Wide Variation Found in Care of Opioid-Exposed Newborns

Abstract

Background Standardized practices for the management of neonatal abstinence syndrome (NAS) are associated with shorter lengths of stay, but optimal protocols are not established. Aim Identify practice variations for newborns with in-utero chronic opioid exposure among hospitals in the Better Outcomes through Research for Newborns (BORN) network. Methods Nursery site leaders completed a survey about hospitals’ policies and practices regarding care for infants with chronic opioid exposure (≥3 weeks). Results The 76/95 (80%) respondent hospitals were in 34 states, varied in size (<500–>8000 births and <10–>200 opioid-exposed infants/year), with most affiliated with academic centers (89%). Most (85%) had protocols for newborn drug exposure screening; 95% used risk-based approaches. Specimens included urine (81%), meconium (73%) and umbilical cords (10%). Of sites (88%) with NAS management protocols, 77% addressed medical management, 72% nursing care, 72% pharmacologic treatment and 58% supportive care. Morphine was the most common first-line pharmacotherapy followed by methadone. Observation periods for opioid-exposed newborns varied; 57% observed short-acting opioid exposure for 2–3 days while 30% observed for ≥5 days. For long-acting opioids, 71% observed for 4–5 days, 19% for 2–3 days and 8% for ≥7 days. Observation for NAS occurred mostly in Level 1 nurseries (86%); however most (84%) transferred to NICUs when pharmacologic treatment was indicated. Conclusion Most BORN hospitals had protocols for the care of opioid-exposed infants, but policies varied widely and characterize areas of needed research. Identification of variation is the first step toward establishing best practice standards to improve care for this rapidly growing population.

Hospital Care of Opioid‐Exposed Newborns: Clinical and Psychosocial Challenges

“…Although universal maternal toxicology testing improves the identification of newborns at risk for NAS, this approach remains controversial; most hospitals use a riskbased approach for maternal toxicology testing. 16,17 Newborn toxicology testing can be performed from samples of hair, urine, meconium, and umbilical cord. Although frequently used, newborn urine testing has the shortest window of detection, ie, the last few days prior to delivery (Table 1).…”

“…18 In a recent survey, 10% of hospitals reported using umbilical cord toxicology as the primary method for detecting intrauterine exposures. 17 This approach allows greater ease of specimen collection but may not yield results that are exactly equivalent to meconium testing. 19…”

“…Although the current American Academy of Pediatrics (AAP) guidelines recommend three days of newborn observation for exposure to short-acting opioids and five to seven days for longer acting opioids, substantial variation has been described across US hospitals in policies related to newborn length of stay for NAS observation. 17,20 In most hospitals, monitoring for NAS occurs in the routine postpartum unit (ie, level 1 nursery), with transfer to the NICU if pharmacologic treatment is indicated. 17 The most widely used assessment tool for NAS is the Finnegan Neonatal Abstinence Scoring System (FNASS) or the modified FNASS, which assigns points for the 21 most common opioid withdrawal symptoms based on perceived severity.…”

“…17,20 In most hospitals, monitoring for NAS occurs in the routine postpartum unit (ie, level 1 nursery), with transfer to the NICU if pharmacologic treatment is indicated. 17 The most widely used assessment tool for NAS is the Finnegan Neonatal Abstinence Scoring System (FNASS) or the modified FNASS, which assigns points for the 21 most common opioid withdrawal symptoms based on perceived severity. 17,21 This tool allows for assessment of symptoms, helps determine need for pharmacologic intervention, and can guide monitoring of symptoms and weaning of therapy.…”

“…32 A small percentage of hospitals use donor breastmilk for this population, although data on outcomes are limited. 17 For formula-fed newborns, emerging research suggests that early initiation of high-calorie (22-24 kcal/ounce) formula may be beneficial to prevent excessive weight loss and poor weight gain after intrauterine opioid exposure. 33…”