May 09, 2017

SAN FRANCISCO — Use of a functional scoring system dramatically reduced morphine treatment and length of stay among infants with neonatal abstinence syndrome (NAS) compared with the widely used Finnegan Neonatal Abstinence Scoring System (FNASS), a new study has shown.

Of 50 infants managed with the functional assessment system, called ESC for eating, sleeping, and consolability, only 6 (12%) received pharmacologic treatment compared with 32 (62%) expected if FNASS had been used, Matthew J. Lipshaw, MD, from the Department of Pediatrics at Yale University School of Medicine, New Haven, Connecticut, said during a presentation here at the Pediatric Academic Societies (PAS) 2017 Annual Meeting.

In addition, the length of stay was dramatically reduced after introduction of the new system, with an average of 5.9 days vs 23 days beforehand. Dr Lipshaw noted that several other changes occurred around the same time as part of a larger quality improvement program, such as having infants room with their mothers and caring for the infants on a regular hospital floor instead of the neonatal intensive care unit. Nonetheless, the reduction in morphine treatment has helped shorten inpatient time for these infants.

"The ESC approach led to less morphine use than if we'd been using the Finnegan approach, and we had no significant adverse events," he said.

"Using the Finnegan thresholds to treat these babies may lead to overtreatment, and a functional approach, such as ESC, may significantly decrease medication use and likely decrease length of stay, as once medication is initiated, it is often a multiday weaning process," he concluded.

Comparing Measures

The American Academy of Pediatrics recommends use of a standardized scoring system to guide management of infants with NAS after opioid exposure in utero. Past surveys show that the vast majority of institutions use FNASS, Dr Lipshaw said.

The FNASS, which was first published in 1975, relies on 21 signs and symptoms of withdrawal that are scored on scale of 0 to 3, based on severity. Typical management for infants with NAS includes FNASS assessment every 2 to 6 hours, with clinicians initiating morphine treatment if an infant has three consecutive scores of 8 or higher or two scores of 12 or higher. Treatment is decreased after infants have 24 hours of scores below 8.

Physicians at Yale-New Haven Children's Hospital, however, have recently developed the ESC functional assessment system. Instead of looking at symptoms of withdrawal, clinicians assess whether an infant is able to eat 1 or more ounce per feeding, sleep for an hour or longer undisturbed, and be consoled in 10 minutes or less.

"If all three of these criteria are met, we considered these infants well managed, despite other signs and symptoms of withdrawal," Dr Lipshaw said. "If one is not met, house staff are notified at any time of day, and treatment is increased, if possible nonpharmacologically, but pharmacologically if needed."

Although all care decisions at the hospital are now based on ESC, nurses still measure and record infants' FNASS. Therefore, in the current study, Dr Lipshaw and colleagues examined how the two systems would have guided treatment in NAS-affected infants.

They reviewed medical record data for 50 infants treated at their hospital between March 2014 and August 2015, comparing actual treatment with what would have happened if they had been managed using FNASS.

In addition to the large reduction in number of infants treated with morphine, the investigators found that ESC led to initiation or increase of morphine on far fewer days than FNASS would have (2.7% vs 26%).

ESC also appeared to be a better predictor of how the infant would do over the next day or so. In 26% of the days when ESC indicated no morphine but FNASS would have led to morphine initiation, the infant appeared better the next day, with FNASS scores dropping below 8 again. Conversely, on the 2 days when ESC led to drug initiation but FNASS did not, the following day, FNASS scores rose.

During the discussion after the presentation, Bonny L. Whalen, MD, a pediatric hospitalist at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said her hospital had also started using a functional scoring approach and seen similar results.

"What we have noticed is that it has really helped decrease initiation of morphine treatment, and just like you, we have seen some babies peak in their symptoms and then are better the next day, where we would have traditionally started them on treatment."

Dr Lipshaw noted that the long-term effects of treatment based on ESC remain unknown.

Let Infants Function as Infants

When asked what led to the shift in scoring systems, Dr Lipshaw deferred to senior author Matthew Grossman, MD, assistant professor of pediatrics and a quality and safety officer at Yale-New Haven Children's Hospital, who was responsible for the change.

"After observing dozens of these patients, I realized that almost all of them will have some withdrawal signs like hypertonicity or tremors," Dr Grossman told Medscape Medical News. "We didn't think Finnegan was telling us what we wanted to know. We knew that all of these babies were going to have withdrawal; we wanted to know how they were handling the withdrawal. Were they able to do the things that babies are supposed to do? The job description of a baby is pretty limited: They should be able to eat, sleep, and you should be able to console them. Even if babies have withdrawal signs, if they can be managed such that the baby can eat, sleep, and be consoled, then the baby is doing well and is well-managed."

Dr Grossman said personal parenting experience helped precipitate his current understanding of an infant's well-being. "I also noticed that my rather difficult infant, who was not withdrawing, would have scored high on the Finnegan score. Nobody would have ever considered giving him these powerful medications. We were expected to manage him as any mother or father would. We thought we should start to look at the NAS babies through the same lens."

The current study did not elaborate on the difference in length of stay; that point was raised during the discussion period. When Dr Lipshaw noted the difference, 5.9 days vs 23 days, several audience members said, "Wow."

Dr Grossman and colleagues have an article reporting the details of length of stay that will be published in June in Pediatrics.

The authors have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2017 Annual Meeting: Abstract 2315. Presented Sunday, May 7, 2017.

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