RECENT NATIONAL STUDY indicated that illicit drug use is 16.2% among pregnant teens and 7.4% among pregnant women aged 18 to 25 years. 1 Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome in newborns following birth. The syndrome most commonly occurs in the context of antepartum opiate use, although other drugs have also been implicated. [2][3][4][5] In addition to NAS, illicit drug use (specifically opioid dependence) during pregnancy is associated with a significantly increased risk of adverse neonatal outcomes such as low birthweight (Ͻ2500 g) and mortality. [6][7][8][9] Neonatal abstinence syndrome is characterized by a wide array of signs and symptoms including increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures, and respiratory distress. 10 Symptoms of withdrawal associated with NAS have been described in 60% to 80% of newborns exposed to heroin or methadone in utero. 11 Recently, analyses from Australia 12 and the Florida Medicaid program (D. Aronberg, JD, written communication, November 30, 2011) found that the incidence of NAS has been increasing. To date, there are no national es-Author Affiliations are listed at the end of this article.

Innovation: Establish formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decreases length of stay for patients with lifethreatening illnesses.Evaluation: Pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls.Setting: Pediatric Intensive Care Unit in a quaternary care Children's Hospital. Participants: Physicians and nurses on staff in the unit.Patients: There were 60 patients in the interventional and 66 patients in the historical control group.Intervention: Over a year, weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU. Results:Moral distress scores measured intermittently with the MDT fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall MDS-R scores were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p=0.015), a statistically significant increase in both code status changes DNR (11% control, 28% PEACE, p=0.013), and in-hospital death (9% control, 25% PEACE, p=0.015), with no change in patient 30 or 365 day mortality. Conclusion:The addition of a clinical ethicist and senior intensivist to weekly interprofessional team meetings facilitates difficult conversations regarding realistic goals of care. The PEACE

Discharges for children associated with LTMV require substantively greater inpatient resource use than other children with CCCs. As the number of discharges and associated aggregate charges increase over time, additional research must examine patterns of care for specific clinical subgroups of LTMV, especially children aged 4 years and younger.