Neonatal Abstinence Syndrome Program Improves Outcomes

Beth Skwarecki

April 19, 2016

A program of webinars, real-time feedback, and discussion of "potentially best practices" resulted in standardized policies and slightly shorter length of treatment and length of stay for infants with neonatal abstinence syndrome (NAS) in a multicenter study.

"The data provide support for the [American Academy of Pediatrics' (AAP's)] call for standardizing NAS care, which we have shown is associated with improved outcomes," Stephen W. Patrick, MD, from the Department of Pediatrics, the Department of Health Policy, and the Mildred Stahlman Division of Neonatology at Vanderbilt University and the Vanderbilt Center of Health Services Research in Nashville, Tennessee, and colleagues write in their report, published online April 15 in Pediatrics.

Those AAP guidelines, issued in 2012, call for hospital nurseries to develop protocols to identify and treat infants with NAS. These include screening for maternal substance abuse, scoring infants' signs of withdrawal with a published assessment tool, and using both medications and supportive nonpharmacologic approaches to treat the infants. The guidelines also state that, absent other contraindications, nurseries should encourage mothers of infants with NAS to breast-feed.

In the Pediatrics study, hospitals in the Vermont Oxford Network, a not-for-profit organization dedicated to infant health, enrolled in an internet-based quality improvement program. The hospitals included level 1 birthing hospitals with no neonatal intensive care unit, as well as level 2 and 3 centers. A total of 223 centers participated, with 199 undergoing at least one audit, including the majority of neonatal intensive care units in Massachusetts and Michigan. On audit dates, auditors reviewed records from the 30 most recent infants who were diagnosed with NAS and treated pharmacologically.

The training included a series of interactive webinars, a video-based "virtual visit" to two centers in Vancouver with successful NAS programs, and coaching and feedback on both the process and outcomes. Participating hospitals also received a quality improvement toolkit and means for standardized data collection.

Rather than specifying best practices, the collaborative instructed hospitals to develop and test their own protocols based on three "potentially best practices": standardizing screening and management of NAS, standardizing a process for measuring and reporting rates of NAS, and creating a culture of compassion and understanding for mothers and infants affected by NAS.

The audits included 3458 infants, of whom 77.6% were born at term and treated with morphine. About a quarter were discharged to foster care, and 34% were tapering their medication when they were discharged.

Centers increased the number of guidelines they followed from February 2013 to August 2014, from an average of 3.7 to 5.1 of the recommended six guidelines. The number of hospitals implementing each guideline also increased during that period. Maternal substance use screening increased from 75.4% to 89.8% (P = 002), standardized evaluation and treatment of infants increased from 76.2% to 95.0% (P < .001), use of a standardized scoring tool increased from 44.8% to 76.5% (P < .001), nonpharmacologic treatment increased from 59.1% to 84.0% (P < .001), pharmacologic treatment increased from 68.0% to 91.6% (P < .001), and breast-feeding or use of expressed human milk increased from 48.6% to 72.3% (P < .001).

Length of treatment decreased from an average 16 days (interquartile range, 10 - 27 days) to 15 days (interquartile range, 10 - 24 days; P = .02), and length of hospital stay decreased from 21 days (interquartile range, 14 - 33 days) to 19 days (interquartile range, 15 - 28 days; P = .002).

The study did not include a control group, instead looking at trends as the centers implemented the protocols. The program also did not measure compliance to the protocols, only whether they had been implemented. The authors write that other limitations include the lack of data on differences in maternal drug use and the possible presence of unidentified confounding factors. The authors note, however, that NAS has been either holding steady or increasing in recent years, according to other studies.

Dr Patrick and one coauthor were consultants for the Vermont Oxford Network. Five coauthors are employees of the Vermont Oxford Network, and one coauthor receives salary support from the Vermont Oxford Network. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online April 15, 2016. Abstract

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