To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS).
We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio’s 6 children’s hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning.
After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P < .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P < .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days).
Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.
Comments
Non-pharmacological strategies need to be included in neonatal abstinence syndrome protocols
Dear editors We read "Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study" by Hall et al (1) with great interest. There is no question that the treatment for NAS has been historically heterogeneous and standardization of evidence-based care is needed. The authors clearly demonstrate how the uptake of guidelines decreased the length of both opioid treatment and inpatient hospital stay. While we applaud the standardization of medication management of NAS, we were dismayed by the absence of non-pharmacological strategies in the treatment protocol. For example there was no mention of breastfeeding. This is unfortunate as breastfeeding reduces the need for treatment in opioid-exposed infants (2) and is an inexpensive intervention with a multitude of other public health benefits. Additionally there is no mention of the importance of skin-to-skin contact which even in the absence of breastfeeding reduces the severity of NAS. Nor is there mention of trauma-informed care despite evidence that health risk behaviors (such as substance use disorder) and exposures in pregnant women are concentrated among nulliparous women with PTSD (3).
The authors should also be applauded for their attention to cost and their demonstration of cost savings with the implementation of their protocol. However the most significant cost-saving measure is not part of the guideline: the location of care for opioid-exposed newborns. Most of the infants in their analysis were treated in the NICU and rooming-in capabilities were not mentioned. This high level of care is rarely necessary and is the primary driver of the high cost of NAS. Additionally the separation of a mother from her newborn worsens the course of NAS increasing the amount of medication needed for treatment (4,5).
Comprehensive guidelines for the treatment of NAS need to include non- pharmacological modalities of care as well as a discussion of the most cost-effective and beneficial location of the care.
Mishka Terplan MD MPH FACOG Diplomate ABAM Mary Faith Marshall PhD FCCM Ronald R Abrahams MD CCFP FCFP
References 1. Hall ES, Wexelblatt SL, Crowley M, et al. Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study. Pediatrics 2015;136(4) doi: 10.1542/peds.2015-1141 2. Gabrielle K. Welle-Strand, et al., Breastfeeding Reduces the Need for Withdrawal Treatment in Opioid-Exposed Infants, 102 Foundation Acta Paediatrica 1060 (2013). 3. Dryden C, Young D, Hepburn M, Mactier H. Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for health care resources. British Journal of Obstetrics and Gynaecology 2009; 116: 665-71. 4. Ronald R. Abrahams, et al., An Evaluation of Rooming-In Among Substance -exposed Newborns in British Columbia, 32 J. Obstet. Gynaecol. Can. 866 (2010). 5. Tolulope Saiki, et al., Neonatal Abstinence Syndrome--Postnatal Ward Versus Neonatal Unit Management, 169 Eur. J. Peds. 95 (2010).
Conflict of Interest:
None declared