Weaning Babies with NAS Better and Faster

Adoption of a strict protocol has enabled six regional perinatal centers across Ohio to wean babies exposed to opioids in utero off drugs faster, send them home sooner and lower the use of adjunctive drugs, new research shows.

In response to the skyrocketing number of babies born to mothers abusing prescription opioids and heroin across the state in the last decade, Akron Children’s, Cincinnati Children’s and Nationwide Children’s hospitals developed and tested stringent rules and procedures using either methadone or morphine to wean newborns with neonatal abstinence syndrome (NAS). All three saw improvements for newborns and families and healthcare cost savings.

The three and Dayton Children’s, Toledo Children’s and University Hospitals Rainbow Babies and Children’s hospitals agreed to adopt a single standardized inpatient weaning protocol in July 2013. The new adopters saw the same kinds of improvements: the average number of days of morphine treatment dropped from 34 to 23, stays declined from 32 days to 24 and use of adjunctive drugs to manage seizures, jitters, diarrhea and vomiting dropped from 21 percent of patients to 5 percent.

Cincinnati weans with methadone, the other five hospitals morphine, but, “The big difference isn’t what drug is used, but how strict the protocol is,” says Mark Klebanoff, MD, a principal investigator at the Center for Perinatal Research in The Research Institute at Nationwide Children’s and an author of the study. “We found that having very strict instructions on increasing and decreasing the dose, clear definitions of getting better and training nurses was more important than the drug used.”

Nurses were trained to assess babies’ NAS symptoms and score them consistently on the Finnegan scale. Physicians, sometimes in consultation with a clinical pharmacist, used the scores as a guide to increase or decrease the morphine or methadone dosage for each patient.

Nationwide Children’s started pursuing a standardized approach after Richard McClead, MD, the hospital’s associate chief medical officer, reviewed costs in 2009. He found great variation in the amount of time newborns with NAS who were being weaned off opioids spent in the neonatal intensive care unit. At about the same time, Cincinnati Children’s and Akron Children’s hospitals began pursuing more consistent assessment and treatment.

“We’ve had great success overall,” Dr. McClead, a study author, says. “The length of stay is down to around 17 days. When we started, some of the babies were here 70-some days.”

Due to its success, the protocol has been expanded to 53 Ohio hospitals. Researchers are collecting length-of-stay data from each.

The children’s hospitals are also continuing to seek improvement. They’re investigating if cuddling and diet may help bring the babies off treatment drugs faster, studying the use of adjunctive drugs and their protocols, testing the new drug buprenorphrine for weaning and more.

Reference: 
Hall ES, Wexelblatt, SL, Crowley M, Grow JL, Jasin, LR, Klebanoff MA, McClead RD, Meinzenn-Derr J, Mohan VK, Stein H, Walsh MC, on behalf of the OCHNAS Consortium. Implementation of a neonatal abstinence syndrome weaning protocol: a multicenter cohort study. Pediatrics. 2015 Oct;136(4):e803-e810.