Neonatal Abstinence Syndrome (NAS) in the NICU

The opioid crisis in the U.S. is ongoing and increasing in many areas. That means that a growing number of infants will be born with Neonatal Abstinence Syndrome (NAS) and need treatment.

Concerns for these infants are many, but as they are medically fragile, the categories of length of stay, transfers, and readmissions remain high for this population.

Recent NAS studies

A recent study published in Pediatric Medscapes by Dr. William T. Basco looked at using methadone treatment compared with morphine to shorten length of stay. Statistics from the study were eye opening:

“The analysis cohort included 7667 infants from 277 NICUs who were treated for NAS with either morphine (85%) or methadone (15%). The mothers were predominantly white (77%). Most (91%) had received prenatal care. At some point during pregnancy, 20% had used buprenorphine and 31% had used methadone. The median birth weight of the infants was 3026 g, and 17% were small for gestational age.”¹

The statistics (from 277 NICUs) show that addiction effects many, and 91% of addicted moms sought prenatal care.

Collaborative efforts to improve NAS healthcare

So, what is being done, or what can we do as clinicians to help with this growing problem?

I found some very hopeful solutions coming from leading agencies in the U.S. and from state initiatives. The first comes from the Centers for Disease Control and Prevention (CDC) with the National Network of Perinatal Quality Collaboratives (NNPQC).

From the CDC site:²

The CDC and the March of Dimes launched the National Network of Perinatal Quality Collaboratives (NNPQC) to support state-based perinatal quality collaboratives in making measurable improvements in statewide health care and health outcomes for mothers and babies. In 2017, CDC awarded the National Institute for Children’s Health Quality (NICHQ) External to serve as the coordinating center for the NNPQC. NICHQ coordinates NNPQC activities, including providing support, mentoring, and resources for perinatal quality collaboratives (PQCs) to:

• Strengthen PQC leadership
• Identify and disseminate best practices for establishing and sustaining PQCs, and
• Identify and develop tools, training, and resources necessary to foster the sharing of best practices to support a sustainable PQC infrastructure

The CDC (working with the March of Dimes) brought individual states to work together as one for a single collaborative to focus on solutions surrounding NAS. They have regular meetings to share data and suggest solutions with multi-state participation. The NNPQC mission is to support the development and enhance the ability of state perinatal quality collaboratives to make measurable improvements in statewide maternal and infant healthcare and health outcomes.

The NNPQC website is so informative. I encourage anyone needing information, resources, conferences and monthly newsletters to visit their website.

Maryland offers a solution

A very promising solution also comes from the state of Maryland, which also launched a NAS collaborative to look at improving outcomes. The Maryland Patient Safety Center developed best practices to focus on improving care of infants with NAS. They were hoping to have participating hospitals implement parts of the bundle to help improve NAS infant care, reduce length of stay, decrease transfers out of the birth hospital, and decrease 30-day admissions. 31 of the 32 birthing hospitals participated in the collaborative – all but one – so a very large group looking at this issue.

The results of the Maryland Patient Safety NAS Collaborative demonstrated the following:³ 

• Three day decrease in LOS of infants with NAS treated pharmacologically – 19 days to 16 days
• 52% decrease in rate of infants transferred out of birth hospital to a higher level NICU or specialty hospital – 22.3% to 10.8%

Additionally, collaborative participants realized the following results:

• 18% increase in infants that received mothers’ own milk in 24 hours preceding discharge – 12.9% to 15.8%
• 21% increase in infants discharged home 

This collaborative looked at 4 categories of which 31 of the states 32 birthing hospitals followed:

• Identification
• Assessment
• Management
• Patient & Family

This bundle of best practices focused on improving the care of NAS infants. The Maryland Patient Safety Center also worked with the Vermont Oxford Network, which has a NAS state-wide implementation package. It is another way to improve access to education to improve outcomes.

State and multi-state networks are working to improve outcomes for infant and maternal health surrounding NAS. Research on the issue is always available, but I encourage clinicians to follow some of these new collaboratives that are trying new ways to look at an ongoing but increasing problem.

 

References:

1. Basco, William T. (2019, February 22) Can Type of Treatment Safely Shorten Hospital Stay in NAS? Retrieved from https://www.medscape.com/viewarticle/908695
2. Centers for Disease Control and Prevention (CDC). (2018, July 23) National Network of Perinatal Quality Collaboratives. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/nnpqc.htm
3. MSPC Perinatal/Neonatal Quality Collaborative, 2019, Bonnie DiPietro RN, MSN