In an article and video abstract being early released this week in Pediatrics, Phillip D. Hahn, MPH, CPH, and colleagues from Boston Children’s Hospital examined the impact of the 2020 AAP Guideline on Neonatal Opioid Withdrawal Syndrome (NOWS; guideline here) on use of pharmacotherapy, length of hospital stay and rate of neonatal intensive care unit (NICU) admission for infants with NOWS (10.1542/peds.2023-063635).
The authors analyzed data from the Pediatric Hospital Information System (PHIS), which is a database that includes resource utilization, billing and clinical information for inpatient, emergency room, observation unit, and ambulatory surgery visits for more than 49 children’s hospitals; data are frequently used to understand inpatient care at freestanding children’s hospitals (learn more here).
In this study, singleton infants with NOWS who were discharged prior to guideline availability (January 2019–December 2020) were compared with those discharged after guideline availability (January 2021–December 2022); infants who were <37 weeks gestation, <1500 grams birthweight, or had congenital abnormalities or other specific complications were excluded. To align with prior studies of NOWS that used PHIS, only those hospitals treating at least 15 infants with NOWS were included.
The main analysis used a technique called “interrupted time series” (ITS) that is particularly useful for “before versus after” quasi-experimental study designs like this one, in which randomization is not possible. The data over the entire period are called the “time series,” and the analysis uses the multiple data points collected over time to identify trends and changes with respect to the intervention (i.e., publication of the guideline).
The authors found:
- No significant change in overall median length of hospital stay (11.0 days pre-guideline versus 10.0 days post-guideline, p=0.55),
- BUT a statistically significant increase in shorter hospital stays (4 days or less) and decrease in longer stays (15 days or more),
- Lower rates of NICU admission post-guideline (78.6% versus 46.7%, p<0.001), and
- Reduced use of opioids, mainly morphine, post-guideline (59.0% versus 50.3%, p=0.01).
The study was not able to compare guideline-recommended non-pharmacologic treatment modalities such as breastfeeding that are not coded in PHIS; however, many more study results await in this excellent article.
This study is relevant whether your practice is mainly inpatient or office-based: although NOWS treatment occurs mainly inpatient, most of us have families affected by opioid use disorder whose infants may have had NOWS. The more we know about optimal care and treatment, the better we can support families in challenging circumstances and help them advocate for their children. This study identifies opportunities for improvement, such as length of stay, that can guide future quality improvement projects.
