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Eat, Sleep, Console: Reducing NICU Admissions of Infants With Prenatal Opioid Exposure

Eat, Sleep, Console: Reducing NICU Admissions of Infants With Prenatal Opioid Exposure 1024 575 Lauren Dembeck

Focusing on non-pharmacological care, emphasizing mother-baby bonding, and natural infant behaviors may keep infants out of the NICU, but other barriers may limit implementation.

Infants exposed to opioids in utero may experience withdrawal symptoms after birth, which can vary in severity depending on many factors, such as length of exposure and type of opioid. In 2020, the incidence of neonatal opioid withdrawal syndrome (NOWS), also known as neonatal abstinence syndrome (NAS), in the United States was 6.2 per 1,000 births. However, rates vary based on geographic location, as seen in the Centers for Disease Control data.

“Historically, we have used the Finnegan Neonatal Abstinence Scoring tool. It was developed in 1970s for the assessment of onset and progression of withdrawal in neonates exposed to heroin in utero,” explains Allison Kelly, DNP, APRN, NNP-BC, NPT-C, neonatal nurse practitioner at Nationwide Children’s Hospital. “Unfortunately, it was never validated, and we can potentially reduce the need for NICU admission by using an alternative assessment method.”

Dr. Kelly and colleagues from Nationwide Children’s led a quality improvement (QI) project at a local delivery hospital to evaluate whether use of the Eat, Sleep, Console (ESC) model of care instead of the Finnegan tool to guide management of neonates with NAS would reduce the number of NICU admissions. Their findings were published in Advances in Neonatal Care.

Under the ESC model, mothers of neonates with NAS are educated on the importance of keeping the baby in the room with them, minimizing environmental stimulation, and feeding the baby on demand. Then every three to four hours, nursing staff evaluate the neonate’s ability to sleep at least one hour uninterrupted, to adequately eat based on gestational age and age in days, and to reach a calm state within 10 minutes when crying.

“The mainstay of this approach is the mother,” adds study co-author Gail A. Bagwell, DNP, APRN, CNS, FAAN, FNAP. “She is the one holding her baby with skin-to-skin contact, breastfeeding, and soothing the baby to help decrease the symptoms of NAS.”

During the 12-week pilot project, 15 neonates who were 35 weeks gestational age or above at birth and with a history of perinatal opiate exposure were managed with ESC in the Mother/Infant unit. Twelve of these neonates were discharged from the Mother/Infant unit without needing transfer to the NICU for pharmacological interventions.

Of five neonates who would have been admitted to the NICU for pharmacological treatment if Finnegan Scores had been used, two were discharged from the Mother/Infant unit after having been managed with ESC. Three neonates were admitted to the NICU for pharmacological treatment.

The reasons for NICU admission varied. Two neonates did not meet the ESC sleeping criteria despite optimization of the environment, and in one of these cases, the neonate was in the nursery instead of with his mother for some time. One neonate was cleared for discharge; however, child protective services took custody of the child just prior to the planned discharge, preventing the mother from being with her child. Hence, the baby was ultimately admitted to the NICU because of the absence of the mother during the intervening time.

“This QI project highlighted some of the barriers and social determinants of health that need to be taken into account to set these babies and moms up for success, while also promoting bonding,” says Dr. Kelly.

One of the major limitations faced by women whose babies need NAS treatment is their continued participation in the baby’s ESC treatment after their hospital discharge when undergoing drug rehabilitation, explain Drs. Kelly and Bagwell.

“When these women are in substance use disorder treatment programs, they have to go in person every day or week to get their medication, such as methadone and buprenorphine. Depending on where they live—sometimes in a county different than that of the hospital—and other circumstances, such as transportation issues or limited time off of work, they may not be able to be at the hospital supporting their babies’ treatment,” shares Dr. Kelly.

“The stigma attached to substance use disorders is very hard to change, but when we care for these babies, we need to shift how we look at these moms. It is really hard to give good care using the Eat, Sleep, Console model if you’re unwilling to acknowledge that the mother’s substance abuse is a disease, and unless the mom is in a treatment program, it is difficult for her to participate,” adds Dr. Bagwell.

The ESC method has been shown to reduce the need for opioid treatment and shorten hospital stays without increasing adverse outcomes in a number of studies and clinical trials (e.g., Young et al. 2023; ClinicalTrials.gov ID: NCT04057820). Nationwide Children’s Hospital has already rolled out ESC in over half of its NICUs and will continue doing so to replace use of the outdated, unvalidated Finnegan tool, focusing more on non-pharmacologic strategies and encouraging mother-baby bonding.

 

References:

  1. Kelly AZ, Bagwell GA, Coates-Huffman P. Our First Steps: A QI Project to Reduce NICU Admissions of Infants With NAS. Adv Neonatal Care. 2024 Dec 1;24(6):517-524.
  2. Young LW, Ounpraseuth ST, Merhar SL, Hu Z, Simon AE, Bremer AA, Lee JY, Das A, Crawford MM, Greenberg RG, Smith PB, Poindexter BB, Higgins RD, Walsh MC, Rice W, Paul DA, Maxwell JR, Telang S, Fung CM, Wright T, Reynolds AM, Hahn DW, Ross J, McAllister JM, Crowley M, Shaikh SK, Puopolo KM, Christ L, Brown J, Riccio J, Wong Ramsey K, Akshatha, Braswell EF, Tucker L, McAlmon KR, Dummula K, Weiner J, White JR, Howell MP, Newman S, Snowden JN, Devlin LA; ACT NOW Collaborative. Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal. N Engl J Med. 2023 Jun 22;388(25):2326-2337.

About the author

Lauren Dembeck, PhD, is a freelance science and medical writer based in New York City. She completed her BS in biology and BA in foreign languages at West Virginia University. Dr. Dembeck studied the genetic basis of natural variation in complex traits for her doctorate in genetics at North Carolina State University. She then conducted postdoctoral research on the formation and regulation of neuronal circuits at the Okinawa Institute of Science and Technology in Japan.

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