NOWS or Never: Questioning the Premise of Inpatient NOWS Care

Neonatal opioid withdrawal syndrome (NOWS) is a postnatal opioid withdrawal syndrome that can occur in newborns exposed to opioids in utero.^1–5  The incidence of NOWS has increased dramatically,^1,6  quadrupling in the past decade.⁷  As Botticelli and colleagues describe in this month’s issue of Hospital Pediatrics,⁸  improving the timing of the transfer of infants with NOWS from acute care settings such as NICUs to tertiary care facilities or inpatient pediatrics units is important. Facilities equipped to provide integrated, multidisciplinary treatment to manage infants with NOWS can help inform the management and timing of referral for these infants and decrease hospital length of stay (LOS).

The authors conducted a single-site retrospective cohort study of 87 infants who were transferred from 14 birth hospitals to the regional tertiary care medical center. Investigators compared the number of days an infant with NOWS was treated with medication, referred to as length of weaning (LOW), between infants transferred before and after 14 days of life. After adjusting for key predictors associated with LOW, the authors found an increase in LOW days by 47% (95% confidence interval: 1.18–1.82) for infants transferred to the regional tertiary after 14 days. In addition, for every 1-point increase in the maximum Finnegan score recorded, the LOW days increased by 5% (95% confidence interval: 1.01–1.08).

The 6.6-day gap in LOW between infants transferred early versus late supports previous literature revealing improved clinical outcomes in infants receiving multidisciplinary NOWS care on units able to provide low-stimulation environments and rooming in with the parent. In the setting described by the authors, earlier timing of referrals for infants with severe NOWS may reduce LOS and minimize other adverse effects of NOWS treatment, such as prolonged medication exposure, separation from caregivers, and additional health care costs. In addition, LOW as an outcome measure (compared with overall LOS), offers more accuracy in accounting for additional hospital days resulting from discharge disposition challenges rather than the need for further NOWS treatment. Previous studies have used “length of treatment” to achieve this same goal. However, the term “length of treatment” refers only to pharmacologic treatment and ignores first-line, nonpharmacologic treatments. LOW more accurately describes medication treatment.

Despite the results of this study, there are questions about how this work adds to the NOWS body of literature. Many variables regarding pharmacologic treatment at the birth hospitals that affect LOW, such as dosing, timing, and length of treatment, were unavailable because of the nature of the study. Characteristics of nonpharmacologic management of infants integral to the care of infants with NOWS before transfer were largely unknown.

Investigators defined early transfer as day of life 14, which was determined by the care protocol of the tertiary care facility. The authors suggest that substantial practice variations in the initial risk assessment and observation period for NOWS at referring hospitals and administrative and social factors related to interinstitutional transfer contributed to the choice of timing of the transfer. It remains unclear why the target of 14 days was not achievable in such a large portion of the patient population and why an earlier target was not chosen. Several studies have revealed significant reductions in LOS and decreased rates of pharmacotherapy with earlier transfer to inpatient pediatric units.^9–14  For example, the initial quality improvement study using the Eat, Sleep, Console (ESC) approach, an approach emphasizing nonpharmacologic treatments as first line, revealed a reduction in LOS from 22.4 to 5.9 days and a reduction in infants treated with morphine from 98% to 14%.¹⁰  In that study, infants were transferred to inpatient units if mothers were discharged from the postpartum unit and Finnegan scores were $≥$8 on day of life 2 to 4.

Most notable is the LOS in both arms of this study. The overall average LOS is 39 days: 48 days in the late transfer group and 25 days in the early transfer group. A large body of literature in the field of NOWS has revealed that lengths of stay <10 days total are achievable by using the ESC approach. The ESC approach includes a focus on nonpharmacologic interventions, prioritizing rooming-in with families, using ESC to monitor infants instead of Finnegan scoring, using medications as needed instead of scheduled weaning, and coaching and supporting families to provide effective care. Using this approach, several community hospitals have demonstrated a >50% reduction in LOS, a 75% reduction in morphine use, and decreased hospital costs.^12–14  The optimization of nonpharmacologic care does not require a specialized tertiary care hospital. In fact, transfer to a regional care facility may mean longer distances from home for parents and may limit the presence of parents at the bedside. Central to the ESC approach is the preservation of the maternal–infant dyad to encourage bonding, provide continuous assessments, and drive care decisions. Although LOS and length of medication treatment were shorter in the group that was transferred early, care should be optimized in both groups at community and tertiary care hospitals using road maps laid out by previously published quality improvement projects that have revealed dramatic improvements in outcomes.^9–14 

The results of the current study highlight the continued need to focus on infants with NOWS as an at-risk population and the wide variability that exists in their care across the United States. Most guidelines recommend nonpharmacologic care as the first-line treatment. However, many NICUs and birth hospitals still do not effectively deliver nonpharmacologic care.^10,15,16 Additionally, although the Finnegan approach has been a predominant management approach over the past several decades, the approach defaults to pharmacological interventions without allowing time to explore nonpharmacologic therapies. The ESC approach shifts the focus from the reduction of withdrawal symptoms using pharmacologic treatment to focusing on the functional wellbeing of the infant and mother–infant bonding.¹⁰  Not only does the ESC approach result in decreases in LOS and lower hospitalization costs but it also results in speedier transitions to home environments, which allows caregivers to work on achieving normal developmental patterns, such as sleep-wake patterns and tummy time with their infants.¹⁷  Thus, delivery hospitals should focus on the development of specialized care pathways, the ability to room in, resources for lactation, support and treatment of the mother, and the provision of low-stimulation environments to inform essential areas of focus in improving care and reduce the need for transfer to tertiary care facilities.

Efforts to maintain caregiver presence at the bedside to provide the most basic needs of a newborn, being held, fed when hungry, and loved should be prioritized. Birth hospitals can provide basic care for newborns and their mothers rather than facilitating their separation from their families. We should expect more from our hospitals; just because this system has been in place for decades does not mean it is acceptable. The nonpharmacologic interventions that have been successful in improving the care of infants with NOWS are not complicated. Rather they are considered routine infant care in the newborn nursery, and all birth hospitals should be willing and able to provide this basic care.

Future research efforts should focus on high-quality evidence needed to address gaps in knowledge for infants with NOWS. Future studies should consistently assess both important short-term outcomes such as infant feeding and nutrition, maternal–infant bonding, parenting and psychosocial support at discharge, and longer-term outcomes, such as neurodevelopmental and social outcomes. However, there are enough data for both community and referral hospitals to begin implementing simple, nonpharmacologic best practices.

Infants with NOWS remain a crucial population of focus. It is critical for care facilities to maximize first-line nonpharmacologic, evidence-based treatments starting from birth; the recognition of key interventions remains difficult to establish based on analysis of administrative data. Given the wide variation in the care of infants with NOWS, a focus on standardized, hospital-based approaches is needed to optimize their care in all birth hospitals.