication treatment. However, using their new strategy, only six infants were administered morphine. Of the 301 patient days evaluated, the older model would have recommended starting or increasing morphine on approximately 25% of the days. By following the newer model, morphine was started or increased on only 3% of the days. This alternative approach also helped reduce hospitalization length from an average of 22 days to six, without an increase in hospital readmission.
Where do we go from here?
Providing opioid medication to babies with NAS is still considered the standard of care in the U.S. and will likely remain the recommended strategy in cases where the mother and infant have severe physical dependence on opioids. However, findings such as those from Dr. Lipshaw’s team make an important contribution and deserve further research to determine which infants born with NAS need opioid medication and which might benefit from alternative approaches emphasizing greater maternal contact and lower stimulation.