What is the best way to treat my opiate-exposed newborn?

A less-invasive approach for infants born after being exposed to opiates in utero helps babies leave the hospital sooner, a new study has concluded. Published in The New England Journal of Medicine in April, the study found that the care approach, called “Eat, Sleep, Console,” is actually much better for these babies than the traditional Finnegan Neonatal Abstinence Scoring tool. The trial study was conducted at 26 hospitals in the United States and enrolled 1,305 infants with neonatal opioid withdrawal syndrome who were born at 36-weeks gestation or more. The study showed dramatic results. The number of days from birth to discharge was 8.2 in the Eat, Sleep, Console group and 14.9 in the usual-care group.

“We switched over to the Eat, Sleep, Console method of assessing babies in 2019 at Cape Cod Hospital, so we were definitely ahead of the curve,” said Janelle Laudone, MD, chief of pediatrics at the hospital.

She said the new study was a good one because it not only included a diverse number of hospitals, but because it also followed up with the babies during the first three months after birth to make sure there were no unintended negative consequences as a result of sending the babies home earlier.

At Cape Cod Hospital, the Eat, Sleep, Console assessment replaced the traditionally-used modified Finnegan Neonatal Abstinence Scoring tool to assess the severity of neonatal opioid withdrawal. The Finnegan scoring included a long list of different symptoms or physical exam findings after doing a head-to-toe examination of the baby, Dr. Laudone said. It included things like their cry, their sleep, whether they had hyperactive reflexes, tremors, increased muscle tone, nasal stuffiness, diarrhea, poor feeding and increased sneezing and yawning.

The babies would score points for every sign or symptom and, once they met a certain threshold, that determined whether to start pharmacological treatment.

“The problem with the Finnegan scoring is that it’s a head-to-toe assessment and you have to unwrap and disturb the baby to do it,” Dr. Laudone said. “And babies were scoring points for things that in the long run aren’t so important. If a baby is sneezing or yawning a lot, is that really affecting the baby negatively? Probably not, and so the Eat, Sleep, Console method really focuses on the infant’s functioning.”

Three Areas of Functioning

That means that nurses observe the baby closely over several hours and look specifically for three areas of functioning:

• How is the infant eating?
• How is the infant sleeping?
• How consolable is the infant?

If the baby is having difficulty with one of those three domains, the first step is to have a team huddle which includes the parent, the nurse and the rest of the care team to see what they can do to help the baby, Dr. Laudone said. They start with non-pharmacological interventions that include:

• Skin-to-skin contact.
• Making sure the baby is swaddled.
• On-demand feeding with an emphasis on breastfeeding.
• A low-stimulation environment.
• A quiet room.
• Low lights.
• Low-volume televisions.
• Minimal visitors.

“We try to maximize those non-pharmacological interventions and then we see if, despite a maximum amount of non-pharmacological interventions, the baby is still having a lot of difficulty in those three domains of eating, sleeping, consoling,” said Dr. Laudone. “It’s only at that point that we move to pharmacological treatment, which is medication.”

Ongoing at CCH Since 2013

Even though Cape Cod Hospital didn’t switch from Finnegan scoring to the Eat, Sleep, Console model for scoring until 2019, they had implemented all of the other non-pharmacological elements of the Eat, Sleep, Console model of care years earlier. In 2013 a local team of 16 pediatricians, nurses and one community representative participated in an intense education program led by the Vermont Oxford Network to learn the latest evidence-based treatment for these babies.

As a result, in 2016, Cape Cod Hospital was named as a Center of Excellence for the treatment of babies born with Neonatal Abstinence Syndrome (NAS), now called Neonatal Opioid Withdrawal Syndrome (NOWS).

Verbal screening for substance use disorder occurs early in the pregnancy at the OB office. Once moms are identified as having a disorder, the obstetrician refers them to a comprehensive treatment program. Oftentimes the moms who have the babies born with neonatal opioid withdrawal syndrome are in active treatment.

“When people hear about babies exposed to substances, I think probably the layperson’s gut reaction is that the moms are using heroin or other illicit opioids,” Dr. Laudone said. “But many of the moms are actually in stable treatment programs on medications that are used in treatment like buprenorphine or methadone. They are stable in their recovery but babies can withdraw from those substances just like they can withdraw from prescription or non-prescription pills or other opioids.”

Family-Centered Care

Once the mom is discharged from the maternity floor, the mom and baby are moved to the pediatric floor where the focus is on family centered care. For many of these moms, the birth of their baby is reason enough to stay in a stable treatment program to continue to get comprehensive treatment for substance use disorder, said Dr. Laudone.

After the moms and babies are released from the hospital there is active follow-up with obstetricians, pediatricians, Early Intervention and the Visiting Nurse Association of Cape Cod.

“We have a great Visiting Nurse program here on the Cape with nurses who are specific to postpartum moms and their babies,” Dr. Laudone said. “We actually refer all moms to them, not just moms of babies exposed to substances in utero, because they are such an excellent resource. They can be very helpful following the couplet, the baby and the mom, for as long as they need to.”